Best Practices for Social Work with Refugees and Immigrants 9780231543583

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BEST PRACTICES FOR SOCIAL WORK WITH REFUGEES AND IMMIGRANTS

BEST PRACTICES FOR SOCIAL WORK WITH REFUGEES AND IMMIGRANTS SECOND EDITION

Miriam Potocky and Mitra Naseh

columbia university press——new york

columbia university press Publishers Since 1893 New York Chichester, West Sussex cup.columbia.edu Copyright © 2019, 2002 Columbia University Press All rights reserved Library of Congress Cataloging-in-Publication Data Names: Potocky, Miriam, author. | Naseh, Mitra, author. Title: Best practices for social work with refugees and immigrants / Miriam Potocky and Mitra Naseh. Description: Second edition. | New York : Columbia University Press, [2019] | Includes bibliographical references and index. Identifiers: LCCN 2019021921 | ISBN 9780231181396 (trade paperback) | ISBN 9780231181389 (cloth : alk. paper) | ISBN 9780231543583 (e-book) Subjects: LCSH: Social work with immigrants—United States. | Refugees—Services for—United States. | Immigrants—Services for—United States. Classification: LCC HV4010 .P67 2019 | DDC 362.87/530973—dc23 LC record available at https://lccn.loc.gov/2019021921

Columbia University Press books are printed on permanent and durable acid-free paper. Printed in the United States of America Cover design: Elliott S. Cairns Cover image: NASA

In memory of my parents —M.P.

CONTENTS

Acknowledgments ix

PART I CONTEXT FOR SOCIAL WORK WITH REFUGEES AND IMMIGRANTS

1. Introduction 3 2. International Migration Policies 44 3. United States Immigration and Refugee Policies 69 4. Human Services Delivery Systems 100 PART II PROBLEM AREAS AND BEST PRACTICES

5. Culturally Competent Social Work Practice 121 6. Health Issues 149 7. Mental Health 187 8. Family Dynamics 217 9. Language, Education, and Economic Well-Being 241 10. Intergroup Relations 279 11. Additional Populations of Concern 303 12. Summary and Conclusions 330 References 343 Index 409

ACKNOWLEDGMENTS

I THANK my wonderful coauthor, Mitra Naseh, for her invaluable contributions to this second edition. Her enthusiasm and diligence in working on this project over several years has been remarkable. Her passion for helping refugees is heartfelt and unflagging. The future for refugees is brighter in the light of this rising star. May we share many more cups of tea. I thank my lifelong friend, Dr. Gail Ukockis, for help with editing and for developing the index and discussion questions throughout the book, as well as for her continued moral support. We met because of our shared youthful idealistic belief that writing can change the world—and we are both still at it. Pravda vítězí—truth prevails. Many thanks to my editors at Columbia University Press, formerly Jennifer Perillo, who first approached me about writing a second edition and shepherded and championed it through its initial stages; and subsequently Stephen Wesley and Christian Winting, who have been incredibly patient and supportive in seeing the project through to completion. Thanks as well to Ben Kolstad for his outstanding editorial services. Thanks also to my colleagues who work with refugees and survivors of torture, Kristen Guskovict, Sabine Balmir-Derenoncourt, and Sylvia Acevedo, for their enthusiasm about the first edition and for providing me with the opportunity be engaged with work that is so personally meaningful and rewarding to me. Finally, I thank my husband, David Rafaidus, for his support of my writing, for his morning cheerfulness, for our human/canine family, and so much more. —M.P.

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ACKNOWLEDGMENTS

I thank my advisor and my mentor for letting me be part of this amazing journey, I enjoyed working on every single page of this book. My name being next to hers is an honor for which I will be forever humble. I thank her for dedicating her life to making a change in the world; she definitely changed my life. —M.N.

BEST PRACTICES FOR SOCIAL WORK WITH REFUGEES AND IMMIGRANTS

PART ONE CONTEXT FOR SOCIAL WORK WITH REFUGEES AND IMMIGRANTS

1 INTRODUCTION

MANY SOCIAL WORKERS PRACTICE in settings that serve immigrant and refugee clients, and most social workers can expect to encounter clients like these at some time in their career. In 2017, 3.4 percent of the world’s population (258 million people) lived outside of their country of origin (United Nations [UN], 2017a). Some voluntarily left their country of origin, and others were forced to flee. In the United States, the foreign-born population accounts for more than 13 percent (43.7 million) of the total population (U.S. Census Bureau, 2016a). The population of immigrants and refugees in the United States is growing rapidly. The foreign-born percentage of the total U.S. population has nearly tripled in the past fifty years (U.S. Census Bureau, 2013). Thus, it is essential that social workers be prepared to work effectively with this population. Social work practice with refugees and immigrants requires specialized knowledge of the unique issues of these populations. It also requires specialized adaptations and applications of mainstream services and interventions. This book provides a comprehensive perspective on social work practice with refugees and immigrants. We examine the multiple factors that affect immigrants and refugees at the micro, meso, and macro levels, and we describe relevant practice approaches at each of those levels. This book adopts a “pancultural” perspective, focusing on the common experiences of and practice approaches for working with immigrants and refugees across all cultures rather than focusing on specific immigrant or refugee groups. By focusing on cultural similarities and universal values, the pancultural perspective offers a baseline for working with people of all cultures (Lum, 1995). Lum (2004) underscores the importance of this perspective: “multicultural social work must offer a pancultural perspective,

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which encompasses the various ethnic groups and also the dominant . . . culture with which they must coexist. . . . Fundamental to the pancultural perspective is the conviction that the culture and ethnicity of all people are important factors in the helping process” (p. 103). Clients’ unique cultural values also are important, and individuals may respond differently to their situations based on these values. Social workers must avoid overlooking specificities of different cultures when using an overarching perspective based on the commonalities among cultures. For instance, one culture may encourage expressing emotions, whereas in another culture such expressions could be strongly discouraged. As a result, members of the latter culture might respond to a situation involving emotional expressions with fear, shame, or embarrassment, whereas members of the former culture might respond to a similar situation with joy, excitement, or contentment (Lum, 2010). Furthermore, individuals may differ in their experience of their own cultures. For instance, some people are alienated from their own cultural heritage and, consequently, find a culturally adapted practice irrelevant. It is also important for social workers to consider diversity within diversity and intersectionality when working with clients; that is, social workers must take into account the impact of factors such as gender, class, sexuality, and race as mutually reinforcing social structures (Mattsson, 2014). All these factors make each client unique, and social workers must take this into consideration to assure relevance in practice. Our focus is primarily on practice in the United States, although we draw on literature from around the world and chapter 2 addresses international migration policies. Due to the great diversity of populations, policies, and practices in other countries, the issues addressed here may or may not be applicable outside of the United States. Readers in other countries should use their own knowledge and judgment to adapt this information to their local context. This book is divided into two parts. Part I sets forth the context for social work practice with immigrants and refugees. This includes descriptions of the populations, relevant policies, and human services delivery systems. We briefly review the history of U.S. immigration policies since 1882 to demonstrate that policies and public attitudes toward immigrants and refugees shift back and forth over time. Clearly, policies and public attitudes in any given period form a critical context for social work practice with these populations. Part II addresses specific problem areas within a bio-psycho-socialspiritual perspective. For each problem area, we discuss assessment and

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intervention techniques, with a focus on evidence-based practice. This includes scientifically validated approaches, as well as social workers’ evaluations of their own practices. Each chapter in part II delineates the “best practices” for the given problem area. We recommend that the chapters be read in sequential order because each one builds on material presented in preceding chapters. In this introductory chapter, we discuss who immigrants and refugees are and why they migrate. We describe the process of migration and provide statistics on these populations, their demographic characteristics, and service utilization patterns. Finally, we briefly describe each major group of immigrants and refugees in the United States.

DEFINITIONS OF IMMIGRANTS AND REFUGEES Definitions of immigrants and refugees differ depending on whether we are using a social science definition, a legal definition, or a self-definition. At the most fundamental level, immigrants and refugees are people who were born in one country and have relocated to another (Zong & Batalova, 2018). In the social science literature, these people are collectively referred to as international migrants, or the foreign-born population. People leaving a country to live elsewhere are called emigrants, and people entering a country to settle there are called immigrants. The fundamental distinction between immigrants and refugees is that immigrants leave their countries voluntarily (usually in search of better economic opportunities or to join family members already in the new country), whereas refugees are forced out of their countries because of human rights violations against them. Therefore, immigrants are also sometimes referred to as voluntary migrants or economic migrants, and refugees may be referred to as involuntary migrants or forced migrants (United Nations Educational, Scientific, and Cultural Organization [UNESCO], 2017). Refugees also sometimes call themselves exiles or émigrés. The social science literature contains further distinctions within these broad categories of immigrants and refugees. A review of four major sources of social work literature in the United States (Proceedings of the National Conference of Social Work [1874–1983], The Survey Mid-Monthly: Journal of Social Work [1909–1952], Social Service Review [1927–present], and The Family [1920–present]) revealed that the foreign-born population has been

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variously referred to as “immigrants,” “foreign-born,” “alien,” “refugees,” “displaced persons,” or any nationality marker (e.g., “Armenian”) (Park, 2008). In legal terms, any person who is not a citizen or national of the United States is categorized an “alien” (Ciment, 2015). In this context, immigrants and refugees are legally recognized as “aliens” in the United States. However, in general documents, anyone who is not a U.S. citizen by birth is referred to as foreign-born, and all others are categorized as native-born (U.S. Census Bureau, 2016b). The foreign-born population is further classified as documented or undocumented. A documented immigrant is a person who has been legally admitted into the United States and granted the privilege to be a permanent resident, also known as “permanent resident alien,” “resident alien permit holder,” and “green card holder” (U.S. Department of Homeland Security, 2018a). A documented nonimmigrant is a foreign-born person who is in the United States temporarily, such as a tourist, a student, or a journalist. Documented nonimmigrants also include temporary, or seasonal, workers, who come to the United States to work during certain periods of the year and return to their countries of origin during the rest of the year. A foreign-born individual who is documented has been granted a legal right to be in the United States, as determined by admissions policy. The U.S. admissions policy details many categories of people who are eligible to be legally admitted. It also specifies how many people from each country may be legally admitted into the United States each year. This policy is described more fully in chapter 2. An undocumented foreign-born individual does not have a legal right to be in the United States. Undocumented people are often referred to with dehumanizing terminologies such as “illegal” immigrants or “deportable aliens” (U.S. Department of Homeland Security, 2018b). Use of such dehumanizing terminologies violates the social work values of respecting the dignity and worth of all people. The preferred term among social workers and immigrant advocates is “undocumented immigrants.” In this text, we use this term except when directly quoting other sources. There are two ways in which people become undocumented. One is by entering the United States without authorization (Hipsman & Meissner, 2013). For example, people who cross the border from Mexico without going through immigration authorities are undocumented. The second way that people become undocumented is by entering the United States legally but then violating the terms of their visa (that is, their authorization to stay in the United States) (Hipsman & Meissner, 2013). For example, a tourist

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may be granted a visa to stay in the United States for a limited time. If the person stays after that period has expired, that person becomes undocumented. Similarly, a student may be granted a visa to attend school in the United States. If that student stops attending school and begins working, that person becomes undocumented. It is important to understand the legal difference between an immigrant and a refugee. As stated previously, immigrants leave their countries of origin voluntarily, whereas refugees leave because of human rights violations against them. Refugees are very specifically defined in international law by the United Nations Convention Relating to the Status of Refugees, which was established in 1951. This law is also sometimes referred to as the Geneva Convention because it was adopted by the United Nations at Geneva, Switzerland. Article 1 of the Convention defines the word “refugee” (see UN General Assembly, 1951, p. 152), and the U.S. Department of Homeland Security (2018b, para. 1) has summarized this definition as “any person who is outside his or her country of nationality who is unable or unwilling to return to that country because of persecution or a wellfounded fear of persecution. Persecution or the fear thereof must be based on the alien’s race, religion, nationality, membership in a particular social group, or political opinion.” Some people find themselves in circumstances that appear similar to those of refugees, but they do not fit the legal definition of refugees. People in refugee-like situations may have moved from one part of their own country into another part of that same country because of the same fear of persecution we have described, This frequently happens in civil wars. Although they may have suffered from the same human rights violations as refugees and may have been forced to move out of their homes, they are not defined as refugees because they have not actually left their country of origin. Instead, these people are referred to as “internally displaced persons.” Another refugee-like situation occurs when people are forced to leave their country of origin due to a natural disaster, such as widespread droughts that have led to starvation. These people are referred to as forced migrants because they were forced to leave by acts of nature rather than by acts of persecution by humans; they are not considered refugees. It is important to remember that the word refugee was defined under international law. Although the United States uses the same definition in its national refugee policy, this does not mean that everyone who qualifies as a refugee under the international law can be admitted into the United States

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as a refugee. The United States president, in consultation with Congress, sets limits on the number of refugees admitted each year. Fiscal year 2019 marked the lowest cap (30,000 refugees) since the creation of the current refugee program in 1980 (Alvarez, 2018). Historically, the United States has been more favorable to granting admission to refugees from certain countries and less favorable to refugees from other countries. For instance, as part of the Trump administration’s travel ban, admission of refugees from Syria—currently the largest refugee population in the world—has been suspended (Krogstad & Radford, 2017). The process of determining whether someone is eligible to be legally admitted to the United States as a refugee is frequently lengthy. The 2018 fiscal year had one of the slowest paces of refugee admission, partly due to a four-month suspension in refugee admissions (beginning in 2017 and continuing into late January 2018) and partly due to tougher security screenings (Connor & Krogstad, 2018). Several categories describe people who are in different stages of the refugee admission process. People who are outside of their country of origin and are applying to be recognized and admitted as refugees by another country are called asylum-seekers. If granted asylum, they become “asylees.” People who arrive in the United States after first being granted asylum in another country are termed refugees.) People who have been allowed to enter the United States under emergency humanitarian conditions pending a final decision are termed parolees.

DISCUSSION QUESTION

Irina is from Russia, where she had been imprisoned for speaking out against the government. She arrives in New York City to visit a friend and decides to apply to stay in the United States. Which term would apply to her, refugee or asylum seeker?

In addition to the various primary legal statuses previously described, many immigrants derive their legal status through their relationship to another immigrant. For example, one member of a family may be recognized

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and admitted as a refugee under the legal definition. Typically, that person’s spouse and children would also be admitted as refugees even though they themselves may not meet the definition per se. Similar standards apply to the various categories of immigrant admissions. Two final types of foreign-born persons are worth noting. The first is stateless people, who are not considered nationals of any country. The United Nations High Commissioner for Refugees (UNHCR) maintains that “statelessness can occur for several reasons, including discrimination against particular ethnic or religious groups, or on the basis of gender; the emergence of new States and transfers of territory between existing States; and gaps in nationality laws” (2018a, para. 6). The second type is not a distinct legal status. This is a person who essentially has permanent residence in two or more countries. Typically, such people spend substantial amounts of time in both countries. They commute back and forth, may have dual citizenship, and are referred to in the social science literature as “transnationals” (Levitt & Jaworsky, 2007). They differ from other foreign-born persons in that both countries are “home” to them. The number of transnationals is growing due to the increasing accessibility of air travel and the technological advances in worldwide communications. A foreign-born person’s legal status can, and usually does, change over time. This is referred to as “adjustment of status.” After one year of residence, a refugee is eligible to become a permanent resident. Permanent residents (including those who were formerly refugees and immigrants) may be eligible to become U.S. citizens after five years of residence. Once they obtain U.S. citizenship, they are referred to as “naturalized citizens.” Undocumented immigrants sometimes become eligible for legal permanent resident status. Certain undocumented immigrants and documented immigrants who have a temporary visa may be allowed to remain in the United States under special circumstances. For example, if the United States has determined that conditions in a given country pose a danger to personal safety due to ongoing armed conflict or an environmental disaster, immigrants from that country may be granted Temporary Protected Status. Similarly, if the United States has judged conditions in a given country to be unstable or uncertain, or to have shown a pattern of denial of rights, immigrants from that country may be granted Deferred Enforced Departure status. The major legal definitions are summarized as follows:

DHS DEFINITIONS OF MAJOR LEGAL CATEGORIES AND TERMS

Alien—Any person not a citizen or national of the United States. Asylee—An alien in the United States or at a port of entry who is found to be unable or unwilling to return to his or her country of nationality, or to seek the protection of that country because of persecution or a well-founded fear of persecution. Persecution or the fear thereof must be based on the alien’s race, religion, nationality, membership in a particular social group, or political opinion. For persons with no nationality, the country of nationality is considered to be the country in which the alien last habitually resided. Asylees are eligible to adjust to lawful permanent resident status after one year of continuous presence in the United States. Beneficiaries—Aliens on whose behalf a U.S. citizen, lawful permanent resident, or employer have filed a petition for such aliens to receive immigration benefits from the U.S. Department of Homeland Security. Beneficiaries generally receive a lawful status as a result of their relationship to a U.S. citizen, lawful permanent resident, or U.S. employer. Deportable Alien—An alien in and admitted to the United States subject to any grounds of removal specified in the Immigration and Nationality Act. This includes any alien illegally in the United States, regardless of whether the alien entered the country by fraud or misrepresentation or entered legally but subsequently lost legal status. Derivative Citizenship—Citizenship conveyed to children through the naturalization of parents or, under certain circumstances, to foreign-born children adopted by U.S. citizen parents, provided certain conditions are met. Migrant—A person who leaves his/her country of origin to seek residence in another country. National—A person owing permanent allegiance to a state. Nonimmigrant—An alien who seeks temporary entry to the United States for a specific purpose. The alien must have a permanent residence abroad (for most classes of admission) and qualify for the nonimmigrant classification sought. The nonimmigrant classifications include: foreign government officials, visitors for business and for pleasure, aliens in transit through the United States, treaty traders and investors, students, international representatives, temporary workers and trainees, representatives of foreign information media, exchange visitors, fiance(e)s of U.S. citizens, intracompany transferees, NATO officials, religious workers, and some others. Most nonimmigrants can be accompanied or joined by spouses and unmarried minor (or dependent) children. Parolee—A parolee is an alien, appearing to be inadmissible to the inspecting officer, allowed into the United States for urgent humanitarian reasons or when that alien’s entry is determined to be for significant public benefit. Parole does not constitute a formal admission to the United States and confers temporary status only, requiring parolees to leave when the conditions supporting their parole cease to exist. Permanent Resident Alien—An alien admitted to the United States as a lawful permanent resident. Permanent residents are also commonly referred to as “CONTINUED”

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“CONTINUED”

immigrants; however, the Immigration and Nationality Act (INA) broadly defines an immigrant as any alien in the United States, except one legally admitted under specific nonimmigrant categories. An illegal alien who entered the United States without inspection, for example, would be strictly defined as an immigrant under the INA but is not a permanent resident alien. Lawful permanent residents are legally accorded the privilege of residing permanently in the United States. They may be issued immigrant visas by the Department of State overseas or adjusted to permanent resident status by the Department of Homeland Security in the United States. Principal Alien—The alien who applies for immigrant status and from whom another alien may derive lawful status under immigration law or regulations (usually spouses and minor unmarried children). Refugee—Any person who is outside his or her country of nationality who is unable or unwilling to return to that country because of persecution or a well-founded fear of persecution. Persecution or the fear thereof must be based on the alien’s race, religion, nationality, membership in a particular social group, or political opinion. People with no nationality must generally be outside their country of last habitual residence to qualify as a refugee. Stateless—Having no nationality. Temporary Protected Status (TPS)—Establishes a legislative basis for allowing a group of persons temporary refuge in the United States. Under a provision of the Immigration Act of 1990, the Attorney General may designate nationals of a foreign state to be eligible for TPS with a finding that conditions in that country pose a danger to personal safety due to ongoing armed conflict or an environmental disaster. Grants of TPS are initially made for periods of 6 to 18 months and may be extended depending on the situation. Removal proceedings are suspended against aliens while they are in Temporary Protected Status. SOURCE: U.S. DEPARTMENT OF HOMELAND SECURITY (2018B).

As the preceding discussion suggests, definitions and categorizations of foreign-born persons are quite complex and can be confusing. In addition to legal definitions, there are also social science definitions and self-definitions. These are often inconsistent with each other. For example, “transnational” is a social science term that does not have a legal counterpart, and people in this circumstance may not use the term to refer to themselves. Another example, which is very common, is when people define themselves as refugees and may even be defined as refugees under international law but are not recognized as such by the United States. Depending on the circumstances, such a person may be admitted as a legal immigrant in some other category or may be an undocumented alien subject to deportation. Another common

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occurrence is that naturalized citizens are often considered immigrants in the social science literature and may also think of themselves as immigrants, even though legally they are no longer immigrants but citizens. To further complicate matters, laypeople and the popular media frequently refer to all foreign-born persons as immigrants without making distinctions among the various categories. Social work practice with foreign-born persons requires that the social worker be familiar with the various social science, legal, and self-definitions. The social science definitions are important because they are often linked with psychological and social phenomena. For example, immigrants and refugees tend to have quite different outlooks, feelings, and experiences from each other; this distinction is discussed throughout the book. A person who is legally defined as an immigrant may in fact have the perspective of a refugee and would be defined as such from a social science standpoint. Therefore, knowledge of these social science definitions is helpful to the social worker in understanding the client. Legal definitions are important because a client’s legal status determines eligibility for publicly funded social service assistance and influences helpseeking behavior. For example, refugees are eligible for far more publicly funded assistance than are immigrants. And undocumented aliens are unlikely to seek help for fear of being reported and deported. Finally, it is important for social workers to understand how clients define themselves. For example, people may be classified as refugees both legally and by social science definitions. However, some may think of the United States as “home” and consider themselves Americans, whereas others may think of the old country as “home” and base their identity on being from that country. Clients’ viewpoints in this regard have important implications for many aspects of their lives, and such information can be gained only from them. When beginning work with a foreign-born client, the social worker should determine the client’s legal status as well as the social science definitions and the client’s self-definition. A good starting point is to find out why the client came to the United States. Several common causes of migration are discussed in the next section.

CAUSES OF INTERNATIONAL MIGRATION Causes of migrations are varied, and many theories have been developed to explain why people migrate from one country to another. The classical

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theory of international migration is referred to as the push-pull theory (Lee, 1966). It posits that people migrate in response to “push” factors in the country of origin and/or “pull” factors in the country of destination (figure 1.1). Push factors are generally negative, such as poor economic conditions, lack of opportunity, discrimination, political oppression, and war. Pull factors are generally positive, such as better economic opportunity, political freedom, and favorable reception toward immigrants. Refugees often are viewed as being pushed out of their countries by oppression and war, whereas immigrants are viewed as being pulled into the destination country by the prospect of economic improvement (Loescher, 1993). However, migration can be a result of both push and pull factors. Although the classical push-pull model retains substantial validity, more complex and nuanced theories have been developed. The more comprehensive theories recognize that international migration is a result of factors operating at three levels: the macro or structural level, which entails political, economic, cultural, and geographic forces in the international arena, the country of origin, and the country of destination; the meso or relational level, which entails the relationships between potential movers and stayers in both the country of origin and the country of destination; and the micro or individual level, which entails personal characteristics and the individual’s freedom to make autonomous decisions about moving or staying (Faist, 1997; Haug, 2008; Malmberg, 1997). The macro level forces are addressed by the push-pull theory and may include political, economic, geographical, and cultural factors. Political forces include elements such as political stability, war, persecution, human rights, emigration policies of the country of origin, immigration policies

Push factors • Poverty • Fear • Disasters • Unemployment

Pull factors • Safety • Opportunity • Stability • Freedom

FIGURE 1.1 Push and pull factors in migration Source: Authors’ synthesis.

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of the country of destination, and the availability of organized assistance for the move and settlement in the new country. For instance, people may leave their country of origin for religious freedom and political rights; they may also choose a host country based on access to civil rights and political privileges (Bodvarsson & Van den Berg, 2013). Political factors are usually the most important push factor for forcibly displaced populations. Conflict around the world is the cause of forced displacement of millions of refugees. Economic forces include elements such as living standards, jobs, working conditions, unemployment rates, and wages in the countries of origin and destination. For instance, better career opportunities, less discrimination in the job market, or lower levels of taxation can be pull factors for migration; undesirable work conditions and high unemployment rates in countries of origin can act as push factors (Bodvarsson & Van den Berg, 2013). Supply and demand also play an important role in migration. For instance, demand for international recruitment of highly skilled workers or “cheap” lower-skilled labor can be an important factor for migration (Bodvarsson & Van den Berg, 2013; Castles, 2010). Most economists favor immigration as a driver for development and positive economic growth, but some argue against it (Bodvarsson & Van den Berg, 2013). It is important to note that immigration is costly for the migrants, and the most vulnerable members of a population don’t have access to the necessary resources for migration (Bodvarsson & Van den Berg, 2013). Geographic forces include elements such as the distance between the two countries, environmental disasters, and climate. The distance between two countries could be an important pull factor, especially in the case of forced displacement, when the closest safe destination is sought (Jacobsen, 2005). Moreover, migration is one of the strategies used by many to adapt to climate and environmental disasters. Climate change–related migration is expected to affect millions in coming decades (International Organization for Migration, 2011). Cultural forces include elements such as the ethnic compositions, languages, and predominant religions of the two countries. Similarity in languages and religious beliefs between the country of origin and the host country can be an important pull factor for migration. Selecting a culturally similar destination provides immigrants with greater opportunity for integration (Adserà, 2015). People who are considering moving to another country voluntarily usually use a complex decision-making process to consider the advantages and

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disadvantages of these political, economic, and cultural factors. Generally, immigrants are more likely to migrate to a country that has more political freedom and stability, favorable immigration policies, better economic conditions, relative geographic proximity, and similar culture and language to the country of origin (Bakewell, 2009; Rodrigue, Comtois, & Slack, 2017). Due to the abrupt nature of forced displacement, this complex decision-making process does not apply to forcibly displaced populations. For forcibly displaced populations, the first destination is usually the nearest safe place (Jacobsen, 2005). Decisions about the above-mentioned macro factors are mediated by the meso and micro factors. The meso level concerns an individual’s family and social network, including ties to kinship groups, friends, neighbors, coworkers, acquaintances, and ethnic, religious, and political associations in both the sending and receiving countries (Faist, 1997; Haug, 2008). The stronger these ties are in the country of origin, both in terms of actual social contact and emotional attachment, the less likely the person is to move voluntarily. Single people are usually more likely to migrate than married people with children. However, sometimes family ties are a stimulus for moving, such as when families leave or escape to provide a better life and safety for their children in another country. People who already have family, friends, or acquaintances in the country of destination are more likely to go there than people who do not know anyone in the new country. Immigration to cities and countries where friends and family members live often results in what is called “chain migration” (Faist, 1997). Although in recent years some people have applied this term in a derogatory fashion, it originally simply referred to family reunification. In this situation, more and more members of a family or social group migrate to a country, following those who came earlier. Again, decisions about the relative importance of maintaining or disrupting family and social ties are mediated by the macro and micro forces. The micro forces include personal characteristics such as age, ethnicity, religion, education, and financial assets. For example, older people are less likely to migrate than younger people because they have more and stronger ties in the country of origin, and because it would be more difficult for them to adapt to a new life. Ethnic and religious minorities within a country are more likely to migrate because they are more likely to have been persecuted than non-minorities. Potential voluntary migrants must consider the economic opportunities available to them in the new country in relation to

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their educational level (Alonso, 2011). This prospect might serve as a deterrent to migration. Financial assets are critical because money is required for the move. Extremely poor people are less likely to migrate (Alonso, 2011) unless they receive assistance from family members in the receiving country or from humanitarian organizations. Some migrants must abandon most of their assets when leaving their country, and this also may serve as a deterrent to leaving. Personality characteristics also influence individuals’ decisions to migrate. Among these characteristics are risk-taking level, time orientation, and emotional ties to geographic places. Moving to another country entails a major risk because it means embarking on a largely unknown new life. People who do not like to take risks are less likely to migrate voluntarily, and those with high openness to experience are more likely to migrate (Jokela, 2009). People who are contemplating moving to another country usually take into consideration all of these macro, meso, and micro factors in making their decisions. Within each level, there are advantages and disadvantages. The individual must weigh these both within and across the levels. The factors within one level often predominate over another level. For refugees escape is commonly unplanned, and the macro factors usually predominate. The necessity of escaping war or political oppression outweighs considerations such as disrupting family ties and losing all assets. Refugees are considered to be forced migrants because they probably would not have chosen to leave their country in the absence of these negative macro-level factors. For economic migrants, the macro and micro levels may outweigh the meso level. The prospect of improvement in living conditions combined with personal risk-taking initiative may outweigh the force of family ties. For the vast majority of people who choose not to leave their country despite poor economic conditions, family and individual factors are probably the overriding consideration. The decision to leave one’s country of birth is a monumental, lifealtering step. People’s reasons for choosing to leave are not simple. Leaving means making some sacrifices, such as leaving behind family, possessions, or a place in society. These losses continue to affect immigrants’ and refugees’ lives in the new country.

STAGES OF MIGRATION The process of moving out of one country and settling in another has been categorized into a number of stages: premigration and departure, transit,

INTRODUCTION

17

resettlement, return to country of origin, and return to country of resettlement (Drachman & Paulin, 2004). Figure 1.2 shows the experiences that characterize each stage. Further, critical variables that influence each migration stage include age, family composition, urban/rural background, race, education, culture, socioeconomic background, occupation, belief system, and social support. The decision-making process described in the previous section characterizes the premigration and departure stage for immigrants. This stage also entails losses such as loss of family and friends and loss of a familiar environment. Generally, the losses are greater and the premigration and departure experience more traumatic for refugees than for immigrants. Refugees may have been subject to discrimination, ostracism, imprisonment, or the death of family members, and they often leave under hurried, chaotic, and dangerous conditions. In many cases refugees flee amid armed conflict. They may be victims of violence during this time, or they may have witnessed violence, rape, torture, or killing (Crumlish & O’Rourke, 2010; Nickerson, Bryant, Silove, & Steel, 2011). In some cases, refugees leave in mass movements, with hundreds or thousands of people. Because refugees flee under these chaotic conditions, they must leave almost all their possessions behind. They lose their homes and other assets and do not know when, if ever, they will be able to return. Leaving behind family and friends is particularly painful because they know they may never see them again.

Premigration and departure

Return to resettlement

Resettlement

Social, political, economic, and educational factors Separation from family and friends Decisions about who leaves and who is left Abrupt departure Long wait and living in limbo prior to departure Leaving a familiar environment Life-threatening circumstances Experiences of violence and persecution Loss of significant others

Cultural issues Reception from host country Opportunity structure of host country Discrepancy between expectations and reality Degree of cumulative stress throughout migration process Different levels of acculturation among family members Intergenerational conflict and family structural changes

Perilous or safe journey Refugee camp or detention center stay Awaiting a foreign country’s decision Immediate and final relocation or long wait before final relocation Loss of significant others

Transit

FIGURE 1.2 Stages of migration Source: Drachman and Paulino (2004).

Duration of time in country of origin Nature of experiences in country of origin Move to 2nd, 3rd, or 4th country of resettlement

Reason for return (family issues, economic issues, retirement, deportation) Duration of time in country of resettlement Nature of experiences in country of resettlement Reception in country of origin

Return to country of origin

18

CONTEXT FOR SOCIAL WORK WITH REFUGEES AND IMMIGRANTS

In contrast, immigrants typically can plan their departure well in advance and leave under relatively calm conditions. The departure is not life-threatening, nor do they have to abandon their possessions. Immigrants can take some assets, especially money, with them, and they retain ownership of their property. Typically, there are no political barriers to prevent them from returning to their country of origin. Nonetheless, the separation from home and family is painful. Not all refugees and immigrants experience all the losses and traumas that can occur during this stage. However, some degree of loss occurs in all cases. The experiences during this stage influence the later stages of the migration process. In particular, these experiences affect people’s health and may affect their mental health into the future. It is important for the social worker to learn about a client’s experiences in the country of origin and during the departure. The transit stage involves the physical move from one country to another. This experience is usually more traumatic for refugees than for immigrants. The experience also differs between legal and illegal immigrants. For legal immigrants to the United States, the transit usually entails arrival by plane or by car at the border. It is typically not traumatic. However, for refugees, the transit may be dangerous or life-threatening. Refugees may be passing through areas of armed conflict and may be subject to or witness the same atrocities as in the premigration and departure stage. They may undertake a lengthy journey on foot during which they may face starvation, dehydration, hypothermia, or other physical ailments (Kulla et al., 2016). Many refugees leave by boat. Often these boats are in poor condition and are overloaded. Sinking, drowning, and illness or death due to sun exposure are not uncommon (Pugh, 2004). In many cases refugees are placed in refugee camps in neighboring countries before they are sent to a permanent home in a third country such as the United States. These camps usually consist of tent cities. They are often overcrowded and have poor sanitary conditions. Diseases and violence in the camps are not uncommon (Ahmed et al., 2013; Hyder, Noor, & Tsui, 2007). Refugees may remain in such camps for years before obtaining permission to enter the United States or being returned to their country of origin. Refugees who arrive directly in the United States requesting asylum may be placed in a detention center while their case is decided. In some cases, these individuals have remained in the detention center for months or years. Immigrants who enter the United States illegally often experience a dangerous transit. The most common illegal point of entry is at the Mexican border (DeLuca, McEwen, & Keim, 2010). Frequently, undocumented immigrants

INTRODUCTION

19

hire a smuggler, or “coyote,” to get them across the border. These smugglers charge very large fees (Gathmann, 2008). Sometimes they assault the immigrants and steal their money without leading them across the border. Other times they take the immigrants only to the border and not across. Immigrants may be crowded and hidden in trucks, and they sometimes die of heat and suffocation. These undocumented immigrants are also subject to assault, theft, and drowning. Not all legal immigrants, refugees, and undocumented immigrants have the same transit experiences, but any trauma experienced during transit can affect the person’s adaptation in the next stage, resettlement. Resettlement lasts as long as people stay in the new country, which may be for the rest of their lives. During this stage, social workers in the United States will encounter and work with these immigrants and refugees. Part II of this book is devoted to the issues and problems immigrants and refugees encounter during this stage: adapting to the cultural norms of the new country; health and mental health problems; language, education, and employment issues; changing family dynamics; and relations between the newcomers and established residents. Some international migrants may return to their country of origin for a variety of economic or legal reasons. The return experience in the country of origin is influenced by factors such as the length of time spent in the resettlement country and the reception the returnees receive in the origin country. Other people return again to the country of resettlement or migrate to yet another country of resettlement. Their experiences there are influenced by their experiences in all the previous stages of migration. Finally, some people engage in circular migration and live as transnationals.

SCOPE OF IMMIGRATION AND REFUGEE POPULATIONS Worldwide, approximately 3.4 percent of the population, or approximately 258 million people, live outside their country of origin (UN, 2017a). The international movement of people is diverse and complex, but only a small number of countries are primary destinations. In 2017, more than half of all international migrants resided in just ten countries (UN, 2017a), and the United States is by far the country with the largest number of international migrants (figure 1.3). Of the total number of global international migrants, over 65 million were forcibly displaced, including more than 22 million refugees (UNHCR, 2018b; figure 1.4).

60 50

49.8

Millions

40 30 20 12.2

12.2

11.7

8.8

10

8.3

7.9

7.9

5.9

n ai Sp

C

an

ad

a

nc e Fr a

Ki Un ng it do ed m U ni te Em d A ira rab te s

us si a R

S Ar au ab di ia G er m an y

U

St nite at d es

0

Host country FIGURE 1.3 Countries hosting the largest numbers of international migrants, 2017 Source: United Nations (2018).

FIGURE 1.4 Forcibly displaced populations Source: UNHCR (2018b).

INTRODUCTION

21

Nearly 44 million foreign-born people resided in the United States in 2016, representing over 13 percent of the population (U.S. Census Bureau, 2016a). The percentage of foreign-born has varied during the past century, ranging from a high of 14.8 percent in 1910 to a low of 4.7 percent in 1970 (U.S. Census Bureau, 2013; figure 1.5). Figure 1.6 shows the top ten countries of origin of the population of foreign-born people living in the United States in 2016. As can be seen, people of Mexican origin far outnumber all others. Approximately one-third of the foreign-born population arrived in the United States before 1990; about one-quarter arrived in 1990–1999 and 2000–2009, and about one-fifth have arrived since 2010 (figure 1.7). Immigrants and refugees tend to be concentrated in certain states (figure 1.8). The highest concentrations are seen in California, New York, and New Jersey. Other high-concentration states are Nevada, Texas, Florida, and Massachusetts. Undocumented immigrants constitute a portion of the total foreign-born population and are estimated at approximately 12 million. Their top countries of origin and states of residence are shown in tables 1.1 and 1.2. The top source countries of unauthorized immigrants are nearly identical to the

FIGURE 1.5 Foreign-born population as a percent of total U.S. population Source: U.S. Census Bureau (2013).

14 12

11.5

Millions

10 8 6 4 2.5

2.2

1.9

2

1.3

1.3

1.2

1.1

1

0.9

a

re D om a R in ep ic ub an lic G ua te m al a

Ko

ub

El

Vi

C

m na

ad lv

pi

Sa

ilip Ph

et

or

s ne

a di In

na hi C

M

ex

ic o

0

Country of origin FIGURE 1.6 Top ten countries of origin of the foreign-born population in the United States, 2016 Source: U.S. Census Bureau (2016c).

2010 or later Before 1990

2000–2009 1990–1999

FIGURE 1.7 Decade of arrival of foreign-born population in United States Source: U.S. Census Bureau (2016d).

AK

WA MT

VT NH ME

ND MN

OR ID

MI

NV UT

PA

IA

NE

CA

MA

NY

WI

SD WY

IL

IN

OH WV

CO KS

KY

MO

CT NJ DE MD DC

VA

RI

NC AZ

OK

NM

MS TX

Percent

TN

AR

AL

SC 20.0 or higher 15.0 to 19.9 10.0 to 14.9 5.0 to 9.9 Less than 5.0

GA

LA FL

U.S. percent: 12.9

HI

FIGURE 1.8 Foreign-born population as percent of state population, 2010 Source: U.S. Census Bureau (2012).

TABLE 1.1 Country of Birth of the Unauthorized Immigrant Population COUNTRY OF BIRTH

NUMBER OF PEOPLE

PERCENT

6,640,000

55

El Salvador

700,000

6

Guatemala

640,000

5

India

430,000

4

Honduras

400,000

3

Philippines

360,000

3

China

270,000

2

Korea

250,000

2

Vietnam

200,000

2

Dominican Republic

180,000

1

2,050,000

17

12,120,000

100

Mexico

All other countries TOTAL Source: Baker (2017).

24

CONTEXT FOR SOCIAL WORK WITH REFUGEES AND IMMIGRANTS

TABLE 1.2 State of Residence of the Unauthorized Immigrant Population STATE OF RESIDENCE

NUMBER OF PEOPLE

PERCENT

California

2,900,000

24

Texas

1,920,000

16

Florida

760,000

6

New York

640,000

5

Illinois

550,000

5

New Jersey

480,000

4

Georgia

430,000

4

North Carolina

400,000

3

Arizona

370,000

3

Washington

290,000

2

3,370,000

28

12,120,000

100

All other states TOTAL Source: Baker (2017).

top source countries of the foreign-born population as a whole. Undocumented immigrants are subject to detention and deportation. More than half a million undocumented immigrants were apprehended in 2016, which was down from over 1 million in 2008 (figure 1.9a). Nearly 450,000 undocumented immigrants were removed or returned in 2016 (figure 1.9b). Having looked at the overall foreign-born population, regardless of time of entry, we now examine the most recent data on arrivals. A lawful permanent resident (LPR), or “green card” recipient, is defined by immigration law as a person who may live and work permanently in the United States; own property; attend public schools, colleges, and universities; join the U.S. Armed Forces; and apply to become a U.S. citizen after meeting certain eligibility requirements. About 1.2 million people received LPR status in 2016 (figure 1.10a). Nearly 40 percent of these migrants were from Asia and more than 33 percent were from North America. More than 66 percent of these individuals obtained their residency status through their relationship

INTRODUCTION

25

1.2

1.0

Millions

0.8

0.6

0.4

0.2

0 2008

(a)

2009

2010

2011

2012

2013

2014

2015

2016

Inadmissibility determinations

Alien removals

Alien returns

274,617 aliens arriving at a port of entry were determined to be inadmissible by CBP office of fields operations (OFO).

340,056 aliens were removed from the United States.

106,167 aliens were returned to their home countries without an order of removal.

The top three ports of entry recorded 50.9% of all inadmissibility determinations: 24.8%

17.5%

8.6%

Laredo, TX

San Diego, CA

EI Paso, TX

Criminals

39.9% or 135,570 of total alien removals were criminal aliens.

Noncriminals

Aliens were returned by the following three DHS components: CBP OFO

CBP USBP

ICE ERO

CBP OFO 77.9%

CBP USBP 15.2%

ICE ERO 6.9%

(b) FIGURE 1.9 Immigration enforcement actions. (a) Alien apprehensions by the U.S. Department of Homeland Security (DHS), 2008 to 2016. (b) Inadmissibility, removals, and returns of unauthorized immigrants in 2016. Source: U.S. Department of Homeland Security (2018c).

to family members already in the United States (i.e., immediate relatives or family sponsorship) (figure 1.10b). The United States provides refuge to people who have been persecuted or have a well-founded fear of persecution through two programs: a refugee program for people outside the United States and an asylum program for people in the United States and their immediate relatives. Approximately 85,000

26

CONTEXT FOR SOCIAL WORK WITH REFUGEES AND IMMIGRANTS

2.0

Millions

1.5 1.0 0.5 (a)

0 1916

1926

1936

1946

1956

1966

1976

Region of birth & top categories of admission Asia | 39.1%

Immediate relatives of U.S. citizens | 39.0%

1986

1996

2006

2016

Category of admission Immediate relatives of U.S. citizens

Family-sponsored preferences

47.9%

20.1%

Employment-based preferences

Refugees

11.7%

10.2%

Family-sponsored preferences | 23.5% Employment-based preferences | 17.6%

North America | 36.1% Immediate relatives of U.S. citizens | 54.2% Family-sponsored preferences | 22.6% Refugees and asylees | 14.5%

Africa | 9.6%

Immediate relatives of U.S. citizens | 45.1% Refugees and asylees | 22.3% Diversity | 17.8%

Europe | 7.9%

25,265 refugees and asylees from Africa adjusted to LPR status.

Immediate relatives of U.S. citizens | 52.9% Employment-based preferences | 22.8% Diversity | 12.8%

South America | 6.7% Immediate relatives of U.S. citizens | 62.6%

The diversity immigrant visa program is available to nationals of countries with historically low rates of immigration. Visas are distributed by lottery and were limited in 2016 to 3,500 per eligible country and to a total of 50,000 visas.

Diversity

4.2%

Family-sponsored preferences | 17.7% Employment-based preferences | 13.3%

Oceania | 0.5%

Asylees

Other

3.1%

2.8%

Immediate relatives of U.S. citizens | 56.0% Employment-based preferences | 22.8% Diversity | 12.1%

(b) FIGURE 1.10 (a ) Lawful permanent residents, 1916 to 2016. (b) LPRs by region of birth and category of admission, 2016. Source: U.S. Department of Homeland Security (2018c).

refugees were admitted to the United States in 2016, and about 20,000 were granted asylum (figure 1.11). The source countries of refugees are very different from those of the overall foreign-born population, but the source countries of asylees are quite similar to those of the overall foreign-born population. The

INTRODUCTION

Refugees

Asylees

Top five countries of nationality

Top five countries of nationality

20,455 12%

individuals were granted asylum1 in fiscal year 2016.

Affirmative asylum

Somalia 9,020 | 11%

Mexico 464

Honduras 620

Defensive asylum

1Affirmative and defensive asylum

(a)

Top states of initial resettlement

Credible fear

In 2016, 34% of admitted refugees were resettled in 5 states:

9.3%

9.2%

5.9%

5.0%

4.9%

California

Texas

New York

Michigan

Ohio

73% of credible fear screenings in fiscal year 2016 were from the northern triangle countries of El Salvador, Guatemala, and Honduras.

Ways of obtaining asylum

Refugee admissions since 1991 120,000 90,000 60,000 30,000 0 1991

Guatemala 632

Iraq 9,880 | 12%

84,989 persons were admitted to the United States as refugees in fiscal year 2016.

China

885 Burma 12,347 | 15%

Honduras

Dem. Rep. of Congo 16,370 | 19%

690

1,317 Guatemala

11%

Egypt

1,404

1,382

EI Salvador

19%

China

15%

El Salvador 753

3,103

15%

Syria 12,587 | 15%

27

1996

2001

2006

2011

2016

Affirmatively through U.S. Citizenship and Immigration 1 Services (USCIS). Defensively before an immigration judge of the Executive 2 Office for Immigration Review (EOIR) of the department of justice. Through derivative asylum status as the spouse or child 3 of an asylee.

(b) FIGURE 1.11 People admitted as refugees or granted asylum in the United States in 2016. Source: U.S. Department of Homeland Security (2018c).

source countries of refugees admitted to the United States tend to change relatively rapidly, depending on world conditions and U.S. political priorities. The naturalization process confers U.S. citizenship upon foreign citizens or nationals who have fulfilled the requirements established by Congress in the Immigration and Nationality Act (INA). After naturalization, foreignborn citizens enjoy nearly all of the same benefits, rights and responsibilities that the Constitution gives to native-born U.S. citizens, including the right to vote. About three-quarters of a million people obtained their U.S. citizenship (naturalization) in 2016 (figure 1.12a). The top five source countries

28

CONTEXT FOR SOCIAL WORK WITH REFUGEES AND IMMIGRANTS

1,000,000 800,000 600,000 400,000 200,000 0 1916

1926

1936

1946

1956

1966

1976

1986

1996

2006

2016

(a)

Top five countries of birth

Time to naturalization 4.8%

North America 10 years

4.3%

5.5%

Oceania 10 years Europe 9 years

13.8%

6.1%

South America 7 years Africa 6 years Asia 6 years

Mexico 13.8% India 6.1% Philippines 5.5% China 4.8% Cuba 4.3%

(c)

(b) FIGURE 1.12 2016 Naturalizations (a) Growth in naturalization of foreign citizens in the United States from 1916 (87, 831 persons naturalized) to 2016 (753,060 persons naturalized). (b) Source countries of the foreign-born population naturalized in 2016; and (c) median years in lawful permanent resident status for people naturalized in 2016. Source: U.S. Department of Homeland Security (2018c).

for people becoming citizens matched the major source countries of the overall foreign-born population (figure 1.12b). The median time to obtain U.S. citizenship after obtaining lawful permanent residence was seven years, which is unchanged from 2012 (figure 1.12c).

DEMOGRAPHIC AND SOCIOECONOMIC CHARACTERISTICS OF IMMIGRANTS AND REFUGEES The following discussion focuses on the demographic and socioeconomic characteristics of the foreign-born compared to the native-born population. The tables break down the foreign-born by naturalized citizens and noncitizens and compare characteristics of the foreign-born to the native-born population.

INTRODUCTION

29

TABLE 1.3 Gender and Age (in %) NATIVE-

FOREIGN-

FOREIGN-BORN;

FOREIGN-BORN;

BORN

BORN

NATURALIZED CITIZEN

NOT A U.S. CITIZEN

Male

49.3

48.5

45.9

51.0

Female

50.7

51.5

54.1

49.0

Under 5 years

7.0

0.7

0.2

1.2

5 to 17 years

18.5

5.1

2.9

7.1

18 to 24 years

10.0

6.9

4.1

9.6

25 to 44 years

24.4

38.6

28.7

47.9

45 to 54 years

12.3

19.2

21.7

16.9

55 to 64 years

12.6

14.3

19.0

9.8

65 to 74 years

8.9

8.8

13.0

4.8

75 to 84 years

4.4

4.6

7.2

2.1

85 years and over

2.0

1.8

3.0

0.7

Median age (years)

36.1

44.4

51.4

38.3

CHARACTERISTIC

Gender

Age

Source: U.S. Census Bureau (2016a).

The percentages of males and females are similar among the foreign-born and native-born populations (table 1.3). A much smaller proportion of the foreign-born population comprises children (under age eighteen) compared to the native-born population. Some children of foreign-born parents were born in the United States, and these children are included in the native-born population. This phenomenon also creates a higher median age among the foreign-born compared to the native-born. The foreign-born have a larger proportion of working-age adults (ages eighteen to sixty-four) than does the native-born population. The foreign-born are much more likely to identify themselves as Asian or Hispanic/Latinx, and much less likely to identify themselves as white, compared to the native-born population (table 1.4). The foreign-born are more likely to live in married-couple families and to be married than are the native-born. The foreign-born also live in larger families than the nativeborn (table 1.5).

TABLE 1.4 Race and Hispanic or Latino Origin (in %) RACE OR NATIONAL

NATIVE-

FOREIGN-

FOREIGN-BORN;

FOREIGN-BORN;

BORN

BORN

NATURALIZED CITIZEN

NOT A U.S. CITIZEN

One race

96.6

97.8

97.6

97.9

White

76.8

46.1

44.4

47.7

Black or African American

13.2

9.0

10.8

7.4

American Indian and Alaska Native

0.9

0.4

0.3

0.5

Asian

2.1

26.6

31.9

21.6

Native Hawaiian and Other Pacific Islander

0.2

0.3

0.2

0.4

Some other race

3.4

15.4

10.1

20.4

Two or more races

3.4

2.2

2.4

2.1

Hispanic or Latino origin (of any race)

13.5

44.9

32.9

56.2

White alone, not Hispanic or Latino

67.9

18.1

23.0

13.4

ORIGIN

Race

Hispanic or Latino origin

Source: U.S. Census Bureau (2016a).

TABLE 1.5 Household Type and Marital Status NATIVE-

FOREIGN-

FOREIGN-BORN;

FOREIGN-BORN;

BORN

BORN

NATURALIZED CITIZEN

NOT A U.S. CITIZEN

In married-couple family (%)

57.4

63.1

66.1

60.2

Average family size (number of people)

3.15

3.83

3.70

4.00

Household type

Marital status (population fifteen years and over) Never married (%)

35.4

24.6

17.5

31.6

Now married, except separated (%)

45.3

59.1

62.4

55.8

Divorced or separated (%)

13.4

11.1

12.9

9.2

5.9

5.3

7.1

3.4

Widowed (%)

Source: U.S. Census Bureau (2016a).

INTRODUCTION

31

Among those twenty-five years old and over, the foreign-born are much more likely to have less than a high school education compared to the native-born. However, their rates of bachelor’s and graduate or professional degrees are similar to the native-born. The vast majority of the foreign-born speak a language other than English at home, and about half speak English less than “very well.” Slightly over one-fourth of foreign-born households are “Limited English Speaking,” meaning all household members fourteen years old and over have at least some difficulty with English (table 1.6). The foreign-born are slightly more likely to be employed than are the native-born (table 1.7). This may be a function of having more people of working age, as mentioned earlier. However, the median earnings and total household income of the foreign-born are lower than those of the native-born, and the foreign-born average more workers per household. The foreign-born are slightly more likely to live in poverty than the native-

TABLE 1.6 Educational Attainment and English-Speaking Ability (in %) NATIVE-

FOREIGN-

FOREIGN-BORN;

FOREIGN-BORN;

BORN

BORN

NATURALIZED CITIZEN

NOT A U.S. CITIZEN

Educational attainment (population twenty-five years and over) Less than high school graduate

9.1

28.8

20.0

38.3

High school graduate (includes equivalency)

28.2

22.4

21.7

23.2

Some college or associate’s degree

31.2

18.7

23.1

14.1

Bachelor’s degree

19.8

17.2

20.6

13.6

Graduate or professional degree

11.8

12.8

14.6

10.9

Language spoken at home and ability to speak English (population five years and over) English only

88.8

15.9

20.9

11.2

Language other than English

11.2

84.1

79.1

88.8

Speak English less than “very well”

1.8

49.1

38.1

59.6

Limited English Speaking Households

0.7

26.3

20.3

34.2

Source: U.S. Census Bureau (2016a).

32

CONTEXT FOR SOCIAL WORK WITH REFUGEES AND IMMIGRANTS

TABLE 1.7 Economic Characteristics NATIVE-

FOREIGN-

FOREIGN-BORN;

FOREIGN-BORN;

BORN

BORN

NATURALIZED CITIZEN

NOT A U.S. CITIZEN

58.5%

62.7%

62.1%

63.3%

Employment status* Employed Median

earnings†

in past twelve months for full-time, year-round workers*

Male

$51,633

$40,870

$51,570

$32,395

Female

$41,146

$35,335

$41,607

$26,695

Income in past twelve months† Median household income

$58,402

$53,755

$63,302

$44,076

Average number of workers per household

1.20

1.54

1.50

1.60

13.7%

16.5%

10.8%

21.9%

Owner-occupied housing units

65.3%

51.0%

64.7%

33.0%

1.01 or more occupants per room

2.0%

11.5%

7.2%

17.0%

Poverty status in past twelve months Below 100 percent of the poverty level Home ownership

* population sixteen years and over; † 2016 inflation-adjusted dollars Source: U.S. Census Bureau (2016a).

born, although there is a large difference in this between naturalized citizens and noncitizens. About half of the foreign-born own their homes, compared to about two-thirds of the native-born. More than five times as many of the foreign-born live in crowded housing conditions compared to the native-born. We have provided a very general overview of the demographic and socioeconomic characteristics of this diverse population. It is critical to realize that there are substantial differences in these characteristics among individual immigrants and refugees. Although the data presented here can be helpful for gaining an overall perspective, it is important for social work

INTRODUCTION

33

practitioners to obtain information about the demographic, educational, and economic status of each individual client.

PROGRAM AND SERVICE UTILIZATION PATTERNS OF IMMIGRANTS AND REFUGEES Contrary to popular belief, foreign-born people do not receive more public welfare benefits than do native-born people. The rates of receiving cash assistance and Medicaid are similar among the native- and foreign-born (table 1.8). However, the foreign-born do have a higher rate of participation in the Supplemental Nutrition Assistance Program (SNAP, formerly known as Food Stamps). It should be noted, however, that these rates vary substantially based on the category of immigrant or refugee due to different eligibility criteria, which are discussed in chapter 3. Research has consistently shown that foreign-born people underutilize health and mental health services compared to the native-born population (Bauldry & Szaflarski, 2017; Yang & Hwang, 2016). Utilization rates also vary depending on people’s characteristics, such as health and mental health status, age, gender, education, English-speaking ability, length of time in the United States, financial status, household composition, and legal status. Foreign-born people who have poorer health and mental health, or are elderly, female, or live alone, are more likely to utilize services. The foreign-born who have less education, less English-speaking ability, have been in the United States for a shorter period of time, are poor, or are undocumented are less likely to utilize services.

TABLE 1.8 Public Benefit Receipt Rates (in %) NATIVE-

FOREIGN-

BORN

BORN

2.4

2.9

2.9

3.0

Supplemental Nutrition Assistance Program (SNAP)

11.8

15.6

13.1

19.0

Medicaid

19.5

19.3%

17.2

21.2

PUBLIC BENEFIT

Cash public assistance income

Source: U.S. Census Bureau (2016a; 2017).

FOREIGN-BORN;

FOREIGN-BORN;

NATURALIZED CITIZEN NOT A U.S. CITIZEN

34

CONTEXT FOR SOCIAL WORK WITH REFUGEES AND IMMIGRANTS

DISCUSSION QUESTION

Your city has recently received one hundred new refugees. The local residents complain about how many services the newcomers will be getting. “I was born in this country and all that money will be going to them!” exclaims one person. As a social worker, how would you respond to this concern?

In addition to these personal characteristics, structural characteristics are also important in determining the utilization of health and mental health services. These factors include health beliefs and practices in the country of origin, the availability of informal health and mental health services, the accessibility and cost of formal services, and the cultural appropriateness of service delivery. Much of social work practice with immigrants and refugees is aimed at increasing their access to health and mental health services. Strategies pertaining to these goals are addressed in part II of this book.

HISTORY AND CHARACTERISTICS OF MAJOR IMMIGRANT AND REFUGEE GROUPS IN THE UNITED STATES In this section, we present brief descriptions of the ten largest foreign-born groups in the United States, as well as the top five most recent refugee arrival groups. We refer to these groups throughout the remainder of the book and expand on their individual characteristics. There is an extensive body of literature pertaining to each of these groups, and social workers are encouraged to consult these sources to learn more about their clients from specific countries. When considering a group of people from a particular country, it is important to be aware of stereotyping, or not viewing people as individuals. Some experiences are common to all immigrants and refugees, some are unique to people from particular countries, and some are unique to individuals. The background information provided here can be helpful as a general guideline, but the best sources of information are usually clients themselves.

INTRODUCTION

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LATIN AMERICAN COUNTRIES

Immigrants and refugees from Latin America share some ethnic, cultural, and demographic commonalities. Most Latin American immigrants and refugees are descended from Spanish colonizers and the indigenous peoples of the Americas. Culturally, Latin Americans place a high value on family and child rearing, and family obligations are a strong force (Harper-Dorton & Lantz, 2007). Latinx immigrants usually have large social networks (Viruell-Fuentes, Morenoff, Williams, & House, 2013). There is high respect for the elderly, and youth are placed in a lower position of authority than older family members. Families tend to be male-dominated, and women generally assume the caregiving responsibilities. Extended families serve as a major social support and informal helping system. Interpersonal exchanges are often characterized by free emotional expression of warmth and by physical affection. Expressions of anger, particularly toward family members in authority, are discouraged (Harper-Dorton & Lantz, 2007). The predominant religion is Roman Catholicism. Immigrants from Mexico constitute the largest proportion of foreign-born people in the United States, both legal and illegal. Much of the southwestern United States was Mexican territory prior to the Mexican-American War (1846–1848). When the United States claimed this territory, the Mexican people who lived there became “foreigners in their own land” (Portes & Rumbaut, 1990, p. 225). Later, rapid economic growth in the United States led to active recruitment of Mexicans to come north to work in agriculture and on the railroads. “Mexican migration thus originated in deliberate recruitment by [U.S.] interests and was not a spontaneous movement” (p. 225). Immigration from Mexico continues today and has risen dramatically during the past five decades, motivated by both economic concerns and extended family networks. In 1970, the population of Mexican immigrants was less than 1 million; today that population is estimated to be 12 million. Because of the long history of Mexicans in the United States, a substantial part of this population today is U.S.-born Mexican Americans. Many Mexican immigrants have family ties that extend across the border into Mexico, and migration to the United States is strongly influenced by these family connections (Portes & Rumbaut, 1990). The majority of Mexican immigrants reside in five states: California, Texas, Illinois, Arizona, and Florida (Zong, Batalova, & Hallock, 2018). MEXICO

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Mexican immigrants face disproportionately high rates of poverty, unemployment, and crowded housing conditions; however, this population is less likely than the native-born to receive public assistance (Osterling & Han, 2011). Moreover, it is important to note that Mexican Americans are a particularly diverse population. They range from extremely poor to middle and upper class (Roosa et al., 2009). Some are short-term temporary (or circular) migrants, and others are relatively long-term or settled. The second generation (U.S.-born) is usually English-speaking, but part of the Mexican immigrant population consists exclusively of Spanish-speaking groups (Roosa et al., 2009). Mexican immigrants are a relatively young population, with a median age of twenty-five (Gonzalez & Lopez, 2014). El Salvador endured a civil war from 1980 to 1992, and many Salvadorans came to the United States at that time. Attacks against civilians, psychological and physical repression, disappearances, killings, rapes, tortures, and other human rights abuses occurred during the civil war (National Partnership for Community Training, 2015a). Furthermore, since the 1980s, El Salvador has been plagued by gang violence and has had the second highest murder rate in the world (excluding countries at war). In recent years, a large number of unaccompanied children have made the perilous journey from El Salvador to the United States seeking safety. In 2011, a major earthquake struck the country, leaving a million residents homeless, and migration increased following this disaster (National Partnership for Community Training, 2015a).

EL SALVADOR

Conditions in Guatemala are similar to those in El Salvador. In fact, Guatemala, El Salvador, and Honduras are often referred to as the Northern Triangle of Central America due to their similarities. Guatemala endured a thirty-six-year civil war (1960–1996) that resulted in hundreds of thousands of people dead, “disappeared,” widowed, or orphaned (Jonas, 2013). Guatemalans sought asylum in the United States during the war years, and immigration continued after the war due to socioeconomic problems and natural disasters such as hurricanes. Today Guatemala has high rates of gang violence and poverty, and as in El Salvador, there have been large-scale migrations of unaccompanied children from Guatemala to the United States (Rosenblum & Ball, 2016). The Guatemalan immigrant population is more ethnically diverse than are other Central American immigrants. Many Guatemalan refugees are GUATEMALA

INTRODUCTION

37

Mayan Indians, and they differ in culture, language, and background from other Latin Americans. Historically, the Mayan population of Guatemala experienced discrimination and high rates of poverty (Jonas, 2013).

DISCUSSION QUESTION

In 2016, the Obama administration admitted hundreds more Central American migrants despite much criticism. Advocates stressed that the violence was so great that these migrants had no choice but to flee. As a social worker, how would you respond to someone who opposes the admission of any Central American migrants?

ASIAN COUNTRIES

Immigrants from Asian countries are more likely to have a postsecondary education, English language skills, and more skilled occupations than the overall immigrant population (U.S. Census Bureau, 2012). More than 50 percent of Asian immigrants reside in five states: California, New York, Texas, New Jersey, and Hawaii (Malik, 2015). Some common cultural values of people from Asia include respect, honor, family and business hierarchies, familism rather than individualism, and experience and wisdom (Harper-Dorton & Lantz, 2007). Others values include “filial piety, parent-child interaction in which communication flows essentially from parent to child, self-control and restraint in emotional expression, respect for authority, well-defined social roles and expectations, shame as a behavioral influence, middle position virtue, awareness of social milieu, fatalism, communal responsibility, inconspicuousness, high regard for the elderly, and the centrality of family relationships and responsibilities” (Chung, 1992, p. 28). However, beyond these general commonalities, Asian immigrants and refugees have extremely diverse backgrounds, religions, and demographic and socioeconomic characteristics. Chinese immigrants have a relatively long history in the United States, dating to the mid-nineteenth century. Chinese communities were already well-established when a large wave of immigrants began arriving after changes in U.S. immigration law in 1965. Culturally, Chinese immigrants CHINA

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arrive with many of the traditional Asian values we have noted. Their beliefs are based in Confucian philosophy, and Buddhism and Taoism are dominant religions. Chinese immigrants tend to have higher educational attainment and higher incomes than other foreign-born populations in the United States, and nearly half of Chinese immigrants age twenty-five or above had a bachelor’s degree or higher in 2013. However, Chinese immigrants are less likely to be proficient in English than the overall foreign-born population; around 62 percent reported limited English skills in 2013. Most Chinese immigrants live in New York, San Francisco, and Los Angeles, and many of them live in “Chinatown” ethnic enclaves (Hooper & Batalova, 2015). Immigrants from India are diverse in ethnicity, culture, language, and religion. Major religions of India include Hinduism, Islam, Christianity, Sikhism, and Buddhism (Das & Kemp, 1997). Many Indian cultural beliefs and behaviors are similar to those described for Asians as a whole (Das & Kemp, 1997). Families are characterized by a hierarchical authority structure, are often male-dominated, and marriages are often arranged. In comparison to the native and overall foreign-born populations, Indians have significantly higher education, are more likely to be employed, and have a higher household income. In general, Indians are more likely to be proficient in English than the overall foreign-born population (Zong & Batalova, 2017a). INDIA

Immigrants from the Philippines have been coming to the United States since the early 1900s. Since 1990, this group has been consistently among the top five countries of origin for the foreign-born in the United States (McNamara & Batalova, 2015). The Philippines was a Spanish colony for three centuries, and this heritage influenced their culture. Filipinos share some cultural affinities with Hispanics (Root, 1997), and most Filipinos are Catholic. The Philippines became a U.S. possession in 1898 and achieved independence in 1946. Thus Filipinos also have familiarity with traditional American culture (Root, 1997). Traditional Filipino families are egalitarian or matriarchal (Okamura & Agbayani, 1991; Root, 1997). Filipino immigrants have relatively high status; more than half are college graduates and their average family income is high. Around 70 percent of Filipinos speak English very well. Almost half of Filipino immigrants live in California (McNamara & Batalova, 2015).

PHILIPPINES

Vietnamese people began arriving in the United Sates as refugees after the end of the Vietnam War in 1975. Like most war refugees,

VIETNAM

INTRODUCTION

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many Vietnamese endured traumatic experiences in their country of origin, such as torture, imprisonment, rape, loss of family members, and witnessing atrocities or being forced to commit atrocities. For many, the transit experience was also traumatic, involving hasty departures in overcrowded boats and long stays in refugee camps. As is characteristic of refugee movements, the earliest arriving refugees were the educated elite, followed successively by the lower socioeconomic classes. In more recent decades, Vietnamese immigrants have arrived to join family members already in the United States (Cheung, Leung & Nguyen, 2016). Vietnamese share many traditional Asian values. In general, the Vietnamese were Westernized and educated in their country of origin, and 68 percent of Vietnamese immigrants reported having limited English skills in 2012. In the same year, 23 percent of Vietnamese immigrants age twentyfive and above had a bachelor’s degree or higher, which is lower than the average of all Asian immigrants. Most Vietnamese have resettled in California, but a substantial number live in Texas, Washington, Florida, and Virginia. Around 15 percent of Vietnamese immigrants were living in poverty in 2012 (Rkasnuam & Batalova, 2014). KOREA Korean immigrants who have come to the United States are from South Korea. Primary reasons for immigration are economic advancement for themselves and better educational opportunities for their children (Rhee, 1996). “Although the Korean culture and traditions are built on the teachings of Confucianism and Buddhism, more than 80 percent of Koreans claim to be Christians. They maintain a Judeo-Christian lifestyle in the United States” (Kim & Kim, 1992, p. 228). In general, Korean immigrants have a high level of education; 52 percent of Korean immigrants age twenty-five and above had a bachelor’s degree in 2013. Their median family income is moderate, and about half of Korean immigrants reported limited English skills. Most Korean immigrants live in California, New York, and New Jersey. Korean immigrants tend to be slightly older than the overall immigrant population in the United States, with a median age of forty-five (Zong & Batalova, 2017b).

The United States government refers to this Asian country as Burma, although that country’s current official name is The Republic of the Union of Myanmar. Burmese began immigrating to the United States in large numbers in 2004. The majority of the foreign-born individuals from Burma are refugees. Burma has experienced political instability for more than fifty years, concomitant with oppression and persecution of at least

BURMA

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seven ethnic minority groups: the Karen, Karenni (Kayah), Chin, Mon, Rakhine (Rohingya), Kachin, and Shan. Each of these groups has distinct beliefs and cultures. Most of the groups are Buddhist, but the Rohingya are primarily Muslim, and some of the Karen are Christian. Family is considered primary (National Partnership for Community Training, 2018a). In working with Burmese refugees, social workers should remember that most, if not all, Burmese refugees have experienced trauma. Most first sought refuge in neighboring countries and stayed in refugee camps with limited resources with the hope of return after the conflict. With no resolution to the conflict, many Burmese have been resettled in the United States (Vang & Trieu, 2014). Burmese refugees are a young population (64 percent are less than forty years old); they have a high rate of high school dropouts at 39 percent, and a poverty rate of 30 percent (Vang & Trieu, 2014).

CARIBBEAN COUNTRIES

Two Caribbean countries are major sources of immigrants and refugees in the United Sates: Cuba and the Dominican Republic. Cuba and the Dominican Republic historically were Spanish colonies. In comparison to other foreign-born populations, immigrants from Caribbean countries are less likely to be new arrivals, are of higher average ages, and have high English proficiency skills (McCabe, 2011). Although there were Cuban communities in the United States in the nineteenth century, a massive migration of Cubans to the United States began in 1959 following the revolutionary overthrow of the Cuban government by Communist Fidel Castro. These migrants were generally considered to be refugees (National Partnership for Community Training, 2015b). That revolutionary government persists today. Human rights, such as freedom of speech, freedom of the press, and free elections, are not upheld in Cuba, and perceived antigovernment activities may be punished by imprisonment. In recent decades, many Cubans have arrived to join family members who were already established in the United States. In the mid-1990s, a “wet-foot, dry-foot” policy was implemented whereby Cubans who reached U.S. soil were admitted, essentially as refugees, and those intercepted at sea were returned to Cuba. This policy ended in January 2017 when diplomatic relations between the United States and Cuba were

CUBA

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reestablished; subsequent Cuban arrivals are now treated the same as other arrivals (Duany, 2017). Ethnically, most Cubans are of Spanish descent, with a minority of African descent. Unlike most Latin Americans, Cubans do not have an Indian heritage. Cuban cultural values and traits are similar to those of other Latin Americans. The dominant religion is Catholicism, but religious beliefs are also influenced by African-based beliefs, resulting in a combined religion called “santeria,” which is used by some Cubans to deal with emotional, spiritual, and personal problems (Queralt, 1984). Cuban-born immigrants in the United States are diverse in terms of education, occupation, and income. On average, their socioeconomic status is higher than that of Latin American immigrants. The vast majority of Cuban-born migrants have settled in the Miami, Florida, metropolitan area. Cubans are less likely to be proficient in English and have lower educational attainment and household income than the overall native- and foreign-born populations (Batalova & Zong, 2017). People from the Dominican Republic began arriving in the United States in large numbers following U.S. intervention to suppress a popular leftist revolt in the 1960s and the subsequent U.S. military occupation. Dominicans have low socioeconomic status on average, and most have received permanent residency through family reunification. Dominicans have settled primarily in New York, New Jersey, and Florida. Foreign-born individuals from the Dominican Republic are more likely to face poverty, are less likely to finish college, and have limited English skills when compared with other immigrant groups (Nwosu & Batalova, 2014). In terms of language and culture, they are similar to Cubans and Latin Americans (Guilamo-Ramos et al., 2007).

DOMINICAN REPUBLIC

MIDDLE EASTERN COUNTRIES

Nearly 40 percent the foreign-born from Iraq are refugees in the United States. These refugees started arriving a few years after the 2003 U.S.-led military intervention in Iraq and the subsequent and persistent civil war in that country. California and Michigan have resettled the most Iraqis (Zong & Batalova, 2017c). Almost all Iraqis are Muslim (National Partnership for Community Training, 2015c). Prior to resettlement in the United IRAQ

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States, most spent time in urban centers in countries neighboring Iraq. Like most other refugees, Iraqis have experienced war trauma; consequently, many experience health and mental health problems (Taylor et al., 2014). Data from 2007 indicated that only 50 percent of Iraqi immigrants and refugees had English language proficiency, and 25 percent of the foreign-born from Iraq had less than a high school education (Terrazas, 2009). Syria has been engaged in a civil war since 2011, resulting in the largest humanitarian crisis in the world today. Traumatic experiences are widespread, with over half of Syrian refugees meeting diagnostic criteria for posttraumatic stress disorder, depression, anxiety, or prolonged grief. Mental health problems were previously stigmatized, but mental health treatment has become more acceptable since the war. Prior to resettling in the United States, Syrian refugees have lived in urban areas (including in abandoned buildings) in neighboring countries. Culturally, Syrians tend to have large and strong families. The vast majority are Muslim with a small minority of Christians and other religions. Syrians derive support from their families and their faith (National Partnership for Community Training, 2018b). The United States began admitting relatively large numbers of Syrian refugees in 2017. The top three states of resettlement are California, Michigan, and Texas. Almost half of the Syrian refugees resettled in the United States have been children under age fourteen (Zong & Batalova, 2017d). SYRIA

AFRICAN COUNTRIES

Conflict, violence, and human rights abuses on this continent have continued to force populations into displacement. Historically, the majority of the foreign-born populations from Africa were from West Africa. In 2009, the Anglophone countries including Ghana, Nigeria, Kenya, Cameroon, Somalia, Liberia, and Sierra Leone accounted for 46 percent of all black African immigrants in the United States. The foreign-born from Africa are one of the fastest-growing immigrant populations in the United States. The foreign-born from African countries have the highest concentrations in New York, Texas, California, Florida, and Illinois (Capps, McCabe, & Fix, 2012). Although people from different African countries are diverse in terms of background, culture, and language, there are some cultural commonalities. In general, African beliefs are strongly spiritual and communal (Kamya, 1997).

INTRODUCTION

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The Democratic Republic of Congo (DRC) has been embroiled in a civil war since the late 1990s, resulting in refugees fleeing to neighboring countries where they typically spend a decade or more in refugee camps. Sexual and gender-based violence is pervasive in this civil war, among other traumas. Consequently, about 50 percent of the population exhibits posttraumatic stress disorder and major depressive disorder. As in many other cultures, however, mental health problems and their treatment are stigmatized (National Partnership for Community Training, 2018c). Most DRC refugees resettled in the United States are from the eastern provinces populated by the Banyamulenge, Hutu, Tutsi, Bembe, and Bashi ethnic groups; 70 percent of this population is Christian. Family is highly valued and encompasses the entire extended family and fictive kin. Folklore and stories are passed from generation to generation to teach cultural values (National Partnership for Community Training, 2018c).

DEMOCRATIC REPUBLIC OF CONGO

Somalia has been engaged in civil war for several decades, and drought and famine have been widespread. Consequently, as with all other refugee groups, mental health sequelae are prevalent. For Somalis, mental health issues are often manifested as physical symptoms. Upon resettling in the United States, Somalis face significant discrimination because they are both black and Muslim. Like other African cultures, Somalis have a rich oral tradition of storytelling, and spiritual beliefs are highly influential. Strong, extended families are also characteristic (National Partnership for Community Training, 2016). Somali refugees in the United States have less education, poor English language skills, and lower income when compared to both the overall foreign-born and native-born populations. Large Somali communities have resettled in Minneapolis, Minnesota; in Portland and Lewiston, Maine; and in Boston, Massachusetts (Ellis et al., 2016).

SOMALIA

SUMMARY The United States has a large and growing population of immigrants and refugees from an extremely diverse variety of countries. Understanding an immigrant or refugee client’s background, cultural beliefs, reasons for migration, socioeconomic status, and legal status are all important starting points for effectively helping members of these populations.

2 INTERNATIONAL MIGRATION POLICIES

INTERNATIONAL AND NATIONAL LAWS provide the legal context for social work practice with immigrants and refugees. International law provides guidelines for how countries should treat their native-born and foreign-born populations. National laws determine which foreign-born individuals are eligible for admission and which are eligible to receive public services and benefits after arrival. These laws have changed over time and will continue to do so. This chapter, on international policies, and the next chapter, on U.S. policies, present major historical and contemporary immigration and refugee policies and examine their causes and consequences. An understanding of these policies and the social, political, and economic forces that have shaped them is a necessary prerequisite to effectively serve these populations.

INTERNATIONAL LAW International law “consists of rules and principles which govern the relations and dealings of nations with each other. . . . [It] concerns itself with questions of rights between several nations or nations and the citizens or subjects of other nations” (Legal Information Institute, n.d., para. 1). International law pertaining to rights and duties is a part of U.S. law unless a statute or treaty provides a different standard. “International law imposes upon the nations certain duties with respect to individuals. It is a violation of international law to treat an alien in a manner which does not satisfy the international standard of justice” (Legal Information Institute, n.d., para. 7). A major source of international law is conventional law, which consists of conventions and treaties agreed to by nations.

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The major branches of international law that address the treatment of immigrants and refugees are international human rights law, international humanitarian law, international refugee law, and international migrant worker law, all of which are codified in a number of conventions (Barutciski, 1998; Good, Jensen, Thompson, & Webster, 1995). International human rights law concerns the protection of basic rights of people within nations. International humanitarian law concerns the protection and treatment of victims of war. International refugee law concerns the protection of people who have fled their country because human rights or humanitarian laws have already been violated. International migrant worker law concerns the rights and treatment of migrant workers. International human rights law pertains to immigrants because it concerns the fundamental rights of all people, including the foreign-born, within nations. Both international human rights and humanitarian laws pertain to refugees because violations of these laws within their country of origin have caused these people to become refugees. These laws, as well as international refugee law, also guide how refugees should be treated by other nations once they have fled their country of origin. Finally, international migrant worker law pertains to immigrants who migrate for employment purposes. In the aftermath of World War II, an international effort was made to prevent future atrocities such as those that were widespread during that war. The conventions that codify international human rights, humanitarian, refugee, and migrant worker laws were developed by the United Nations and have been adopted by the UN General Assembly. After adoption, member states ratify the conventions and treaties, signifying their willingness to bind themselves to the legal obligations contained in the documents. Not all member states have ratified all the conventions, and nonratifying states are not legally bound by the conventions. However, if the UN acts consistently on a resolution, eventually even the nonratifying member states are deemed to have acquiesced to the resolution. Despite this effort, the fact remains that mechanisms for enforcing international human rights, humanitarian, and refugee laws worldwide are not completely effective. The major UN human rights, humanitarian, and refugee instruments pertaining to immigrants and refugees are listed in the following text box. The fundamental human rights document is the Universal Declaration of Human Rights, which specifies thirty basic rights to which all people are entitled (figure 2.1). This declaration is not legally binding, but it laid the foundation for all of the other human rights conventions, which are legally binding (United Nations High Commissioner for Human Rights [UNHCHR], 2018a).

FIGURE 2.1 The thirty basic rights of all people listed in the Universal Declaration of Human Rights Source: United Nations High Commissioner for Human Rights (2018c).

MAJOR UNITED NATIONS HUMAN RIGHTS, HUMANITARIAN, AND REFUGEE INSTRUMENTS PERTAINING TO IMMIGRANTS AND REFUGEES

International Human Rights Law Q Q Q Q Q Q Q Q

Q Q Q

Q Q Q

Q

Universal Declaration of Human Rights (1948) Convention on the Prevention and Punishment of the Crime of Genocide (1948) Convention Relating to the Status of Stateless Persons (1954) Convention on the Elimination of All Forms of Racial Discrimination (1965) Covenant on Civil and Political Rights (1966) Covenant on Economic, Social, and Cultural Rights (1966) Convention on Elimination of all Forms of Discrimination Against Women (1979) Convention Against Torture and Other Cruel, Inhuman, or Degrading Treatment or Punishment (1984) Convention on the Rights of the Child (1989) United Nations Principles for Older Persons (1991) Declaration on the Rights of Persons Belonging to National or Ethnic, Religious and Linguistic Minorities (1992) Standard Rules on the Equalization of Opportunities for Persons with Disabilities (1993) Declaration on the Elimination of Violence Against Women (1993) Declaration on the Right and Responsibility of Individuals, Groups, and Organs of Society to Promote and Protect Universally Recognized Human Rights and Fundamental Freedoms (1998) United Nations Millennium Declaration (2000) “CONTINUED”

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“CONTINUED”

Q Q Q Q

Convention on the Rights of Persons with Disabilities (2006) United Nations Declaration on the Rights of Indigenous Peoples (2007) United Nations Declaration on Human Rights Education and Training (2011) Political Declaration on the Peaceful Resolution of Conflicts in Africa (2013)

International Humanitarian Law Q

Q

Q Q

Geneva Convention (I) for the Amelioration of the Condition of the Wounded and Sick in Armed Forces in the Field (1949) Geneva Convention (II) for the Amelioration of the Condition of Wounded, Sick, and Shipwrecked Members of the Armed Forces at Sea (1949) Geneva Convention (III) Relative to the Treatment of Prisoners of War Geneva Convention (IV) Relative to the Protection of Civilian Persons in Time of War (1949)

International Refugee Law Q Q

Convention Relating to the Status of Refugees (1951) Protocol Relating to the Status of Refugees (1967)

International Migrant Worker Law Q Q Q

Migration for Employment Convention (1949) Migrant Workers Convention (1975) Convention on the Protection of the Rights of All Migrant Workers and Members of Their Families (1990) SOURCE: UNITED NATIONS HIGH COMMISSIONER FOR HUMAN RIGHTS (2018B).

Humanitarian law addresses the treatment and protection of victims of war, particularly the wounded, sick, and shipwrecked; prisoners of war; and civilians. Humanitarian law is codified in four Geneva Conventions. These conventions are particularly pertinent to refugees because refugees are often victims of war. Specific rights of refugees are codified in the Convention and Protocol Relating to the Status of Refugees. This document provides the international definition of a refugee and specifies who is not a refugee. For example, people who have participated in massive violations of international humanitarian or human rights law cannot be considered refugees. People who have fled their country to escape prosecution for nonpolitical crimes but who have not been persecuted for other reasons cannot be considered refugees. People who do meet the refugee definition do have

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a fundamental right to non-refoulement (meaning “no forcible return”). People cannot be forcibly returned to a place where they could be persecuted (International Committee of the Red Cross, 2018). Finally, migrant worker law stipulates that immigrants should receive the same treatment as citizens with regard to wages, trade union memberships, collective bargaining, accommodations, basic necessities of living, schooling, and public benefits related to poverty and unemployment. Migrant worker law is codified in several conventions, the first of which is the Migration for Employment Convention.

DISCUSSION QUESTION

In 2017, Bangladesh announced its plans to build a huge refugee camp to house incoming Rohingya who were being persecuted in Myanmar. Bangladesh is a low-income country. How much should the international community help with this influx of refugees?

THE UN 2030 AGENDA FOR SUSTAINABLE DEVELOPMENT The UN 2030 Agenda for Sustainable Development is a call for action consisting of a Declaration, seventeen Sustainable Development Goals (SDGs), and 169 targets and 230 indicators associated with the SDGs (UNHCR, 2017a). The agenda has been agreed to by 193 countries around the world with the commitment to achieve the SDGs by 2030 and a pledge to leave no one behind (UN, 2015). The SDGs and the Declaration of the 2030 agenda are based on inclusion and ensuring human rights for all, including migrants and the forcibly displaced. Applicability of the agenda to the forcibly displaced and migrants is explicitly mentioned in the Declaration: “Those whose needs are reflected in the Agenda include all children, . . . refugees and internally displaced persons and migrants” (UNHCR, 2017a, para. 23). The seventeen SDGs include: 1. No poverty 2. Zero hunger 3. Good health and well-being

INTERNATIONAL MIGRATION POLICIES

4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17.

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Quality education Gender equality Clean water and sanitation Affordable and clean energy Decent work and economic growth Industry, innovation, and infrastructure Reduced inequalities Sustainable cities and communities Responsible production and consumption Climate action Life below water Life on land Peace, justice, and strong institutions Partnerships for the goals

Although all seventeen SDGs are applicable to immigrants and refugees, goals 1, 2, 3, 4, 5, 8, and 10 are the most relevant targets for this population. The first SDG is to “end poverty in all its forms everywhere,” and among the listed targets under this goal are eradicating extreme poverty and ensuring access to economic resources. Economic inclusion and equal opportunities are also among the targets listed under the tenth SDG, “Reduce inequality within and among countries” (UN, 2015). Migration is a strategy used by many people to escape poverty and to access equal opportunities (De Haan & Yaqub, 2010; Kumar, 2004); however, migration, especially forced displacement, can place individuals at risk of poverty and economic exclusion during their journey and after arrival at desired destinations. Those living in extreme poverty usually lack the resources to migrate and rarely migrate except when forcibly displaced (Alonso, 2011; Du, Park, & Wang, 2005). Migrants may experience higher risks of poverty and economic exclusion due to lack of social support, loss of financial assets, limited access to a fair job market, and devaluation of their certificates and degrees in a new country. This risk could be even higher for the forcibly displaced because the majority live in developing countries where resources are extremely limited. For instance, more than four million refugees live in countries in which the average national income is below the extreme poverty line (Kuhle, Taylor-Grosman, & Mitchell, 2018). Studies show high rates of poverty among forcibly displaced groups in developing countries (Chaaban, Seyfert, Salti, & El Makkaoui, 2013; Cherri & Hariri, 2018;

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Grijalva-Eternod et al., 2012; Iriart, Handal, Boursaw, & Rodrigues, 2011; Polonsky, Ronsse, Ciglenecki, Rull, & Porten, 2013). Moreover, a recent study of refugees’ access to the job market in fifteen countries reported that 45 percent of the refugee population in these countries had no legal access to employment (Wirth, Defilippis, & Therkelsen, 2014). Ending poverty and economic inclusion for immigrants and the forcibly displaced requires national and international policies to assure access to resources, especially a fair job market, and investment in capacity building and self-reliance. Ending poverty may result in less displacement and migration for many. National policies on access to the job market for migrants are discussed in the next section of this chapter, and immigrant and refugee poverty is discussed in chapter 9. The second and third SDGs are to “end hunger, achieve food security and improved nutrition and promote sustainable agriculture” and to “ensure healthy lives and promote well-being for all at all ages.” Among the listed targets under these two goals are ending hunger and malnutrition, preventing deaths of newborns and children under five years old, ensuring access to sexual and reproductive health care services, and achieving health coverage for all (UN, 2015). Similar to poverty, hunger and lack of access to health services is the reason for migration for many. Historically, famine has been connected to migration, and only the less vulnerable are likely to escape through migration (Sadliwala & de Waal, 2018). The arduous journey for most migrants and the forcibly displaced can cause health problems and malnutrition. Moreover, immigrants and refugees can experience challenges in securing food and barriers in accessing health care in host countries due to lack of social support, lack of access to a sustainable livelihood, language barriers, lack of knowledge about the health care system, and discrimination. Studies show high rates of malnutrition, child and maternal mortality, and health problems among some groups of migrants, and particularly for refugees in developing countries (Dasgupta & Menzies, 2005; De Bruijn, 2009; Philibert, DeneuxTharaux, & Bouvier-Colle, 2008; Schutte et al., 2010; Verwimp & Van Bavel, 2005). Achieving the SDGs of ending hunger and ensuring healthy lives for all can decrease migration and forced displacement. Meanwhile, ending hunger and ensuring healthy lives for immigrants and the forcibly displaced requires a policy level commitment at both the national and international levels. National health policies for migrants are discussed in

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the next section of this chapter, and immigrant and refugee health issues are discussed in chapter 6. The fourth SDG is to “ensure inclusive and equitable quality education and promote life-long learning opportunities for all.” Among the listed targets under this goal are ensuring free and quality primary and secondary education and eliminating gender disparities in education (UN, 2015). Some researchers believe that educational attainment increases the likelihood of migration, but others argue for a reverse relationship (Curran & Rivero-Fuentes, 2003; Williams, 2009). In either case, migration and forced displacement can interrupt schooling and education. Moreover, adaptation to a new educational system is challenging for migrants due to language barriers and cultural differences. Consequently, immigrants and refugees may experience lower educational attainment when compared to the general population. In a 2009 survey among a sample of refugees in ninety-two camps and forty-seven urban settings in seventy-three countries, the average school enrollment for refugees aged six to eleven was about 76 percent; for those between twelve and seventeen, enrollment was about 36 percent (Dryden-Peterson, 2011). As a point of comparison, participation in primary schooling was 90 percent and secondary school enrollment 67 percent worldwide in the same year (Dryden-Peterson, 2011). Assuring quality education and eliminating gender disparities in education for immigrants and refugees requires appropriate national policies and increased awareness among the target population. National policies on migrants’ access to education are discussed in the next section of this chapter, and education for immigrants and refugees is discussed in chapter 9. The fifth SDG is to “achieve gender equality and empower all women and girls.” Among the listed targets under this goal is ending violence against women and girls, including trafficking. Eradicating trafficking is also among the targets listed under the eighth SDG, to “promote sustained, inclusive and sustainable economic growth, full and productive employment and decent work for all” (UN, 2015). Female immigrants represent slightly less than half of the total immigrant population in the world and slightly over half of the foreign-born population in the United States (UN, 2017b; Zong et al., 2018). Women and girls are more likely to be victims of violence and trafficking, and addressing this problem requires national policies and international interventions. Moreover, investment in empowerment of women and girls and increased awareness in this field is needed. Violence against

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women is discussed as part of the family dynamic issues in chapter 8, and trafficking is discussed in chapter 11.

NATIONAL POLICIES Each nation has policies regarding the admission of immigrants and refugees, as well as policies regarding the social and economic integration of the foreign-born following their admission. The Migrant Integration Policy Index (MIPEX) tracks integration policies in thirty-eight countries, including all member states of the European Union plus Australia, Canada, Iceland, Japan, South Korea, New Zealand, Norway, Switzerland, Turkey, and the United States. The index yields “a rich, multi-dimensional picture of migrants’ opportunities to participate in society . . . [and] is a useful tool to evaluate and compare what governments are doing to promote the integration of migrants” (Huddleston, Bilgili, Joki, & Vankova, 2015, para. 2). MIPEX examines the eight policy areas shown in figure 2.2. For each policy area, the hypothetical best and worst scenarios are described, and the thirty-eight countries are ranked. We have summarized these descriptions and findings and included some additional sources in the sections that follow. (All data are from MIPEX unless otherwise noted.)

Family reunion - 08 How easily can immigrants reunite with family?

01

Access to nationality - 07 How easily can immigrants become citizens? Permanent residence - 06 How easily can immigrants become permanent residents? Political participation - 05 Do immigrants have comparable rights and opportunities to participate in political life?

01 - Health Is the health system responsive to immigrants’ needs?

08

07

02 - Education Is the education system responsive to the needs of the children of immigrants?

02

03

Integration

06

04 05

03 - Labor market mobility Do immigrants have equal rights and opportunities to access jobs and improve their skills? 04 - Antidiscrimination Is everyone effectively protected from racial/ethnic, religious, and nationality discrimination in all areas of life?

FIGURE 2.2 Integration policies monitored by the Migrant Integration Policy Index Source: Huddleston, Bilgili, Joki, & Vankova (2015).

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53

HEALTH POLICIES

Health is a fundamental aspect of well-being in life. Healthier immigrants can better participate in the labor market and can rebuild their social networks in the new society. Immigrants active in the labor market have a better chance of improving their health outcomes and of seeking health care when needed. In the best-case scenario, immigrants have access to health care coverage similar to that of native-born individuals, and health policies are in place to respond to the needs of diverse populations. Immigrants are able to access health information in their preferred language and to receive services in a culturally sensitive manner. Moreover, health care providers are trained and equipped to provide such services. In the worst-case scenario, migrants are deprived of full access to health care coverage, and the system lacks measures to address the needs of diverse immigrant groups. Language barriers or lack of documentation can deprive immigrants of access to the health care system. Across the MIPEX countries, the most favorable health policies were observed in New Zealand, Switzerland, the United States, Australia, and Norway. In New Zealand, where the best health policies were reported, most legal migrants and certain vulnerable undocumented migrant groups enjoyed health care rights similar to those of their native-born peers. Moreover, in case of an accident, equal health care coverage applies to all undocumented migrants. In New Zealand, some migrant patients benefit from targeted information delivered in their native language and in a culturally sensitive way. More important, free interpretation services in dozens of languages are available in the health care system, and service providers are required to provide interpretation when needed. Furthermore, cultural diversity training and guidelines on diversity are available for service providers. Among the MIPEX countries, the least favorable health policies were reported in Latvia, Slovenia, Croatia, Poland, and Lithuania. In Latvia, where the worst health policies were observed, ambiguity in entitlements for immigrants was the main challenge. Permanent residents and EU citizens have access to state-guaranteed medical services similar to that of nationals, but temporary residents had to pay full costs. Refugees could benefit from medical services, but asylum seekers and undocumented migrants were deprived of this right. In Latvia, access of asylum seekers to medical services depended on approval of a committee, and for undocumented migrants

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this access was only guaranteed if they were detained. Latvia has limited opportunities for health education and information sharing for migrant populations, and provision of interpretation is only informally expected from providers in two common languages: Russian and English. In the category of favorable health policies, the United States ranked third among the MIPEX countries. The main challenge was lack of health care coverage and a large population of uninsured noncitizens. Lawful permanent residents must wait five years to benefit from health care entitlements equal to those of citizens, but refugees and asylum seekers enjoy equal access upon arrival. Undocumented immigrants in the United States are excluded from federal health care coverage, but they can buy private insurance. Some language support and targeted information-sharing programs exist for immigrants across the country, but only federally funded programs are mandated to provide free language assistance services for clients with limited English proficiency. Moreover, implementation of standards of cultural competence is supported by accreditation requirements. The World Health Organization (WHO) reports that governments in African and Asian countries are committed to protecting the rights of migrants, including access to health care. The governments of Algeria, Ghana, Mauritius, Nigeria, and Uganda provide the same fundamental rights for both immigrants and nationals (WHO, 2018a, 2018b). In Angola, Ghana, Liberia, and Uganda, refugees have access to national health services similar to that of the general population, but access to health care is low in these African countries when compared to other regions of the world, and migrants’ access to health care is likewise limited (WHO, 2018a). In 2014, among 132 refugee sites in Africa reviewed by the UNHCR (2015), only about 45 percent met the minimum standards for water and about 65 percent met the minimum standards for sanitation. Moreover, high rates of global acute malnutrition were reported among refugees in this region. The highest rate, 41 percent, was reported in Cameroon. For migrants in Southeast Asia, WHO reported a lack of comprehensive national health policies, and only Thailand demonstrated favorable health policies for immigrants. In Thailand, legal labor immigrants enjoy its Social Security scheme and benefit from its Compulsory Migrant Health Insurance (CMHI) scheme. Universal health coverage for immigrants is weak in the rest of Southeast Asia (WHO, 2018b). Among twelve UNHCR monitored refugee sites in Asia, only about 15 percent of refugees had access to the minimum standards for water and about 82 percent had

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access to the minimum standards for sanitation. Reported global acute malnutrition rates among refugees in seven monitored refugee sites in Asia ranged from less than 1 percent in Jordan to 14 percent in Bangladesh (UNHCR, 2015).

EDUCATION POLICIES

Foreign-born children or native-born children of immigrant parents made up between 0.2 percent and 46 percent of the total population of students in the MIPEX countries in 2012. In the best-case scenario, all immigrant children benefit from different levels of education from kindergarten to university. In the worst-case scenario, immigrant children are deprived of the right to full education. Immigrant children may need additional support in the educational system to quickly learn the language and to adjust to the new system. In the best-case scenario, children benefit from additional support, and teachers are trained to recognize their needs. In this case, children benefit from extra language training courses, and parents are involved in their journey despite language barriers. In the worst-case scenario, immigrant children are treated just like other children of their age, and teachers are unable to recognize their specific needs. Parents are rarely involved due to language barriers, and children may struggle to learn and thrive. According to the MIPEX report, the most favorable education policies were observed in Sweden, Australia, New Zealand, Norway, and Canada. In Sweden, schools and municipalities are responsible for informing newly arrived immigrants about their rights to high-quality language training and extra support for education. Immigrant children benefit from ad hoc measures that facilitate their access to higher education, and schools are mandated to communicate with parents and provide interpreters if needed (Huddleston et al., 2015). Individual support is mandated from preschool to upper secondary school, including language training for immigrant children. In Sweden, schools are encouraged to celebrate diversity and to welcome new skills that immigrants bring to classrooms. Moreover, teachers receive guidance and materials to provide intercultural education. Students have a right to choose native-language courses, depending on availability and number of children, and children of undocumented parents have access to primary and secondary education.

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The least favorable education policies were reported in Bulgaria, Turkey, Hungary, Croatia, and Latvia. In Bulgaria, barriers to access exist for certain categories of immigrant children. Migrant parents whose children have short-term residency status have to pay high tuition fees to access compulsory education. Higher education and vocational training are not available to children of temporary or undocumented residents. The educational system in Bulgaria lacks policies or measures to address specific needs of most categories of migrant children; such measures only exist for children of refugees and those with international protections. Moreover, migrant children are not entitled to receive quality support to learn Bulgarian. The country is slowly taking measures to train teachers on cultural diversity and tolerance. The United States is ranked eighth across the MIPEX countries for education policies. All immigrant students, regardless of their status, can attend free education from kindergarten to high school. Targeted programs, such as funding English language training and parental outreach, exist to help minority students achieve their potential. Limited measures are in place in the United States to guarantee bilingual education for immigrant children and to support diversity in education. However, many states do not require teachers to learn about cultural diversity. Undocumented immigrants cannot receive federal aid or in-state tuition in thirty-two states. In 2016, the UNHCR reported that only 61 percent of refugee children attended primary school compared to 91 percent of the world’s children. In addition, about 55 percent of the total population of school-aged refugees (3.5 million) were out of school for the whole year. The secondary education enrollment rate was 84 percent for adolescents worldwide but only 23 percent for refugees. About two million refugee adolescents were out of school in 2016. Refugee children are five times more at risk of being out of school when compared to their peers, and refugee girls are particularly at risk of being out of school. For every ten refugee boys in primary and secondary school, less than eight refugee girls are in primary and fewer than seven are in secondary school. Rates for higher education are even worse. The worldwide higher education rate is 36 percent among all youth, but only 1 percent among refugees (UNHCR, n.d.). Early childhood education, including preschool, kindergarten, and day care, can affect future educational achievements of immigrant children. Immigrant children who received preschool education had better literacy results at age fifteen than those who did not attend preschool. The

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socioeconomic background of children also affects their future educational achievements, and this can put immigrant children in a vulnerable position (Organisation for Economic Co-operation and Development [OECD] & European Union, 2015). Migrant pupils rarely receive additional support to prevent them from dropping out of school. Only a few school systems among the countries reviewed by MIPEX had measures in place to professionally assess what newly arrived immigrant children had already learned abroad. Lack of information about the educational needs of newly arrived immigrant children is an important impediment in their adaptation to the new system. Moreover, in most countries teachers are not required to receive training regarding migrants’ needs or cultural diversity. Early and long-term compulsory education, late ability tracking, targeted programs based on immigrants’ needs, and additional teaching hours have been demonstrated to help immigrant pupils. Parents’ educational background and language proficiency, composition and quality of schools, and the quality of the education system are the most significant determinants of educational attainment for immigrant children.

LABOR MARKET POLICIES

Access to a fair labor market is a cornerstone of a new life for most migrants and a path to self-sufficiency. An economically sustainable job can help immigrants find their place in the new society, and labor market policies are an important factor in immigrant integration. Not all foreign residents have a right to work in the countries in which they live, and not all those with the right to work have equal access to the labor market. In the bestcase scenario, migrants have access to work from the first day of arrival and have the same chances as native-born individuals in the labor market. In the worst-case scenario, migrants cannot work or fully participate in the labor market. Even in the best case of equal access to the labor market, foreign-born individuals often experience unique challenges such as language barriers or reevaluation of their certificates. In the best-case scenario, migrants have a chance to improve their skills, take language courses, and receive recognition for their qualifications and certificates from abroad. In the worst-case scenario, the skills of migrants receive no recognition, and they must start over with no general or targeted support.

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According to the MIPEX report, Sweden, Portugal, Norway, Germany, and Canada had the most favorable labor market policies for immigrants among the thirty-eight countries reviewed. Sweden had the highest labor market index score, and it grants immigrants equal access and rights with native-born individuals to participate in the labor market and to benefit from the general support system. Nearly all newcomers enjoy legal access to the labor market in both the public or private sectors. Temporary migrant workers can change jobs and sectors in a short period of time. Immigrants also have access to social safety nets, and the government increasingly expands access to targeted programs. Moreover, public employment services are responsible for assessing the skills of immigrants and informing them of available general or targeted support. Immigrants are informed about their rights in the labor market through different programs, and they can easily access language or vocational training. According to the MIPEX report, the least favorable labor market policies were observed in Turkey, Slovakia, Cyprus, Slovenia, and Ireland. In Turkey, where the lowest labor market index score was reported, most legal migrants have critically limited access to the labor market. They rely on temporary work permits from employers for years before they can freely change their sector. In Turkey, immigrants are deprived of equal rights in the labor market. Only long-term residents can receive permission for self-employment, and only immigrants with special expertise can work in the public sector. Immigrants in Turkey are excluded from general or targeted support to improve their skills, such as vocational training. The United States is ranked twelfth in the MIPEX list for labor market policies. Legal status grants most immigrants rights similar to those of nativeborn individuals in the labor market, but noncitizens are denied access to the social security net available to citizens. Immigrants who have work authorization can work in all sectors or be self-employed. They can receive education and training, but evaluation of their foreign degree and skills can be complex. Limited targeted support exists in the United States to help immigrants in the labor market, and the level of support varies among the states. Some states have one-stop career centers where immigrants, mainly refugees, can receive English language and job training. Although the right to work is mentioned in the UN Convention and Protocol Relating to the Status of Refugees, which has been ratified by 147 countries worldwide, refugees have limited access to the job market in many countries around the world. In a global study, 45 percent of surveyed countries legally barred employment for refugees in 2014. Even with

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59

access to employment, barriers such as encampment or exorbitant permit fees were observed. Moreover, 70 percent of the surveyed refugees in this study reported that they were paid less than nationals for doing the same job (Asylum Access, 2014). It is more difficult for immigrants with higher education levels to find jobs when compared to their native-born peers, but immigrants with lower levels of education find it easier to join the labor market compared to their native-born peers. Unemployment is generally lower among people with a higher education; however, the gap in unemployment between foreign-born and their native peers is wider among those with a postsecondary education. An average of 35 percent of immigrants with high levels of education are overqualified for their jobs, whereas only 25 percent of native-born peers are overqualified. This difference is partly due to difficulty in evaluating the credentials of immigrants (OECD & European Union, 2015). Targeted employment interventions can improve labor market outcomes for immigrants, especially when provided at the early stages of work. Country-specific vocational training in line with work experiences, funding for startups for entrepreneurs, and job search assistance also boost labor market outcomes for certain immigrants (Huddleston et al., 2015).

ANTIDISCRIMINATION POLICIES

Discrimination against immigrants is a major impediment to successful integration. In the best-case scenario, all residents, including immigrants, have equal opportunities and a chance to fight discrimination. Racial profiling and discrimination is illegal in sectors such as employment, education, and housing, and the justice system uses a wide range of sanctions to discourage discrimination. In the worst-case scenario, immigrants are discriminated against purely based on their race, religion, or nationality, and the country lacks both a legal support system for immigrants to fight discrimination and policies to promote equality. Across the MIPEX countries, Canada, the United States, Bulgaria, Portugal, and the United Kingdom had the best reported antidiscrimination policies. Canada had the strongest commitment to equality among the thirty-eight countries reviewed. Different types of discrimination are clearly defined in Canada, and human rights codes at federal, provincial, and territorial levels protect immigrants from discrimination. Official equality

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and human rights bodies are available in each province to both investigate incidents of discrimination and advise victims. Moreover, the government informs the public about discrimination and promotes equality. According to the MIPEX report, Iceland, Japan, Turkey, Switzerland, and Estonia had the least favorable antidiscrimination policies. Across the MIPEX countries, Iceland had the fewest developed policies to prevent discrimination. Immigrants are vulnerable to racial, ethnic, nationality, and religious discrimination more than in any other country reviewed. In Iceland, immigrant victims are deprived of specific tools to fight discrimination, and they must carry the full burden of proof. The government lacks any commitment to promoting equality or informing the public about discrimination. The MIPEX report indicates that the United States ranks second in antidiscrimination policies after Canada (Huddleston et al., 2015). Both countries explicitly define multiple discriminations and provide paths for potential victims of discrimination to seek justice. Legislation is in place to prevent discrimination based on race, ethnicity, religion, and national origin. Such discrimination in the United States is fully prohibited in the job market, housing, and education sectors. A strong mechanism is in place to enforce the law and to help potential victims of discrimination, and the Department of Justice’s Civil Rights Division promotes equality and equal opportunities. Interpreters are provided for those with limited English proficiency in federal and state courts. Moreover, in the United States, disadvantaged groups can receive support for minority businesses or benefit from affirmative action programs. Slightly favorable laws prohibiting discrimination based on race, ethnicity, and religion exist and are promoted across all MIPEX countries, but enforcement mechanisms are weak in some countries. EU countries have increasingly adopted antidiscrimination laws over the past fifteen years, specifically laws that guarantee equal protection (Huddleston et al., 2015). Moreover, definitions of discrimination developed by Canada, the United Sates, and the United Kingdom have largely been adopted in other countries in recent years.

POLITICAL PARTICIPATION POLICIES

Political participation is an important integration indicator for immigrants. In the best-case scenario, immigrants participate in democratic life and enjoy the same civil liberties as citizens. After a limited number of years of

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legal residence, a newcomer is able to vote or to be elected in local, regional, and national elections. Moreover, in the best-case scenario, immigrants are informed of their political rights and supported by the host country in practicing them. In the worst-case scenario, immigrants cannot fully participate in the political decisions that affect them, their city, or their country of residence. Immigrants’ civil rights are limited, and they cannot join a party, vote, or work as journalists. Moreover, in the worst-case scenario, policies of the host country deprive immigrants of full participation in democratic life. Among the countries reviewed by MIPEX, Norway, Luxembourg, Finland, Portugal, New Zealand, and Sweden had the most favorable policies toward political participation of immigrants. Norway, ranked number one on the list, has the most inclusive voting rights. Norway grants voting rights for all elections, except national elections, to newcomers after three years. Newcomers also can stand as candidates in local elections after this period. Leaders of the society consult with immigrants and receive inputs from them through different channels. Moreover, immigrants are encouraged to become active in civil society, and they receive multilingual information about national elections. Countries with the least favorable political participation policies for immigrants were Romania, Poland, Turkey, Croatia, and Latvia. Over 48,000 non-EU citizens aged fifteen and above were disenfranchised in Romania. Only a limited number of non-EU citizens and long-term residents can vote or stand for election. In Romania, non-EU citizens cannot initiate or join political parties. Immigrants are not consulted in policy making or systematically informed about policies that could affect them. The United States ranked twenty-second on this list. Noncitizens are deprived of the right to vote in cities or towns, but they enjoy the same basic political freedom as citizens. Some states, such as Massachusetts and New Jersey, consult with immigrants and receive feedback from them about the policy-making process. Immigrants in the United States must rely on their own or private funding to become politically active. State-funded outreach and information systems for elections are rarely focused on newly naturalized voters.

DISCUSSION QUESTION

If you were a social worker in a community with many newly naturalized voters, would you want to encourage their political involvement? Why or why not?

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PERMANENT RESIDENCY POLICIES

Access to permanent residency is an important step toward integration and full citizenship. With permanent residency, immigrants can start their settlement process on a secure path with near-equal rights. In the best-case scenario, temporary residents are able to settle permanently in the country if they obey the law, have a basic legal income, and have acquired language skills through free courses or study materials. The application process for permanent residency is nearly free and short, the granted status is secure, and permanent residents have equal opportunities and responsibilities with nationals. In the worst-case scenario, immigrants live in limbo as temporary legal residents for long periods of time, without equal opportunities or rights. Minimum requirements for permanent residency applications are too demanding, such as requiring immigrants to have a high level of language proficiency without any support in acquiring the skill or to have a high level of income. Such difficult requirements exclude certain groups of immigrants, such as older adults. Furthermore, permanent residency status is insecure and must be renewed after a period of time, providing limited rights for residents. As reviewed in the MIPEX report, Belgium, Sweden, Spain, Denmark, and Estonia had the most favorable permanent residency policies. In Belgium, EU citizens can apply for permanent residency after five years, and the granted residency is secure and provides equal rights with nationals. Non-EU citizens also have a clear path to permanent residency. After five years of uninterrupted stay, non-EU citizens can choose between applying for Belgium or EU permanent residency. Basic legal income is required for permanent residency, and non-EU and EU citizens are treated equally (Huddleston et al., 2015). Permanent residence status is relatively secure and is renewed automatically every five years with an exception for limited grounds that allow withdrawal. In case of withdrawal, minors and longsettled residents have strong protection and support. Based on the MIPEX report, Turkey, Cyprus, France, Ireland, and Malta have the least favorable policies for permanent residency. Turkey has the most restrictive policies for access to permanent residency. In Turkey, humanitarian migrants such as refugees are deprived of the right to apply for permanent residency. Other migrant groups can apply for permanent residency in Turkey after eight years of uninterrupted legal residency, subject to proof of sufficient resources and absence of social assistance use in the past three years. Permanent residency status does not guarantee equal

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rights with nationals and can be withdrawn on vague grounds. Long-term residents and minors have very limited protection or support in the case of permanent residency withdrawal. The United Sates ranked twenty-fifth in terms of favorable policies for permanent residency among the MIPEX countries in 2014 (Huddleston et al., 2015). Many groups of immigrants are deprived of the right to apply for permanent residency in the United States. Eligible immigrants can apply for permanent residency after five years, or one year for refugees and asylees. To receive permanent residency, immigrants must pay high fees and wait for years, and permanent residency status provides fewer rights than those of U.S. citizens. Permanent residents cannot benefit from federal assistance in their first years in the United States. Moreover, permanent residents can be deported from the country, and only limited protection exists for children and long-term residents. Temporary residents in most EU countries have the right to become permanent residents after five years. Minimum conditions to apply for permanent residency vary between countries. In thirty of the thirty-eight countries reviewed in the MIPEX report, permanent residents had rights similar to those of nationals; however, permanent residency was insecure and could be withdrawn from immigrants in countries such as Turkey and the United States.

ACCESS TO NATIONALITY POLICIES

Citizenship is one of the most important policies affecting immigrants. In the best-case scenario, all residents are able to receive full support to become citizens and have dual nationality if they meet the legal conditions, such as lack of a recent criminal record. Moreover, children have access to birthright citizenship if they are born in the country, and all new citizens have the same access as native-born individuals to services and protection. In the worst-case scenario, host countries prevent immigrants from pursuing nationality through long-term and complex application processes. In some countries, immigrants must wait more than ten years to be eligible to apply for citizenship, or immigrants must pass expensive language or integration tests without any support. In this case, children and sometimes grandchildren of immigrants remain foreigners, and new citizens can easily be stripped of their citizenship. According to the MIPEX report, Portugal, Sweden, Germany, New Zealand, and Australia had the most favorable policies on access to

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nationality. Portugal had the most favorable policies; immigrants can apply for citizenship after six years, and spouses of citizens can apply after three years. Dual nationality is respected and welcomed in Portugal, and children born in Portugal are entitled to citizenship if their parents have been living there legally for five years. Among the required conditions for immigrants to apply for citizenship is respecting the law, speaking basic Portuguese, and paying a €250 registration fee. According to the MIPEX report, Latvia, Estonia, Bulgaria, Slovakia, and Austria had the least favorable policies on access to nationality. Latvia had one of the most restrictive policies and had the largest share (about 40 percent) of second-generation immigrants without citizenship. Absence of dual nationality, except for citizens of EU countries, the European Free Trade Association, and the North Atlantic Treaty Organization, discourages many immigrants from applying for citizenship. Moreover, immigrant newcomers must wait ten years to apply for citizenship. Since 2013, children born in Latvia can be registered as Latvian citizens, but the path to citizenship for foreign-born individuals is complex. Immigrants must pay a basic fee, go through an income check, and provide proof of “good character” to be able to apply for citizenship. Limited support exists to help immigrants pass a high-level Latvian test for citizenship. This review process for citizenship is one of the most discretionary procedures across the MIPEX countries, and applicants can be rejected without a right to appeal. Even after this long and difficult process, the government can withdraw citizenship from new citizens on broad grounds and leave them stateless. The United States ranked eleventh across MIPEX countries in access to nationality. In the United States, children have access to universal birthright. Permanent residents can apply for citizenship after five years, and spouses of U.S. citizens can apply after three years by paying a $680 fee. This fee is more than twice as high as the average fee across MIPEX countries. The United Sates accepts dual nationality, but new U.S. citizens enjoy weaker protection against withdrawal of their citizenship when compared to their peers in European countries.

FAMILY REUNION POLICIES

Family reunion policies can have a major effect for transnational immigrant families in integration in host communities. In the best-case scenario, immigrants have access to family reunion if they have the legal requirements,

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including minimum legal income. Family reunion procedures are short and free, and reunited family members can fully participate in the host society. Reunited family members have the same access as that of their sponsors to fully participate in society. In the worst-case scenario, immigrants are forced to live apart from their families or must wait long periods of time to become eligible to apply for family reunion. The law recognizes only nuclear family members, and minorities are excluded. Moreover, family reunion sponsors must meet difficult minimum requirements without any support from the government. Sponsors must have a high income and a stable job and go through expensive and lengthy procedures. Reunited family members remain dependent on their sponsor and cannot have an autonomous life even if the sponsor abuses them. Among the MIPEX countries, Spain, Portugal, Slovenia, Canada, and Sweden had the most favorable policies for family reunion. Spain has the most family-friendly policies. EU or non-EU residents can reunite with close family members (spouse or partner and children) after one year of residency if they have basic legal income and housing. Basic income should be stable during the past six months and expected for the next year and be equal or more than 150 percent of the minimum family income for social benefits. For every added family member, 50 percent is added to the minimum required income. For sponsoring parents and grandparents, proof of long-term residence or urgent care is also needed. The family reunion process is short, around three months, and reunited family members have equal rights to fully participate in Spanish society. Reunited family members have rights similar to those of their sponsors to work, education, housing, and social security. In addition, they have a right to an autonomous permit that protects them in case of separation from their sponsors (Huddleston et al., 2015). The United Kingdom, Cyprus, Ireland, Denmark, and Malta had the least favorable policies for family reunion. In the UK, which has the least family-friendly policies for immigrants, non-EU citizens usually cannot reunite with their family members until they are permanent residents. Few non-EU or UK citizens can reunite with their adult children (age eighteen and above), parents, or grandparents. The UK has one of the most restrictive requirements for family reunion. Applicants who are outside the country must pass a preentry English language test, and those who are in the country require B1-level English fluency and must prove they have knowledge about life in the UK. Sponsors must pay a £956 fee and show proof of a yearly income of £18,600 to sponsor their partners or

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spouses. Proof of annual income of £22,400 is required for a couple with one child, and £2,400 is added for every additional child. This income requirement is higher than the average income of about half of the working population in the UK. Reunited family members have to wait two months to five years for spouses or partners to enjoy rights similar to those of their sponsors. The United States ranked fourteenth among the thirty-eight MIPEX countries in policies related to family reunion of immigrants. In the United States, the modern definition of family is accepted for family reunion, and same-sex couples can have spousal benefits if their marriage is legal where it was celebrated. Permanent residents can apply to sponsor their parents or adult children if they are naturalized and after the age of twenty-one. Sponsors must pay a fee and have proof of income or assets equal to or above 125 percent of the poverty level. Reunited family members have a secure future, but they do not have rights similar to those of their sponsors. In some cases, such as divorce and domestic violence, reunited family members can apply for autonomous residence permits.

DISCUSSION QUESTION

In your opinion, is family reunion a basic human right or only an option? How does this issue relate to social work values?

SUMMARY This chapter began by briefly reviewing major international laws pertinent to immigrants and refugees. Then examples were presented of best- and worst-case scenarios of national immigrant integration policies in eight areas developed by the Migrant Integration Policy Index in 2015. The best and worst countries among those included in the index were described for each of the eight policy areas. Table 2.1 ranks the MIPEX countries when all eight policy areas are considered together. Clearly, the scope of countries in MIPEX is limited; the index does not include any countries in Africa, Latin America, or the Caribbean, and only

TABLE 2.1 MIPEX Overall Country Rankings, 2014 RANK

COUNTRY

SCORE

1

Sweden

78

2

Portugal

75

3

New Zealand

70

4

Finland

69

5

Norway

69

6

Canada

68

7

Belgium

67

8

Australia

66

9

USA

63

10

Germany

61

11

Netherlands

60

12

Spain

60

13

Denmark

59

14

Italy

59

15

Luxembourg

57

16

United Kingdom

57

17

France

54

18

South Korea

53

19

Ireland

52

20

Austria

50

21

Switzerland

49

22

Estonia

46

23

Czech Republic

45

24

Iceland

45

25

Hungary

45

26

Romania

45

27

Greece

44

28

Japan

44

29

Slovenia

44

30

Croatia

43

31

Bulgaria

42

32

Poland

41

33

Malta

40

34

Lithuania

37

35

Slovakia

37

36

Cyprus

35

37

Latvia

31

38

Turkey

25

Source: Huddleston, Bilgili, Joki, & Vankova (2015).

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three in Asia. However, the framework for analysis is useful. Readers interested in the conditions of immigrants and refugees in a particular country can investigate the policies of that country using the MIPEX framework to gain some sense of where that country might rank on the spectrum of best to worst. Chapter 3 addresses U.S. policies, the country that is the primary focus of this book.

3 UNITED STATES IMMIGRATION AND REFUGEE POLICIES

U.S. IMMIGRATION and refugee policies have changed considerably over time due to a combination of domestic policy, foreign policy, and humanitarian considerations (McBride, 1999). Domestic considerations include economic concerns and the general public’s attitude toward foreigners. The interests of domestic employers in manufacturing, agriculture, and other sectors which benefit from immigrant labor often influence domestic policies (DeSipio & de la Garza, 1998). Foreign policy considerations are involved when refugees from specific countries are admitted as a way to embarrass or weaken the governments of the source countries. And humanitarian considerations guide the admission of refugees to promote human rights. U.S. immigration and refugee policies can be divided into two major time periods: historical and contemporary. A major shift in U.S. immigration policy occurred in 1965, and contemporary policy dates from the 1965 legislation. Earlier legislation is no longer in effect, but this history is important because it laid the foundations for contemporary policies.

HISTORICAL POLICIES It is well known that the United States was created by immigrants. For the first hundred years, immigration was generally unrestricted and unregulated. Two factors influenced this: the need for new citizens to promote the country’s geographic, economic, and political growth; and an ideological perception of the United States (by both citizens and foreigners) as a place of refuge for the oppressed of other nations (Congressional Research Service, 1991). During this period, massive numbers of immigrants from northern

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and western Europe came to the United States for economic, political, and religious reasons. No distinction was made between immigrants and refugees during this period. But a third group of involuntary migrants also entered the United States at that time; they were brought from Africa and sold as slaves. Immigrants were generally viewed positively because they served the nation’s needs. However, strong anti-immigrant sentiments also arose periodically and were rooted in various feelings such as anti-Catholicism, a perceived link between immigration and crime and poverty, and concerns about the economic and political impact of immigrants (Congressional Research Service, 1991). These sentiments led to enactment of the first general immigration statute, the Immigration Act of 1882. This law excluded the admission of convicts, paupers, and people deemed mentally defective because it was thought likely that they would become “public charges”— that is, dependent upon public funds for their financial support. In the same year, the first law excluding people based on national origin was enacted, the Chinese Exclusion Act. Although people from China had been actively recruited during the 1840s due to labor shortages, by the 1870s the United States was in an economic recession and Chinese immigrants were vilified (Fix & Passel, 1994). The Chinese Exclusion Act stopped Chinese immigration for ten years, denied Chinese immigrants the right to become U.S. citizens, and provided for deportation of undocumented immigrants from China. In 1943, the act was repealed to improve relations with China, which was then a U.S. ally in World War II (McBride, 1999), providing one illustration of how foreign policy interests have influenced immigration policies. The economic depression deepened during the 1880s, and new laws prohibited the immigration of contract laborers. Three elements of early immigration law formed the basis for most of the subsequent U.S. immigration policies: individual qualifications of immigrants, national origin, and protection of U.S. labor (Congressional Research Service, 1991). These restrictive policies supplanted the traditional U.S. stance that had granted asylum, or open immigration, to all. During the late nineteenth and early twentieth centuries, immigration from northern and western Europe decreased, but immigration from southern and eastern Europe increased dramatically. These new immigrants were viewed with ambivalence. They supplied needed labor for the industrial revolution, but many citizens believed that these immigrants adversely affected the wages and working conditions of native-born workers. In addition,

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they came to be associated with urban problems such as crime and poverty. Many were illiterate, and this was also viewed as undesirable. Consequently, the Immigration Act of 1917 barred immigrants who were illiterate in any language, which was specifically intended to bar these southern and eastern European immigrants. The same act also extended the ban on Chinese immigrants to other Asians. These developments grew out of economic concerns and were reinforced by wartime nationalism and growing isolationism during World War I (Congressional Research Service, 1991). In addition to these concerns, eugenics theories, which held that some races were biologically superior to others, became popular during the 1920s. All of these factors contributed to the first legislation that placed quantitative, or numerical, restrictions on immigration in addition to the qualitative restrictions based on individual characteristics. The Immigration Act of 1924 limited European immigration to 150,000 people per year and continued the immigration ban against Asian countries (Congressional Research Service, 1991; Fix & Passel, 1994). It also established a national origins quota system whereby admissions were “based on the proportion of national origin groups that were present in the United States according to the census of 1890. Because this Census preceded the large-scale immigrations from Southern and Eastern Europe, this provision represented an explicit effort to ensure that future immigration flows would be largely composed of immigrants from Northern and Western Europe” (Fix & Passel, 1994, p. 10). After 1927, the 1920 census was used as the basis for setting quotas. This legislation also established, for the first time, a preference system within each quota, giving preference for admission to relatives of U.S. citizens and to those who were skilled in agriculture. Immigrants from the Western Hemisphere were exempt from the quota regulation due to a desire to attract cheap labor from those countries and to promote good relations with countries in close proximity to the United States (McBride, 1999). The national origins quota system remained in force until 1965. With implementation of the 1924 act, immigration admissions dropped drastically, and the United States soon faced its greatest economic depression. However, the rise of Nazism in Europe in the 1930s again brought humanitarian concerns forward. Between 1933 and 1941, the United States admitted a quarter-million refugees from Nazi persecution. However, efforts to liberalize immigration law to admit more refugees were defeated, and many more refugees from Nazism were turned away. At the end of World War II,

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huge numbers of refugees were in displaced persons camps in Europe. The Displaced Persons Act of 1948 was enacted based on these humanitarian concerns, and this was the first refugee legislation in U.S. history. This act allowed for the admission of hundreds of thousands of refugees by borrowing from future immigration quotas (Congressional Research Service, 1991). Even though the United States restricted permanent immigration, it encouraged temporary admission of foreign laborers. In 1942, the Mexican “bracero” program was established, which authorized the entry of almost five million temporary agricultural workers. Additional temporary workers were admitted from several Caribbean countries (Congressional Research Service, 1991). The Immigration and Nationality Act of 1952 (INA) was a comprehensive statute that brought together previously enacted immigration laws. This legislation was influenced by then-popular sociological theories about cultural assimilation. It barred discrimination in admissions on the basis of race and gender but continued the national origins quota system, with a modification of the quota formula. Essentially, continuation of the national origins quota system was defended by the view that western and northern Europeans would assimilate more easily into U.S. society (Congressional Research Service, 1991). Substantial limitations remained on immigration from southern and eastern Europe, and restrictions on Asian immigration were slightly relaxed. Immigration from Western Hemisphere countries remained unrestricted. In addition to maintaining the quota system, the 1952 act established a preference system based on employment skills and family relationships. This was the antecedent to the current immigrant admissions system, which is based on employment and family member preference categories. The 1952 system consisted of four categories. Within each national quota, first preference was given to people with a high education or urgently needed skills, and three other preference categories were established for relatives of U.S. citizens and permanent residents. Many people were opposed to the 1952 legislation because its national origin quotas precluded the admission of refugees from eastern Europe, which by that time was under Communist rule. U.S. foreign policy was strongly anti-Communist, and this legislation was viewed as incompatible with traditional U.S. humanitarian concerns. Consequently, several pieces of legislation were soon enacted to permit admission of these refugees outside of the quota system. The Refugee Relief Act of 1953 specifically authorized the admission of escapees from Communist countries of eastern Europe. The Refugee-Escapee Act of 1957 extended the definition of refugees and

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escapees to include people fleeing persecution in Middle Eastern countries. It also repealed the quota deductions that had been required by the Displaced Persons Act of 1948. These anti-Communist refugee laws also laid the foundation for the subsequent admission of refugees from Communist Cuba through various legal means (Congressional Research Service, 1991). In summary, U.S. immigration and refugee policies prior to 1965 evolved from open admissions to gradually more restricted admissions. At different points in time, specific groups of immigrants were effectively denied admission. This was first accomplished by excluding people based on characteristics such as national origin and educational and skill levels and later by imposing numerical quotas based on national origin. Undocumented immigrants and deportation were addressed from the first immigration legislation, but the policy distinction between immigrants and refugees was not made until after World War II. These shifts in immigration and refugee policies were influenced by a combination of factors, including the state of the domestic economy, humanitarian concerns, foreign policy, and popular beliefs about racial superiority and assimilation. The major historical policies are summarized as follows:

MAJOR HISTORICAL U.S. IMMIGRATION AND REFUGEE POLICIES

Chinese Exclusion Act of 1882 Q Q Q

Restricted Chinese immigration Barred Chinese immigrants from naturalization Provided for deportation of Chinese illegal immigrants

Immigration Act of 1882 Q Q Q

First general immigration law Established a system of central control of immigration Excluded admission of people likely to become a public charge (paupers, convicts, and mental defectives)

Immigration Act of 1917 Q Q Q Q Q

Codified all previously enacted exclusion provisions Excluded admission of illiterate people Expanded list of people excluded for mental health and other reasons Further restricted admission of Asian immigrants Broadened classes of foreign-born undocumented individuals “CONTINUED”

“CONTINUED”

Immigration Act of 1924 Q Q Q Q

Q Q

Established first permanent numerical limitation on immigration Established national origins quota system Excluded Japanese admissions Established a preference system for relatives of U.S. citizens and for agricultural immigrants Exempted Western Hemisphere immigrants from quota limitations Imposed fines on transportation companies that landed illegal immigrants

Displaced Persons Act of 1948 Q Q

Q

First expression of U.S. policy for admitting people fleeing persecution Aimed at addressing the problem of over one million displaced people in Europe following World War II Admitted displaced people by borrowing from future years’ quotas

Immigration and Nationality Act of 1952 Q

Q Q Q

Q

Q

Brought into one comprehensive statute the multiple laws that previously had been enacted Eliminated race and gender as barriers to immigration Maintained national origins quota system, with a modified formula Introduced four-category preference system based on skills and relationship to U.S. citizens and permanent residents Broadened grounds for deportation but gave greater procedural safeguards to foreign-born undocumented individuals at risk of deportation Established a central registry of all foreign-born individuals in the United States

Refugee Relief Act of 1953 Q

Authorized admission of refugees from war-torn Europe and escapees from Communist countries

Refugee-Escapee Act of 1957 Q

Q Q

Removed the requirement contained in the Displaced Persons Act of 1948 of borrowing from future years’ quotas for admission of refugees and escapees Facilitated admission of stepchildren, illegitimate children, and adopted children Gave the attorney general authority to admit certain formerly excludable foreign-born individuals

Migration and Refugee Assistance Act of 1962 Q

Q

Authorized funds to assist foreign-born people from the Western Hemisphere with a well-founded fear of persecution based on race, religion, or political opinion Was intended specifically to assist Cuban nationals

SOURCE: U.S. CITIZENSHIP AND IMMIGRATION SERVICES (2012); MIGRATION POLICY INSTITUTE (2013).

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DISCUSSION QUESTION

Select one of the times when the United States restricted immigration, such as the Chinese Exclusion Act. Would you consider this to be a historical trauma for the affected ethnic group? Why or why not?

CONTEMPORARY POLICIES Contemporary U.S. immigration and refugee policies have their roots in the 1965 legislation that radically changed prior laws. Contemporary policies are guided by five major goals: “social—unifying U.S. citizens and legal residents with their families; economic—increasing U.S. productivity and standard of living; cultural—encouraging diversity; moral— promoting human rights; and national and economic security—controlling illegal immigration” (Fix & Passel, 1994, p. 13). Social, economic, and cultural goals are embodied in policies pertaining to legal immigration; moral goals are embodied in policies pertaining to refugees; and national and economic security goals are embodied in policies pertaining to illegal immigration. Similar to historical policies, contemporary policies have been shaped by shifting public sentiments related to economic concerns, humanitarian concerns, foreign policy, and public attitudes. Contemporary immigration policy “has been subject to many twists and turns—proposals put forth and discarded, compromises reached and abandoned, legislation passed and modified. . . . [It is developed] in an environment that is subject to push and pull factors from a number of directions: Congress, presidents, Supreme Court decisions, interest groups, U.S. domestic and foreign policy concerns, public opinion, intergovernmental organizations, and international and national guidelines” (McBride, 1999, p. 23). The major contemporary policies, their causes, and consequences, are reviewed here. The policies and their principal provisions are summarized in the following box:

MAJOR CONTEMPORARY U.S. IMMIGRATION AND REFUGEE POLICIES

Immigration and Nationality Act Amendments of 1965 Q

Q

Q Q Q Q

Abolished national origins quota system, eliminating national origin, race, or ancestry as a basis for admission Established an admissions preference system based on family reunification and employment skills Placed numerical limits on Eastern and Western Hemisphere immigration Established per-country numerical limits Exempted Western Hemisphere countries from preference system and per-country limits Established requirement demonstrating that employment-based immigrants would not adversely impact U.S. labor force

Immigration and Nationality Act Amendments of 1976 Q

Q

Applied per-country limits and a modified version of preference system to the Western Hemisphere Subsequent legislation passed in 1978 combined separate total admissions limits for Eastern and Western Hemispheres into one and applied a single preference system to both hemispheres

Refugee Act of 1980 Q

Q Q Q Q

Q Q

Q

Provided the first permanent and systematic procedure for the admission and effective resettlement of refugees of special humanitarian concern to the United States Defined the term “refugee” to conform to international refugee law Eliminated refugees as a category of the preference system Removed refugees from worldwide numerical limits on immigration Established procedures for determining annual numerical limits for refugees, and for responding to emergency refugee situations Distinguished between refugees and asylees Provided for adjustment to permanent resident status of refugees after one year of U.S. residence, and for asylees one year after asylum is granted Established a comprehensive program for domestic resettlement of refugees

Immigration Reform and Control Act of 1986 Q Q

Q Q

Q

First comprehensive legislation addressing illegal immigration Established sanctions prohibiting employers from knowingly hiring or recruiting illegal foreign-born individuals Increased border control and enforcement Established amnesty program authorizing legalization of certain illegal foreign-born individuals who had resided continuously in the United States since 1982 Created a new classification of seasonal agricultural workers and provisions for their legalization “CONTINUED”

“CONTINUED”

Immigration Act of 1990 Q Q Q Q Q

Q

Q Q Q

Increased total annual legal immigration limits by 40 percent Tripled the admission limit for employment-based immigration Revised preference system of family-sponsored and employment-based admissions Created a new category of diversity immigrants Authorized the attorney general to grant Temporary Protected Status to illegal foreign-born individuals from countries subject to armed conflict or natural disasters Repealed legislation that permitted exclusion or deportation of foreign-born individuals based on political or ideological grounds Increased border patrols Revised employer sanction provisions of 1986 act Revised naturalization requirements

Violent Crime Control and Law Enforcement Act of 1994 Q

Gave the U.S. attorney general the option of bypassing the deportation process for certain crimes

Personal Responsibility and Work Opportunity Reconciliation Act of 1996 Q

Q

Q

Q

Q

Q

Q Q

Established restrictions on the eligibility of legal immigrants for means-tested public assistance Barred legal immigrants (with certain exceptions) from obtaining food stamps and Supplemental Security Income Barred legal immigrants (with certain exceptions) from entering the United States after the date of enactment from most federal means-tested programs for five years Provided states with broad flexibility in setting public benefit eligibility rules for legal immigrants by allowing states to bar current legal immigrants from both major federal programs and state programs Increased the responsibility of immigrants’ sponsors by making the affidavit of support legally enforceable, imposing new requirements on sponsors, and expanding sponsor-deeming requirements to more programs and lengthening the deeming period Broadened the restrictions on public benefits for undocumented immigrants and nonimmigrants Barred undocumented immigrants from most federal, state, and local public benefits Required the Immigration and Naturalization Service to verify immigration status in order for immigrants to receive most federal public benefits

Illegal Immigration Reform and Immigrant Responsibility Act of 1996 Q Q Q

Placed added restrictions on benefits for immigrants Declared undocumented immigrants ineligible for Social Security benefits Established procedures for requiring proof of citizenship for federal public benefits “CONTINUED”

“CONTINUED”

Q

Q Q Q

Q

Q

Q Q

Provided for verification of immigration status for purposes of Social Security and higher educational assistance Made the sponsor’s affidavit of financial support a legally binding contract Provided authority of states to limit general cash assistance to immigrants Exempted undocumented immigrants who are victims of domestic violence from denial of public benefits Exempted nonprofit organizations from the requirement to verify immigration status of public benefit applicants Established measures to control U.S. borders, protect legal workers through worksite enforcement, and remove undocumented immigrants Allowed denial of admission to people deemed likely to become public charges Required asylum applications to be filed within one year of entry into the United States and provided expedited procedures for asylum hearing and appeals

Enhanced Border Security and Visa Entry Reform Act of 2002 Q

Q

Required development of an electronic data system for sharing information on foreign-born people Required implementation of an integrated entry-exit data system

Homeland Security Act of 2002 Q

Created the Department of Homeland Security, which assumed almost all functions of the former Immigration and Naturalization Service

Real ID Act of 2005 Q Q Q

Established guidelines for removal cases Expanded terrorism-related grounds Mandated states to verify applicants’ legal status before issuing drivers’ licenses or personal identification cards

Secure Fence Act of 2006 Q

Q

Mandated construction of more than seven hundred miles of double-reinforced fencing along the border with Mexico in areas experiencing drug trafficking and illegal immigration Allowed for more border monitoring equipment to control illegal immigration SOURCES: U.S. CITIZENSHIP AND IMMIGRATION SERVICES (2012); MIGRATION POLICY INSTITUTE (2013).

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IMMIGRATION AND NATIONALITY ACT AMENDMENTS OF 1965

The Immigration and Nationality Act Amendments of 1965 abolished the national origins quota system. In place of ethnic and national origin admissions criteria, a preference system was established based on family reunification and needed employment skills. This change represented a major policy shift and was in large part the result of two major factors: the personal influence of President John F. Kennedy and the civil rights movement (Congressional Research Service, 1991; Fix & Passel, 1994). John Kennedy’s book, A Nation of Immigrants, severely criticized the national origins quota system. Kennedy was also influential in the civil rights movement, which led to massive legislation prohibiting racial and ethnic discrimination. The strong antidiscrimination sentiments of the general public during this period extended to immigration, resulting in the 1965 amendments, which ended preference categories admissions discrimination based on ethnicity, race, or national origin. The amendments established a seven-category admission preference system that prioritized relatives of U.S. citizens and permanent residents, needed occupationally skilled immigrants, and refugees. An annual limit of 170,000 immigrants from the Eastern Hemisphere, with a 20,000 per-country limit, was established. Immediate relatives (spouses, children, and parents) of U.S. citizens were exempted from the numerical limitations. Immigrants entering under the employment preference categories required the secretary of Labor to issue a finding that the immigrant’s admission would not replace a worker in the United States nor adversely affect the wages and working conditions of similarly employed people in the United States. Furthermore, for the first time, a numerical limit of 120,000 (annually) was placed on Western Hemisphere immigrants. However, Western Hemisphere immigrants were not subject to the per-country limits or to the preference system. The 1965 amendments resulted in a massive shift in the national origin of immigrants. Prior to the 1965 law, most immigrants were from Europe. From 1965 onward, most immigrants have been from Asia and Latin America. Asians, who had been effectively barred under previous legislation, were now able to enter, mostly under the skills preference categories. And Latin Americans entered under both the family reunification and skills preference categories. These post-1965 arrivals are sometimes referred to as “the new immigrants.” The preference system established by the 1965 law, with some modifications, has remained the basis for admission of legal immigrants.

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DISCUSSION QUESTION

Several commentators have expressed worry over what they call the “browning” of America due to immigration and the lower birth rates of white families. As a social worker, how would you respond to these remarks?

IMMIGRATION AND NATIONALITY ACT AMENDMENTS OF 1976

This legislation applied the 20,000 per-country limit to the Western Hemisphere and also applied a slightly modified version of the seven-category preference system to the Western Hemisphere. In 1978, the separate total admissions limits for the Eastern and Western hemispheres were combined into one, and a single preference system was applied to both hemispheres (Congressional Research Service, 1991).

REFUGEE ACT OF 1980

Between 1975 and 1980, the United States experienced a large influx of refugees from Southeast Asia. These people fled the region at the end of the Vietnam War and resettled in the United States as a result of the 1975 Indochina Migration and Refugee Assistance Act. In this five-year period, more than 400,000 of these refugees entered the United States (Congressional Research Service, 1991). During the same time, the Soviet Union began allowing Jews to emigrate, and large numbers came to the United States (Feen, 1985). The federal government found it increasingly difficult to effectively cope with these massive influxes under the existing refugee policies, which had been developed in a piecemeal fashion in response to refugee crises in various regions of the world over time. Rather than being occasional crises, refugee outflows had become a persistent problem. A consensus developed that a more comprehensive and coordinated approach to refugee admission and resettlement was needed. The Refugee Act of 1980 provided the first permanent and systematic procedure for the admission and resettlement of refugees. The act entailed major revisions to refugee policy. First, it redefined the term refugee.

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Previously, refugees had been defined as people fleeing Communist or Middle Eastern countries. The 1980 act replaced this ideologically and geographically based definition with the international definition of refugees contained in the UN Convention and Protocol Relating to the Status of Refugees (i.e., a person who is outside his or her country of origin and is unable or unwilling to return to the country of origin due to a well-founded fear of persecution because of race, religion, nationality, membership in a particular social group, or political opinion). Second, the act removed refugees from the preference system for admissions. Refugees were now recognized as a special case that should not be subject to the numerical limitations set on legal immigrants. Procedures were established for setting annual numerical limitations on refugee admissions and for responding to emergency refugee situations outside of these numerical limitations. Third, the legislation made a clear distinction between refugees and asylees. Refugees were identified as people who applied for admission from outside the United States, usually after having been granted asylum by another country. Asylees were identified as people who applied for asylum after they were already in the United States, usually having entered illegally. Fourth, the act allowed refugees and asylees to apply for adjustment to permanent resident status after one year of residence in the United States. Finally, this act created, for the first time, a comprehensive and coordinated program for resettlement assistance to refugees after their arrival in the United States. This resettlement program was established in recognition of the fact that refugees differ fundamentally from immigrants in that they are fleeing persecution, their departure is involuntary and usually unplanned, they frequently have been traumatized, and they arrive with little if any money and usually no family or business connections. Thus “there is a strong practical and ethical case for providing them support upon arrival” (Fix & Passel, 1994, p. 63). Consequently, refugees are eligible for far more public assistance than are immigrants, and this assistance is delivered through a coordinated program, which is also not the case for immigrants. The Refugee Act of 1980 defined the goal of the refugee resettlement program as helping refugees achieve economic self-sufficiency as rapidly as possible. Economic self-sufficiency was defined as not receiving financial assistance from public welfare programs. To achieve this goal, three forms of assistance were established: cash and medical assistance, social services, and preventive health services. Cash and medical assistance are provided to refugees who arrive with no financial resources and who are not eligible for other public welfare

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programs such as Temporary Assistance to Needy Families (TANF), Supplemental Security Income (SSI), or Medicaid. Under the original legislation, refugees were eligible for this assistance for the first three years after arrival, but the eligibility period has been progressively reduced and is now eight months. Social services are available for up to five years after arrival and are primarily English-language training, employment training and placement, and case management. Refugees who receive cash and medical assistance are required to participate in employment training and to accept offers of employment. Preventive services include a preventive health assessment and treatment for infectious diseases (U.S. Office of Refugee Resettlement, 2017a, 2018a). In addition to these direct services, the Refugee Act also authorized funds for a Voluntary Agency Matching Grant program and a Targeted Assistance Grant program. The Voluntary Agency Matching Grant program matches federal funds to private funds or in-kind donations from private agencies assisting refugees during the first four months after arrival. The Targeted Assistance Grant program provides additional funds to local communities that have a high concentration of refugees and a high use of public assistance by refugees (U.S. Office of Refugee Resettlement, 2017a, 2017b).

IMMIGRATION REFORM AND CONTROL ACT OF 1986

In the early 1970s, the U.S. government began considering ways to reform immigration law to better control undocumented immigration. This concern arose due to the increasingly large numbers of undocumented immigrants that were apprehended each year (Congressional Research Service, 1991). The increase in undocumented immigration was fueled in part by an economic recession in Mexico in the 1970s (McBride, 1999). There was concern that the large number of illegal immigrants threatened the economic security of U.S. workers. The Immigration Reform and Control Act (IRCA) was passed in 1986, and it contained three major provisions pertaining to the control of undocumented immigration. First, it imposed sanctions, or penalties, on employers who knowingly hired undocumented immigrants. It also created a national tracking system for immigrants and required states to use the system to check the immigration status of those who applied for welfare. These measures were intended to decrease undocumented immigration by reducing the monetary incentives. Second, IRCA increased border control and enforcement.

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Finally, the act provided for legalization of certain undocumented immigrants. To deal humanely with undocumented immigrants who had already established roots in the United States, IRCA included an amnesty provision permitting legalization of those who had resided in the United States continuously since 1982. To address the needs of U.S. agriculture, which depended heavily on seasonal migrant laborers, IRCA created a new classification of seasonal agricultural workers and provisions for their legalization (Congressional Research Service, 1991; Fix & Passel, 1994; McBride, 1999). The amnesty provision of IRCA led to the legalization of almost three million residents. However, the employer sanctions largely failed to control illegal immigration. The prevalence of fraudulent documents made it difficult for employers to ascertain the real immigration status of job applicants. In addition, limited government resources were allocated for enforcement of the employer sanctions (Fix & Passel, 1994).

IMMIGRATION ACT OF 1990

After addressing undocumented immigration with IRCA, Congress turned its attention to legal or documented immigration. There were some concerns about the numerical limits and preference system created in 1965 and subsequently amended. One concern was that more immigrants had been admitted under the family reunification categories than under the employment-based categories. Another concern was that a limited number of admissions were available under the preference system to certain countries (Congressional Research Service, 1991). The Immigration Act of 1990 entailed several major revisions to immigration law. First, it increased total annual legal immigration limits by 40 percent, including almost tripling the admission limit for employment-based immigration. Second, it revised the preference system, creating new family-sponsored preference categories, employment-based preference categories, and two categories of legal immigrants outside of the preference system. This system remains in place to the present (table 3.1). The total annual limit for legal immigration is set at 675,000, and each of the three major admission categories has a numerical limit: familysponsored (480,000 limit), employment-based (140,000 limit), and diversity (55,000 limit). Annual limits are adjusted each year based on usage in the previous year. Refugees are not included in these categories because their

TABLE 3.1 Family-Sponsored and Employment-Based Preference Categories CATEGORY

NUMERICAL LIMIT

Total family-sponsored immigrants

480,000

Immediate relatives Immigrants who are the spouses and unmarried minor children of U.S. citizens and the parents of adult U.S. citizens

Unlimited

Family-sponsored preference immigrants

226,000 (floor)

First preference

Unmarried sons and daughters of U.S. citizens

23,400 plus unused visas from fourth preference visas

Second preference

2A: Spouses and minor children of lawful permanent residents

114,200 plus unused first preference visas (77% are reserved for 2A preference)

2B: Unmarried sons and daughters of lawful permanent residents Third preference

Married sons and daughters of U.S. citizens

23,400 plus unused first or second preference visas

Fourth preference

Siblings of adult U.S. citizens

65,000 plus unused first, second, or third preference visas

Employment-based preference immigrants

140,000

First preference

Priority workers: people of extraordinary ability in the arts, science, education, business, or athletics; outstanding professors and researchers; and certain multinational executives and managers

28.6% of total plus unused fourth and fifth preference visas

Second preference

Members of the professions holding advanced degrees or people of exceptional abilities in the sciences, art, or business

28.6% of total plus unused first preference visas

Third preference—skilled

Skilled shortage workers with at least two years training or experience, professionals with baccalaureate degrees

28.6% of total plus unused first or second preference visas

Third preference—“other”

Unskilled shortage workers

10,000 (taken from number available for third preference)

Fourth preference

“Special immigrants,” including ministers of religion, religious workers other than ministers, certain employees of the U.S. government abroad, and others

7.1% of total (religious workers limited to 5,000)

Fifth preference

Employment creation investors who invest at least $1 million (amount may vary in rural areas or areas of high unemployment) that will create at least ten new jobs

7.1% of total (3,000 minimum reserved for investors in rural or high unemployment areas)

Source: Kandel (2018).

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admission is governed by the Refugee Act of 1980. The family-sponsored and employment-based categories each include preference categories that represent the descending order of admission priority. Any unused admissions in a given preference category are reallocated to the next lower category. Family-sponsored immigrants are required to have a “sponsor” (a U.S. citizen or lawful permanent resident family member) who promises to support them if they are unable to support themselves. There are four preference categories of family-sponsored immigrants. Immediate relatives (spouses, minor children, and parents) of U.S. citizens are outside of the preference system, and their admission is unlimited. In the employment-based category, the five preferences together have an overall allocation of 140,000 immigrants. In addition, the 1990 act created a new category, Diversity Visa Lottery, that was intended to increase admissions from countries from which relatively few immigrants had been admitted since the 1965 act. Most immigrants since 1965 had been from Latin America and Asia, and the diversity category was intended to increase the number of immigrants from Europe. It was also intended to increase the overall skill level of new arrivals and to promote the ethnic and cultural pluralism of the United States (Fix & Passel, 1994). This visa is randomly allocated to nationals from countries that have sent fewer than 50,000 immigrants to the United States in the previous five years. Since the 1990s, these immigrants have shifted from having a western European origin to being from Africa and eastern Europe (Kandel, 2018). Another major provision of the Immigration Act of 1990 was authorizing the attorney general to grant Temporary Protected Status to undocumented foreign-born immigrants from countries that were subject to armed conflict or natural disasters. An additional major provision was the repeal of previous laws that permitted exclusion or deportation of foreign-born individuals based on political or ideological grounds. The 1990 act also revised enforcement activities pertaining to undocumented immigration control, including changing the employer sanction provisions of IRCA and increasing border patrols. Finally, the Immigration Act of 1990 made some revisions to naturalization requirements. The current requirements for naturalization, as established by this act and subsequently slightly modified, are summarized in figure 3.1. Part of the naturalization process requires passing a test of knowledge of U.S. history, government, and civics principles. Applicants are asked ten questions out of a bank of one hundred questions, and they must answer six of them correctly in order to pass.

Be at least 18 years old at the time of filing the Application for Naturalization (Form N-400)

Be a lawfully admitted permanent resident of the United States

At the time of filing the application, have been a permanent resident in the United States for at least five years (or for at least three years if you meet all eligibility requirements to file as a spouse of a United States citizen)

Have demonstrated continuous permanent residence

Have demonstrated physical presence

Have lived within the State or USCIS District for at least three months prior to filing

Have demonstrated good moral character

Demonstrate an attachment to the principles and ideals of the U.S. constitution

Demonstrate an ability to read, write, speak, and understand basic English

Demonstrate a basic knowledge of U.S. history, government, and civic principles

Take an oath of allegiance to the United States

Receive a Certificate of Naturalization FIGURE 3.1 Pathway to U.S. citizenship. Source: U.S. Citizenship and Immigration Services (2017b).

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The Immigration and Nationality Act as amended by the Immigration Act of 1990, with some minor subsequent revisions, remains the major piece of legislation guiding legal immigration admissions and naturalization to the present.

THE CIVICS TEST: HOW WOULD YOU DO?

Answer these ten questions. Answers are at the end of the chapter. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

What is the supreme law of the land? What is freedom of religion? What is the economic system in the United States? The House of Representatives has how many voting members? Why did the colonists fight the British? What is one thing Benjamin Franklin is famous for? What did Susan B. Anthony do? Name one war fought by the United States in the 1900s. Name one American Indian tribe in the United States. Name one U.S. territory. SOURCE: U.S. CITIZENSHIP AND IMMIGRATION SERVICES (2017A).

VIOLENT CRIME CONTROL AND LAW ENFORCEMENT ACT OF 1994

The Violent Crime Control and Law Enforcement Act of 1994 enhanced penalties for foreign-born people involved in smuggling, reentry without legal documents after deportation, and crimes relevant to immigration. The act allocated funds for deportation and incarceration of those involved in immigration-related crimes and expedited the deportation process.

PERSONAL RESPONSIBILITY AND WORK OPPORTUNITY RECONCILIATION ACT OF 1996

Increasing anti-immigrant sentiment in the mid-1990s led to the passage of two major pieces of federal immigration legislation in 1996. The first of these was the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA). This act, commonly known as welfare reform, pertained to the welfare system in general and contained major provisions

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specific to immigrants and refugees. Before PRWORA, native-born citizens, naturalized citizens, and lawful permanent residents (LPRs) generally had equal eligibility for public benefits and services, and few rights and privileges were denied to LPRs. The PRWORA restrictions on eligibility for public assistance for immigrants and refugees are complex. In brief: Title IV of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA, P.L. 104–193) established comprehensive new restrictions on the eligibility of noncitizens for means-tested public assistance—with significant exceptions for those with a substantial U.S. work history or military connection. For legal permanent residents (LPRs) who were resident as of enactment of the law (August 22, 1996), the act generally barred eligibility (food stamps/SNAP and SSI) or allowed it at state option (Medicaid and TANF). For food stamps/SNAP and SSI benefits, LPRs entering after August 22, 1996 (new entrants) also were denied eligibility, with no time constraint. On the other hand, new entrants applying for Medicaid and the newly established Temporary Assistance for Needy Families (TANF) program were barred for five years after their entry, and then allowed eligibility at state option. Refugees and asylees were allowed eligibility for five years after entry/grant of status, then made ineligible (unless they became citizens or qualified under another status). Nonimmigrants (i.e., aliens on temporary visas) and unauthorized aliens were barred from almost all federal programs. (A. SISKIN, 2016, P. 11)

PRWORA was amended several times in subsequent years to ease some of the restrictions (A. Siskin, 2016). Current eligibility criteria for federal programs for legal immigrants and refugees are listed in the text box.

LEGAL IMMIGRANT AND REFUGEE ELIGIBILITY FOR FEDERAL ASSISTANCE PROGRAMS Q Q

Refugees and asylees are eligible for food stamps/SNAP. Refugees and asylees are eligible for SSI benefits and Medicaid for seven years after arrival and are eligible for TANF for five years. After this term, they generally are ineligible for SSI but may be eligible, at state option, for Medicaid and TANF. “CONTINUED”

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“CONTINUED”

Q

Q

Q Q Q Q Q

Q

Q

LPRs with a substantial work history—generally ten years (forty quarters) of work documented by Social Security or other employment records—or a military connection (active duty military personnel, veterans, and their families) are eligible for the full range of programs. LPRs are not eligible for SSI during the first five years even if they had forty credits of earnings (e.g., as a temporary worker prior to receiving LPR status). LPRs receiving SSI as of August 22, 1996, continue to be eligible for SSI. Noncitizen SSI recipients are eligible for (and required to be covered under) Medicaid. Disabled LPRs who were legal residents as of August 22, 1996, are eligible for SSI. Disabled LPRs are eligible for SNAP. LPRs who were elderly (sixty-five or older) and legal residents as of August 22, 1996, are eligible for SNAP. LPRs who have been legal residents for five years or are children (under eighteen) are eligible for SNAP. LPRs entering after August 22, 1996, are barred from TANF and Medicaid for five years, after which their coverage becomes a state option. States have the option to cover LPRs who are children or who are pregnant during the first five years. SOURCE: A. SISKIN (2016).

Even before PRWORA, undocumented immigrants were ineligible for most public benefits and were denied many rights and privileges. PRWORA did not fundamentally change the eligibility and rights of undocumented immigrants, although it did make the denials of rights and benefits more explicit. Undocumented immigrants are eligible for the following programs: public elementary and secondary education; school breakfast and lunch programs; treatment under Medicaid for emergency conditions (except organ transplants); short-term, in-kind emergency disaster relief; immunizations, testing, and treatment of communicable diseases; and in-kind services delivered at the community level that are necessary for the protection of life and safety and are not based on individual needs assessments (A. Siskin, 2016).

ILLEGAL IMMIGRATION REFORM AND IMMIGRANT RESPONSIBILITY ACT OF 1996

Within a few weeks of passing PRWORA, Congress passed a second major piece of immigration legislation, the Illegal Immigration Reform and

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Immigrant Responsibility Act (IIRIRA). The impetus for this legislation was the same restrictionist sentiments that had led to PRWORA. Portions of IIRIRA also addressed public benefit eligibility. IIRIRA imposed, for the first time, a minimum income requirement on legal immigrants’ sponsors. The minimum income requirement was defined as 125 percent of the poverty level. Further, sponsors were required to support the immigrants until the immigrants had worked for ten years or had become citizens; and sponsors were made liable for repayment of certain benefits that the immigrants may have used during that time (A. Siskin, 2016). IIRIRA also declared foreign-born individuals not lawfully present ineligible for Social Security benefits; established procedures for requiring proof of citizenship for federal public benefits; required verification of immigration status for Social Security and higher educational assistance; and provided states with the authority to limit general cash public assistance to foreign-born individuals (U.S. Citizenship and Immigration Services, 2005). IIRIRA also allowed the denial of admission of people who were deemed likely to become a “public charge,” i.e., likely to use public benefits (Gimpel & Edwards, 1999). IIRIRA eased some of PRWORA’s restrictions. For example, it allowed undocumented foreign-born individuals who were victims of domestic violence to receive public assistance. Also, it exempted nonprofit organizations from having to verify an applicant’s immigration status to determine benefit eligibility (Gimpel & Edwards, 1999). In addition, IIRIRA contained provisions to increase control of undocumented immigration: increased border and workplace enforcement personnel; increased penalties for illegal entry, overstay, alien smuggling, and document fraud; reformed exclusion and deportation procedures to expedite removal; and increased detention space for undocumented foreign-born individuals (U.S. Citizenship and Immigration Services, 2005). A final major provision of IIRIRA was requiring asylees to file an asylum application within one year of entry into the United States and creating expedited procedures for asylum hearings and appeals (Gimpel & Edwards, 1999).

ENHANCED BORDER SECURITY AND VISA ENTRY REFORM ACT OF 2002

After the terrorist attacks of September 11, 2001, the Enhanced Border Security and Visa Entry Reform Act of 2002 became law. This act

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enhanced border control by linking all internal databases of the Immigration and Naturalization Service and making information accessible through a single search. The act also mandated that federal law enforcement and intelligence agencies share data on foreign-born people with the INS and the State Department. Moreover, this act made all the travel and entry documents issued to foreign-born individuals machinereadable, tamper-resistant, and included a standard biometric identifier (Jenks, 2002).

HOMELAND SECURITY ACT OF 2002

The Homeland Security Act of 2002 led to establishment of the Department of Homeland Security (DHS). It was introduced after the September 11, 2001, attacks to prevent terrorist attacks within the United States, reduce the vulnerability to terrorism, minimize the damage, and assist recovery. DHS is headed by the secretary of Homeland Security who is selected by the president with the consent of the Senate. In 2003, nearly all the responsibilities of the INS were transferred to the Department of Homeland Security and split into three operational components (figure 3.2):

U.S. Citizenship and Immigration Services (USCIS) Administers the nation’s lawful immigration system, safeguarding its integrity and promise by efficiently and fairly adjudicating requests for immigration benefits while protecting Americans, securing the homeland, and honoring the nation’s values.

U.S. Customs and Border Patrol (CBP)

U.S. Immigration and Customs Enforcement (ICE)

Mission of keeping terrorists and their weapons out of the U.S.; responsibility for securing and facilitating trade and travel while enforcing hundreds of U.S. regulations, including immigration and drug laws.

Promotes homeland security and public safety through the criminal and civil enforcement of federal laws governing border control, customs, trade, and immigration.

FIGURE 3.2 Operational components of the U.S. Department of Homeland Security Source: U.S. Department of Homeland Security (2018c).

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REAL ID ACT OF 2005

The Real ID Act of 2005 aimed to improve the reliability of state-issued identification documents through a harmonized effort by the states and the federal government. It mandated that states verify applicants’ legal status before issuing drivers’ licenses or personal identification cards (U.S. Department of Homeland Security, 2015).

SECURE FENCE ACT OF 2006

The Secure Fence Act of 2006 aimed to help secure the southern U.S. border by building seven hundred miles of fence along the U.S.-Mexico border. The goal was to decrease illegal entries, drug trafficking, and security threats. Moreover, this act reinforced security checks by expanding checkpoints and by using advanced technology to monitor the border.

EXECUTIVE ACTIONS Despite a widely recognized need for comprehensive immigration reform by both the public and Congress, the last congressional action on immigration was in 2006. Several efforts have been made by Congress since then, notably a bipartisan bill that passed in the Senate in 2013 but was refused consideration by the House and subsequently died. Frustrated by congressional inaction, President Obama and President Trump have both undertaken Executive actions on immigration in the form of Executive Orders, Presidential Proclamations, and Presidential Memoranda. These actions focus on policy goals and have the force and effect of law. However, they are easily modified or revoked by a sitting or subsequent president (Chu & Garvey, 2014).

OBAMA EXECUTIVE ACTIONS

The Obama administration undertook numerous Executive actions on immigration (Zamora, 2016), and the three that have received the most public attention are addressed here: Secure Communities/Sanctuary

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Cities/Priority Enforcement; Deportation Priorities; and Deferred Action for Childhood Arrivals. SECURE COMMUNITIES, SANCTUARY CITIES, AND PRIORITY ENFORCEMENT

This series of three Executive actions evolved from each other. The Secure Communities deportation program was initiated in the final year of the George W. Bush administration and was fully implemented during the Obama administration. It entailed cooperation between local and state law enforcement agencies and Immigration and Customs Enforcement (ICE). The state or local jurisdiction sent the fingerprints of individuals arrested or booked into custody to the FBI, which in turn sent them to ICE. ICE checked the fingerprints against its databases to determine whether the person was in the United States unlawfully and, if so, decided whether to take immigration enforcement action (U.S. Immigration and Customs Enforcement, 2018). If ICE decided to act, it issued a detainer order to the local agency to detain the individual in custody for forty-eight hours beyond the scheduled release time (Zamora, 2014). However, many state and local jurisdictions soon found Secure Communities to be problematic. Despite the stated intent of ICE to prioritize the deportation of undocumented immigrants who posed a serious criminal threat to the public, many of those deported had committed only minor crimes, sometimes decades earlier, or no crimes at all. Further, racial and ethnic profiling concerns were raised. Law enforcement officers felt that they had lost the trust of immigrant communities, which was contrary to the widely adopted ethos of community policing (Waslin, 2011). Consequently, many jurisdictions decided to stop cooperating with ICE in the Secure Communities program. These jurisdictions came to be labeled “Sanctuary Cities,” although there was no agreed-upon definition of that term (Zamora, 2017). In 2014, the Obama administration replaced Secure Communities with the Priority Enforcement program. Under this program, ICE only sought custody of undocumented immigrants from state and local authorities if the individuals were convicted of Priority 1 or 2 criminal offenses (see Deportation Priorities), and the detainer orders were replaced with requests for notification. Local jurisdictions were requested to notify ICE of a pending release of such an individual (Zamora, 2014). Over the years, the Obama administration progressively narrowed the focus of deportation actions. In 2014, the

DEPORTATION PRIORITIES

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administration implemented the following priorities for removal of undocumented immigrants (Zamora, 2014): Priority 1: undocumented immigrants who pose national security threats (terrorism), convicted felons, gang members, and illegal entrants apprehended at the border. Priority 2: persons convicted of significant or multiple misdemeanors, as well as individuals who entered or reentered this country unlawfully after January 1, 2014. Priority 3: noncriminals who have failed to abide by a final order of removal issued on or after January 1, 2014.

DEFERRED ACTION FOR CHILDHOOD ARRIVALS In 2001, the Development, Relief, and Education for Alien Minors (DREAM) Act was introduced in Congress. Its aim was to provide a pathway to legal status for undocumented young adults who had been brought to the United States as children (typically by their parents). These individuals subsequently came to be referred to as “Dreamers.” Numerous versions of this act were introduced in subsequent years, but it was never passed (American Immigration Council, 2017). In response to congressional inaction on the issue, the Obama administration created the Deferred Action for Childhood Arrivals (DACA) program in 2012. This allowed certain Dreamers protection from deportation and authorization to work. The eligibility criteria for this program were highly restrictive, and the program was temporary for two years. DACA was expanded in 2014 to allow existing participants to reapply, adjusted the date of entry requirement from 2007 to 2010, extended the period of protection from two to three years, and removed the age limit (Zamora, 2014).

TRUMP EXECUTIVE ACTIONS

Like the Obama administration, the Trump administration has taken many actions on immigration. Trump’s actions have essentially moved in a direction opposite to Obama’s actions. President Trump signed nine Executive Orders related to immigrants and refugees from January 2017 through June 2018.

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The Trump administration has taken several measures to decrease illegal border crossings and increase detentions and deportations. These include enforcing border security; prioritizing criminal prosecution of illegal entry and reentry and human smuggling; arresting and prosecuting parents who have paid to have their children brought to the United States as unaccompanied minors; prosecuting parents who cross the border illegally with their children, and separating families by detaining the parents and children separately (Pierce, Bolter, & Selee, 2018a). Trump signed Executive Order 13767, “Border Security and Immigration Enforcement Improvements,” one week after his inauguration (White House, 2017a). This order calls for construction of a wall along the U.S.-Mexico border and expansion of detention practices. Although prototypes for the wall have been tested, funds have not been allocated for construction (Pierce, Bolter, & Selee, 2018b). Undocumented immigrants comprise about 5 percent of the labor force in United States (López, Bialik, & Radford, 2018), and some believe their deportation may cripple the economy in specific fields. To further deter unauthorized entries, DHS enforced a “zero-tolerance” policy at the border between the United States and Mexico and criminally prosecuted people making unauthorized border crossings in 2018. This policy resulted in family separations and deportation of at least 463 parents without their children (Miroff, 2018). In response to the public outcry regarding family separations, Executive Order 13841 was signed on June 20, allowing DHS to detain family units together without separating parents from their children (White House, 2018). The Trump administration also expanded the target population of undocumented immigrants for deportation beyond the priority groups targeted by the Obama administration to include not only those convicted of a crime but also those charged with a crime or having committed an act that could result in a criminal charge. About 61,000 immigrants were deported by ICE between January 20 and September 30, 2017, which was a 37 percent increase over a similar period of time in 2016 (Pierce et al., 2018b). Moreover, the Trump administration limited work visas following Executive Order 13788, “Buy American and Hire American,” to protect the interest of national workers and prevent fraud in the immigration system (White House, 2017b). This Executive Order resulted in an increase in rejection and required review time for work visa applications, added evidentiary IMMIGRATION ENFORCEMENT

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requirements for some temporary work visas, and ended the parole admission of foreign-born entrepreneurs to the country (Pierce et al., 2018b). Trump also restored the Secure Communities program, although many local jurisdictions continue to refuse to cooperate with it. In a similar vein, Trump attempted to crack down on sanctuary cities through Executive Order 13768 and by threatening to cut off their federal funding (White House, 2017c). This Executive Order, “Enhancing Public Safety in the Interior of the United States,” was also signed in late January 2017 but was found unlawful by the federal courts in late April 2017; a permanent injunction against its implementation was issued in November 2017 (Pierce et al., 2018a). The most significant Executive action of the Trump administration was the termination of DACA in September 2017, which meant that DACA holders would no longer have this status after its two-year expiration. In January 2018, a federal court issued an injunction, and the U.S. Citizenship and Immigration Services began accepting applications for DACA renewals but no new applications while the Department of Justice appealed the decision (Pierce et al., 2018a). In April 2018, a federal court ordered USCIS to continue accepting applications for DACA even from new applicants (Pierce et al., 2018b). The ultimate fate of DACA or introduction of a future DREAM act is unknown. ELIMINATION OF TEMPORARY PROTECTIONS FOR NONCITIZENS

Almost immediately after taking office, President Trump issued Executive Order 13769, immediately suspending entry to the United States of nationals from seven majority Muslim countries: Iran, Iraq, Libya, Somalia, Sudan, Syria, and Yemen (White House, 2017d). Almost immediately thereafter, the ban was challenged in court, and the administration subsequently developed a new version of the ban, Executive Order 13780 (White House, 2017e). This version of the travel ban removed Iraq from the list of countries, set a delay in implementation time of the order, and exempted individuals who had previously received authorization to travel to the United States (Chishti, Pierce, & Plata, 2018). On March 15, one day before the date set for the ban to become effective, the order was subject to a “nationwide temporary restraining order,” which prevented implementation of some parts of the ban (Pierce et al., 2018b). The third version of the travel ban was released in September 2017 as a proclamation, and it was approved by the Supreme Court in December 2017. The travel ban in force currently bars entry of

REFUGEE ADMISSIONS REDUCTION AND TRAVEL BAN

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groups from Iran, Libya, North Korea, Somalia, Syria, Venezuela, and Yemen. Concurrently, the administration reduced the number of refugees admitted to a maximum of 50,000 for fiscal year 2017, down from 85,000 from the prior year set by the Obama administration. Trump also increased vetting of refugees from eleven countries (Egypt, Iran, Iraq, Libya, Mali, North Korea, Somalia, South Sudan, Sudan, Syria, and Yemen). The result of all of these measures has been a drastic reduction in refugee admissions to a number much lower than even the 50,000 ceiling (Pierce et al., 2018a).

DISCUSSION QUESTION

In 2017, the National Association of Social Workers (NASW) stated its opposition to the “Muslim ban.” What other positions has NASW taken regarding immigrants and refugees?

OTHER POLICIES AND LAWS AFFECTING IMMIGRANTS AND REFUGEES Specific policies affect immigrants and refugees, but other more general policies addressing people’s rights and privileges also apply to them. In addition to these policies, which form statutory law, numerous foreign-born individuals’ rights and privileges have been established by case law, or judicial rulings on specific cases. These rulings establish precedents that are then a basis for law. In general, outside of specific immigration and refugee laws, foreign-born individuals are subject to the same laws as citizens. Major exceptions to this are in the areas of public benefits (previously described), electoral rights, and employment/occupational rights (DeSipio & de la Garza, 1998). Noncitizens do not have the right to vote, except in a very few local elections in a few jurisdictions. Clearly, this has implications for the political power and influence of immigrant groups. Legal immigrants generally have the same employment and occupation rights and privileges as citizens, except that most government jobs are restricted to citizens. Undocumented foreign-born individuals, of course, do not have the right to work. However, as noted earlier, undocumented foreign-born children have been granted the right to public education.

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Foreign-born individuals have benefited from laws designed for U.S.born ethnic minorities such as African Americans, Hispanic Americans, Asian Americans, and Native Americans. Civil rights laws, voting rights protections, and affirmative action programs were not originally designed for foreign-born individuals, but these laws have nonetheless benefited foreign-born individuals of these ethnic minority groups (DeSipio & de la Garza, 1998). This has caused some controversy. These laws were designed to remedy past discrimination experienced by U.S.-born minority groups. Foreign-born individuals did not experience this past discrimination, and concern about the equity and effectiveness of these laws has set up a potential for backlash by the U.S.-born minority groups against foreign-born individuals, putting the two populations in competition for public resources and public sympathy (DeSipio & de la Garza, 1998). Consequently, it has been argued that explicit policies addressing foreign-born individuals’ needs should be developed because their needs differ from those of native-born minorities (DeSipio & de la Garza, 1998).

POLICY IMPLEMENTATION

Immigration and refugee policies usually provide broad authority and apply to general situations. Agencies must then apply the general provisions of the statutes to specific, detailed situations. To implement immigration and refugee policies, federal agencies such as DHS develop regulations that apply the law to daily situations. These proposed, interim, and final rules and regulations are published in the Federal Register, a centralized government document published daily. Proposed rules are open to public comment before they become interim or final rules, both of which have the force of law. After publication in the Federal Register, the regulations are collected and published in the Code of Federal Regulations (CFR). Title 8 of this code, often referred to as 8 CFR, pertains to “Aliens and Nationality” and contains most of the immigration and refugee regulations. These resources and more can be found at the U.S. Citizenship and Immigration Services website (https://www.uscis.gov/legal-resources). Finally, implementation of policies is carried out through the daily operations of a variety of federal, state, and private agencies. Chapter 4 describes these operations as part of the service delivery system.

ANSWERS TO CIVICS TEST

1. 2. 3. 4. 5.

6.

7. 8.

9.

10.

The Constitution You can practice any religion, or not practice a religion. Capitalist economy or market economy 435 Because of high taxes (taxation without representation), or Because the British army stayed in their houses (boarding, quartering), or Because they didn’t have self-government U.S. diplomat, or Oldest member of the Constitutional Convention, or First Postmaster General of the United States, or Writer of “Poor Richard’s Almanac,” or Started the first free libraries Fought for women’s rights, or Fought for civil rights World War I, or World War II, or Korean War, or Vietnam War, or (Persian) Gulf War Any one of the following: Q Cherokee Q Navajo Q Sioux Q Chippewa Q Choctaw Q Pueblo Q Apache Q Iroquois Q Creek Q Blackfeet Q Seminole Q Cheyenne Q Arawak Q Shawnee Q Mohegan Q Huron Q Oneida Q Lakota Q Crow Q Teton Q Hopi Q Inuit Puerto Rico, or U.S. Virgin Islands, or American Samoa, or Northern Mariana Islands, or Guam

4 HUMAN SERVICES DELIVERY SYSTEMS

and diverse network of organizations and personnel delivers human services to refugees and immigrants. This network includes international, national, state, and local agencies, both public and private. It also includes professionals and paraprofessionals from a variety of disciplines. This chapter describes these organizations and workers and the major service delivery strategies they use. A LARGE

SERVICE DELIVERY ORGANIZATIONS INTERNATIONAL ORGANIZATIONS

International organizations assist people during the premigration, departure, transit, and return stages of the migration process. Most immigrants do not require assistance during these stages, and they make their departure, transit, and return arrangements on their own. However, some immigrants and all refugees do require international assistance. International organizations include intergovernmental organizations and private agencies. Additional information about specific organizations can be obtained by visiting their websites. Intergovernmental organizations are associations, such as the United Nations, that consist of member nations. Many intergovernmental bodies are involved with immigrants and refugees. For some, serving these populations constitutes their exclusive mandate, whereas for others it is only part of their mandate. The world’s leading intergovernmental body is the United Nations; its numerous programs and funds are outlined in the following box.

INTERGOVERNMENTAL ORGANIZATIONS

SELECTED UN FUNDS, PROGRAMS, SPECIALIZED AGENCIES, AND OTHERS RELEVANT TO IMMIGRANTS AND REFUGEES

The UN system is made up of the UN itself and many affiliated programs, funds, and specialized agencies, all with their own membership, leadership, and budget. The programs and funds are financed through voluntary rather than assessed contributions. The specialized agencies are independent international organizations funded by both voluntary and assessed contributions. Programs and Funds UNDP (www.undp.org) The United Nations Development Programme works in nearly 170 countries and territories, helping to eradicate poverty, reduce inequalities, and build resilience so countries can sustain progress. As the UN’s development agency, UNDP plays a critical role in helping countries achieve the Sustainable Development Goals. UNICEF (www.unicef.org) The United Nations International Children’s Emergency Fund provides long-term humanitarian and development assistance to children and mothers. UNHCR (www.unhcr.org) The United Nations High Commissioner for Refugees protects refugees worldwide and facilitates their return home or resettlement. WFP (www.wfp.org) The World Food Programme aims to eradicate hunger and malnutrition. It is the world’s largest humanitarian agency. Every year, the program feeds almost eighty million people in about seventy-five countries. UNODC (www.unodc.org) The United Nations Office on Drugs and Crime helps member states fight drugs, crime, and terrorism. UNFPA (www.unfpa.org) The United Nations Population Fund is the lead UN agency for delivering a world where every pregnancy is wanted, every birth is safe, and every young person’s potential is fulfilled. UNEP (www.unep.org) The United Nations Environment Programme, established in 1972, is the voice for the environment within the UN. It acts as a catalyst, advocate, educator, and facilitator to promote the wise use and sustainable development of the global environment. UNRWA (www.unrwa.org) The United Nations Relief and Works Agency for Palestine Refugees has contributed to the welfare and human development of four generations of Palestine refugees. Its services encompass education, health care, relief and social services, “CONTINUED”

“CONTINUED”

camp infrastructure and improvement, microfinance, and emergency assistance, including in times of armed conflict. It reports only to the UN General Assembly. UN Women (www.unwomen.org) UN Women merges and builds on the important work of four previously distinct parts of the UN system that focus exclusively on gender equality and women’s empowerment. UN-Habitat (www.unhabitat.org) The mission of the United Nations Human Settlements Programme is to promote socially and environmentally sustainable human settlements development and to achieve adequate shelter for all. UN Specialized Agencies The UN specialized agencies are autonomous organizations working with the United Nations. All were brought into relationship with the UN through negotiated agreements. World Bank (www.worldbank.org) The World Bank focuses on poverty reduction and the improvement of living standards worldwide by providing low-interest loans, interest-free credit, and grants to developing countries for education, health, infrastructure, and communications, among other things. IMF (www.imf.org) The International Monetary Fund fosters economic growth and employment by providing temporary financial assistance to countries to help ease balance of payments adjustment and technical assistance. The IMF currently has $28 billion in outstanding loans to seventy-four nations. WHO (www.who.org) The World Health Organization is the directing and coordinating authority on international health within the UN. The objective of WHO is the attainment by all peoples of the highest possible level of health. Health, as defined in the WHO Constitution, is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity. UNESCO (www.unesco.org) The United Nations Educational, Scientific, and Cultural Organization focuses on everything from teacher training to helping improve education worldwide to protecting important historical and cultural sites around the world. UNESCO added twenty-eight new World Heritage Sites this year to the list of irreplaceable treasures that will be protected for today’s travelers and future generations. “CONTINUED”

“CONTINUED”

ILO (www.ilo.org) The International Labor Organization promotes international labor rights by formulating international standards on the freedom to associate, collective bargaining, the abolition of forced labor, and equality of opportunity and treatment. FAO (www.fao.org) The Food and Agriculture Organization leads international efforts to fight hunger. It is both a forum for negotiating agreements between developing and developed countries and a source of technical knowledge and information to aid development. IFAD (www.ifad.org) The International Fund for Agricultural Development, created in 1977, has focused exclusively on rural poverty reduction, working with poor rural populations in developing countries to eliminate poverty, hunger, and malnutrition; raise their productivity and incomes; and improve the quality of their lives. UNIDO (www.unido.org) The United Nations Industrial Development Organization is the specialized agency of the UN that promotes industrial development for poverty reduction, inclusive globalization, and environmental sustainability. Other Entities UNISDR (www.unisdr.org) The United Nations Office for Disaster Risk Reduction serves as the focal point in the UN for the coordination of disaster reduction. UNOPS (www.unops.org) The United Nations Office for Project Services is an operational arm of the UN supporting the successful implementation of its partners’ peacebuilding, humanitarian, and development projects around the world. Related Organizations IOM (www.iom.int) The International Organization for Migration works to help ensure the orderly and humane management of migration, to promote international cooperation on migration issues, to assist in the search for practical solutions to migration problems, and to provide humanitarian assistance to migrants in need, including refugees and internally displaced people. SOURCE: UN (N.D.).

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Three major UN organizations are exclusively concerned with international migration and refugees: UNHCR, which assists refugees worldwide (except Palestine); IOM, which assists immigrants, refugees, and internally displaced people; and UNRWA, which assists original Palestinian refugees from the 1948 Israeli War of Independence and their descendants. Further detailed information about each agency can be found on their websites. In carrying out their missions, UN agencies work closely with private, nonprofit international and national humanitarian organizations. These organizations are often referred to in the international arena as nongovernmental organizations (NGOs) or private voluntary organizations (PVOs). NGOs sometimes provide more assistance to vulnerable populations than do some governments, and they may be more active and credible than government aid agencies (Ferris, 2005). In 2000, about 26,000 international NGOs were active, compared to only 6,000 in 1990. The United States alone has about 1.5 million NGOs (U.S. Department of State, 2017a). As a group, NGOs provide more aid to vulnerable populations than does the UN system (Ferris, 2005). Refugee-serving humanitarian organizations range from small-staffed enterprises to large-scale organizations with annual budgets close to those of UNHCR (Ferris, 2005). PVOs and NGOs are often faith-based organizations and receive funding from religious organizations. PVOs and NGOs often carry out many of the assistance tasks during the premigration stage, such as the administration of refugee camps and the provision of food, shelter, and medical care. Many PVOs and NGOs have a broader orientation toward social and economic development, yet they are also relevant to refugees because 84 percent of the world’s refugees are in developing countries, and the successful, long-term resolution of refugee problems depends in part on the larger issue of development (UNHCR, 2017b). A sampling of major private international humanitarian agencies and their activities is provided in the text box. The service delivery system for international migrants is large and complex. Consequently, services are not always delivered effectively and efficiently. Constricted mandates, lack of integration of policies and programs, and inadequate funds are among the factors contributing to this problem (Simich, Beiser, Stewart, & Mwakarimba, 2005). One challenge is the narrow mandate of the service providers, which limits eligibility for assistance. For example, services for refugees are different from services for internally

PRIVATE ORGANIZATIONS

SELECTED MAJOR PRIVATE INTERNATIONAL HUMANITARIAN ORGANIZATIONS RELEVANT TO IMMIGRANTS AND REFUGEES

Action Against Hunger (www.actionagainsthunger.org/) Works to save lives of malnourished children while providing communities with access to safe water and solutions to hunger, food security, and livelihoods. CARE (www.care.org) Dedicated to ending poverty, saving lives, and achieving social justice. Doctors Without Borders (www.doctorswithoutborders.org) Comprised mainly of doctors and health workers providing assistance to populations in distress and to victims of disasters and armed conflict. International Medical Corps (https://internationalmedicalcorps.org) Assists those in urgent need, providing first response health care and related emergency services. Islamic Relief Worldwide (https://www.islamic-relief.org) Independent humanitarian and development organization with a presence in over forty countries across the globe. International Rescue Committee (IRC) (www.rescue.org) Humanitarian relief and development organization founded at the request of Albert Einstein. Offers emergency aid and assistance to people displaced by war, persecution, or natural disaster. International Committee of the Red Cross (www.icrc.org) Helps people affected by conflict and armed violence and promotes the laws that protect victims of war. Mandate stems from the Geneva Conventions of 1949. International Federation of the Red Cross and Red Crescent Societies (www .ifrc.org) Carries out relief operations to assist victims of disasters combined with development work. Oxfam International (www.oxfam.org) Works to create solutions for poverty using sustainable development programs, public education, campaigns, advocacy, and humanitarian assistance. World Jewish Relief (www.wjr.org.uk) British Jewish community humanitarian agency tackling Jewish poverty, primarily in the former Soviet Union. World Vision (www.wvi.org) Global Christian relief, development, and advocacy organization working with children, families, and communities to overcome poverty and injustice. SOURCE: UNIVERSITY OF CALIFORNIA AT BERKLEY (2018).

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displaced people, even though both groups may have been uprooted by the same causes. Moreover, the different phases of migration are handled by different agencies, and lack of coordination between these agencies creates problems in service delivery. Other challenges include the lack of harmony and integration between policies and programs and the ineffective enforcement of international and national laws and policies. Another factor is overlap and gaps in services due to insufficient coverage and funds. Furthermore, conflict may develop between the aims and approaches of international and local agencies working in the same area. Conflict may also occur between the philosophical or religious orientations of PVOs. Finally, although PVOs may strive to be apolitical, their activities may have political implications within the country they serve. Most challenges in providing services for immigrants and refugees are systemic and are not attributable to the immigrants and refugees themselves; therefore, there is a need to address these challenges systemically (Simich et al., 2005). In addition to international agencies that provide and coordinate direct assistance to immigrants and refugees, other agencies provide indirect assistance through advocacy. These organizations monitor human rights around the world, mount public information campaigns, and lobby for policy changes. The major advocacy organizations and their activities are as follows:

MAJOR ADVOCACY ORGANIZATIONS INVOLVED WITH IMMIGRANTS AND REFUGEES IN THE INTERNATIONAL ARENA

Amnesty International (www.amnesty.org) Campaigns for a world where human rights are enjoyed by all. Human Rights Watch (www.hrw.org) Presses for changes in policy and practice that promote human rights and justice around the world. Women’s Refugee Commission (www.womensrefugeecommission.org) Advocates for the rights and protection of women, children, and youth fleeing violence and persecution. Organization for Refuge, Asylum, and Migration (www.oramrefugee.org) Specializes in the protection of exceptionally vulnerable refugees, including LGBTI refugees. Refugees International (www.refugeesinternational.org) Advocates for lifesaving assistance and protection for displaced people and promotes solutions to displacement crises. SOURCE: AUTHORS’ SYNTHESIS.

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UNITED STATES NATIONAL ORGANIZATIONS

National organizations serving immigrants and refugees in the United States are concerned primarily with admissions, border control, deportation, and the resettlement stage of migration. Like international organizations, national organizations include both governmental and nongovernmental agencies. Several federal agencies provide services to immigrants and refugees. The U.S. Citizenship and Immigration Services (USCIS) (http://www.uscis.gov) is part of the Department of Homeland Security. USCIS’s responsibilities include administering immigrant sponsorship, adjustment of status, work authorization and other permits, naturalization, and issues pertaining to refugees and asylees. USCIS has offices throughout the United States and around the world (USCIS, 2018). A second major federal government agency is the Bureau of Population, Refugees, and Migration (PRM) (http://www.state.gov/j/prm), which is part of the State Department. PRM “provides aid and sustainable solutions for refugees, victims of conflict and stateless people around the world, through repatriation, local integration, and resettlement in the United States” (U.S. Department of State, n.d.a, para 1). Domestically PRM administers the admission of refugees who are referred by UNHCR or are otherwise eligible for admission (e.g., a close relative of the refugee is already in the United States). PRM has established a worldwide processing priority system that sets the guidelines for the orderly management of refugee applications for admission. This process takes two years or longer. Once refugees enter the United States, they receive assistance through the State Department’s Reception and Placement Program for up to ninety days. This program is delivered by contracted NGOs and addresses basic needs such as shelter, food, clothing, applying for a Social Security card, arranging for medical appointments, and so forth (U.S. Department of State, n.d.b). After three months, many refugees are eligible to receive additional assistance from the Office of Refugee Resettlement (ORR) (www.acf.hhs.gov/orr), located within the Administration for Children and Families in the Department of Health and Human Services. This agency plans, develops, and directs implementation of the comprehensive domestic refugee resettlement program. This program provides time-limited cash and medical and social service assistance to eligible refugees, asylees, Cuban/Haitian entrants, special immigrant visa holders, Amerasians, and victims of human trafficking,

U.S. GOVERNMENT AGENCIES

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usually during their first eight months in the United States, to help them attain self-sufficiency as rapidly as possible. Additional programs serve eligible populations beyond the first eight months after arrival, and some serve survivors of torture. ORR develops, recommends, and issues program policies, procedures, and interpretations to provide program direction. ORR administers grants to state social welfare departments to implement the resettlement program. The states, in turn, typically contract with private agencies to deliver the resettlement services. ORR monitors and evaluates the performance of the states and private agencies in administering the program and supports actions to improve them. ORR also funds technical assistance to states and private agencies (U.S. Office of Refugee Resettlement, 2017a). Several other federal agencies also serve immigrants and refugees, although that is not their exclusive function. The Bureau of Consular Affairs (www.travel.state.gov) in the State Department issues visas to nonU.S. citizens at its overseas offices (U.S. Department of State, n.d.c). The U.S. Agency for International Development (USAID) (http://www.usaid. gov) engages in humanitarian efforts in foreign countries to save lives, reduce poverty, strengthen democratic governance, and empower people to help themselves (USAID, 2015). Finally, the Centers for Disease Control and Prevention (CDC) (http://www.cdc.gov) tracks diseases among immigrant and refugee populations, responds to disease outbreaks in the United Sates and worldwide, provides advice on health care for refugee groups, and educates and communicates with immigrant and refugee groups and their service providers (CDC, 2016). At the state government level, each state (except Wyoming) has a refugee coordinator, and most states have a refugee health coordinator (U.S. Office of Refugee Resettlement, 2018b). The state social welfare department also administers all public benefits to immigrants and refugees under federal and state welfare laws. Some state and local governments may have additional designated departments or employees to deal specifically with immigrants or refugees (Singer & Wilson, 2006). At the national level, private organizations are primarily involved with immigrants and refugees in the resettlement stage of migration. A comprehensive resettlement program is available for refugees but not for immigrants, and most private agencies at the national level coordinate services to refugees. Agencies that provide U.S. NATIONAL PRIVATE ORGANIZATIONS

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refugee services exclusively are known are resettlement agencies. These agencies and their local offices contract with federal and state governments to deliver resettlement services. Agencies contract with the State Department’s Bureau of Population, Refugees, and Migration to provide predeparture and initial resettlement assistance. Predeparture assistance is provided abroad prior to departure of the refugees for the United States. It includes gathering basic information about family members, determining any medical problems that will require follow-up, determining addresses of any relatives already in the United States, and determining where refugees and their family members will be resettled. The resettlement agency decides where to resettle refugees based on whether they already have relatives in the United States and on the availability of jobs and resettlement services (Refugee Council USA, 2016; Singer & Wilson, 2006). Initial resettlement assistance provided for refugees by resettlement agencies includes meeting refugees at the arrival airport and covering all necessary expenses for the first thirty days. For the first ninety days, resettlement agencies arrange for food, housing, furnishings, clothing, employment, medical care, counseling, English-language training, cultural orientation, orientation to the public transportation system, orientation to the U.S. monetary system, school enrollment for children, and any other necessary services (Refugee Council USA, 2016). Resettlement agencies also contract with state social welfare departments to deliver services under the resettlement program of the ORR, which provides help for low-income refugees who are ineligible for other federal or state assistance programs. These services are aimed at helping refugees become self-sufficient and are available for the refugees’ first eight months in the United States. The services include cash and medical assistance and social services. The bulk of social services provide English-language training, employment training, and job placement, but other interventions aimed at enhancing self-sufficiency also may be included, such as counseling (Nawyn, 2006). The resettlement agency that serves refugees during the first ninety days may or may not be the same agency that provides services under the ORR resettlement program. Resettlement agencies may provide additional services outside of the scope of their government contracts, such as assisting asylum-seekers in the United States, participating in national policy development, engaging in advocacy, and mounting public education

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campaigns to increase awareness of immigrant and refugee issues and to build community between newcomers and established residents. Most private resettlement agencies are national organizations with local chapters or affiliates. Many are associated with religious institutions and receive part of their funding from them, but they are prohibited from encouraging refugees to join the agencies’ affiliated religions or religious activities. The major national refugee resettlement agencies are listed here:

MAJOR PRIVATE U.S. REFUGEE RESETTLEMENT AGENCIES Q Q

Q Q Q Q Q Q Q

Church World Service (CWS) (http://cwsglobal.org) Episcopal Migration Ministries (EMM) (http://www.episcopalchurch.org/page/episcopal-migration-ministries) Ethiopian Community Development Council (ECDC) (http://www.ecdcus.org) Hebrew Immigrant Aid Society (HIAS) (http://www.hias.org) U.S. Committee for Refugees and Immigrants (USCRI) (www.refugees.org) International Rescue Committee (IRC) (http://www.rescue.org/) Lutheran Immigration and Refugee Services (LIRS) (http://www.lirs.org) United States Conference of Catholic Bishops (USCCB) (www.usccb.org) World Relief Corporation (WR) (http://www.worldrelief.org) SOURCE: U.S. OFFICE OF REFUGEE RESETTLEMENT (2012A).

In addition to these direct service organizations, some national organizations provide indirect service through advocacy. These organizations promote harmonious relations between newcomers and established residents and lobby for humane, fair, and generous national immigration and refugee policies and procedures. The major advocacy organizations are listed here:

MAJOR U.S. IMMIGRANT AND REFUGEE ADVOCACY ORGANIZATIONS Q Q Q Q

American Immigration Lawyers Association (http://www.aila.org) National Immigration Forum (http://www.immigrationforum.org) Human Rights First (http://www.humanrightsfirst.org) National Network for Immigrant and Refugee Rights (http://www.nnirr.org) “CONTINUED”

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“CONTINUED”

Q Q Q Q

National Immigration Law Center (www.nilc.org) Welcoming America (https://www.welcomingamerica.org) Grantmakers Concerned with Immigrants and Refugees (www.gcir.org) Refugee Council USA (http://www.rcusa.org) SOURCE: AUTHORS’ SYNTHESIS.

LOCAL ORGANIZATIONS

As previously noted, many national organizations have affiliates that operate at the local level. In addition, immigrants and refugees may receive services from agencies that are essentially local. These agencies may be either public or private, and they may or may not serve immigrants and refugees exclusively or predominantly. Service delivery systems that are not targeted specifically to immigrants or refugees are referred to as mainstream organizations. These include hospitals, medical clinics, community mental health centers, schools, child welfare agencies, family service agencies, and others. Sometimes these organizations have a program specifically designed for immigrants and refugees, but often they do not. Frequently, staff members of these organizations do not have any specialized training to work with immigrants and refugees. When these agencies do not consider the unique characteristics and needs of immigrants and refugees, they severely limit access to and the effectiveness of their services for these populations. Historically, mainstream social service agencies have presented barriers to service utilization by members of ethnic minority groups, including immigrants and refugees. Refugees have faced a stigma and have been viewed as troublesome immigrants (Park, 2008). Minority people may feel distrustful of mainstream services because of the history of oppression of the minority group by the majority group that operates the mainstream services. Minority clients also may feel that the mainstream system is paternalistic and that they have no input into the operation of the service delivery systems. Language and cultural barriers may lead to isolation and loss of social support (Holley, 2003a). Because immigrants’ problems may not be visible to these organizations nor expressed by refugees and immigrants, a failure

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to reach out and provide services for these groups may result despite their vulnerability (Healy & Link, 2012). Due to these barriers within mainstream agencies, many communities have established private social service agencies to serve certain immigrant or refugee populations, or certain ethnic populations that might include immigrants and refugees. These ethnic agencies are defined by the following characteristics: Q Q

Q

Q

Q Q

created to serve specific racial and ethnic communities; staffed by a majority of individuals who are of the same ethnicity as the client group; individuals and families approaching the agency are usually members of the same ethnic and racial community; usually offer programs that support awareness relevant to the community’s culture; integrate ethnic content into their programs; and actively work to strengthen the links among community members (Holley, 2003a).

Ethnic agencies have access to engage in community building because they are usually trusted by community members. Ethnic agencies may focus on one area of social service, such as mental health, or they may be multiservice agencies. Ethnic agencies are founded on the belief that access and effectiveness of services for ethnic minority clients is enhanced by their staff–client similarity and because client participation is encouraged in decision making (Iglehart & Becerra, 1995). Another type of ethnic-specific service delivery system in many refugee and immigrant communities is the Mutual Assistance Association (MAA). These self-help organizations are formed by the community members themselves. They differ from ethnic agencies in that they usually do not have professional paid staff. They provide services such as community orientation, transportation, clothing, and furniture to newcomers (Nawyn, 2010). Some advantages and disadvantages of both ethnic agencies and mainstream agencies have been noted. Ethnic agencies have the advantage of being built on a relationship between staff and clients due to common ethnic identity. However, ethnic agencies may prefer to recruit nonprofessional staff who are members of the community over professional staff (Holley, 2003b). The services provided also may be substandard because the agency

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is likely to have less access to resources, such as funds and personnel, from the general population (Holley, 2003b). In addition, ethnic agencies may increase the isolation of ethnic groups from the majority society. And workers in ethnic agencies may be less employable in other settings, which may lead them to foster client dependence on the agency as a means of maintaining their own job security. One advantage of mainstream services is that minimal funding for services to ethnic minority groups can be leveraged with more general funds. Further, the mainstream agency can serve as a model of minority-majority group integration, and job security for agency workers tends to be better. A disadvantage is that special minority group funding may get lost in the general funds, and promises of service delivery to minority populations may not be met. As noted previously, the major disadvantage of mainstream services is that they frequently present barriers to access by minority clients. Mainstream organizations, such as hospitals and schools, provide essential services that cannot be provided by ethnic agencies alone. To assure adequate and effective service delivery to immigrants and refugees, it is important for mainstream organizations to decrease their access barriers. The absence of immigrants and refugees among their clients does not necessarily mean that there is no need; rather, it could be an indicator of barriers to access (Healy & Link, 2012). Mainstream organizations can use interpreters to address the language needs of immigrant and refugee clients, but these interpreters should be carefully selected. They should be bicultural and knowledgeable about social work values. Some immigrants and refugees ask their children to be their interpreters, but this results in a parent–child role reversal that places undue responsibility on the child and creates stress in the family (Healy & Link, 2012). In summary, a vast and complex system of organizations delivers social services to immigrants and refugees. Some social workers are employed in agencies that specifically serve these populations, but most social workers’ contacts with refugees and immigrants will occur in the course of their work in mainstream social service agencies.

SERVICE DELIVERY PERSONNEL Most U.S. social workers who work with refugees or immigrants will encounter their clients in the resettlement stage of migration through

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work in resettlement agencies, ethnic agencies, or mainstream agencies. In these agencies, social services to immigrants and refugees are delivered by professionals and paraprofessionals. Professionals include social workers, physicians, nurses, psychologists, teachers, marriage and family therapists, vocational counselors, attorneys, and so forth. Professionals have at least a bachelor’s degree in their discipline and usually have a graduate degree. Paraprofessionals are workers who have not completed a formal university education in the discipline, work under the supervision of a professional, and typically have different job titles in different agencies (Global Social Service Workforce Alliance Interest Group on Para Professionals, 2017). Some titles might include community worker, interpreter, counselor, social adjustment worker, social work associate, mental health assistant, mental health worker, outreach worker, or para-social worker. There are two fundamental distinctions between professionals and paraprofessionals. First, health and social service professionals have the authority to diagnose, treat, and prescribe treatment for health and social problems. Paraprofessionals do not have such authority. Second, professional service delivery is based on technical skills and specialized information, whereas paraprofessional service delivery is based on personal knowledge through experience, background, or culture (Ivry, 1992). Ideally, professionals who are ethnically and culturally matched with their clients would deliver social services to refugees and immigrants (Cabral & Smith, 2011). Thus the ideal service provider is a member of the client’s own refugee or immigrant group who is a professional in the relevant discipline. However, bilingual, bicultural professionals are scarce relative to the considerable number of immigrant and refugee groups. Therefore, the next best option is service delivery by teams of professionals and paraprofessionals working together. Although professionals have a high degree of training in their particular discipline, they often do not have special training for working with refugees and immigrants. This is especially true for professionals in mainstream agencies. The specialized knowledge and skills needed by social work professionals when working with these populations are addressed in detail in later chapters. Here we focus on the functions of paraprofessionals, the challenges they may present to agencies, and issues of hiring, training, and supervising paraprofessionals.

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Paraprofessionals serve as bridges between immigrant or refugee clients and nonindigenous professional staff (Egli, 1991; Leiper de Monchy, 1991). They serve the dual function of representing “the ideals, values, and perspectives of the refugee [or immigrant] community to the agency, and those of the agency to the community” (Egli, 1991, pp. 90–91). Paraprofessionals provide numerous benefits to agencies and clients: Benefits in employing an indigenous staff include a shared common historical, cultural, and linguistic background with the client population as well as close ties, insights and information which may facilitate rapport and enhance communication between service provider and service recipient. As a member of the client group . . . the indigenous worker can also be a socializing agent, role model and guide to the challenges of assimilating into a new society. Furthermore, the indigenous worker is usually less formal than the professional, more responsive. (Ivry, 1992, p. 109).

Paraprofessionals have several roles within an agency and may work as interpreters/translators, outreach team members, and co-counselors (Dubus, 2012). Without careful training and supervision, paraprofessionals can create problems for clients and agencies. This is a particular hazard in the interpreter and mental health worker roles. Provision of interpretation and translation is important because a recently arrived immigrant, refugee, or asylum seeker may not be fluent in English (Tribe, 2002). Misinterpretation and miscommunication can lead to serious consequences. Interpreters must be able to communicate both verbatim and through elaborate explanations that consider cultural subtexts, idioms, affect, and nonverbal cues. To overcome these potential problems, it is important to select interpreters carefully. Interpreters must have excellent linguistic skills and be familiar with social work values. They must be knowledgeable about the cultural values in the settlement country and in the country of origin of refugees and immigrants (Healy & Link, 2012). Unfortunately, untrained agency staff members, other clients, or family members are sometimes brought into an interview to interpret. This is completely inappropriate, except in a medical emergency. In addition to the normal hazards of interpretation, family dynamics may result in family members withholding sensitive information when placed in the role of interpreter (Healy & Link, 2012).

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DISCUSSION QUESTION

Your agency is using an interpreter who does not understand procedures for protecting the client’s privacy. When you try to explain the procedures to this interpreter, he responds angrily because he says that he knows what is best for his community. How would you handle this dilemma?

When paraprofessionals take on the role of mental health worker, problems can arise from lack of training in mental health or an unclear understanding of roles. Paraprofessionals from the same ethnic group as clients may fall into “identity limbo” between professional and client roles. Unclear roles and job descriptions make supervision and evaluation difficult. Professionals and paraprofessionals need to explicitly exchange information on treatment goals and objectives (Walter & Petr, 2006). In hiring paraprofessionals, several issues need to be considered. First, paraprofessionals must possess excellent language skills, good knowledge of both cultures, and personal qualities such as empathy, ability to take charge, patience, persistence, and flexibility (Walter & Petr, 2006). Demographic and socioeconomic factors such as gender, age, religion, ethnicity, socioeconomic level, and sociopolitical orientation need to be considered as well because they can pose barriers between clients and paraprofessionals. For example, in many cultures it is not appropriate for younger people to give advice to older people, or for unrelated men and women to discuss their personal problems with each other. In addition, refugees who are members of the same community may dislike and distrust each other because of their premigration political orientations or other beliefs and values. Training of paraprofessionals should include the eight competencies shown in figure 4.1. Paraprofessionals should also be given opportunities for formal education and career advancement, preferably before starting provision of services or during that time (Global Social Service Workforce Alliance Interest Group on Para Professionals, 2017). Unfortunately, most training provided for paraprofessionals is in the form of informal, on-the-job advice (Walter & Petr, 2006). Regular individual or group supervision by professionals is needed for paraprofessional service providers. Paraprofessionals should be able to easily reach professional staff if needed (Walter & Petr, 2006). In the supervisory

HUMAN SERVICES DELIVERY SYSTEMS

Communication skills

1

5

Collaboration skills

Direct work with clients

2

6

Organization and leadership

Application of knowledge

3

7

Monitoring and evaluation

Community work

4

8

Developing self and others

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FIGURE 4.1 Paraprofessional competencies Source: Global Social Service Workforce Alliance Interest Group on Para Professionals (2017).

relationship, the supervisor must be attuned to potential conflicts (Egli, 1991; Musser-Granski & Carrillo, 1997). For example, professionals might find themselves dependent on paraprofessionals to carry out their jobs, and this might cause resentment. Likewise, paraprofessionals might feel that they are devalued by professionals, and they might resent working in a subsidiary position when they may have been highly respected professionals in their country of origin. Supervisors also need to be alert to potential abuses of power by paraprofessionals, such as showing favoritism to family and friends. In the country of origin of some paraprofessionals, such practices may have been commonplace, but they are unethical in U.S. culture. Supervisors should also be aware that paraprofessionals are often caught between the demands of their refugee or immigrant community and the agency. Community members may resent paraprofessionals for their apparent privileged position.

DISCUSSION QUESTION

A paraprofessional has been creating tension in his ethnic community by trying to use his power at your agency. He has said, “I have connections, so I can get better service for you if you treat me right.” This behavior would have been appropriate in his country of origin, but it does not comply with the norm of avoiding corruption in the United States. When your agency hears about this behavior, how should it respond?

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Good supervision should include support, trust, and respect. Supervisors may need to help paraprofessionals deal with their own issues related to their immigrant or refugee experience and their position in the community. Paraprofessionals may need help in setting boundaries and establishing limits to the help they offer their community. Clinical supervision should include pre- and postsession debriefings. Finally, effective work with paraprofessionals requires developing clear job descriptions for all agency employees, training in effective teamwork, and monitoring the effectiveness of the team approach. Paraprofessionals should also receive appreciation from their supervisors (Walter & Petr, 2006).

SERVICE DELIVERY STRATEGIES AND TECHNIQUES Service delivery to immigrants or refugees in the resettlement phase entails a wide range of strategies and techniques. Social workers and paraprofessionals may assist refugees in a number of areas, including housing, employment, youth services, asset development, counseling, education, legal services, and health care. This not a comprehensive list; other areas have been identified in the discussion of organizational functions and professional and paraprofessional worker functions. In conclusion, social workers serving refugees or immigrants work in and with a variety of organizational structures, with a variety of service delivery personnel, and use a wide array of service delivery strategies and techniques. The following chapters address each of these service delivery strategies in detail in the context of helping immigrant and refugee clients in various problem domains.

5 CULTURALLY COMPETENT SOCIAL WORK PRACTICE

IN THIS CHAPTER, we turn to the practice of social work itself. Subsequent chapters in part II describe specific problems faced by refugees and immigrants and best social work practice responses. Evidence-based practice integrates the best-researched evidence and clinical expertise with client values, and we advocate using evidence-based social work practices with immigrants and refugees. Evidence-based practice combines research with clinical experience, ethics, client preferences, and culture to guide and inform the delivery of interventions (National Association of Social Workers [NASW], 2018a). Best social work practice responses entail these five steps:

1. Create an answerable question based on client or organizational needs. 2. Locate the best available evidence to answer the question. 3. Evaluate the quality and applicability of the evidence. 4. Apply the evidence. 5. Evaluate the effectiveness and efficiency of the solution.

It is important to stress that the last step is particularly important and often overlooked. Evidence-based practice is not limited to applying researchbased interventions; it also includes evaluating one’s practice. This must be kept in mind throughout the subsequent chapters as they address specific issues for immigrants and refugees. Consonant with evidence-based practice, social workers must base all of their work with refugees or immigrants on a foundation of culturally competent practice. Cultural competence refers to the process by which social workers and social service systems respond respectfully and effectively to people of all cultures,

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languages, classes, races, ethnic backgrounds, religions, spiritual traditions, immigration status, and other diversity factors in a manner that recognizes, affirms, and values the worth of individuals, families, and communities and protects and preserves the dignity of each. . . . Cultural competence is a set of congruent behaviors, attitudes, and policies that come together in a system or agency or amongst professionals and enable the system, agency, or those professions to work effectively in cross-cultural situations. NASW (2015, P. 13)

The following discussion of culturally competent practice first provides definitions of some important terms. Specific standards of cultural competence developed by NASW are then presented, and practice with specific reference to immigrants and refugees is discussed.

TERMINOLOGY FOR A CULTURALLY COMPETENT PRACTICE Descriptions of culturally competent practice incorporate specific terms that can help social workers understand its complexities. These terms describe the characteristics of people and the processes people experience.

CHARACTERISTICS OF PEOPLE

Particular characteristics such as race, culture, and ethnicity are often used to categorize people. Race refers to genetic differences among people that are manifested in physical characteristics such as skin color. The U.S. government uses five official race categories when collecting data on individuals: American Indian or Alaskan Native; Native Hawaiian and Other Pacific Islander; black or African American; Asian; and white. However, it has been demonstrated that the concept of race has no scientific validity. That is, physical differences between people are not due to genetics but to environmental influences and the biological process of evolution (Marger, 2015). Nonetheless, people do differ in physical appearance, which can affect their life experiences. In most societies, a majority of people look “alike” in basic characteristics such as skin color, and only small groups of people look “different.” In most cases, the majority group dominates and mistreats members of minority groups in these societies. Thus the most important

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implication of the concept of race for social work is understanding the societal advantages (for majority group members) and disadvantages (for minority group members) that physical appearance bestows upon people. These are discussed further throughout this chapter. Culture is a complex combination of ethics, information, beliefs, rules, skills, and other abilities and customs acquired by members of a society. Contemporary definitions of culture refer to the unspoken knowledge or chain of meaning through which groups of people in particular social settings interpret their existence (Turner, 2005). Culture is transmitted from generation to generation. Ethnicity refers to groups of people having a shared culture and language that is distinctive to members of that group within a society (O’Neill et al., 2014; Zagefka, 2009). Often, ethnicity refers to national origin and background and biophysical traits (Cokley, 2007; O’Neill et al., 2014). For example, Latinx refers to people who have ancestors from Spanish-speaking countries. Ethnicity is sometimes used rather than race to refer to people with similar biophysical traits based on the assumption that people in a “racial” group may share other characteristics and experiences in addition to physical appearance. However, it is important to note that individuals sharing a distinct physical characteristic may be part of different ethnic groups (Cokley, 2007). The term minorities (based on race/ethnicity, language, etc.) is less about a numerical minority than it is about a subordinate status. Black South Africans in the apartheid era, for example, were the numeric majority in that country, but they were an oppressed group. Social scientists use the term minority to stress the discrimination, mistreatment, and disadvantages faced by the subordinate group (Wilkinson, 2000). Language, religion, and sexual orientation are also traits that may be used to define majority/minority relations. None of these terms adequately describes a person’s total and unique reality, and many people do not belong to a single racial or ethnic category. Great variation also exists among people within the same category. For example, Latinx encompasses an extremely diverse group of people from many countries and all races. In addition, people can be further differentiated by their socioeconomic status. For example, the reality of a low-income black person may be more similar to that of a low-income Latinx person than to a middle-class black person. Applying broad categories to describe people is often more harmful than helpful.

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Two additional terms also characterize people’s experiences. Diversity within diversity may describe a Latinx from a family that arrived in the United States five generations ago or five years ago. Intersectionality refers to a combination of social constructions and identities that may include race, ethnicity, social class, gender, sexual orientation, and others that can contribute to the oppression of marginalized groups (Murphy, Hunt, Zajicek, Norris, & Hamilton, 2009). For example, the lived experience of an immigrant woman is different from that of an immigrant man. One need only multiply this by the numerous other social constructions and identities to realize the importance of approaching each client as a unique individual. It is important to keep in mind that these are not static categories but indicators of the dynamic processes that people undergo. Therefore, cultural humility is the key for social workers in this field. Cultural humility in social work practice refers to attitudes and practices toward clients at the micro, meso, and macro levels. This approach encourages social workers to learn from clients and to communicate with them when helping clients make decisions (NASW, 2015). Cultural humility requires three major commitments: (1) a commitment to self-evaluation and self-critique; (2) a commitment to correct power imbalances; and (3) a commitment to develop partnership with those who advocate for others (Tervalon & Murray-Garcia, 1998). The first commitment, self-evaluation and self-critique, acknowledges that service providers should be humble and flexible and that we should critically evaluate ourselves and show a desire to learn more. The second commitment, to correct the power imbalance, acknowledges that clients are the experts on their own lives but that service providers possess a body of knowledge helpful to clients. Therefore, both parties should collaborate for the best outcome. The third commitment acknowledges that positive change also requires advocacy and the involvement of advocates (American Psychological Association, 2018).

INDIVIDUAL AND SOCIAL PROCESSES

What is your ethnic identity? How much do you identify with it? Individuals may have a strong or weak association to a particular ethnic group. The term ethnic identity refers to this sense of belonging. Although many people

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may feel that their ethnic identity is only a minor factor in their lives, others may have a strong connection to their ethnic group. Foreign-born people usually have a strong ethnic identity (St. Louis & Liem, 2005). The classic model of ethnic identity posits that ethnic minority groups follow a three-stage process as a developmental pathway to attain their ethnic identities (Phinney, 1989). The first stage is the unexamined ethnic identity, which represents little or no exploration of one’s identity. In this stage, individuals tend to adapt to the majority values and dominant society. In the second stage, ethnic identity search, individuals search actively for an ethnic identity. In the third stage, identity achievement, they achieve an ethnic identity (St. Louis & Liem, 2005).

DISCUSSION QUESTION

An immigrant family includes a son who embraces his ethnic identity through language and music and a daughter who has tried to assimilate into mainstream U.S. culture and listens to jazz instead of music from her country of origin. Which stage of ethnic identity is each of them demonstrating?

Ethnic identity changes over time and across generations. When compared to the first generation of immigrants/refugees, later generations are more likely to identify with the dominant culture (Schwartz et al., 2012). For example, in a refugee family, parents may work full time and have little time to learn English, whereas their children attend school with English as a Second Language (ESL) classes. These second-generation children learn English quickly and become more assimilated in their new country, whereas their parents may find it difficult to keep up with the cultural changes. When individuals from different cultures are in direct and continuous contact, their process of adaptation is known as acculturation. These contacts can lead to changes in cultural patterns on one or both sides (Rudmin, 2003). Acculturation can take place from any direction when there is continuous contact among two groups or individuals, but it is more common among people who have left their country of origin (Schwartz, Unger, Zamboanga, & Szapocznik, 2010). Newcomers are usually the ones who must adapt to the dominant culture—not the people from the dominant culture.

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Researchers once regarded acculturation on a unidimensional continuum. At one end was the complete maintenance of the native culture, and at the other end was the complete adoption of the new culture, with varying degrees of blending of the two cultures in between. However, scholars now stress that acculturation is much more complex than this (Rudmin, 2003). Acculturation can occur on both individual and group levels. At the individual level, psychological and behavioral acculturation occurs, and at the group level, structural acculturation occurs. This is a multifaceted combination of the physical, socioeconomic, and political positions of various ethnic groups. Berry (1984) presented the contemporary two-dimensional model of acculturation. On the first dimension, individuals have high or low degrees of identification with their native, heritage culture. On the second dimension, individuals seek high or low amounts of relationship with the new, dominant culture. The crossing of the two dimensions results in four possible acculturation outcomes (figure 5.1). Berry later added structural acculturation and its characteristics to his model, illustrating four possible outcomes for societies, rather than individuals (figure 5.2).

Maintenance of heritage culture and identity

Relationships sought among groups

+

–

Integration The individual identifies with both cultures; feels equally comfortable in both.

–

Separation The individual completely maintains the native culture and completely rejects the new culture; this may result from being denied access to the dominant culture.

FIGURE 5.1 Individual acculturation Source: Berry (2005).

Assimilation The individual rejects the native culture an adopts the new one.

Marginalization The individual does not identify with either culture; this can result from withdrawal or exclusion.

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Maintenance of heritage culture and identity

Relationships sought among groups

+

–

Multiculturalism Cultural diversity is common in the society; both cultures adapt to each other Segregation Forced separation of the minority group in housing, schools, etc.

Melting pot Minority culture has assimilated into the dominant one.

Exclusion Dominant culture enforces marginalization of the minority group; oppression.

– FIGURE 5.2 Structural acculturation Source: Berry (2005).

From the perspective of social work values, the desired outcome for individual acculturation is integration, in which individuals maintain their heritage culture while fully engaging with the new culture; all other outcomes are considered harmful to the individual. Likewise, the desired outcome of structural acculturation is multiculturalism, with all other outcomes being harmful in various ways. Although assimilation and the melting pot may appear to be innocuous, in reality they are oppressive outcomes because they require individuals or minority groups to give up their own cultural heritage. Acculturation is a process, and a person’s position on the two acculturation dimensions can change over time. The process is influenced by factors such as personality, distance between the heritage culture and the new culture, social support, family influences, and environmental influences (Sam & Berry, 2006). The process is stressful for individuals and for families. Acculturation status also has major implications for service delivery, which is addressed in subsequent chapters. Finally, several additional terms associated with individual and structural acculturation are defined in the following text box.

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TERMS RELATED TO ACCULTURATION AND DOMINANT GROUP RESPONSES Q

Q

Q

Q

Q Q

Segmented assimilation refers to racial minority segmentation of the dominant culture. For example, some black immigrants or refugees may assimilate into the minority African American culture, whereas others may assimilate into the dominant culture. Emergent third culture, also known as ethnogenesis, transculturation, and hybridity, refers to the creation of a new culture out of the interaction of two cultures. Panethnogenesis, also known as pan-ethnicity, refers to a racial or pan-ethnic group rather than to a specific culture. For example, Asian American is a pan-ethnic term spanning Chinese American, Japanese American, and so forth. Ethnocentrism is the belief that one’s own culture is superior to others and that other cultures should be judged using the values of the superior culture. Xenophobia refers to a fear, dislike, or hatred of foreigners. Institutional discrimination, also known as institutional racism and oppression, refers to policies and procedures that lead to denial of equal opportunities in employment, housing, education, political participation, health care, and other areas. SOURCE: AUTHORS’ SYNTHESIS.

CULTURALLY COMPETENT PRACTICE The National Association of Social Workers (2015) has established ten standards for cultural competence in social work practice (see text box). Each standard is discussed below with specific reference to immigrants and refugees.

NASW STANDARDS FOR CULTURAL COMPETENCE IN SOCIAL WORK PRACTICE. Social workers shall . . . 1. Ethics and Values: Function in accordance with the . . . NASW Code of Ethics. 2. Self-Awareness: Demonstrate an appreciation of their own cultural identities and those of others. 3. Cross-Cultural Knowledge: Possess and continue to develop specialized knowledge and understanding . . . of . . . the history, traditions, values, family systems, and artistic expressions such as race and ethnicity; immigration and refugee status; tribal groups; religion and spirituality; sexual orientation; gender identity or expression; social class; and mental or physical abilities of various cultural groups. “CONTINUED”

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“CONTINUED”

4. Cross-Cultural Skills: Use a broad range of skills (micro, mezzo, and macro) and techniques that demonstrate an understanding of and respect for the importance of culture in practice, policy, and research. 5. Service Delivery: Be knowledgeable about and skillful in the use of services, resources, and institutions and be available to serve multicultural communities. 6. Empowerment and Advocacy: Be aware of the impact of social systems, policies, practices, and programs on multicultural client populations, advocating for, with, and on behalf of multicultural clients and client populations. 7. Diverse Workforce: Support and advocate for recruitment, admissions and hiring, and retention efforts in social work programs and organizations. 8. Professional Education: Advocate for, develop, and participate in professional education and training programs that advance cultural competence within the profession. 9. Language and Communication: Provide and advocate for effective communication with clients of all cultural groups, including people of limited English proficiency. 10. Leadership to Advance Cultural Competence: Be change agents who . . . work effectively with multicultural groups in agencies, organizational settings, and communities. . . . [D]emonstrate responsibility for advancing cultural competence within and beyond their organizations, helping to challenge structural and institutional oppression and build and sustain diverse and inclusive institutions and communities. SOURCE: NASW (2015).

ETHICS AND VALUES

Social workers are committed to the fundamental values of social justice and uphold the dignity and worth of every person. These are critical underpinnings of culturally competent practice.

SELF-AWARENESS

Service providers should have self-awareness and humility regarding other cultures (Lum, 2010). For example, a worker may anticipate meeting a client from a country of which the worker knows little. Before the first appointment, the worker could look up that country on the

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internet. During the appointment, the worker could say, “I know only a little about your home country. I heard that the mountains are beautiful there, though. What would you like me to know so I can help you better?” This technique, which shows both the worker’s sincere effort and cultural humility, should provide a positive start for the worker–client relationship. A combination of cultures influences all social work practice: the worker’s culture, the client’s culture, and the organizational and societal culture. The first step in developing culturally competent practice is to analyze your own racial, cultural, and ethnic background and biases. How have they influenced your life experiences? By becoming aware of your own ethnic background and how it has shaped your outlook and experiences, you become aware that the decisions your are making may be ethnocentric. Cultural self-awareness and security in your own ethnic identity can lead to greater flexibility and openness toward members of other ethnic groups and lessen negative reactions and judgmental attitudes (Miu Chung Yan & Yuk-Lin, 2005).

CULTURAL SELF-AWARENESS EXERCISE Q

Q

Q

Q Q

Q

Q

Every person is the product of more than one culture, such as family, ethnic group, neighborhood, city, school, church, and social groups. Internet gamer culture is yet another example. List the cultures that you were exposed to and the ones you have accepted. Write down a few values of each of these cultures. Your college, for example, values higher education, and the social work profession values helping others. Which of these values influence you most? Is there anything that people from other cultures do that annoys or alienates you? Think about smells, mannerisms, personal space, conversational styles, and other nonverbal aspects of interactions. How do you react to them? What do you value about other cultures? Be specific. Consider how someone from a different culture might regard you. Do you do anything that might seem rude? For example, do you rush through introductions when others may want more time to chat? Have you ever felt “erased” because of your age, ethnicity, gender, etc.? Perhaps somebody has said to you, “You’re only saying that because you’re just twenty.” How did that make you feel? Have you ever “erased” somebody without realizing it at the time?

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All social workers have their own sets of beliefs that influence their practice. Although people from white mainstream American culture may consider themselves to be unbiased because they grew up in the dominant group, they have as many cultural traits as any minority group.

DISCUSSION QUESTION

As a biracial child, Sharona could “pass” as white but chose to embrace her Asian heritage. She is understandably angry when she hears an ethnic slur. Her new housemate is Michael, who grew up in a white neighborhood and has little awareness of his own culture. His friends are mostly from the dominant culture, and the only culture-specific activity he participates in is St. Patrick’s Day parties every March. He has trouble understanding why people stress their cultural heritage. He asks, “Aren’t we all American?” If you were the third housemate, how would you help these two get along?

After becoming aware of your own ethnic background and how it has shaped your outlook and experiences, the next step is identifying your own negative attitudes, beliefs, and behaviors toward other ethnic groups. This is a challenging task because most people, and particularly those who are in the helping professions, do not like to think of themselves as possessing these negative traits. However, almost everyone has human reactions to people who are different from them. Negative reactions to other people derive from learning—that is, from the messages received from parents, other significant role models, peers, and media—and from interactions (or lack thereof) with members of other ethnic groups. These are learned attitudes and behaviors, and they can also be unlearned. Identifying these negative characteristics in yourself is a positive step toward reversing them. It is also a prerequisite to effective helping. Lum (2010) suggests several tasks to increase awareness of your own negative attitudes and behaviors toward other ethnic groups. These include the identification of a specific belief or attitude from your cultural background that could impede a respectful attitude toward a different group. A feminist who values gender equality, for example, may have a negative reaction to a male client from a traditional culture who demands obedience from his wife. Another task is to describe three kinds of experiences you have had with a different ethnic group: positive, negative,

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and mixed. These experiences may have occurred years ago but still may influence your attitudes toward a group. Stereotypes are another aspect of self-awareness to explore. Stereotypes are generalizations about a particular group. Consider when you have been stereotyped and how it feels. This self-reflection should assist you in realizing why it is critical to be aware of how we stereotype others. In addition to identifying your negative attitudes toward other ethnic groups, reflect on any negative attitudes you have toward the members of your own group. For example, workers who are ethnic minorities themselves may have negative feelings toward members of their ethnic group who have been less successful in society—an attitude of, “I made it, why can’t you?” On the other hand, you can also be in denial about negative characteristics of your own ethnic group or its members. Social workers must identify these attitudes to ensure that they are removing bias from their practice. The next step to improving your cultural competence is to shift your feelings and thoughts toward valuing and respecting cultural differences. By recognizing that no culture is superior to another, culturally competent social workers are nonjudgmental about cultural differences. However, there is a limitation to this. A social worker cannot remain nonjudgmental when cultural norms lead a person to harm someone else. For example, it is acceptable for a man to beat his wife in some cultures. The social worker has an ethical obligation to intervene in this case (in many possible ways) to attempt to stop the harm. The process of shifting from an ethnocentric and negative perspective to a nonjudgmental one requires a conscious and purposeful effort to change your attitudes. The process is enhanced by increasing your contacts with members of other ethnic groups, including social contacts and contacts with clients and coworkers. Seek out these contacts, and use them to enhance your learning about ethnic differences. Finally, culturally competent workers must recognize their own limitations. Cultural differences might interfere with the worker’s efforts to achieve rapport with clients or to help clients accomplish their goals. For example, a gay man may feel uncomfortable working with a client whose traditional culture is homophobic. In these cases, culturally competent workers should consult with their supervisors or coworkers. Professional development activities may help the worker address these differences, or a referral to more appropriate helping resources may be the best option.

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CROSS-CULTURAL KNOWLEDGE

To be culturally competent, social workers need a broad base of knowledge that includes multiple theories, characteristics of different ethnic groups, environmental influences on people, and the cultural basis of social work practice. Culturally competent social workers draw upon a wide range of theories from the social sciences, including the fields of psychology, sociology, anthropology, political science, history, ethnic and women’s studies, and economics (Lum, 2010). Particularly important among these are theories pertaining to ethnicity and related concepts. Theories from each of the disciplines provide varied perspectives on these issues, which are the foundation for developing interventions. Familiarity with a broad range of theories increases the likelihood of developing successful interventions.

MULTIPLE THEORIES

DISCUSSION QUESTION

Select a theory such as labeling theory from sociology. How would that apply to working with a client who is a new arrival from a war-torn country?

To select an appropriate intervention, social workers must be familiar with multiple theories of social work practice, such as critical, cognitive-behavioral, crisis, systems/ecological, macro practice/social development, strengths, empowerment, feminist, and antidiscriminatory theories.

DISCUSSION QUESTIONS

A client enters your office looking defeated and downtrodden. How would the strengths approach be helpful? An immigrant group asks your agency for help regarding police violence. What theories would be helpful?

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Critical thinking, of course, is essential in developing an expertise in these theories and interventions. This thinking requires the systematic, rational consideration of each theory to determine its usefulness for understanding or resolving a particular client problem. For this purpose, the following aspects of a theory should be examined (Lum, 2010): Q

What is the historical context of the theory?

Q

What are the assumptions of the theory?

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Does the theory have any logical flaws?

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Does the theory apply to the specific client?

Culturally competent social workers need to be knowledgeable about the characteristics of the ethnic groups with whose members they work (George, 2012). Knowledge of cultural stresses and strengths, adaptive strategies, and community resources allows the worker to identify factors that contribute to a client’s problem and factors that can be used to help resolve the problem. There are several ways for social workers to gain knowledge about ethnic groups: background preparation, use of cultural guides, and participant observation. Background preparation involves reading about the group. Sociological, psychological, and anthropological studies, personal narratives, and fiction all provide valuable insight into the experiences of ethnic group members. Cultural guides are members of the ethnic group who can teach the social worker about that group. They can include community or religious leaders, coworkers, or former clients. The third method of learning about an ethnic community is participant observation. It involves entering the community, with the help of a cultural guide, and spending extensive amounts of time participating in community activities. This can include participating in family events, community meetings or celebrations, religious activities, or the activities of an ethnic social service agency.

CHARACTERISTICS OF ETHNIC GROUPS

In addition to knowledge about the cultural characteristics of ethnic groups, it is crucial for culturally competent social workers to have knowledge about how ethnic group members are influenced by forces at the levels of the family, group, organization, community, and society. This includes information about the effects of negative attitudes and behaviors of others toward members of the group,

ENVIRONMENTAL INFLUENCES ON PEOPLE

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such as stereotyping, racism, xenophobia, and individual and institutional discrimination. These issues must be understood from both historical and contemporary perspectives. It is important to know not only what discriminatory practices ethnic group members face today but also what they have faced historically. History shapes a person’s ethnic identity, experiences, and outlook, and it provides lessons about past achievements, mistakes, and failures. To improve societal conditions for ethnic group members, it is important to avoid perpetuating past oppression and not to repeat past mistakes. Figure 5.3 illustrates this ecological perspective on the factors that must be considered in working with immigrants and refugees. In learning about other ethnic groups, it is important to remember that there are differences among individuals and families within those groups. These differences are a function of variations in socioeconomic status, level of acculturation, and many other factors. Not all ethnic group members will strictly conform to a generalized description about that group;

Macrosystem Microsystem Workplace, schools, family, peers, community agencies and supports

Exosystem

Family Community agencies

Schools

Individual Age, race, ethnicity, gender, SES, language, trauma exposure, documentation status, sexual orientation, special and/or medical needs, temperament

Individual

Peers Workplace

Exosystem Public policy—pathways to legalization; health care and educational policies

Macrosystem Economic, historical, and cultural context; xenophobia

Mesosystem Relationships between microsystems Chronosystem Change over time

FIGURE 5.3 Ecological model of immigration Source: American Psychological Association (2012).

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it is essential to approach each client as an individual. The knowledge you have about the client’s ethnic group should serve as a starting point for working with the client; it should not serve as a set of unquestioned assumptions about the client. It may be appropriate to check with the client about the validity of specific ethnic group characteristics. For example, you may ask, “In many families from your cultural background, [describe a common belief or behavior]. Is this true in your family?” Most immigrant and refugee clients are happy to share information about their ethnic group characteristics and experiences with the social worker. Their ethnicity is important to them, and they welcome an expression of genuine interest and respect. Culturally competent social workers must understand that generic social work practice (i.e., practice not developed specifically for ethnic minority clients) is itself culture-bound. It has been developed in a specific cultural context and subscribes to specific cultural values. The fundamental roots of social work are found in Western civilization’s view of the individual and society and in Judeo-Christian beliefs. Further, generic social work practice is greatly influenced by five values that characterize mainstream American culture:

CULTURAL BASIS OF SOCIAL WORK PRACTICE

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Active self-expression

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Informality in relationships

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Achievement and accomplishment

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Control of self and one’s destiny while in pursuit of a better future

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Individualism and autonomy

These values are manifested in the way clients’ problems are defined and approached by social workers. These values may conflict with those of clients whose heritage culture defines and approaches problems through the lens of a different set of values. Similarly, many commonly used assessment instruments were initially developed using white, middle-class respondents. These initial respondents are called the normative group, and their responses establish the norms for the instrument; i.e., they determine what scores define the “normal” and “abnormal” ranges. When these instruments are applied to people from a different normative group, they often result in biased assessments that provide inaccurate interpretations.

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CROSS-CULTURAL SKILLS

Skills are the behaviors that effective social workers use in the practice process. Regardless of the underlying theoretical orientation, the social work practice process consists of these sequential steps: 1. Engagement 2. Problem identification and assessment 3. Goal setting and contracting 4. Intervention implementation and monitoring 5. Termination and evaluation 6. Follow-up

Culturally competent social workers need to possess specific skills for each of these phases, which are discussed in the following sections. The worker’s initial contact with the client marks the beginning of the engagement phase of the social work practice process. The major tasks of this phase are to build rapport, establish trust, and establish a mutually respectful relationship. This may require overcoming the client’s feelings of suspicion, distrust, or anger due to past oppression by members of the worker’s ethnic group or more generally by people in authority, which the worker represents. The worker may uncover these negative feelings by asking a question such as, “How do you feel about coming here?” The worker then needs to accept these feelings, discuss their causes, and express understanding of the legitimacy of the client’s feelings. In addition to open and positive communication, culturally competent workers must adjust their communication style to be compatible with that of the client’s culture. This includes using terms or words appropriate to the client’s education and socioeconomic background and using appropriate visual clues, tone of voice, facial expressions, and so forth. For example, it is well known that steady eye contact is considered a sign of attentiveness in the dominant American culture, but it is considered rude or disrespectful in some other cultures. Workers will not know all the cultural nuances of the communication style for various ethnic groups. But to the extent that workers do have such knowledge, they should adjust their own communication style accordingly. ENGAGEMENT SKILLS

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Culturally competent social workers also need to follow culturally appropriate relationship protocols, including customs such as inquiring about one’s family or removing your shoes when entering a home. Use of these protocols conveys sincere respect in a manner congruent with the client’s cultural beliefs. A final crucial skill in building trust and rapport is the appropriate use of self-disclosure. Sharing information about yourself with the client presents the worker as a human being who has some common experiences and feelings with the client rather than as a remote professional who is superior to the client. Self-disclosure is important in working with culturally different clients because discussion of personal problems only occurs in the context of close personal relationships in some cultures; self-disclosure begins to establish that type of relationship. Further, self-disclosure helps to establish common ground and a basis for mutual understanding. Appropriate topics for self-disclosure are sharing information about your background and family, work, and helping philosophy; experiences and feelings that you have had that are similar in some way to those of the client; and strategies you have successfully used to deal with your own problems. It is not appropriate to use self-disclosure to seek help from the client for the worker’s problems, thereby reversing the helping roles. It is also important not to overidentify with the client; acknowledge the differences in feelings and experiences that do exist. Problem identification is the process of creating a definition of the problem that is mutually agreed upon by the client and the worker. Assessment is the analysis of personal and environmental stressors that contribute to the problem and personal and environmental strengths that can be used to help resolve the problem. The first step in this phase is to facilitate the client’s disclosure of the problem (Lum, 2010). Clients from cultures that discourage disclosure of personal problems to anyone but immediate family members may hesitate and feel shame about discussing the problem with the worker. The worker needs to exhibit patience and give the client time to disclose the problem. The client may disclose the problem indirectly, by describing a “friend’s” problem and seeking advice for the “friend.” Or the client may make only vague allusions to the problem. Problem disclosure can be facilitated by asking open-ended and probing questions; treating the client as the “expert” and the worker as the “learner”

PROBLEM IDENTIFICATION AND ASSESSMENT SKILLS

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regarding the problem; and allowing for extended silences. Another technique is to allow the client to depersonalize the problem, which may make disclosure easier. Workers can encouraged clients to talk about “people who experience this problem” rather than talking about themselves directly. A client’s problem may appear to be obvious, for example, when a client is referred for a specific service such as employment assistance. However, even in this case it is important to understand the client’s perspective on the problem because the client’s perspective may well differ from the perspective of the referring agency. In defining the problem, the culturally competent social worker should frame it in terms of the client’s wants or needs rather than focusing on client pathology or blaming the client for the problem. In this way, the worker utilizes a strengths perspective (Saleebey, 2008) as opposed to a client deficit perspective. A problem may be located in one or more of three system levels: micro (individual, family, and small group), meso (local communities and organizations), or macro (complex organizations or systems) (Lum, 2010). The problem definition should identify the levels of the problem because problems often lie at the boundary between two levels, such as in interactions between an individual and the local community. For example, for a refugee who is experiencing difficulty finding a job, the problem is located at the micro-meso boundary. Part of the problem may be that the client does not have the work skills needed in the local community or that the client lacks job-seeking skills. Another part of the problem may be that local employers are unwilling to hire refugees because of xenophobia, fear of high training costs, or for other reasons. Identifying the levels of the problem points the way toward appropriate interventions. In this case, appropriate interventions would include both working on skill development with the client and working with potential employers to increase hiring of refugees. For refugee and immigrant clients, problems often lie in the meso or macro levels in the form of societal discrimination as manifested in factors such as lack of access to health care or employment. These environmental and societal conditions may be responsible for the client’s unsatisfied needs and unfulfilled wants (Lum, 2010). In such cases, working only with the client (the micro level) is highly unlikely to resolve the problem; meso- and macro-level interventions are required. The culturally competent social worker must avoid the tendency to focus only on micro-level problem definitions and make a deliberate effort to comprehensively identify the problem levels.

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Another essential task in problem definition is to identify the problem details. This means defining the problem in terms of specific feelings, thoughts, behaviors, or events; when and where these occur; and their frequency, duration, or magnitude (Bloom, Fischer, & Orme, 2009). The more detailed the problem definition, the easier it is to identify appropriate interventions and the greater the likelihood of successful problem resolution. For example, defining the problem as “acculturation difficulty” is much less useful than defining it as “the client has felt very lonely and has cried every day for the past six months because she wishes she had someone to talk to from her home country.” It is crucial that the worker and the client define the problem by working together. The social worker should continuously verify the accuracy of tentative definitions with the client until a mutually agreed-upon definition is reached. Culturally competent social workers do not impose their views of the problem on the client. After appropriately defining the problem, the next task is problem assessment. The factors that contribute to the problem and those that can be used to help resolve it must be identified. The first step in assessment is to examine the problem within the client’s total biopsychosocial context (see figure 5.3). The worker should assess stresses and strengths that are relevant to the problem. Stresses are factors that contribute to or exacerbate the problem. Strengths are factors that keep the problem from being worse or that can be used to help resolve the problem. Stressors and strengths should be systematically identified at the micro, meso, and macro levels. For example, for a refugee client seeking employment, a micro stressor may be lack of job-seeking skills; a meso stressor might be a high local unemployment rate; and a macro stressor might be societal age discrimination in hiring practices. A micro strength might be the refugee having a good educational background; a meso strength might be the local refugee community having a good job-referral network; and a macro strength might be the availability of a federally funded program for refugee job training. In working with immigrant or refugee clients, it is important to assess cultural strengths such as religious beliefs, historical achievements, and ethnic pride. The discussion of problem identification and assessment so far has referred to “the problem,” as though there were only one. In reality, however, immigrant and refugee clients usually are confronted with a multitude of problems. Culturally competent social workers must identify and assess

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the totality of the problems their clients face. Apply the identification and assessment techniques described here to each of the problems separately and analyze how the problems are related to each other. Often, drawing some type of diagram or map can be helpful in this process. Following this, the work can proceed to the next phase. Goal setting involves determining what the client and practitioner expect the client to experience at the end of their work together. Contracting involves developing an agreement between the client and the worker about how the goals will be achieved, including the responsibilities of the worker, the client, and other relevant parties. A fundamental element of culturally competent practice in this phase is actively involving the client in determining goals and intervention approaches. Workers should solicit clients’ input about desired goals and intervention alternatives and come to agreement on them. Workers should never impose goals and contracts upon clients. The first step in this process is to help clients prioritize their problems. The worker and the client usually do not have the time or resources to address all the problems at once, so they must decide which one to tackle first. The next step is for the worker to educate the client about the intervention process, such as goal setting, expectations, the worker’s orientation, and any relevant legal issues. This helping process may be an entirely new experience for these clients. Many refugee and immigrant clients come from cultures where formal helping relationships such as social work do not exist, or where such relationships may have been used to oppress people rather than help them. Explaining the process to clients before it begins will decrease confusion, bewilderment, fear, resistance, or other reactions that could impede effectiveness. In the third step, the worker and the client together determine the goals and objectives of their work. Goals are long-term, ultimate outcomes, whereas objectives are shorter-term outcomes, or subgoals, that are steps on the way toward achieving goals. For example, a client’s goal may be to obtain work in the same profession that he or she had in the country of origin. The objectives that must be achieved to attain this ultimate goal may include reaching a certain level of English competency, completing necessary educational requirements for professional licensure, and getting licensed. Objectives should be “SMART” (figure 5.4).

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S

pecific

M

easurable

A

chievable

R

elevant

T

ime-bound

FIGURE 5.4 SMART objectives Source: www.presentationgo.com.

The fourth step is to formulate alternative interventions that may be used to attain the objectives. Culturally relevant practice requires that intervention alternatives be multilevel; that is, they target micro, meso, and macro systems. Micro interventions target the individual or family. Meso interventions involve the local community, such as religious and community support systems, with the goal of connecting clients with their ethnic communities, which provide a basis for identity, support, and cultural resources. Macro interventions target the larger society, such as legal advocacy or community organizing (Lum, 2010). The problems of immigrant and refugee clients often have a basis in meso and macro systems, and culturally competent interventions must target those systems for change. To aim for change in the client when the problem really lies in society would further the client’s oppression; it would make the helping relationship a means of oppression rather than a means of help. Worker and client should brainstorm together to develop alternative ways to address the problem. Ask clients what coping strategies and problem resolution strategies they successfully used in the past. These are client strengths that should be built upon when addressing the current problem. All the possible intervention alternatives that the worker and the client generate should be written down. The fifth step is to choose one or more of the interventions from the list of alternatives that has been developed. The selected intervention must fit with the values, beliefs, and norms of the client’s culture. The final step in this phase of practice is to formulate an explicit contract. The contract is an agreement that spells out the intervention(s)

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to be employed; the responsibilities of the worker, the client, community resources, and other relevant parties; the time frame; the frequency of intervention activities; mechanisms for monitoring the process; and practical activities for problem solving (Lum, 2010). Some immigrant or refugee clients may be fearful or apprehensive about contracting, perceiving it as an instrument of authoritarian coercion. Therefore, it is essential for the worker to fully involve clients in the contracting process. Clients can be involved by asking for their suggestions about elements of the contract and by getting their opinions and approval of the worker’s suggestions. Intervention implementation is the process of carrying out the intervention. It involves the activities, behaviors, and statements in which the worker, client, and relevant others engage. Monitoring consists of two parts: monitoring the intervention implementation and monitoring client progress. The exact nature of interventions will vary depending on the approach selected in the preceding practice stage. However, culturally competent interventions share some common elements. Interventions in culturally competent practice have a dual aim: to enhance or restore a client’s psychosocial functioning and to change structural inequities at the societal level. In addition, culturally competent interventions are uniquely tailored to the client’s problem definition, help-seeking patterns, and selection of solutions. Further, culturally competent interventions employ both formal help provided by the social worker or other professionals and informal help provided by community resources such as traditional healers, religious or spiritual leaders, mutual aid groups, and volunteers. To enhance or restore clients’ psychosocial functioning, some general elements of culturally competent intervention apply in addition to the specific intervention strategies that have been selected. First, the worker must explore issues of authority or equality in the therapeutic relationship. The worker is an expert who has access to helping resources, and the client is in need of those resources. This establishes a power differential between the worker and the client. By virtue of their education, socioeconomic status, and often membership in the dominant ethnic group, workers have greater power in society than do immigrant or refugee clients. These power differences are obvious to clients, and workers who fail to acknowledge them communicate a lack of respect and understanding of the client’s reality.

INTERVENTION IMPLEMENTATION AND MONITORING SKILLS

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The worker must acknowledge the power differences and work to decrease them by actively involving the client in the intervention implementation phase, just as was done in earlier phases. The client should be involved by undertaking specific intervention tasks, contributing to the monitoring process, and providing feedback about the relevance and effectiveness of intervention activities. The social worker must monitor interventions as they are implemented. The purpose of monitoring is to determine whether the intervention is being implemented as planned and whether it is being implemented consistently. Monitoring is an important function of evaluation. When a client problem improves, worsens, or stays the same, it is essential to know what intervention activities were associated with that outcome. Interventions with immigrants and refugees frequently must be adapted to be culturally appropriate, and it is important to document these adaptations and their results to build knowledge for work with future clients. A final element of the implementation stage is monitoring client progress. This is different from monitoring intervention implementation. Monitoring client progress refers to tracking the problem that is being addressed to determine whether it is improving, worsening, or staying the same. The frequency, magnitude, or duration of problem behaviors, thoughts, feelings, abilities, or events can be measured through questionnaires, scales, observation, and so forth. In addition to these written monitoring methods, the worker should review progress verbally by soliciting the client’s perceptions of whether and how the problem is improving, worsening, or staying the same. TERMINATION AND EVALUATION SKILLS Termination signals the end of the working relationship. Evaluation is the assessment of the extent to which the client’s problems have been resolved and the goals achieved. Evaluation also measures the extent to which the intervention may have contributed to the problem resolution. Culturally competent workers must undertake several tasks in this phase (Lum, 2010). First, workers should review with clients the progress and growth that clients have made. Workers should provide positive verbal reinforcement for the gains the client has made and the hard work that went into achieving those gains. This review and reinforcement serves to increase the client’s sense of mastery and is an empowering process. The review also helps clients identify their own strengths and

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coping strategies, as well as community resources that they can use when faced with future problems. Another important task is for the client and the worker to discuss their feelings about termination. These feelings are likely to be both positive and negative. Positive feelings include happiness and pride in the accomplishments that have been made and a sense of enrichment from participating in the helping relationship. Negative feelings may include sadness about ending the relationship and apprehension about what might happen in the future. Workers should acknowledge clients’ feelings of sadness and let clients know that they will be available if needed in the future. Workers should also reiterate the mastery and new skills clients have gained that will help clients feel more able to face future problems on their own. Workers should connect clients with other community resources that can help clients maintain their gains or deal with future problems. These resources may include neighborhood networks, religious institutions, social or recreational organizations, educational institutions, mutual aid groups, and so forth. In some cases, it may be appropriate to involve family members in helping clients maintain the gains they achieved in the working relationship (Lum, 2010). Follow-up is the final stage of the social work process. The purposes of follow-up are to encourage clients to continue their path of progress, provide brief assistance if needed, assess whether improvement has been maintained, and demonstrate interest in the client.

FOLLOW-UP SKILLS

SERVICE DELIVERY

Social workers may possess all the cultural competence skills we have described, yet their efforts will be stymied if the agencies they work in are not organizationally culturally competent. Figure 5.5 illustrates a continuum of agency cultural competence. Culturally competent social workers should determine where on the continuum their agency currently operates. They must recognize cultural barriers when they exist in their own agencies and work toward decreasing those barriers and moving their agency toward cultural proficiency.

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Cultural destructiveness

Cultural blindness

Cultural competence

Culturally oppressive policies and practices

Belief that cultures make no difference

Effective services for culturally diverse clients

1

3

5

4

2

6

Cultural incapacity

Cultural precompetence

Cultural proficiency

Inability to help culturally diverse clients

Recognition of agency problems

Agency serves as a model and leader for others

FIGURE 5.5 Agency cultural competence continuum Source: Goode (2004).

Moving an agency toward cultural proficiency can be done in the following ways: Q

Design social service programs for ethnic minority clients and communities.

Q

Develop accessible, pragmatic, and positive service delivery systems.

Q

Recruit bilingual/bicultural workers.

Q

Participate in community outreach programs.

Q

Establish linkages with other social agencies.

Q

Correct insensitive services that lead to agency underuse.

Q

Incorporate cultural information into agency procedures, structures, and services.

Social workers should also be aware of the ethnic helping networks within the client’s community. This requires research by talking to coworkers, community members, and clients about resources for specific cultural groups.

EMPOWERMENT AND ADVOCACY

Client empowerment aims to decrease client powerlessness, which is the inability to control self and others, alter problem situations, or reduce environmental distress. It is a fundamental element in culturally competent

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interventions. Empowerment involves the use of strategies that enable clients to experience themselves as competent, valuable, and worthwhile both as individuals and as members of their cultural group. Empowerment also enables the client to implement interpersonal influence, improve role performance, develop an effective support system, and work with others to change social institutions (Lum, 2010). Empowerment techniques include educating clients regarding the effects of the oppressing system, mobilizing material and interpersonal resources, building support systems, informing people about their societal entitlements and rights, and strengthening a positive self-image. These techniques aim to increase client self-efficacy, develop group consciousness, reduce self-blame, and aid clients in assuming personal responsibility for change (Lum, 2010).

DIVERSE WORKFORCE

To enhance effectiveness in working with immigrant and refugee clients, it would be helpful to have more immigrant and refugee social workers. This is not to say that U.S.-born social workers cannot be effective; however, working collaboratively with those who are not only members of client groups but who are also trained professionals can only enhance services.

PROFESSIONAL EDUCATION

Social workers should take leadership in educating their colleagues about culturally competent work with immigrants and refugees. Workshops, conferences, and so forth are means to achieve this. So are personal interactions.

DISCUSSION QUESTION

A female social worker holds out her hand to a man from a traditional Muslim country. He refuses to shake it because it would require touching a woman, which is forbidden in his culture. Insulted, she turns away and says to you, her coworker, “What is wrong with him? Some people!” How would you respond?

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LANGUAGE AND COMMUNICATION

In working with immigrants and refugees, social workers must take responsibility for providing services in the language requested by the client. Some clients will be comfortable interacting in English, but others will not. If the worker does not speak or has inadequate speaking ability in the client’s language, the worker should either obtain the services of a competent interpreter or refer the client to a competent bilingual/bicultural worker. When this is not possible because no trained interpreter or referral source is available, the worker must proceed in English if the client does have some comprehension. Clearly, the worker will need to spend more time overcoming linguistic barriers. If the client has no English comprehension, it will be necessary to ask a family member or friend to interpret; however, the worker must be highly sensitive to the inaccuracies and relationship problems that can arise in this circumstance.

LEADERSHIP TO ADVANCE CULTURAL COMPETENCE

Culturally competent social workers must address structural inequity through macro-level interventions such as social policy development, social planning, social administration, community organizing, political impact, and legal advocacy.

CONCLUSION Cultural competency is not something that a social worker acquires overnight. In fact, no one is probably ever completely culturally competent. Rather, cultural competency is a process in which the social worker is continually developing and improving. Cultural competency requires lifelong learning. You have begun the journey!

6 HEALTH ISSUES

social workers are employed in health care settings, they should be familiar with the unique health issues of immigrants and refugees. Cultural issues can have a powerful impact on the health of this population. Not everyone defines “health” and “illness” the same way, nor do they have the same concept of medicine. Chinese culture, for example, stresses the “yin/yang” concept in which an imbalance of these forces causes illness. Communication issues also may occur. In a Dutch study of immigrants who had negative experiences in the hospital, researchers found that the clients felt that the exchange of information was inadequate. One client, for example, suffered from severe pain after a stent had perforated her bladder. The doctors’ reluctance to tell her what had happened caused her further trauma: “I don’t speak Dutch well, and if you’re in pain then it’s easier to speak Spanish. The doctors thought something had happened, and they didn’t tell me. There was a complication, and I wasn’t told about it. . . . I’m still in pain now, and I have totally lost trust” (Suurmond, Uiters, de Bruijne, Stronks, & Essink-Bot, 2011, p. 4). Other issues identified in the study were clients’ beliefs that they were being discriminated against by the hospital staff and that they had different expectations of the medical procedures. Several factors can affect the health of immigrants and refugees. Research indicates that immigrants enjoy better health compared to native-born individuals, at least during the early stages of acculturation. This is called the “healthy immigrant paradox,” and researchers disagree on the reason for this. Some say this could be due to healthy lifestyles before immigration to the United States, and others suggest that healthier

WHETHER OR NOT

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foreign-born individuals are more likely to immigrate. Other studies indicate that some groups of immigrants are more prone to specific diseases due to low-quality health care in their country of origin (Kandula, Kersey, & Lurie, 2004). In the long-term, however, immigrants’ health status becomes more similar to that of native-born individuals (Cunningham, Ruben, & Narayan, 2008). Some health problems are more common in the foreign-born than in native-born people. For instance, diabetes is more common among migrants than among U.S-born individuals. Infectious diseases such as malaria and typhoid fever can affect people from certain countries. Moreover, foreignborn individuals are more likely to face occupation- and transportationrelated injuries and are less likely to participate in prevention programs such as cancer screening (Cunningham et al., 2008). The situation for forced migrants is quite different. Refugees and asylees fleeing countries affected by conflicts usually undertake an arduous journey to safety. Before arriving at a safe place, they are at risk of infectious diseases due to stress and inadequate access to sanitation and heath care (Asgary & Segar, 2011; Segal, Elliott, & Bopp, 2012). Moreover, due to the hardships they have faced, there is an increased chance that they will arrive with poor mental or physical health (Palic & Elklit, 2011). This chapter begins by describing the relevant health issues, including the reasons for this population’s vulnerability to poor health. Then we present best practices for addressing these issues. Throughout the chapter, discussion questions based on case studies are presented for contemplation of appropriate social work action.

HEALTH AND HEALTH CARE CHALLENGES The health status of the foreign-born is often comparable to that of U.S.born individuals of similar race or ethnicity, and sometimes with the health status of individuals in the country of origin (Cunningham et al., 2008). In addition to the health condition of immigrants and refugees upon arrival in the United States, the major considerations pertaining to the health and health care of immigrants and refugees are health care access problems, differential health status, health beliefs and health practices, psychosocial issues, and subpopulations with unique health issues.

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HEALTH CARE ACCESS

Access to health care is complex and consists of both the availability of services and the opportunities for access. Health care access requires that effective measures be in place to obtain satisfactory health outcomes. Equity in access is another important concept (Gulliford et al., 2002), and both vertical equity (giving the same opportunity to all) and horizontal equity (giving opportunities based on need) must be considered (Cisse, Luchini, & Moatti, 2007). For example, a horizontal equity policy would invest more funds in a low-income area that needs more health services. Inadequate access to health care also affects the overall U.S. population (Derose et al., 2009). Delayed health care often results in higher public expenditures. For example, a person who did not receive early preventive treatment and now seeks emergency treatment once the condition has become life-threatening incurs higher costs for care. Untreated communicable diseases also pose a threat to public health. Healthy immigrants and refugees are better positioned to reach self-reliance, find employment, and integrate into the community (Halpern, 2008). Thus access to health care is important not only to immigrants and refugees but to the whole society. The major barriers to access are structural, financial, and personal/cultural. Structural barriers arise when patients cannot access health care because of complexity, lack of funding, bureaucratic procedures, or outdated systems (Betancourt, Green, Carrillo, & Ananeh-Firempong, 2003). Racial and ethnic minorities are more likely than whites to live in medically underserved areas (Politzer et al., 2001). Additional structural barriers include limited clinic hours, long wait times, discontinuity in physicians, lack of transportation, lack of insurance, lack of documentation, and fragmentation of the health care system (Asgary & Segar, 2011; Foley, 2005; Garcés, Scarinci, & Harrison, 2006; Scheppers et al., 2006). Furthermore, minority patients sometimes receive differential treatment, such as less access to organ transplants and fewer referrals for cancer screening and other oncology services (Allford, Qureshi, Barwell, Lewis, & Kai, 2014; Derose at al., 2009; Hasnain-Wynia et al., 2007; Kressin & Petersen, 2001).

STRUCTURAL BARRIERS

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Policies that link health care eligibility to the legal status of immigrants and refugees are another critical structural barrier. Lack of documentation is a major barrier in access to health care. The Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA) is the major federal policy restricting immigrants from accessing health care through the public system (see chapter 3). This act largely shifted responsibility for immigrant eligibility policy from the federal to the state level, and eligibility for public health programs for immigrants and refugees now varies among states. Although PRWORA severely restricted access to a range of health benefits for immigrants, some health benefits are still available (see chapter 3). All foreign-born people, including undocumented immigrants, remain eligible for the following programs: public elementary and secondary education; school breakfast and lunch programs; treatment under Medicaid for emergency conditions (except organ transplants); short-term, in-kind emergency disaster relief; immunizations, testing, and treatment of communicable diseases; and in-kind services delivered at the community level that are necessary for the protection of life and safety and are not based on individual needs assessments (Siskin, 2016). Undocumented immigrants face additional structural barriers to health care services, and large numbers of undocumented people do not seek needed health care (Edward, 2014). In one study, a provider described the response of one individual to his medical crisis: “A case comes to mind of a young man badly injured in a work accident. As soon as he was conscious, but still badly injured, he tried to leave the hospital because he was so fearful of being discovered and deported” (Hacker, Chu, Arsenault, & Marlin, 2012, p. 655). According to the National Immigration Law Center (NILC, 2017), hospitals and other medical buildings are considered “sensitive locations” where Immigration and Customs Enforcement (ICE) and Customs and Border Protection (CBP) cannot arrest or question any immigrants in most cases. However, ICE has become more aggressive during the Trump administration. In 2018, for example, this incident took place: “In Texas, ICE agents stood outside the hospital room of 10-year-old Rosa Maria Hernandez as she underwent emergency gallbladder surgery. She was brought to the US when she was just 3 months old, and has cerebral palsy” (Lontine & Pabon, 2018).

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DISCUSSION QUESTION

In 2018, two state lawmakers proposed a bill to protect the constitutional rights of state residents. Its primary purpose was to limit ICE actions in hospitals and other settings once considered to be safe from immigration enforcement. What is the best argument for this bill? What would be the best argument against it?

A related problem is that many health program application forms request the applicant’s Social Security number. Undocumented people usually have a falsified number or none at all, which is another structural barrier to health care. Legal immigrants also have fears that prevent them from accessing health care, including those arising from the “public charge” provisions of PRWORA and the Illegal Immigration Reform and Immigrant Responsibility Act of 1996 (IIRIRA). In Entitled to Nothing: The Struggle for Immigrant Health Care in the Age of Welfare Reform, Park (2011) describes how a legal Chinese immigrant was deemed a “public charge” for using Medicaid services for the birth of her twin babies. Upon her return trip to the United States from China to visit her mother, she was forbidden entry and had to fly back to China—leaving her babies behind for her mother-in-law to pick up at the airport. From 1998 to 2003, immigrants such as this woman were denied access at entry points despite their legal status. Although this program of “welfare fraud enforcement” ended, Park argues that the policy has further stigmatized these immigrants. How would immigrants be able to prove that they will not become public charges? These factors are considered: age, health, assets, resources, family status, education, skill, financial status, and past receipt of benefits. Due to widespread confusion about the issue, many legal immigrants did not apply for public benefits for which they were eligible lest they be deemed a public charge and possibly deported (Broder, Moussavian, & Blazer, 2015). In 2010, the Patient Protection and Affordable Care Act attempted to reform the system for better access. Also known as the Affordable Care Act (ACA) and Obamacare, this act allowed all legal immigrants and refugees to have health insurance coverage. However, the act maintained

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the prohibition on undocumented immigrants’ access to federally funded health services and insurance coverage (Edward, 2014). As noted earlier, undocumented immigrants and refugees remain eligible for emergency care, emergency Medicaid if they are low-income, and can seek nonemergency health services at their community health centers or safety-net hospitals. Children of undocumented immigrants remain eligible to purchase insurance from the state insurance exchange and Medicaid (NILC, 2014). The ACA also improved insurance access for naturalized citizens, because they have the same rights as U.S.-born persons. Legal immigrants also gained access to federal coverage, including premium tax credits and lower copayments. Eligibility restrictions for Medicaid include a waiting period (at least five years) for most lawfully residing, low-income immigrant adults. However, states can provide Medicaid and the Children’s Health Insurance Program (CHIP) without a waiting period to documented children and pregnant women, although this is left for the states to decide individually. As of August 2012, individuals covered under the Deferred Action for Childhood Arrivals (DACA) program are ineligible for Medicaid, CHIP, and ACA benefits (NILC, 2014). Immigrants and refugees also face the structural barrier of language. People with limited English proficiency face numerous obstacles to health care access such as making an appointment, understanding directions to the facility, registering with a health care provider, making sense of parking instructions, navigating the facility, greeting the receptionist, filling out intake forms at the front desk, and lack of interpretation and translation services (Asgary & Segar, 2011; Derose et al., 2009; Garcés et al., 2006). These obstacles all occur before the person is even seen by the health care provider. During treatment, linguistic differences can cause further problems such as misunderstanding, misdiagnosis, incorrect treatment, and lack of adherence to treatment recommendations. One contributing factor to linguistic barriers to health care is the multiplicity of languages spoken in the United States coupled with the fact that about 12 percent of the U.S. population does not speak English (Berry-Cabán & Crespo, 2008). The law that mandates linguistic access to publicly funded health care is Title VI of the Civil Rights Act of 1964. It states that “no person in the United States shall, on ground of race, color, or national origin, be excluded from participation in, be denied benefits of, or be subjected to discrimination under any program or activity receiving

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federal financial assistance.” Almost every health care provider is bound by Title VI, which is interpreted to require linguistic access to health care that entails providing free interpreter services and translated materials. However, current levels of funding are inadequate to meet the rising demand for interpretive services (Substance Abuse and Mental Health Services Administration, 2016). Another relevant law is the Hill-Burton Act of 1946, which funds the construction and modernization of public and nonprofit community hospitals and health centers. Again, the government has interpreted this to include providing linguistic access. In addition to other federal laws, accrediting bodies such as the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) have adopted standards requiring linguistic access. Financial barriers may restrict access of immigrants and refugees to needed medical services, and patients may not adhere to certain therapies due to high costs (Scheppers et al., 2006). Some physicians and hospitals may not accept refugees and immigrants if they lack the financial resources for treatment (Wood & Newbold, 2012). Studies suggest that socioeconomic status is a stronger predictor of health care–seeking behavior than racial/ethnic or immigrant status (Adamson, Ben-Shlomo, Chaturvedi, & Donovan, 2003; Fiscella, Franks, Gold, & Clancy, 2000). Lack of health insurance is one key barrier to access for immigrants and refugees (Asgary & Segar, 2011; Choi, 2009; Derose et al., 2009; Edward, 2014; Siddiqi, Zuberi, & Nguyen, 2009; Tanner et al., 2014; Yu, Huang, & Kogan, 2008). According to a Kaiser Family Foundation report in 2017, “Noncitizens are significantly more likely than citizens to be uninsured. Among the nonelderly population, 17 percent of lawfully present immigrants and nearly four in ten (39 percent) undocumented immigrants are uninsured compared to less than one in ten (9 percent) U.S. born and naturalized citizens”(para. 3). Also, immigrants and refugees are more likely to lack access to prevention services (Tung, 2011). Many jobs filled by immigrants and refugees do not provide health insurance, or they require high insurance premiums (Derose et al., 2009). Latinx are more likely than other immigrant groups to be uninsured, which correlates with high rates of poverty, low education levels, employment in industries that usually do not offer health insurance, FINANCIAL BARRIERS

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and higher rates of undocumented immigrant status among this group (Kandula et al., 2004). Personal/cultural barriers are another factor in accessing health care. For example, cultural beliefs may encourage immigrants and refugees to seek traditional healing services instead of Western medical practices (Gany, Herrera, Avallone, & Changrani, 2006; Scheppers et al., 2006). Three barriers affect the health care–seeking behavior of immigrants and refugees: demographic and social-relational factors; culturally determined beliefs, perceptions, and expectations; and pathways to care and decision-making processes (Cauce et al., 2002; Zanchetta & Poureslami, 2006). Figure 6.1 shows some of the factors that make it less likely for immigrants and refugees to seek Western health care. Another factor is acculturation level, which is usually related to the duration of stay in the United States (Brown et al., 2013). As acculturation level over time changes, the epidemiology of health and disease among immigrants and refugees may change (Rasbridge & Vilaythong, 2012). When African immigrants first arrive to the United States, for example, infectious diseases are a major concern. Later these immigrants may be at risk for chronic diseases such as hypertension (Venters & Gany, 2011).

PERSONAL/CULTURAL BARRIERS

01-Older age

Lower knowledge of health care system-08

Lower english proficiency-07

01 08

02

07

Lower education-06

02-Female gender

03

06

04 05 Living alone-05

FIGURE 6.1 Personal/cultural barriers to seeking health care Sources: Derose et al. (2009); Scheppers et al. (2006).

03-Worse health

04-More recent arrival

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Probably the most important aspect of acculturation is the extent to which a person subscribes to health beliefs of the old and the new culture. These culturally determined beliefs can affect the perception of an illness. In Korean culture, for example, some believe that lasting anger can be the cause of an illness. Expectations about an illness or its treatment also differ between cultures. The traditional Mexican belief in witchcraft may cause some patients to expect an herbal remedy (Gany et al., 2006). The culturally patterned symptom classification system for illness in many cultures is manifested in “culture-bound syndromes” or “folk illnesses.” A person may feel ill or manifest symptoms of illness, but this illness may not fit into the Western medical typology. The following text box provides some examples of folk illnesses.

EXAMPLES OF FOLK ILLNESSES Q

Q

Q

Korean—Hwabyung is caused by lasting anger, disappointments, and sadness. The symptoms seem to symbolize the nature of fire (anger) with feeling hot, having nightmares, and gastric distress. Vietnamese—soul loss is caused by fright or shock. A soul could also leave a body during sleep. The symptoms are thinness, fatigue, and pallor. Wind illness (phong han) is caused by the wind blowing through a woman’s head after giving birth. Symptoms include colds, fatigue, stomach ache, and rheumatism. West African—heat causes ka, which appears as large red bumps that are infected. SOURCES: BAER ET AL. (2003); CAMERON & LEVENTHAL (2003); LUNDBERG & THU (2011); MCDONOUGH (2014); MIN (2009); TOWNS, EYI, & VAN ANDEL (2014).

DISCUSSION QUESTION

Many cultures believe in the concept of soul loss, which can occur in several different ways and is associated with evil spirits. Your Vietnamese client says he is suffering from soul loss. What would you say? Would you try to label the condition using the DSM-5 manual of mental disorders? What would be a culturally competent approach?

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Heath care–seeking behavior also relies on pathways to care. Informal networks of friends and relatives can guide a person to seek Western medical care or to use traditional methods (Hanley, Gravel, Lippel, & Koo, 2014; Pang, Jordan-Marsh, Silverstein, & Cody, 2003). Other personal and cultural factors influencing decisions about health care include historical distrust of Western medicine, limited English, and family structure (Kirmayer et al., 2011). Although Westerners usually separate their professional and personal identities, those from other cultures may prefer a relationship that combines both identities. A Western doctor may not understand a client’s concept of the “evil eye” when the doctor only sees a bacterial infection. It may be difficult for clients who are asymptomatic to understand screenings for high blood pressure and other conditions (Asgary & Segar, 2011; Betancourt et al., 2003; Davidson et al., 2004; Juon, Seung-Lee, & Klassen, 2003; Kirmayer et al., 2011; NgoMetzger et al., 2003).

DIFFERENTIAL HEALTH STATUS

The terms immigrant and refugee do not encompass the wide variations within these groups regarding their health status. Also, Asian and Hispanic/ Latinx include numerous racial and ethnic subgroups. It is beyond the scope of this book to describe variations among all immigrant and refugee populations; therefore, only some general facts are noted. Social workers who work in health care settings should familiarize themselves with the prevalent health problems among the specific immigrant and refugee groups they serve (Centers for Disease Control and Prevention, 2016; Segal et al., 2012). Multiple disparities in health status across various immigrant and refugee groups arise from a complex combination of socioeconomic, physiological, psychological, societal, and cultural factors. As noted previously, socioeconomic factors greatly influence access to health care, which in turn influences health status (Gany et al., 2006). Physiological factors include genetic traits that predispose members of some ethnic groups to certain diseases (Burchard et al., 2003). And cultural factors can include diet, social support networks, norms such as the Muslim prohibition against alcohol, and health beliefs and practices (Helman, 2007).

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HEALTH BELIEFS AND PRACTICES

O’Connor (1998) identified five health beliefs that are common to many immigrant and refugee cultures. Harmony or balance. This refers to the body, relationships with people, and relationships with spiritual entities. Bodies should have a hot/cold balance; for example, drinking a cold liquid to offset a “hot” condition would restore balance. This concept is related to the Chinese yin/yang emphasis on opposites. Imbalance in social relationships can also cause poor health, so rules about proper behavior are stressed. Relationships with spiritual entities can be harmful, and some belief systems such as Haitian voudou emphasize the importance of rituals (Rasbridge & Vilaythong, 2012). Integration of the body, mind, and spirit. Many cultures do not distinguish between mental and physical illnesses, and strong emotions are believed to cause bodily sickness. Vital essence. This is a special energy that enables the person to have good health. The Chinese call it qi (chi) and Haitians call it the gros bon ange (“big good angel”). Magical or supernatural elements that cause illness. Demon possession, curses by humans, and punishment by deities must be addressed for healing to occur. Envy. An envious person may get sick, or the object of envy may suffer from the covetous gaze called the “evil eye” (Khalifa, Hardie, Latif, Jamil, & Walker, 2011; Lovering, 2006; Vandebroek, 2013). COMMON HEALTH BELIEFS

COMMON THERAPEUTIC PRACTICES Immigrants and refugees are more likely than native-born people to use traditional and nonconventional treatments, but medical staff may be unaware of these treatments because clients may not feel comfortable talking about them (Reiff et al., 2003). Cultural healing systems employ herbs and other natural substances, religious and spiritual actions, traditional healers, and physical therapies (Lundberg & Thu, 2011; McDonough, 2014). Natural substances such as botanical, animal, and mineral preparations are used to produce physical, mental, emotional, or spiritual effects. They are used in a variety of ways including ingestion, inhalation, in baths, or moxibustion, which is burning small amounts of herbs on or near the skin.

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Folk healers are popular among some immigrants and refugees because they are more trusted than Western doctors, appear to understand health conditions better, and are less expensive (Reiff et al., 2003). These (folk healers) commonly include midwives, massagers, bonesetters, blood-stoppers, healers of burns and other skin conditions, spiritual specialists, and herbalists or “leaf doctors.” The knowledge and practice of herbalists typically extends to animal and mineral natural substances in addition to botanicals. The curandero/a (“healer”), well-known in most Spanish-speaking cultures, is often a general practitioner. (O’CONNOR, 1998, P. 155)

Physical therapies may include physical exercises such as tai chi or qi gong, which are intended to control the movement of qi in the body, or massage and rubbing of specific body parts. In Southeast Asian cultures, physical therapies include cupping and dermabrasion. In cupping, small cups or jars are heated and placed on the skin. The heat creates a vacuum and suction, which draws impurities out of the body. Dermabrasion, also called coining, involves rubbing a lubricated spoon or coin against the skin to remove “wind” from the body. Moxibustion can cause small burns or blisters. When seen in a medical setting, marks from these procedures may appear to be injuries caused by abuse. Social workers should be aware that these traditional practices can be mistaken for child abuse (Stewart & Rosenberg, 1996).

INTEGRATION OF TRADITIONAL AND CONVENTIONAL HEALING SYSTEMS

Typically, immigrants and refugees make use of both their traditional healing systems and conventional Western medical systems. This integration may have been common in their country of origin or may be a new practice adopted after arrival. Contrary to expectations, neither educational nor acculturation level are associated with a preference for either Western or traditional medicine. Even highly educated and assimilated immigrants and refugees often use traditional healing systems in combination with Western medicine. Two major factors are cost and the type of illness (Graham et al., 2005).

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All immigrants and refugees, of course, are unique in their choices of treatments. As Saha, Beach, and Cooper (2008) explained, service providers should not view clients solely as members of ethnic or cultural groups because such stereotyping can be detrimental. A recent study of health care providers and ethnic minority health care consumers revealed that some health care providers do hold stereotypes of some ethnic groups (Burgess, Warren, Phelan, Dovidio, & Van Ryn, 2010), sometimes because of time pressure when appointments have to be short (Ashton et al., 2003). As a result, clients may feel that medical staff assume that they do not understand. One explained that the doctor was “talking to me as if I was like 10 years old” (Grady & Edgar, 2003).

PSYCHOSOCIAL ISSUES

In addition to health beliefs and health practices, many other psychosocial issues are related to the health and health care of immigrants and refugees. These include treatment adherence, somatization, family involvement, and ethical issues. TREATMENT ADHERENCE Immigrants and refugees often do not adhere to the recommendations of physicians and other health care professionals, which can be a major barrier in providing health services for minorities (Garcés et al., 2006). Reasons for this lack of treatment adherence include: Q

Linguistic issues, such as the inability to read food labels when there are dietary restrictions (Scheppers et al., 2006).

Q

Financial problems, such as the inability to afford prescriptions (Scheppers et al., 2006).

Q

Differences in health beliefs. For example, patients may stop a medication as soon as symptoms have disappeared because they may not understand or believe that the underlying illness may still be present in the absence of symptoms (Hill, Graham, & Divgi, 2011).

Q

Cultural norms that stress the present rather than the future, so preventive measures are disregarded (Maciosek et al., 2006).

Q

Religious practices and spiritual beliefs such as fasting during certain holy days (Wasti, Simkhada, Randall, Freeman, & Van Teijlingen, 2012).

Q

The simultaneous use of traditional healing mitigating the effects of Western medical treatments (Bodeker & Kronenberg, 2002).

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Somatization refers to bodily symptoms for which no natural cause is found (Elklit & Christiansen, 2009). Refugees have a high rate of somatization (Pumariega, Rothe, & Pumariega, 2005). Some authors have argued that the rate of somatization among refugees is not necessarily higher than in the general population but is commonly seen initially as the presenting medical condition (Beiser, 2005). The reasons for somatization among refugees include worrying, medically unexplained issues, and cultural differences that can amplify the explanation of symptoms (Kirmayer & Sartorius, 2007). Other reasons are “the traditional backgrounds of most refugees which discourage direct expression of feelings; culturally-shaped health beliefs which favor psychosomatic unity; lack of familiarity with the concepts of mental health and mental health care; and the language barriers which prevent refugees from communicating in a more abstract psychological manner” (Garcia-Peltoniemi, 1991, p. 49). If unrecognized, somatization can lead to unnecessary and costly medical procedures and delay the start of appropriate psychosocial treatment (Barsky, Orav, & Bates, 2005; Gili et al., 2014). Frequent use of medical services, including hospital and emergency room visits, should alert health care providers and social workers to the possibility of somatization.

SOMATIZATION

Families have a significant role in health and health care; “family members can facilitate and provide care, report symptoms, assist in decision making, and help patients adopt healthy lifestyles and cope with illness” (Horowitz, 1998, p. 165). However, family problems also can contribute to illness. For immigrants and refugees, family involvement in health and health care may be more relevant than for the general population (Scheppers et al., 2006). One reason is that the stress of migrating to and living in a foreign culture may create stronger family ties and family dependence (Zhang & Ta, 2009). Conversely, family members who have been separated by immigration may lack their customary sources of social support. Many immigrant and refugee families have different family structures than U.S.-born families. For example, the father may be the most powerful family member, and he makes the important decisions—including health-related issues and treatment for family members (Scheppers et al., 2006). Further, immigrants and refugees may rely on family for functions that U.S.-born people typically handle without family involvement. Many cultures stress that family needs are more important than individual needs;

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thus illness is a family matter. Immigrants and refugees may make health care decisions based on the impact on the family. An expensive prescription, for example, may not be purchased because of the impact on the family’s budget. Families also play an important role in treatment adherence. For example, families may maintain traditional diets as a means of maintaining their cultural identity. If treatment recommendations include dietary changes, then the whole family needs to be involved. Finally, immigrant and refugee families may define “family members” differently. In some cultures family members include immediate and extended members (Scheppers et al., 2006). Health care frequently poses moral dilemmas that must be resolved through the application of ethical principles. The U.S. health care system has developed a set of principles for resolving ethical problems; however, “the orientation of bioethics reflects the strong emphasis on individualism and autonomy in the United States” (Marshall, Koenig, Grifhorst, & van Ewijk, 1998, p. 204). This orientation conflicts with the cultures of many immigrants and refugees. Consequently, bioethical dilemmas, which are already complex and difficult, become even more so when they pertain to immigrants and refugees. One of the major ethical issues pertaining to immigrants and refugees is the principle of autonomy. The American concept of self-determination rejects the more traditional view that telling patients bad news about their health can be distressing (Marshall et al., 1998). The principle of autonomy must be weighed against the client’s cultural background. There are no clear resolutions to these cultural and ethical dilemmas, but “three elements are essential in successfully resolving moral problems in cross-cultural patient care: an ability to communicate effectively with patients and their families; sufficient understanding of the patient’s cultural background; and identification of culturally relevant value conflicts” (Marshall et al., 1998, p. 204).

ETHICAL ISSUES

SUBPOPULATIONS WITH UNIQUE HEALTH ISSUES

At least three subpopulations of immigrants and refugees have unique health issues different from the health issues of the general immigrant and refugee population. These subpopulations are women; lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) people; and older adults.

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Reproductive health is a crucial issue for most women. Reproductive health is “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and to its functions and processes” (World Health Organization, 2010). The aspects of reproductive health that are particularly relevant to immigrant and refugee women are folk concepts of reproductive anatomy and physiology, prenatal care, infectious diseases that impact pregnancy, nutritional deficiencies, pregnancy outcomes, family planning, neonatal care, and female genital mutilation. The folk concepts that constitute health beliefs and healing systems apply to all aspects of health, including reproductive anatomy and physiology, and these concepts influence decision making about conception, birth, and prenatal and postnatal behavior (DeSantis, 1998). For example, hot/cold beliefs can affect reproductive health decisions. Pregnancy is considered a hot state and menstruation a cold state. Maintaining the hot/cold balance is vital, so it is common that newborn babies and mothers are protected from cold weather and “cold” food. This practice may result in not going to the doctor for weeks to avoid the potential exposure to cold wind. In this example, home visits by health care providers could be considered (Winch et al., 2005). Immigrant and refugee women face barriers to obtaining health care, including access to prenatal care. In many cultures, prenatal care is not seen as necessary unless there is an obvious problem with the pregnancy. Modesty and privacy concerns also may prevent women from seeking prenatal care because exposing the pelvic region and discussing sensitive issues with strangers or with male doctors may be culturally unacceptable. For women who have experienced rape and other traumas, pelvic examinations may be both physically and psychologically traumatic. Immigrant and refugee women are also at risk for infectious diseases and nutritional deficiencies that may affect pregnancy. These problems may arise due to their current living conditions or to those in their country of origin. Despite these risks regarding prenatal care, foreign-born women generally have better birth outcomes than the native-born in terms of infant mortality, low birth weight, and preterm birth; these outcomes are factored into the healthy immigrant paradox (Wingate & Alexander, 2006). Variations in outcomes do occur across different immigrant and refugee groups, and each woman’s risk factors affecting pregnancy outcomes need to be considered in providing health care. Contraception is another issue that immigrant and refugee women may encounter. Many women may not understand their anatomy or birth

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control. They may have been “forcibly sterilized or coerced into contraception by governments attempting to dramatically impact population growth. Immigrant women have been subjected to spousal or societal abuse for attempting to regulate their fertility” (DeSantis, 1998, p. 460). Immigrant women from may be unaware of legal abortion services and may resort to dangerous abortion procedures. The final major reproductive health issue pertaining to immigrant and refugee women is female genital mutilation (FGM), sometimes referred to as female circumcision or female genital cutting (FGC). This procedure, usually done by village women rather than by medical professionals, involves removal of parts or all of the female external genitalia. Type III is the most extensive procedure, in which the remaining portions of the outer labia are sewn together, leaving only a very small opening. As a result, urination can take a long time and menstruation can become an excruciating ordeal. The first sexual intercourse experience may involve a knife or other sharp object cutting open the hole, and extensive cutting may be needed for childbirth (World Health Organization, 2018c). Since FGM is usually done with nonsterile instruments such as razor blades or broken glass, infection occurs in approximately 15 percent of FGM cases. The mortality rate is impossible to determine. Other health consequences are pain, shock, injury, urinary retention, urinary incontinence, menstruation difficulties, obstetric complications, and psychological impacts (Powell, Leye, Jayakody, Mwangi-Powell, & Morison, 2004). Practiced in thirty countries that are mostly in Africa and Asia, FGM affects an estimated two hundred million women and girls worldwide. Some immigrants may continue to practice FGM in the new country or send girls back to the country of origin for this procedure (Powell et al., 2004). FGM is usually done in a ceremonial context so young girls can guarantee their virginity to their future husbands. Although many Muslim countries practice FGM, it has no religious basis and is considered a cultural practice (Utz-Billing & Kentenich, 2008). Performing FGM on a minor is illegal in the United States and is punishable by prison or a fine or both; it also has potential immigration-related consequences (U.S. Department of State, n.d.d). LGBTQ Many traditional cultures regard homosexuality as sinful, and LGBTQ immigrants and refugees may have internalized this stigma and face discrimination in their own communities (Ullah & Huque, 2014). This stigma deters immigrant and refugee men who have sex with men from participating in HIV prevention programs, so the men are at greater risk of HIV infection than native-born men (Dang, Giordano, & Kim, 2012).

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However, HIV/AIDS is not the only health issue relevant to this population. Facing rejection from their communities, LGBTQ clients may experience depressive symptoms that cause them to avoid clinics and refuse to take their prescriptions (Dang et al., 2012). Further, clients usually do not discuss their sexual orientation with health care providers. Social workers need to be aware of the increased potential for health problems among this population (Koku, 2010). Older adults comprise a small portion of immigrant and refugee communities, but they are more likely than younger individuals to experience chronic or terminal illness, disability, depression, and a lack of social support (Cummings, Sull, Davis, & Worley, 2011; Kirmayer et al., 2011). Older immigrants and refugees, particularly those who came to the United States when they were already older, are likely to be socially isolated. Adjustment to the new country can be harder for them. They may have low English proficiency, feel more connected to their home country, and have a high degree of dependence on their adult children (Kirmayer et al., 2011). Immigrants and refugees facing the end of their lives often have unique psychosocial needs, such as coming to terms with the loss of their homeland and the likelihood that they will never return. In a study conducted by Hunter (2016), many older immigrants stated their willingness to return. Living with relatives is slightly more common among older immigrants than it is among U.S.-born older adults. In a study conducted by the Organization for Economic Co-operation and Development (OECD), 7 percent of single older immigrants (80+ years old) stated that they lived with someone else; however, only 4 percent of the native-born did so (cited in Larsson, 2007). All of these issues must be considered in the context of providing health care for this population. OLDER ADULTS

DISCUSSION QUESTION

Flora, an 84-year-old Russian immigrant with end-stage renal disease, is in the hospital. The social worker is trying to place her in a nursing home because Flora’s daughter is unable to care for her at home. The daughter insists on one particular facility because the Russian community recommends it, but Flora wants to be placed in another one. If you were the social worker, what cultural aspects of this situation should you consider before you meet with Flora and her daughter? SOURCE: ALTHAUSEN (1993).

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BEST PRACTICES Social work in health care for immigrants and refugees takes place within the broader context of health care social work. Before addressing the specific needs of immigrants and refugees, it is first necessary to understand this context. In the United States, social work is critical in the health care system. Social workers are well positioned to provide emotional support as well as tangible support for clients and their families. Serving as a link between clients and health care professionals, social workers are key to developing insights on the impact of social factors (Allen & Spitzer, 2015). A 2007 NASW (2008) survey found that 14 percent of social workers were involved with health care settings, with 9 percent working with older adults. The standards for social work practice in health care settings developed by NASW (2016) are outlined here:

NASW STANDARDS FOR SOCIAL WORK PRACTICE IN HEALTH CARE SETTINGS. SOCIAL WORKERS PRACTICING IN HEALTH CARE SETTINGS SHALL: 1. . . . adhere to and promote . . . the NASW Code of Ethics. 2. . . . possess a . . . degree in social work from a . . . program accredited by the Council on Social Work Education, shall comply with the licensing and certification requirements of the state(s) or jurisdiction(s) in which she or he practices, and shall possess the skills and professional experience necessary to practice social work in health care settings. 3. . . . acquire and maintain . . . knowledge of current theory and evidence-informed practice, and shall use such information to ensure the quality of . . . practice. 4. . . . provide and facilitate access to culturally and linguistically appropriate services. 5. . . . engage clients and, when appropriate, members of client support systems, in screening and assessment. 6. . . . develop and implement evidence-informed care plans that . . . ensure a clientand family-centered continuum of care. 7. . . . advocate for . . . clients and client support systems and promote system-level change to improve outcomes, access to care, and delivery of services, particularly for marginalized . . . populations. 8. . . . promote collaboration among health care team members, other colleagues, and organizations to support, enhance, and deliver effective services. 9. . . . participate in ongoing formal evaluation. “CONTINUED”

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“CONTINUED”

10. . . . maintain timely documentation that includes pertinent information regarding client assessment, and intervention, and outcomes, and shall safeguard the privacy . . . of client information. 11. . . . responsibly advocate for workloads and scope of work that permit efficient and high quality social work services delivery. 12. . . . assume personal responsibility for their own continued professional development. 13. . . . strive for leadership roles in educational, supervisory, administrative, and research efforts . . . and shall mentor others . . . to develop and maintain a robust health care social work workforce. SOURCE: NASW (2016).

Social workers are most often involved with their clients on the micro level. However, as seen in the text box on social work standards, other obligations entail meso- and macro-level support, such as leadership, system planning, and advocacy for clients’ rights. On the macro level, service outreach can link individuals in need of health care to service providers. Health fairs in low-income neighborhoods and billboards advertising free blood pressure screenings can promote public health. Social workers may act as liaisons to immigrant or refugee communities that distrust the medical establishment. Social workers are attentive to ethical issues and to cultural sensitivity regarding health beliefs. Social workers must ensure that services are provided without discrimination and in line with clients’ needs and concerns (Allen & Spitzer, 2015). The meso level presents opportunities for social work leadership. The primary focus is on linkage. Social workers act as a bridge between individuals, families, health care providers, and the community. Social workers should also take initiative in developing research projects on quality improvement in health care settings due to their unique perspective., Several aspects of micro practice are critical for social workers in health care settings. Many aspects are typical of social work methodologies, such as assessment and psychosocial evaluation. Providing both emotional support and concrete services (e.g., helping a client apply for disability benefits) are integral to medical social work. Social workers should be aware of recent changes in the health care environment. For example, a new emphasis on chronic illness has developed as the

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population is aging. Another change is the emphasis on health care decisions being made by clients and their families rather than by medical professionals. This is related to an increased recognition of social and environmental influences such as poverty. The health care industry’s struggle to control costs means that market forces can affect a client’s care (Kitchen & Brook, 2005; Marshall et al., 2011). Other major changes stress the importance of client outcomes research to evaluate the effectiveness of social work interventions. There is also an increased effort to encourage clients to be more proactive about their health. Prevention through diet and exercise is an ongoing issue for most people. The following discussion integrates issues of the medical social work context with previously identified health and health care issues of immigrants and refugees. Best social work practices are addressed at the macro, meso, and micro levels.

MACRO PRACTICE

Immigrants and refugees often encounter two aspects of U.S. health care: access and differential health status. These macro-level issues require effective interventions by social workers, including community needs assessment, policy and program advocacy, community-based policy and program planning, and community health education. As the first step in macro practice, social workers need to identify the specific health care access problems and differential health status issues affecting the immigrants and refugees in a local community. The community needs assessment should be developed to answer questions such as the following: COMMUNITY NEEDS ASSESSMENT

Q

What health problems are prevalent among immigrants and refugees in the local community?

Q

What health care resources are available in the community to address these identified problems?

Q

What are the existing service gaps and service duplications?

Q

To what extent do immigrants and refugees utilize available health care services?

Q

What are the specific barriers to immigrants’ and refugees’ health care service utilization?

Q

What community resources can be mobilized to enhance health care utilization?

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Several methods are available for a needs assessment, including focus groups and public forums. Public data such as vital statistics and hospital records are possible resources (Soriano, 2012). A participatory community needs assessment encourages a dialogue between community members and researchers at all levels. In this approach, community members and researchers are considered equal partners. This approach has become more popular during the past ten years, particularly in health fields and in work with minority populations (Jacquez, Vaughn, & Wagner, 2013).

DISCUSSION QUESTION

In a participatory community-based study, focus groups of rural Latinx immigrants contributed to a needs assessment. They identified transportation and language barriers and shared their thoughts about discrimination: “In some clinics and health care centers, they make us Latinos wait too long. It is common to wait for two or three hours to get assistance and the situation is worse if you don’t have health insurance. It is evident that they prefer Americans” (Cristancho, Garces, Peters, & Mueller, 2008, pp. 262–263). If you were a social worker for these clients, how would you advocate for them?

POLICY AND PROGRAM ADVOCACY After identifying the health and health care needs of immigrants and refugees in the local community, social workers plan and implement interventions to address those needs. Clearly, policy advocacy on the national level is essential to address the health care needs of immigrants and refugees. Program advocacy, which involves a smaller-scale intervention, is also necessary for successful intervention. Social workers concerned with immigrant and refugee health should undertake national-level advocacy as well as local- and state-level advocacy to address the unique needs of their communities. A best practice model for effective health care policy advocacy is presented in table 6.1.

DISCUSSION QUESTION

An outbreak of a highly contagious disease has occurred in a neighborhood largely inhabited by a certain immigrant group. This has led to some anti-immigrant feelings in the city. Using the advocacy model, develop an advocacy effort to decrease the tensions and improve access to care for the immigrant group.

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TABLE 6.1 Best Practice Model for Effective Health Care Policy Advocacy POLICY ADVOCACY TASK

DESCRIPTION

Analysis

What is the problem? What are the possible solutions? The stronger the foundation of knowledge of these questions, the more persuasive the policy advocacy can be.

Strategy

How are we going to accomplish our goals? Every advocacy effort needs a strategy. Planning the strategy should involve engagement of both the public and professionals at every step. Advocacy strategies are more successful when multiple stakeholders are involved.

Mobilization

Mobilization for collective action should have maximum positive impact on policy makers and maximum participation by all coalition members, while minimizing responses from the opposition. Advocacy positions must be linked to the interest of policy makers.

Action

Repetition of the message and using credible materials will maintain the public’s attention on the issue. Advocates must not fear controversy and should try to turn it to their advantage. Monitoring the responses of others is critical, especially when the responses require a rapid response. A positive relationship with local media is another asset.

Monitoring and evaluation

Leaders should monitor and evaluate their advocacy efforts on a regular and objective basis. Monitoring and evaluation is a tool to reshape the strategy if needed. Questions to examine include: Are the aims and objectives clearly presented? What are the key factors that are contribution to policy change? Are there any unintended consequences to the activism?

Continuity

Accomplishment of a tangible result may take time. Advocacy through communication, for instance, is an ongoing process. Planning for continuity means articulating long-term goals, keeping coalitions together, and keeping data and arguments in tune with changing situations. Perseverance is key to any advocacy effort. If an effort is not succeeding, the advocates should revise the action plan.

Sources: Coates & David (2002); Freudenberg, Bradley, & Serrano (2009); Scribner & O’Hanlon (2000); Servaes & Malikhao (2010).

In addition to advocacy, social workers should consult with community members about the health issues of immigrants and refugees. Successful community-based policy and program planning necessitates a sense of ownership by all the involved parties. If an immigrant group does not feel it is involved in the coalition, this group may later oppose the new policy. Policy change should COMMUNITY-BASED POLICY AND PROGRAM PLANNING

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be long-lasting, and sustainability is an important aspect to consider. Setting up a temporary clinic for six months may not be the most effective intervention (Magnussen, Ehiri, & Jolly, 2004; UNHCR, 2008). Traditional healers and immigrant and refugee community members from different age and gender segments should be members of the coalition. A local university may be a valuable resource to involve in this public health effort (Barnett, 2012; Graham et al., 2005; Servaes & Malikhao, 2010; UNHCR, 2008). Sometimes organizations can become involved in a cultural setting for better access to a group. For instance, the Hmong Health Care Professionals Coalition in Minnesota works closely with the annual Fourth of July Lao Family Hmong Sports Tournament. At this event, the coalition provides information about cancer and other conditions. This effort is productive because it has built a long-term relationship with the Hmong community through frequent meetings. With a sense of mutual respect, the relevant stakeholders feel invested in the effort (Mancini & Marek, 2004; Norris et al., 2007).

DISCUSSION QUESTION

Find a local event that involves an immigrant or refugee group. If you had to plan a coalition to start an outreach at this event, which parties would you contact? How would you approach them—networking, phone, email, or social media? How could you find out who the community leaders are for that group?

The final macro-level strategy for social workers is community health education, which aims to improve health status by promoting healthy behaviors and changing unhealthy behaviors. These programs use multiple approaches to provide people with the knowledge, skills, and attitudes necessary for healthier lives. Local organizations can help to identify the community members who can ensure more participation (Macera, 2003). One striking example of a successful community health education program used lay health advisers. After being trained, fifteen Latino soccer players worked with their teammates to promote condom use and HIV

COMMUNITY HEALTH EDUCATION

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testing among immigrants. The immigrants, who had recently arrived in rural North Carolina, were receptive to the public health message from these lay health advisers (Rhodes, Hergenrather, Bloom, Leichliter, & Montaño, 2009). Using Spanish-language pamphlets about sexually transmitted illnesses helped the advisers communicate the risks of unprotected sex: “In some cases, I showed them the pictures (of illnesses) . . . and it helped them a lot. Many of them reacted when seeing them . . . and were frightened because they had been involved with women without condoms. Two or three even decided to get tested” (Vissman et al., 2009, p. 225). The use of community health workers is similar to the practice of lay health advisers. However, one study of these workers indicates that in the Latinx community they are usually female because it is seen as a woman’s role (Villa-Torres, Fleming, & Barrington, 2015). Raising awareness of a health issue is another form of community intervention. Public information programs attempt to influence attitudes and social norms, such as campaigns against smoking and domestic violence (Macera, 2003). Effective public information programs are innovative. They should have a measurable program objective (e.g., lower rate of smoking) and communicate in an accurate and timely manner. Having a political commitment to obtaining resources and support is also important (Frieden, 2014). After selecting a target audience, the program developers choose which communication channel to use. An ethnic radio station may be a better venue than a mainstream station. Religious leaders and hotline counselors are also possible channels for the message (CDC, 1995). The internet provides access to several venues for public information programs, but the competition for attention can be fierce. Social media and websites are essential components of most outreach efforts. Simple measures such as posters in a doctor’s office are also relevant (CDC, 2011; Dutta-Bergman, 2004; Staten et al., 2004). Before finalizing any educational program, social workers should pretest the materials. The goal is to provide functional knowledge that is basic, accurate, and health-promoting. Clear writing and researchbased evidence are necessary components. The reading level should fit the audience; avoid professional jargon. Graphics and illustrations capture readers’ interest (CDC, 2015b; Whittingham, Ruiter, Castermans, Huiberts, & Kok, 2008).

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As with all evidence-based practices, community health education programs need to be evaluated to assess their effectiveness (CDC, 2005). Questions such as these help social workers evaluate a program: Q

Are the stakeholders involved in the evaluation?

Q

How would you describe the program in its current state?

Q

What public health concern was addressed by your program?

Q

Which activities did the program utilize to spread its message?

Q

How are you measuring the program’s efficacy?

MESO PRACTICE

Meso-level social work practice in health care for immigrants and refugees involves the improvement of organizational activities within the worker’s health care agency. The U.S. Department of Health and Human Services (2013) established a set of national standards for culturally competent and linguistically appropriate health care service delivery (see the text box). The purpose of meso-level social work practice for immigrant and refugee health care is to assist organizations in implementing these standards. Both interdisciplinary collaboration and organizational development are ways for social workers to promote the standards.

NATIONAL STANDARDS FOR CULTURALLY AND LINGUISTICALLY APPROPRIATE SERVICES (CLAS) FOR HEALTH CARE

The national CLAS standards are intended to advance health equity, improve quality, and help eliminate health care disparities by establishing a blueprint for health and health care organizations. Principal Standard 1. Provide effective, equitable, understandable, and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs. “CONTINUED”

“CONTINUED”

Governance, Leadership and Workforce 2. Advance and sustain organizational governance and leadership that promotes CLAS and health equity through policy, practices, and allocated resources. 3. Recruit, promote, and support a culturally and linguistically diverse governance, leadership, and workforce that are responsive to the population in the service area. 4. Educate and train governance, leadership, and workforce in culturally and linguistically appropriate policies and practices on an ongoing basis.

Communication and Language Assistance 5. Offer language assistance to individuals who have limited English proficiency and/ or other communication needs, at no cost to them, to facilitate timely access to all health care and services. 6. Inform all individuals of the availability of language assistance services clearly and in their preferred language, verbally and in writing. 7. Ensure the competence of individuals providing language assistance, recognizing that the use of untrained individuals and/or minors as interpreters should be avoided. 8. Provide easy-to-understand print and multimedia materials and signage in the languages commonly used by the populations in the service area.

Engagement, Continuous Improvement, and Accountability 9. Establish culturally and linguistically appropriate goals, policies, and management accountability, and infuse them throughout the organization’s planning and operations. 10. Conduct ongoing assessments of the organization’s CLAS-related activities and integrate CLAS-related measures into measurement and continuous quality improvement activities. 11. Collect and maintain accurate and reliable demographic data to monitor and evaluate the impact of CLAS on health equity and outcomes and to inform service delivery. 12. Conduct regular assessments of community health assets and needs and use the results to plan and implement services that respond to the cultural and linguistic diversity of populations in the service area. 13. Partner with the community to design, implement, and evaluate policies, practices, and services to ensure cultural and linguistic appropriateness. 14. Create conflict and grievance resolution processes that are culturally and linguistically appropriate to identify, prevent, and resolve conflicts or complaints. 15. Communicate the organization’s progress in implementing and sustaining CLAS to all stakeholders, constituents, and the general public. SOURCE: U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES (2013).

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Team-based practice entails interdisciplinary collaboration (Judd & Sheffield, 2010). Social workers can collaborate with medical professionals and other team members on a caseby-case basis or through consultation. Promoting cultural competence in health care is one goal of this teamwork. Research has shown that culturally competent care improves diagnostic accuracy, increases adherence to recommended treatment, reduces delays in seeking care, and improves service utilization (Guerrero, Marsh, Khachikian, Amaro, & Vega, 2013; Pavlish, Noor, & Brandt, 2010). Culturally competent health care providers integrate traditional healing approaches into their treatment plans when appropriate. For example, a Southeast Asian family may use coining as a treatment for their child. A culturally competent medical professional would let the mother continue this healing practice while ensuring that the child was taking the prescribed medicine for a bacterial infection (Antshel, 2002; Campinha-Bacote, 2011). Most folk medical practices are not harmful and do not interfere with biomedical treatment, so they can be integrated with Western medicine (Berry-Cabán & Crespo, 2008). However, health care providers cannot ethically support cultural practices that are harmful or illegal. For example, using whiskey for infants’ teething discomfort might cause alcohol poisoning and risk hypoglycemia (Smitherman, Janisse, & Mathur, 2005). Likewise, health care providers should not support female genital mutilation or other harmful practices. Social workers can assist physicians and other health care providers to incorporate general principles of cultural competence into their practice. Research has linked effective communication between clients and providers with successful health outcomes (Betancourt, 2003). The LEARN model (figure 6.2) is a useful tool for developing cultural competence.

INTERDISCIPLINARY COLLABORATION

Social workers can help enhance the cultural competence of the organization as a whole. Social workers should be familiar with several models that have been used by health care organizations to overcome linguistic and cultural barriers. These include using bilingual/bicultural providers, bilingual/bicultural community health workers, employee language banks, professional interpreters, and written translation materials and signs (U.S. Department of Health and Human Services, 2013).

ORGANIZATIONAL DEVELOPMENT

HEALTH ISSUES

Recommend a treatment plan while remembering the client’s cultural parameters

Explain your perceptions of the problem and your strategy for treatment

L Listen with sympathy and understanding to the client’s perception of the problem

E

177

A

R

Acknowledge and discuss the differences and similarities between these perceptions

N Negotiate agreement

FIGURE 6.2 LEARN model of culturally competent health care Source: Thom, Tirado, Woon, & McBride (2006).

Bilingual/bicultural staff may not be fully bilingual. Misunderstandings and frustration can result if the providers’ linguistic skills are not assessed for knowledge of medical terminology and dialects. Research reveals that bilingual individuals usually overestimate their ability in using both languages, and tests should be given to verify their proficiency (U.S. Department of Health and Human Services, 2001). Moreover, organizations should monitor bilingual staff for possible burnout because they may have an excessive workload. Retention of bilingual staff can be a challenge for organizations, especially if they face a “glass ceiling” in reaching higher positions. Organizations should consider promotion and continuous training and equal opportunities for bilingual providers (U.S. Department of Health and Human Services, 2013). Without bilingual staff, organizations may use professional interpreters. Telephone interpreters are another option (U.S. Department of Health and Human Services, 2013). Using interpreters who are regular employees is a good option when there is a high demand for a particular language. A final strategy for overcoming cultural and linguistic barriers is the use of translated written materials. This can include bilingual written phrases that clients and providers can point to in order to communicate. Written materials can include translated forms, documents, and health education materials. Like interpretation, medical translation is a complex process. Some documents such as registration forms have to be translated in any case (U.S. Department of Health and Human Services, 2013).

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MICRO PRACTICE

Micro social work practice in health care involves three categories: case management, health education and counseling, and psychosocial treatment. Each of these is addressed separately following a discussion of general principles for micro social work practice in health care for immigrants and refugees. As discussed in the previous chapter, the first steps of the social work practice process involve engagement, problem identification and assessment, and goal setting and contracting. In the health care setting, additional considerations are also relevant. In the engagement stage in the health care setting, social workers may need to develop criteria for identifying immigrants and refugees who need their services. Many hospitals have screening protocols to identify clients who may be at high risk of experiencing psychosocial difficulties related to their presenting health problem (Auerbach, Mason, & Laporte, 2007). Criteria for referral to social work may include cases of suspected child abuse or cases involving financial problems. These referral criteria usually do not include any criteria specifically pertaining to immigrants and refugees. Social workers may need to develop criteria such as limited English proficiency or being a recent arrival to the United States. In developing criteria, social workers must collaborate with other members of the health care team to determine what factors related to immigration status could pose problems. Legal issues or treatment adherence challenges, for example, could be among the criteria. Cultural competence is essential in the problem identification and assessment stage. The following assessment questions, known as “Kleinman’s Questions” are particularly useful for eliciting clients’ health beliefs and expectations of treatment (Kleinman, 1981): GENERAL PRINCIPLES

1. What do you call your illness? 2. What name does it have? 3. Why and when did it start? 4. What do you think the illness does? How does it work? 5. How severe is it? Will it have a short or long course? 6. What kind of treatment do you think you should receive? What are the most important results you hope to receive from this treatment? 7. What are the chief problems the illness has caused? 8. What do you fear most about the illness?

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DISCUSSION QUESTION

In one study, West African mothers “said that certainly parents and children can contribute to health and illness but ‘ultimately it is God who decides.’ Regarding illness etiology, one parent eloquently offered, that ‘there is a difference between something natural like fire and snow. Some illnesses are natural and some can be prevented’ ” (Vaughn & Hollway, 2010, p. 32). If you were the social worker working with West African immigrants, how would you respond to these comments? Do you have any common ground with these mothers’ beliefs, or are they completely different from your own beliefs about illness?

The other stages of the social work process also require a high level of cultural competence. Best practices for improving cross-cultural relationships between providers and clients include understanding that immigrants and refugees may not consider themselves to be equal partners in their care. Instead, they may prefer a direct and authoritative approach from medical professionals. Clients from traditional cultures may expect a distant relationship with providers, so formal address is usually recommended for adult patients. Eye contact is regarded as disrespectful in some cultures. Avoiding assumptions about the client’s culture is essential. Ask open questions when discussing their health beliefs. Mutual respect is also critical in the relationship. Clients may be afraid to tell a Western provider that they are visiting a folk healer or are taking an alternative medicine because they have experienced ridicule. If clients believe in supernatural causes of their illnesses (e.g., evil eye), they are less likely to follow medical advice. Providers should be sensitive to the belief systems of their clients so they can work together. CASE MANAGEMENT The contemporary health care system requires more case management, which is a client-centered approach that coordinates services such as housing and counseling (Jardine & Rigby, 2010). Case management is particularly important for immigrants and refugees because they are less likely to be aware of the resources that could help them. Some

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clients might need help negotiating with authorities and immigration services, completing forms, or following complex instructions (Paris, 2008). It can be difficult to find services and programs that perfectly fit a client’s needs, so effective case managers also need skills in compromise and conflict resolution. Case advocacy, which focuses on a single case and not a policy, enables workers to secure needed services or benefits for clients (Bunger, 2010). This type of advocacy may be necessary both within one’s agency and with outside agencies. Immigrants and refugees are more likely to need case advocacy than other clients because of the health care access barriers they face. The three key questions for case advocacy are: Q

What are the client’s care goals, wishes, and preferences?

Q

What is in the best interest of the client and the client’s support system?

Q

Are the client and the client’s support system capable of self-advocacy?

Case management with immigrants and refugees requires a high level of cultural competence. A complete environmental analysis of the client’s needs and support systems must be conducted. For example, a client might be living with an extended family that is highly committed to the individual’s well-being. Case management also involves monitoring a client’s health care progress, especially regarding access. Obtaining authorization for treatments is critical in the U.S. health care system. Above all, transparency with clients and their support systems regarding the details of the medical care is important—including the cost of services (Hussein, 2016). During the case management process, the worker may need to use an interpreter. Best practices for using interpreter services include trying to match the client with an appropriate interpreter. Confidentiality is essential, but an interpreter may be an acquaintance of the client or a member of the same social group. Brief the interpreter before the meeting, especially if the situation is emotionally charged, such as meeting to deliver bad news about a medical condition. If an interpreter is not available, it is inappropriate to ask children or family members to interpret. A child who is forced to discuss a parent’s health condition or other concerns could be traumatized by the situation (Miletic et al., 2006). The following text box summarizes best practices for working with medical interpreters.

BEST PRACTICES FOR WORKING WITH INTERPRETERS

Precontact Telephone Call Q

Q Q

Q

Check whether the interpreter will be available. Will this be one-time or on a continuing basis? Explain what you are trying to accomplish. Explore the client’s and the interpreter’s background: How good is the match? (Try to match in terms of gender, age, rural-urban differences in experience, competence in dialects, and whether the interpreter is related to the family.) Negotiate and schedule a presession face-to-face discussion. How much extra time is anticipated for interpretation and clarification and for a short postsession debriefing?

At the Presession Discussion Q Q Q Q Q

Q Q

Q

Q Q

Review confidentiality. Explain and reinforce the meeting’s goals. Build a relationship with the interpreter. Learn how to pronounce the client’s name. Request information about proxemics—norms of eye and physical contact—and culturally sensitive topics (e.g., personal finances). Decide if the interpretation will be word for word or paraphrased. Establish norms about timing and clarification: How long will each speak? When are interruptions permitted? Discuss technical terms (e.g., medications, providers, entitlement programs) that are likely to be used in the upcoming contact. Decide how each person will be introduced to the client. Establish ground rules for interpreter feedback: Will this be provided during or after the session? Will it include nonverbal cues, speech pattern observations, and volunteered cultural information?

The Client Contact Q Q Q

Q

Q Q

Introduce everyone present at the beginning. Establish the client’s agreement to the ground rules for communication. Try to establish how much English the client knows; do not assume that the client does not understand what you and the interpreter are discussing. Be sensitive to indications that the client is attempting to “split” your relationship with the interpreter. Use simple English; avoid technical terms and slang. Monitor nonverbal and process dynamics while the interpreter and the client are speaking. “CONTINUED”

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“CONTINUED”

Postsession Discussion Q Q Q Q

Debrief issues that were not adequately discussed during the session. Exchange impressions of the client. Discuss problems or misunderstandings. Schedule follow-up sessions, if needed. SOURCE: RAIFF & SHORE (1993).

Social workers may become involved in health promotion and preventive intervention. The macro-level intervention of community education was discussed earlier, but microlevel health education and counseling also deserve attention. The purpose is to assist “individuals to become cognizant of what factors are important to maintaining their own health and wellness . . . ; to help communicate needed information that will assist the individual in making needed changes; assist individuals in using this information to develop self-help skills that can empower them to address health needs; and assist individuals to gain access to the techniques or technology that can help them in meeting their needs” (Dziegielewski, 2013, p. 336). Outreach staff can strategize about which method to use: tailored health messages, peer educators, or counselors (Fisher, Burnet, Huang, Chin, & Cagney, 2007). Effective health education workshops and presentations need to be carefully planned, have clear goals and objectives, be tailored to the characteristics and knowledge level of the audience, follow a detailed outline, and encourage audience participation (Kendall & Sullivan, 2012). Many community outreach programs for immigrants and refugees use peer educators, also known as lay health advisers, community health workers, community health advisers, community health aides, natural helpers, peer outreach workers, or promotores (Ayala, Vaz, Earp, Elder, & Cherrington, 2010). These paraprofessionals are usually active and trusted indigenous members of the community (Ayala et al., 2010; Khamphakdy-Brown, Jones, Nilsson, Russell, & Klevens, 2006). In addition to community outreach and peer educators, social workers themselves can deliver health education and counseling to immigrants and refugees. HEALTH EDUCATION AND COUNSELING

HEALTH ISSUES

183

Effective health education and counseling begins with the person-in-environment perspective. Framing the health message in the context of the client’s culture is a fundamental component. For example, a traditional culture that values motherhood would be congruent with a “healthy babies” initiative by a health educator. Specific information will help motivate the client to make changes (Grigg-Saito, Och, Liang, Toof, & Silka, 2008; Kelly & Falvo, 2011; Sue, Zane, Nagayama Hall, & Berger, 2009).

DISCUSSION QUESTION

In one study, a group of East African women told the researcher that they were developing health problems due to gaining weight since their arrival in the United States: “At home they used to walk everywhere, visit with each other in their neighborhoods, herd cattle, farm, eat fresh vegetables and drink fresh milk from their camels. Here, they fear crime, they do not like the cold during the winter, they talk on the telephone, they stay home” (Shipp, Francis, Fluegge, & Asfaw, 2014, p. 20). Design a health education program for this population. Would you use peer educators or another method? What would be the best way to link their culture to changing their exercise and eating habits?

The final micro social work intervention in health care is psychosocial treatment, or direct clinical counseling. Well-constructed psychosocial treatment may improve the lives of clients and families and can influence social functioning (Mittan, 2009). The purpose of such treatment is to help clients and families cope with and adapt to illness, and to address psychosocial issues that affect health, such as interpersonal conflicts, psychological and behavior problems, dissatisfaction with social relations, difficulties in role performance, problems of social transition, problems in decision making, problems with formal organizations, and cultural conflicts (Dziegielewski, 2013, p. 113). Contemporary social work in health care is characterized by an emphasis on brief treatment. Most social work interventions in health care consist of only one or two sessions. Brief interventions are designed for this short time frame, or for periods up to six or eight weeks with a minimal required follow-up (National Institute on Alcohol Abuse and Alcoholism, 2005). Research has established that brief treatment is an effective intervention for

PSYCHOSOCIAL TREATMENT

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certain problems (Roche & Freeman, 2004). Brief interventions have seven major characteristics (Dziegielewski, 2013): Q

The client is viewed as basically having healthy psychosocial functioning, with an interest in increasing personal or social changes.

Q

Brief interventions are most helpful when administered during critical periods in a person’s life.

Q

The goals and objectives of the intervention are mutually defined by the client and the worker.

Q

Goals and objectives are concretely defined and intervention activities extend outside the client–worker encounter.

Q

There is little emphasis on insight.

Q

The therapist is seen as active and directive.

Q

Termination is discussed early in the process.

These characteristics of brief treatment are highly congruent with the cultural expectations of immigrants and refugees who view the helping professional as an expert and expect rapid and active treatment. Lengthy, insight-oriented therapy is an unfamiliar concept to most immigrants and refugees. Brief treatment may be appropriate for refugees and immigrants in an acute health care setting such as a hospital. However, due to the complex psychosocial issues of immigrants and refugees, it must be recognized that brief treatment alone is insufficient to address the totality of their needs. Brief treatment should be viewed as part of a comprehensive social work approach that includes all the other interventions discussed in this chapter and throughout the rest of this book. Brief treatment includes all the elements of engagement, problem identification and assessment, goal setting and contracting, intervention implementation and monitoring, termination and evaluation, and follow-up that were discussed in chapter 5. In brief treatment, these tasks must be compressed into a short time frame. Specific, concrete, and measurable problem definitions and goals are required in brief treatment. Once the problem is identified, goals are established, and contracting is done, the intervention phase begins. Four methods of brief treatment are commonly used in social work in health care: interpersonal psychotherapy or counseling, solution-focused intervention, cognitive-behavioral interventions and therapies, and crisis intervention (Cowen, Harrison, & Burns, 2012; Kim, Smock, Trepper, McCollum, & Franklin, 2010; Thompson, McManus, & Voss, 2006).

HEALTH ISSUES

185

Interpersonal psychotherapy focuses on reducing symptoms and dealing with interpersonal problems such as grief, role disputes, or role transitions. It focuses on the client’s current life, present events, and ongoing social and interpersonal functioning to understand symptoms and provide intervention. Interpersonal psychotherapy explains patients’ affective experiences in the framework of their social relations (Rafaeli & Markowitz, 2011). Distress is a common problem among refugees and immigrants, and this intervention could be considered an appropriate approach (Meffert et al., 2014). It also addresses applying what has been learned in the sessions to problems that may arise in the future. Further, this method often involves “helping the client to learn how to recognize the need for continued intervention” (Dziegielewski, 2013, p. 143). This is particularly likely to be true for immigrants and refugees due to the complexity of the problems they encounter. In this case, social workers need to use their case management function to arrange for ongoing interventions. Solution-focused intervention focuses on identifying alternative solutions to problems using the client’s strengths. There is little attention to the cause of the problem (Enea & Dafinoiu, 2009). Simply stated, in “solution-focused” interventions, the emphasis in practice is placed on constructing probable solutions to a problem. The idea that it is easier to construct solutions than it is to actually attempt to change problem behaviors prevails. By not spending a great deal of time on the cause of the problem, the emphasis on the intervention is switched away from the past toward present and future survival. There is often more than one solution, and it becomes the role of the health care social worker and the client together to help construct alternative and possible scenarios of assistance. (DZIEGIELEWSKI, 2013, P. 146)

Cognitive-behavioral therapy (CBT) interventions are effective for different psychological diagnoses or symptoms such as anxiety disorders or depression. CBT is usually explained as a combination of interventions addressing behavioral change and cognitive processing or restructuring. The first fundamental concept of CBT is that individuals’ behaviors are affected by cognitive activities and that these activities can be monitored and altered. CBT can be focused on coping skills, problem solving, or cognitive structuring (Dobson, 2009).

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7. Follow up 6. Restore functioning 5. Generate new coping strategies 4. Encourage exploration of feelings 3. Identify the major problems 2. Establish a collaborative relationship 1. Plan and conduct assessment FIGURE 6.3 Stages of crisis intervention Source: Roberts & Ottens (2005).

The final method of brief treatment in health care social work is crisis intervention. A crisis is defined as an acute disruption of psychological homeostasis in which one’s usual coping mechanisms fail and distress and functional impairment are evident. The subjective reaction to a stressful life experience has compromised the individual’s stability and ability to cope or function. Roberts and Ottens (2005) identified seven stages of crisis intervention, which are shown in figure 6.3. As with all other social work interventions discussed in this chapter, outcome evaluation is a necessary component of these brief interventions. In working with immigrants and refugees, these methods of brief intervention may need to be adapted to be culturally congruent. The specific application of these methods, as well as other psychosocial interventions, to immigrants and refugees is discussed in much more detail in the next two chapters, which address mental health and family dynamics.

7 MENTAL HEALTH

WHETHER REFUGEE or immigrant, significant traumas can affect clients long after their migration. Also, depression and other mental health conditions may affect individuals regardless of culture, country of origin, or migration experience. Nonetheless, “migration is a condition of risk for developing mental disorder. If one migrates as a refugee, the jeopardy to emotional well-being is even greater. . . . But risk is not destiny. The social and historical contingencies surrounding resettlement as well as personal strengths which individuals bring to the situation determine whether exposure to risk results in break-down or in personal fulfillment” (Beiser, 1990, p. 52). Unique stressors for immigrants and refugees characterize the premigration and departure, transit, and resettlement stages. In this chapter, we begin with a brief review of these stressors, then examine the role of cultural factors in mental health, and discuss common manifestations of mental health problems among immigrants and refugees. Finally, best practices in this area are addressed. Although this chapter focuses on individual factors, mental health is usually intertwined with family dynamics, which is the subject of chapter 8. The close links between this chapter and the next should be kept in mind. Many of the health issues discussed in chapter 6 are also directly applicable to mental health.

MENTAL HEALTH AND MENTAL HEALTH CARE PROBLEMS The major issues related to the mental health of refugees and immigrants are migration stressors, cultural factors, and the common manifestations

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of mental health problems among this population. Each of these issues is addressed in the sections that follow.

MIGRATION STRESSORS

Each stage of the migration process entails unique stressors. The premigration and departure stage entails separation from family members, friends, home, and a familiar environment. Refugees also may experience traumas such as war, famine, violence, sexual exploitation, imprisonment, torture, or witness the death of family members and close friends; in addition, they may suffer from discrimination, ostracism, and other forms of persecution (Crumlish & O’Rourke, 2010; Kulla et al., 2016; Nickerson at al., 2011; Palic & Elklit, 2011; Slobodin & de Jong, 2015; ter Heide, Mooren, Knipscheer, & Kleber, 2014). For refugees, departure is often unplanned, hasty, chaotic, and dangerous. The transit stage is not as stressful for legal immigrants, but refugees often have to flee a dangerous situation and may endure hardships such as starvation (Kulla et al., 2016; Slobodin & de Jong, 2015; ter Heide et al., 2014). Refugees may spend months or even years in refugee camps, which are often overcrowded and unsanitary, and their future is uncertain (Dudley, 2011; Hanafi, 2008). Asylum seekers may endure adverse circumstances, especially if they are detained in the country where they are seeking help. One study on asylum seekers noted that they had already been highly traumatized in their country of origin and showed signs of posttraumatic stress disorder (PTSD) as well as depression and anxiety (Filges, Montgomery, Kastrup, & J rgensen, 2015). For illegal immigrants, the transit stage often entails dangerous border crossings by land or water and exploitation or violence by smugglers. The resettlement stage entails a host of new stressors as migrants attempt to come to terms with their losses and to adapt to life in the new country (Caplan, 2007; Lee, 2007; Ornelas & Perreira, 2011). Immigrants and refugees often separate from the people they love and leave their possessions and familiar surroundings behind. Loss of status may occur; many immigrants and refugees find that they have lower social and occupational status in the new country. The stresses of adaptation include those shown in figure 7.1.

MENTAL HEALTH

Legal status - 08

01 - Language

01 08

189

02

Family conflict - 07

02 - Employment

Stress

07

03

Role changes - 06 Discrimination, racism, xenophobia - 05

03 - Social isolation

06

04 05

04 - Modernization/ industrialization

FIGURE 7.1 Resettlement adaptation stressors Source: Authors’ synthesis.

DISCUSSION QUESTION

A refugee family arrives from Nepal to a bustling city. This family has moved from a low-tech environment (e.g., no electricity) to a high-tech one. They do not know how to cross a busy street using the crosswalk. If you were their social worker, which of the adaptation stressors would you address? How would you rate each of these stressors—immediate need or long-term goal?

Another adaptation stressor is acculturative stress caused by cultural changes (Smokowski & Bacallao, 2008). Acculturative stress includes psychological and physical discomfort caused by experiences in a new cultural environment (Duru & Poyrazli, 2007). Acculturative stress is commonly known by the lay term of “culture shock.”

DISCUSSION QUESTION

Have you ever experienced culture shock when you encountered or entered a new culture? What was the experience like?

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Many scholars have divided the resettlement stage itself into distinct phases. For example, the early stages of resettlement usually bring optimism, but disappointment in the new location and missing the country of origin can become depressing later (Kirmayer et al., 2011). Further, during the resettlement stage, traumas from the previous migration stages may affect individuals’ mental health (Saechao et al., 2012; Schweitzer, Melville, Steel, & Lacherez, 2006). These trauma-related symptoms may diminish over time, but they still have cumulative effects (Schweitzer et al., 2006). Not all immigrants and refugees develop mental health problems because of migration stressors (Kirmayer et al., 2011). Answers to two key questions can help you evaluate the affects of stressors: (1) How long did the migration stress last? and (2) How did the individual appraise it? (Yakushko, Watson, & Thompson, 2008). Other factors, such as age and social support, can enhance resiliency in the individual (Sam & Berry, 2006; Schweitzer et al., 2006; Yakushko et al., 2008). Protective factors against the development of mental health problems include personal resources such as personality and possessions (Caspi, Slobodin, & Klein, 2015), coping behaviors such as a person’s response to stress (Jibeen, 2011), and social resources such as friends (Hwang, Cao, & Xi, 2010).

CULTURAL FACTORS AND MENTAL HEALTH

Cultural factors may affect the mental health of immigrants and refugees in the following areas: conceptualizations of mental health, diagnosis and symptom expression, communication styles, and service utilization. Each of these is addressed in the following sections. Cultural beliefs influence how people conceptualize normal and abnormal behavior (Donnelly et al., 2011; Lee, Lytle, Yang, & Lum, 2010; Pavlish, Noor, & Brandt, 2010). For example, the U.S. norm is that loud, boisterous behavior is acceptable, whereas reticence is the norm in some cultures. Individuals from cultures that value reticence might be viewed as being abnormally shy or unsociable by those in mainstream U.S. culture. Many cultures do not separate physical health from mental health. Consequently, the very idea of mental health problems is foreign to many

CONCEPTUALIZATIONS OF MENTAL HEALTH

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immigrants and refugees, and it may be difficult for them to define their mental health problems (Pavlish et al., 2010). The idea that psychological difficulties such as depression or anxiety may underlie or accompany physical complaints or difficulties is not within many cultural belief systems and is highly stigmatized in some cultures (Pavlish et al., 2010). As mentioned in chapter 6, some cultures attribute health problems to spiritual, supernatural, or magical forces (De Anstiss & Ziaian, 2010), and these immigrants and refugees may not feel that they need professional mental health help (Colucci, Minas, Szwarc, Paxton, & Guerra, 2012). They may not be responsive to mainstream mental health services and are likely to discontinue such treatment.

DISCUSSION QUESTION

An adolescent son in an immigrant family is showing signs of mental illness. The parents are ashamed of their son and hide his problem to avoid stigma. They view it as a curse or a punishment from God (Wood & Newbold, 2012). How would you use cultural competence to address their concerns and educate them about the Western view of mental illness?

DIAGNOSIS AND SYMPTOM EXPRESSION Diagnoses rely on symptoms (subjective experiences reported by the client, such as worry) and signs (behaviors or physical indicators). Some symptoms and signs are universal: clients “everywhere complain of insomnia, worry, crying spells, anorexia, weakness, anergy, anhedonia, suicidal ideation, and ego-dystonic hallucinations and delusions [signs]; and their families and communities report social withdrawal, inappropriate or purposeless behavior, incomprehensible speech, damage to property, and assaultiveness [symptoms]” (Westermeyer, 1991b, p. 60). But mental health diagnoses differ across cultures: “For example, uncontrollable crying and headaches are symptoms of panic attacks in some cultures, while difficulty breathing may be the primary symptom in other cultures” (American Psychiatric Association, 2013a). Further, many cultures have cultural concepts of distress, which refer to characteristic modes of expressing suffering. Table 7.1 describes the cultural concepts of distress listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (American Psychiatric Association, 2013b).

TABLE 7.1 DSM-5 Cultural Concepts of Distress SYNDROME

DESCRIPTION

POPULATIONS

Ataque de nervios

Symptoms include uncontrollable shouting, attacks of crying, trembling, heat in the chest rising into the head, and verbal or physical aggression. A general feature of an ataque de nervios is a sense of being out of control. Ataques de nervios frequently occur as a direct result of a stressful event relating to the family. People can experience amnesia for what occurred during the ataque de nervios, but they otherwise return rapidly to their usual level of functioning.

Caribbean, Latin American, Latin Mediterranean

Dhat (jiryan in India, skra pramehain Sri Lanka, shen-k’uei in China)

Severe anxiety associated with the discharge of semen, whitish discoloration of the urine, weakness, and exhaustion.

Asian Indian

Nervios

Refers both to a general state of vulnerability to stress and to a syndrome evoked by difficult life circumstances. Nervios includes a wide range of symptoms of emotional distress, somatic disturbance, and inability to function. Common symptoms include headaches and “brain aches,” irritability, stomach disturbances, sleep difficulties, nervousness, tearfulness, inability to concentrate, trembling, tingling sensations, and dizziness. Nervios tends to be an ongoing problem.

Latin American

Shenjing shuairuo

Characterized by physical and mental fatigue, headaches, difficulty concentrating, dizziness, sleep disturbance, and memory loss. Other symptoms include gastrointestinal problems, sexual dysfunction, irritability, excitability, and autonomic nervous system disturbances.

Chinese

Susto(espanto, pasmo, tripa ida, perdida del alma, or chibih)

An illness attributed to a frightening event that causes the soul to leave the body and results in unhappiness and sickness. Symptoms can appear days or years after the fright is experienced. Typical symptoms include appetite disturbances, inadequate or excessive sleep, troubled sleep or dreams, sadness, lack of motivation, and feelings of low self-worth or dirtiness. Somatic symptoms may include muscle aches and pains, headache, stomachache, and diarrhea.

Latino American, Mexican, Central and South American

Taijin kyofusho

An individual’s intense fear that his or her body, its parts, or its functions displease, embarrass, or are offensive to other people.

Japanese

Source: Center for Substance Abuse Treatment (2014).

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Workers must keep concepts of both universality and cultural relativity in mind when conducting assessments to avoid misdiagnosis. Finding the right balance between recognizing the universal nature of some illnesses and the cultural aspects will prevent diagnostic mistakes. These issues are addressed in more detail in the assessment section of this chapter. COMMUNICATION STYLES In general, the communication style favored in mainstream U.S. society consists of elements such as assertiveness, forthrightness, and an open expression of emotions. These elements are not part of the communication style in many other cultures. For example, in some cultures individuals do not disclose problems due to a norm of not complaining or a belief that problems should not be shared with outsiders (Colucci et al., 2012; De Anstiss & Ziaian, 2010). Cambodians believe distress is caused by past misdeeds and karma; therefore, it is associated with shame and is underreported (Rasbridge & Vilaythong, 2012). Some immigrants believe that the problems they are facing are part of the migration process and so suffer silently (Pavlish et al., 2010). In many cultures, people are uncomfortable sharing their feelings with nonfamily members. These differences in communication styles can lead to misunderstandings, misdiagnoses, and ineffective provision of services.

As is the case with physical health services, immigrants and refugees use fewer mental health services than the native-born population (Davidson, Soltis, Albia, de Arellano, & Ruggiero, 2015; Ma, Shea, & Yeh, 2012; Pandey & Kagotho, 2010). The rate of underutilization is probably higher for mental health services than physical health services due to cultural differences. Stigma also deters many immigrants and refugees from seeking help (Donnelly et al., 2011; Ma et al., 2012). For example, Asian cultures discourage the open discussion of feelings and problems, which is expected in psychotherapy (Ma et al., 2012). The barriers to care are the same as those related to physical health: structural, personal, and cultural.

SERVICE UTILIZATION

MANIFESTATIONS OF MENTAL HEALTH PROBLEMS

Immigrants generally have lower rates of mood, anxiety, and substance use disorders when compared to the native-born population; however, prevalence

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increases with longer residence in the new country, which is consistent with the healthy immigrant paradox (Kirmayer et al., 2011; Shekunov, 2017). Refugees do have higher rates of posttraumatic stress disorder (PTSD), anxiety, and depression than does the general population (Fazel, Wheeler, & Danesh, 2005; Giacco, Laxhman, & Priebe, 2018). It is important to note that prevalence varies by specific population group and is based on factors such as trauma exposure and personal resiliency. Commonly observed mental health problems among immigrants and refugees include grief, alienation and loneliness, decreased self-esteem, depression, anxiety, paranoia, guilt, PTSD, and substance abuse (Allan, 2015; Crumlish & O’Rourke, 2010; Slewa-Younan, Guajardo, Heriseanu, & Hasan, 2015; Steel et al., 2011; Tempany, 2009). Not all of these constitute psychiatric diagnoses; however, conditions such as loneliness still cause much pain. These mental health problems are discussed in the following sections, and intervention approaches for each are addressed in a later section. Grief in response to the multiple losses experienced is a common reaction among immigrants and refugees. This is true even for those who migrated voluntarily. Geographical relocation itself can create a sense of loss and produce expressions of grief. Immigrants and refugees may grieve over the loss of their friends, their culture, their homeland, and their valued possessions (Casado, Hong, & Harrington, 2010). Social workers should be alert to the possibility of grief arising at any time in the resettlement phase. Also, social workers should remember that some overt reactions, such as anger, may have their roots in grief.

GRIEF

Immigrants and refugees have left behind all or part of their natural support system of family and friends. Even when family members migrate together, the whole family system can be adversely affected. Unfortunately, some receiving countries are hostile toward newcomers. No matter the level of hostility, moving into a land of strangers can be difficult, and language and cultural differences make it hard to establish new friendships (Yakushko, Watson, & Thompson, 2008). In addition, some cultures stress that friendship formation is a lifelong process that often begins in childhood. Making new friends as adults may not be the norm, and interacting with strangers may involve formal responses instead of emotional intimacy.

ALIENATION AND LONELINESS

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Living in a community with others from the same country does not guarantee immigrants and refugees a social support system. Sometimes the only commonality individuals have with each other is the fact of their migration. People have differences in personality, socioeconomic background, political views, sexual orientation, gender identity, and a host of other factors that can discourage social bonding. Different reactions to adjusting to resettlement also may deter friendships from forming. Some people are highly adaptable and may not understand why others are taking more time to adjust to the new culture. Immigrants and refugees are at risk of decreased self-esteem, especially if they have lost their professional status (Yakushko, Watson, & Thompson, 2008). Many immigrants, and particularly refugees, must take jobs in the new country that are of lower occupational status than their former jobs. For example, an engineer may have to work as a custodian because of language difficulties and lack of certification in the United States (Dryden-Peterson, 2011; Nicolopoulou, Karatas-Ozkan, Tatli, & Psoinos, 2007). A second reason for lowered self-esteem is changing gender and generation roles. Most immigrant and refugee cultures are male-dominated, but women often adopt egalitarian perspectives more quickly than men do (Franz, 2003). Women may obtain jobs more quickly, may be working outside the home for the first time, and may be the sole financial providers for the family. In many cases, men lose their traditional dominant positions, leading to lowered self-esteem (Bui & Morash, 2008; Hyman, Guruge, & Mason, 2008). In addition, children usually assimilate into the mainstream culture and acquire language skills more quickly than their parents. By acting as translators and culture brokers for their parents, the children gain more power. This role reversal can lead to lowered self-esteem for the parents (Oznobishin & Kurman, 2009; Suárez-Orozco & Suárez-Orozco, 2009). Third, unfamiliarity with new norms may cause embarrassment or feelings of social isolation (Leipzig, 2006). Becoming a minority in the new country equates with losing social status, which is another reason for lower self-esteem (Gee, Ryan, Laflamme, & Holt, 2006). This is especially hard for “visible” minorities who have a darker skin color or other distinct features.

DECREASED SELF-ESTEEM

Scholars have extensively documented problems of depression in immigrant and refugee groups (Cummings et al., 2011). Older

DEPRESSION

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immigrants and refugees are more likely than their native-born counterparts to be depressed. However, depression rates vary among different groups of immigrants and refugees (Cummings et al., 2011).

DISCUSSION QUESTION

A study of Korean older adults in California posits two reasons for their depression: limited English proficiency and lack of acculturation despite years of U.S. residence (Lee & Yoon, 2011). If you were the social worker for a recently arrived family that brought along an older relative, how would you be proactive in addressing these risk factors for depression?

The symptoms of depression can manifest in many ways, including physical symptoms with little mention of emotional distress (Kirmayer et al., 2011). For example, unexplained medical symptoms such as fatigue or body aches could indicate depression (Pottie et al., 2011). Because families may not take conditions such as postpartum depression seriously, workers should be aware of the importance of family reactions to an immigrant or refugee who may need care (Teng, Blackmore, & Stewart, 2007). Symptoms of anxiety are frequent among refugees. Hardships related to resettlement can trigger even more anxiety (Kirmayer et al., 2011). Hardships, for both immigrants and refugees, may include lack of social support, low socioeconomic status, linguistic barriers, possible discrimination, and acculturation challenges (Revollo, Qureshi, Collazos, Valero, & Casas, 2011). Although both documented and undocumented immigrants may feel anxiety, undocumented immigrants are at a higher risk for anxiety. Not only do undocumented immigrants have to avoid being apprehended, but they face more stigma and potential exploitation by employers than do their legal counterparts (Dow, 2011; Gonzales, Suárez-Orozco, & Dedios-Sanguineti, 2013).

ANXIETY

PARANOIA Paranoia causes suspicion and mistrust in communication with people and in one’s general worldview. Individuals with a high level of mistrust may incorporate conspiratorial belief systems and live with high

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levels of distress (Harper, 2011). The origin of the paranoid thoughts needs to be carefully explored because these thoughts often have a well-founded basis in reality. Some forms of distrust and advanced paranoia are problematic, such as distrust of medical service providers (Elwell, Junker, Sillau, & Aagaard, 2014). Immigrants and refugees are more likely than native-born individuals to experience paranoia (Gilliver, Sundquist, Li, & Sundquist, 2014), especially those who have endured prolonged social isolation (Dow, 2011). Refugees and others who have been persecuted may feel threatened by the new country’s social systems, institutions, or authority figures (Hargrave, 2015). Resettlement stressors, particularly stigma and discrimination, also increase the feeling of paranoia (Harper, 2011). Leaving one’s homeland can cause guilt, especially survivor guilt among refugees (Kleinman, 2011). The key question in survivor guilt is this: “Why did I survive when so many others died?” A person may have taken morally questionable actions to survive and may not have been able to help others in dire need. Immigrants also may feel guilty for abandoning the people they left behind (Douglas, 2010). Their families, expecting them to prosper in the United States, may demand more financial assistance than is possible.

GUILT

DISCUSSION QUESTION

As a social worker, you have a client who is on the verge of being evicted every month. Each month he asks your agency for help. When you sit down to develop a budget with him, you find that he is sending a significant portion of his income to his parents back home. He insists that he has to send the money every month because they sacrificed to send him to the United States and depend on him financially. How would you handle this situation?

PTSD can be a long-term effect of trauma. It occurs when people reexperience the traumatic event through flashbacks or nightmares; experience negative thoughts, moods, and heightened arousal; and avoid stimuli associated with the event (American Psychiatric Association, 2013c). Chronic PTSD may cause cognitive impairment

POSTTRAUMATIC STRESS DISORDER

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and may persist for decades (Qureshi et al., 2011); PTSD may even be transmitted multigenerationally to the trauma survivor’s children (Karenian et al., 2011; Vaage et al., 2011). For refugees, PTSD is often accompanied by depression (Ginzburg, Ein-Dor, & Solomon, 2010; Ikin, Creamer, Sim, & McKenzie, 2010).

DISCUSSION QUESTION

In a study of Cambodian refugees, most had lost a loved one and had witnessed atrocities. Life in work camps in their country of origin was especially harsh and brutal. After living in refugee camps for years, they finally arrived the United States (Blair, 2000). If you were the social worker, how would you help them understand how PTSD could affect them?

The rates of substance abuse among immigrants and refugees varies widely by groups (e.g., country of origin and socioeconomic status). During the period of acculturation, some immigrants and refugees may try to follow new cultural norms of drinking or using street drugs. Also, the stresses of the migration process may lead to substance abuse as a form of self-medication. In general, substance use increases with increased assimilation, and it is higher among subsequent generations of immigrants and refugees than among the first generation. Research also suggests that patterns of and reasons for involvement in substance abuse are different for immigrants and refugees than for their native-born counterparts because of cultural influences and other factors. Young people are at higher risk than their elders, and there is a high likelihood of comorbidity (i.e., substance abuse coexisting with another mental health problem) among these populations, which needs special attention (Keyes et al., 2012).

SUBSTANCE ABUSE

SUMMARY OF MENTAL HEALTH PROBLEMS

After reading about these mental health issues, you may infer that all immigrants and refugees have mental health issues, but the reality is

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far different. In fact, most do not develop any significant mental health problems. Despite the multiple stresses of migration, many immigrants and refugees have strong protective factors such as family. Research during the past several decades has identified effective models for addressing mental health problems among these populations. The remaining sections of this chapter address this knowledge as it relates to assessment, prevention, and intervention.

BEST PRACTICES Social work practice in mental health care for immigrants and refugees should fundamentally be based on five guiding principles (American Psychological Association, 2012): 1. Use an ecological perspective to develop and guide interventions. 2. Integrate evidence-based practice with practice-based evidence. 3. Provide culturally competent treatment. 4. Use comprehensive community-based services. 5. Use a social justice perspective as a driving force for all services.

As can be seen, these principles echo the various practice recommendations in chapter 5 on culturally competent practice; everything discussed in preceding chapters applies equally to mental health practice. Previous chapters have included meso- and macro-level recommendations that also apply to mental health care, so in this section we emphasize the micro-practice level. First, however, macro- and meso-level practice are briefly addressed.

MACRO PRACTICE

The macro-practice approaches of community needs assessment, policy and program advocacy, community-based policy and program planning, and community health education that were discussed in chapter 6 also apply to mental health care. As with physical health, these approaches aim to increase clients’ access to mental health services and prevent mental health problems through community education.

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The research on community education on mental health in immigrant and refugee communities is sparse. To complicate matters, social workers rarely meet clients before the resettlement stage, and the stressors of the earlier stages have already occurred and cannot be changed. Although the risks for emotional distress are high for this population, preventive measures could be enhanced to stop, lessen, or delay potential mental health disorders (Weine, 2011). The logical preventive strategy is to change the risks that are most easily and quickly amenable to intervention. It is essential to support integrated community-based mental health services that are sensitive to clients’ needs, such as gender-specific groups so women can talk in an all-female setting. Also, workers should recognize not only the risk factors but the resilience factors in the community (Khanlou, 2009). Advocating for the funding of community mental health services is another macro-level intervention. Immigrants and refugees have unique mental health needs, and they can thrive in a practice setting in which their background is understood.

MESO PRACTICE

As with macro practice, the meso-practice strategies discussed in chapter 6 also apply to mental health. These strategies of interdisciplinary collaboration and organizational development are aimed at enhancing the effectiveness of agencies when serving refugees and immigrants. In developing prevention and intervention plans, workers should incorporate inputs from key stakeholders. For example, a worker who is starting a clinic for torture survivors should be in constant touch with those from countries where war and other traumas have occurred. Implementing the plans requires input not only from community members but also from providers in related fields. Psychiatrists and other professionals, for instance, should have a sense of ownership in the program. Furthermore, outreach activities such as participating in a cultural fair can educate the public in a nonclinical setting. All social work interventions require monitoring and evaluation. Funding organizations and community partners will demand accountability. In addition to outcome measures, regular meetings with community partners can be beneficial to the program (Nazzal, Forghany, Geevarughese, Mahmoodi, & Wong, 2014).

01

Distrust of authority and power

Community engagement

05

02

Stigma of mental health services

Embedding services in service system

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03

Linguistic and cultural barriers

04

Primacy of stressors related to new living conditions

Partnership of providers and cultural experts

Integration of services

07

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Strategies

Barriers

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FIGURE 7.2 Barriers to immigrant and refugee mental health care and strategies to address them Source: Ellis, Miller, Baldwin, & Abdi (2011).

As shown in figure 7.2, immigrants and refugees usually face multiple barriers when accessing mental health services. Service providers should be aware of these common barriers in providing mental health services and work to overcome them.

DISCUSSION QUESTION

In a Mexican immigrant neighborhood in Chicago, community activists were proud of their work. One self-described “powerhouse” said, “Here everybody goes all out . . . we all kind of work together closely, so it makes it so much easier. . . . Yes, we do have issues in our neighborhood, but we do have people fighting for it, right?” (Hebert-Beirne et al., 2018, p. 6). If you were developing a mental health outreach program for Mexican immigrants, how would you approach this activist as a potential community partner?

Community partnership is a comprehensive approach to help with acculturation. One innovative approach, the Refugee Well-Being Project, pairs refugees with undergraduate students to engage in mutual learning and advocacy. Sessions include cultural exchange and one-on-one learning for ESL and other homework. Qualitative studies on the project have

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confirmed a reduction in acculturative stress and an improvement in adaptation (Goodkind, 2006; Goodkind, Hang, & Yang, 2004; Hess et al., 2014). Schools are another community resource for expanding mental health care. In one study, school-based mental health services for minority children showed promising outcomes in improving hyperactivity and emotional symptoms (Fazel, Doll, & Stein, 2009). School-based health services are also an effective alternative to meet the needs of newly arrived students. Families can be influential partners with mental health service providers. Their engagement in planning, service provision, and follow-up can enhance trust, improve cultural appropriateness, and diminish power differences between providers and clients (Ellis et al., 2011). For example, Coffee and Family Enhancement Services, a family engagement program aimed at facilitating refugee youth’s access to mental health services, yielded useful information about family beliefs that helped clinicians provide better service (Weine et al., 2006). Partnership with cultural experts is another solution to overcoming language and cultural barriers (Ellis et al., 2011). A collaboration between Montreal Children’s Hospital and a refugee organization formed a transcultural psychiatry team that improved treatment adherence (Measham, Rousseau, & Nadeau, 2005). Moreover, researchers recommend the use of ethnically matched service providers if possible (National Child Traumatic Stress Network, 2005).

MICRO PRACTICE

Micro practice in mental health entails the provision of direct clinical services. Assessment and treatment are critical components of micro practice. The following sections address assessment, general clinical considerations, and interventions for acculturative stress, depression and anxiety, posttraumatic stress disorder, and substance abuse. Common manifestations of mental health problems discussed previously (e.g., grief) are considered to be symptoms subsumed under these diagnostic categories. We primarily address individual and group interventions for adults here. Interventions for families are addressed in chapter 8. Fundamentally, assessment in mental health follows the principles of culturally competent assessment described in chapter 5.

ASSESSMENT

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This includes assessing the problem within the client’s total biopsychosocial context, identifying stressors and strengths relevant to the problem and its resolution, and using assessment and testing instruments appropriately. Several other considerations are important in mental health assessments for immigrants and refugees. First is the need to take extra time. Not only are there linguistic and cultural differences, but the worker needs to obtain a full history of the premigration and departure, transit, and resettlement stages of the client’s life. Second, practitioners should obtain a clear understanding of the client’s expectations of treatment. As noted previously, many immigrants and refugees are not familiar with Western mental health concepts or related services. Moreover, language barriers and cultural differences may lead to different expectations (Morris, Popper, Rodwell, Brodine, & Brouwer, 2009). Some clients may have specific expectations based on their beliefs about mental health. Third, the service provider should ask particular types of questions. Short statements and simple questions are usually more productive than just sitting back and listening. Open-ended questions elicit more information about feelings than do closed-ended questions. Questions should be culturally appropriate and meaningfully interpreted if needed (Raval, 2005). For example, “Was there a precipitating incident that caused distress?” Refugees may require an additional set of questions, such as the following: Q

Were you ever affected by violence, combat, or other threats? If so, please tell me what occurred.

Q

Were you subjected to a head injury? Have you experienced loss of consciousness or seizures?

Q

Have you received medical health treatment or interventions before?

Q

Do you use alcohol or drugs? How often?

Q

Have your children attended school or shown any learning difficulties?

Q

Have you ever experienced purposeful physical mistreatment or torture? (CDC, 2015B)

Fourth, the assessment interview should focus on facilitation and clarification, and workers should avoid any statements of interpretation (Raval, 2005).

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Fifth, the practitioner should carefully observe the client’s body language and general appearance for indications of emotional state. Service providers can consult with interpreters or culturally informed collaborators to understand nonverbal messages and body language (Nguyen, 2013). Assessments should involve a multimethod approach that includes interview, observation, and the administration of written instruments. If tests are used, workers should first make sure the test is a good fit for the client: Can it be translated correctly? Will the test measure the client’s traits as well as it does for the target population for which it was written? (Goldsmith, 2003; Paniagua & Yamada, 2013). Cultural assessment is necessary before administering and reviewing a test (Paniagua & Yamada, 2013). Fortunately, researchers have already tested the validity and reliability of some mental health assessment tools for use with immigrants and refugees:

CULTURALLY VALIDATED ASSESSMENT TOOLS FOR IMMIGRANTS AND REFUGEES Q Q Q Q Q Q Q Q Q

Harvard Trauma Questionnaire (HTQ) Clinician Administered PTSD Scale (CAPS) SCL-90 Symptom checklist-90 (SCL-90) Brief Symptom Inventory (BSI) Hopkins Symptom Checklist (HSCL) Hamilton Rating Scale for Depression (HDS) Hamilton Rating Scale for Anxiety Migratory Grief and Loss Questionnaire Refugee Health Screener—15 (RHS-15) SOURCE: AUTHORS’ SYNTHESIS.

During the assessment process, workers should remember the multidimensional aspects of a client’s background. Factors may include the client’s legal status, poverty, and the living conditions in the country of origin, which may include malnutrition and no access to services (ter Heide et al., 2014; Williams & Thompson, 2011). It is unlikely that immigrants and refugees will compartmentalize their problems in a way that fits the provider’s defined categories (Fitzpatrick, 2002).

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Finally, consistent with the evidence-based practice approach, workers should consider all assessments to be hypotheses that are subject to further verification. The practitioner’s provisional assessments need constant reevaluation to include new information and insights. Immigrants and refugees are a special population with distinctive traits. In clinical interventions with them, workers should consider these general issues: the use of traditional healers, cultural differences and role preparation, language barriers and the use of interpreters, the use of psychotropic medications, and evidence-based knowledge about treatment effectiveness. Traditional Healers. Many immigrants and refugees first try traditional treatments before using Western medicine, or they use a combination of both. Mental health practitioners must be aware of these traditional healing practices and not discourage clients from using them, unless they are known to be harmful or exploitative. Cultural Differences and Role Preparation. To overcome cultural differences, the worker should research the client’s culture before the first meeting. Role preparation entails the worker explaining the roles of client and therapist to the client, who is probably unfamiliar with the therapeutic process. If role preparation is done, the intervention is more likely to be successful (Liu, 2009). Language Barriers and Use of Interpreters. Whether or not the client has English proficiency, workers need to remember the role of language in the clinical encounter. Clients may not have the vocabulary to express their situations nor understand workers’ statements. Avoiding potential misunderstandings can make sessions longer than usual (van der Veer, 1998). Language differences can sometimes facilitate therapy. Several studies have shown that individuals experience less emotion in their second, or nonnative language (Caldwell-Harris & Ayçiçeği-Dinn, 2009). In part this is because when people switch languages they also tend to switch roles to some extent. Thus they adopt the cultural expectations of the new language’s context. Interpreters may be necessary to overcome language and cultural barriers (Miletic et al., 2006). In this setting, interpreters must have extensive training in both mental health and cultural interpretation because their errors could lead to serious mistakes in clinical decisions. For instance, “blue” is an idiom meaning depression in English, but in Vietnamese it indicates

GENERAL CLINICAL CONSIDERATIONS

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“hope” and “calmness” (Miletic et al., 2006). Except in emergency situations, untrained personnel or family members should never be used as interpreters. Psychotropic Medication. Psychotropic medication such as antidepressants have proven effectiveness. However, immigrants and refugees may respond to these medications differently than the general population. At least twenty-nine medications have been discussed in peer-reviewed journals to have differences in efficacy and safety across racial groups, but this area of research is still controversial (Weigmann, 2006). In addition to ethnic differences in dose response, adherence is another issue for immigrants and refugees (Avery, Lewy, & Erickson, 2008; Thao, 2009). Some clients may expect immediate results, and others may be using traditional herbs that could interact with the drug. Also, clients may not be able to read or understand the instructions that come with the medication. Another consideration is that some clients may have been tortured or in combat, which may have included forcible administration of drugs. Some child soldiers, for example, were forced to take hallucinogens before combat (Beah, 2007). In view of all these issues, service providers should consider the following practices when using psychotropic medications with immigrants and refugees.

BEST PRACTICES FOR USE OF PSYCHOTROPIC MEDICATIONS WITH IMMIGRANTS AND REFUGEES Q

Q

Q

Q

Q

Q

Because this population usually has a negative perspective about these medications, they should only be used as a last resort for severe symptoms. Medication nonadherence can occur, so providers must ensure that clients are not just saying “yes” in response to questions about their adherence. Immigrants and refugees may expect immediate results and discontinue their medication based on unrealistic expectations. Traditional practices, including fasting and herbs, may affect the medication’s efficacy. All other prescription drugs, over-the-counter drugs, and alcohol should also be discussed. It is critical to stress the importance of not sharing one’s medication with others for any reason. Asking clients to explain their medication regimen themselves is a good way to ensure that they understand it. SOURCES: AVERY ET AL. (2008); THAO (2009).

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Evidence-Based Knowledge About Treatment Effectiveness. The final issue about clinical mental health services for immigrants and refugees is the state of evidence-based knowledge about treatment effectiveness. Many of the existing recommendations for mental health intervention with immigrants and refugees are based on logical deductions and inferences and on clinical experience rather than on proven evidence of effectiveness. Therefore, mental health treatment with immigrants and refugees is a knowledge-building enterprise. The following sections address best practices for particular problem areas, based on the existing evidence-based knowledge, logic, and clinical experience. The interventions discussed here focus on the resettlement stage, the stage when most social workers will work with these populations. INTERVENTIONS FOR ACCULTURATIVE STRESS Interventions for acculturative stress are primary prevention methods aimed at decreasing this source of stress, which can lead to depression and anxiety. These interventions usually occur during the resettlement stage, but they could be used during the premigration or transit stages. Four interventions are effective for acculturative stress: case management, supportive counseling, information and skills training, and crisis intervention. Case Management. Where is the family going to live? Where are the children going to school? Where can they see a doctor or get job training? Case managers address these basic needs before dealing with the other aspects of acculturative stress. Moreover, case management builds trust between service providers and clients for further assessment and treatment (Birman et al., 2008). Best practices for culturally competent case management are shown in the following text box.

BEST PRACTICES FOR CULTURALLY COMPETENT CASE MANAGEMENT Q Q

Q

Concentrate on what the client sees as “real life” problems. Do a complete current environmental analysis; assess financial and social needs; back this with action. Prepare clients for services by offering role rehearsal and information; help clients complete forms; provide information on neighborhood resources using materials (e.g., graphics, translated materials) the client can understand. “CONTINUED”

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“CONTINUED”

Q

Q

Q Q Q

Q Q Q

Q Q Q

Q

Q Q Q Q Q

Call clients by their correct name and with the degree of formality expected in their culture; if in doubt, ask the client about pronunciation and cultural protocols related to the first and last name and other honorifics. Be prepared to disclose information about yourself, your home, your family, and your ideas so the client can get to know you as a person. Be prepared to involve the family. Accompany clients and family members to clients’ appointments. Be supportive of clients and family members who want to use indigenous healers/ helpers. Be alert to clues about intergenerational conflict. Be sensitive to indirect issues that are raised. Make advance calls to service providers to confirm they are ready to receive the family. Coordinate service appointments and locations. Provide transportation and coaching in the use of mass transit. Explore reimbursement mechanisms for neighbors or other supports who could provide transportation or other short-term assistance. Have staff available after hours and evenings and on weekends where community members congregate; attend cultural immersion activities (e.g., festivals, ceremonies). Develop relationships with the community’s most trusted helpers and gatekeepers. Develop relationships with cultural informants. Teach/encourage self-advocacy. Link to the community’s agency supports and volunteer assistance. Be patient. SOURCE: RAIFF & SHORE (1993).

Supportive Counseling. In supportive counseling, therapists engage clients by deeply valuing their perspective in a respectful way through empathetic understanding, trust-building, improving social relationships, respect, praise, assurance, and active therapeutic techniques (Jacobs & Reupert, 2014; Manne et al., 2008). Clients may discuss any negative feelings, including helplessness and powerlessness. By strengthening clients’ coping skills, the therapist can help them to analyze social situations in which they feel uncomfortable. As clients realize their special position in relation to both their country of origin and their new country, they can better understand themselves. Supportive counseling may include cognitive restructuring, which aims to change maladaptive thoughts. For example, a client may misinterpret a social situation and engage in negative self-talk. A therapist can help the client shift to a more positive cognition.

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Information and Skills Training. Learning about new customs can be difficult, but these interventions help clients develop skills for intercultural interactions. For instance, the Entre Dos Mundos prevention program is an eight-week multifamily group session program that brings groups of adolescents and parents from eight to ten families together on a weekly basis to discuss acculturation stressors and challenges. This program, which showed positive effects on acculturative stress, focuses on preventing stressors in the parent–adolescent relationship. In each session, participants discuss a theme that has been empirically linked to acculturative stress, such as coping with racial discrimination and family conflicts (Bacallao & Smokowski, 2009). Familias: Preparando la Nueva Generación (FPNG) is another preventive program that focuses on strengthening family functioning, empowering parents, and enhancing communication skills (Williams, Ayers, Garvey, Marsiglia, & Castro, 2012). Social skills training is a component these programs because having good social skills can promote mental well-being (Segrin & Taylor, 2007). Immigrants who have participated in social skills training have shown improved knowledge about social skills and relationship attitudes and have reported increased social support networks and greater satisfaction with interactions in the new culture (Wu & Lee, 2015). Assertiveness training is critical for survival in U.S. culture. Studies show that assertiveness training improves acculturative stress (Tavakoli, Lumley, Hijazi, Slavin-Spenny, & Parris, 2009). This training consists of discussion, modeling, and rehearsal of the assertive communication sequence (Tavakoli et al., 2009). Cultural differences, of course, require consideration during these interventions. Workers must strike a delicate balance between helping their clients cope with their new environment and maintaining their own cultural heritage. Promoting an assimilationist agenda at the expense of a client’s culture may be harmful. Workers must help clients identify situations in which they should use or not use these new behaviors and attitudes. Also, celebrating the newcomers’ cultural heritage is beneficial.

DISCUSSION QUESTION

A college student living with her traditional family tells her counselor that her parents are telling her which classes to take and imposing a curfew on her. The counselor is shocked and says, “That’s terrible! You need to stand up for yourself! You aren’t a teenager they can boss around!” What could be a more appropriate response from the counselor?

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Crisis Intervention. Ideally, interventions such as social skills training would prevent the occurrence of crises during the resettlement stage. However, sometimes these services are not available. Even when services are available, immigrants and refugees may not use mental health services in a timely manner until a crisis occurs (Snowden, Masland, Libby, Wallace, & Fawley, 2008). Therefore, crisis intervention is often needed for dealing with acculturative stress. A crisis occurs when a person is unable to cope with a situation using previously learned coping mechanisms. Feelings of tension and anxiety increase. If the problem remains unresolved, extensive personality disorganization and emotional breakdown may occur (Roberts & Ottens, 2005). Immigrants and refugees are particularly vulnerable to crises because they are faced with new situations in which their prior coping strategies may be ineffective. Also, they may not have their former support systems. Crisis intervention aims to reduce stress, relieve symptoms, and prevent further breakdown by restoring self-esteem and avoiding further maladjustment. It includes a limited time frame, often just one session; limited goals; development of a working alliance; maintenance of focus; high therapist activity; rapid, early assessment; therapeutic flexibility; promptness of intervention; and encouragement of ventilation. It is also helpful to teach clients the sequential steps of the problem-solving process shown in figure 7.3. General treatments for anxiety disorder are psychotherapy, medication, or a combination of both. In terms of psychotherapy treatments, cognitive-behavioral therapy (CBT) has shown promising outcomes in controlling anxiety disorder symptoms (National Institute of Mental Health [NIMH], 2016a). Research also has INTERVENTIONS FOR DEPRESSION AND ANXIETY

Analysis

01

• Who is involved? • Where is the problem? • Why?

Assessment and verification • Did the response lead to the desired outcome? • What is the next step?

03

FIGURE 7.3 Problem-solving process Sources: Braga (2008); D’Zurilla & Nezu (2010).

02

Response • What should be done? • Who should take action? • How?

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demonstrated that among the general population, CBT, interpersonal therapy (IPT), and problem-solving therapy are effective psychotherapeutic approaches for depression (Foroushani, Schneider, & Assareh, 2011; NIMH, 2016a). Each of these therapeutic approaches is discussed next. Cognitive and Behavioral Therapies. Both cognitive and behavioral approaches are time-limited, have a here-and-now focus, emphasize client education and active collaboration, use evaluation of apparent cause-and-effect relationships between thoughts, feelings, and behaviors, and use straightforward strategies to lessen symptoms. Behavioral therapy focuses on clients’ actions with the aim of changing unhealthy behaviors (NIMH, 2008). CBT is based on a cognitive model that emphasizes the effect of distorted thinking that leads to unrealistic evaluation of events and specific feelings and behaviors as outcomes (Knapp & Beck, 2008). CBT, usually effective for minor and moderate depression, can be combined with medication (NIMH, 2015). The underlying premise of CBT is that by changing negative thinking and its interpretation the client can develop more positive and realistic interactions. It also helps clients identify contributing elements to depression and change behaviors that make depression worse (NIMH, 2015). CBT is an effective treatment for anxiety disorder because it helps clients to think, behave, and react differently in anxiety-producing situations (NIMH, 2016a). Research on CBT with immigrants and refugees has demonstrated its efficacy (Antoniades, Mazza, & Brijnath, 2014). In a systematic review conducted by Palic and Elklit (2011), culturally sensitive CBT was shown to be effective in the treatment of anxiety, depression, and PTSD among adult refugees. CBT also showed promising outcomes in the treatment of depression, anxiety, and PTSD for immigrant and refugee children in a systematic review in school settings (Tyrer & Fazel, 2014). Cognitive and behavioral approaches are compatible with several religious belief systems, such as Buddhism and Hinduism, and with health belief systems such as those of many Latinx (Egli, Shiota, Ben-Porath, & Butcher, 1991). Interpersonal Psychotherapy. IPT has been found to be effective for the treatment of depression because it recognizes that depression can occur in the context of interpersonal relationships. Like cognitive and behavioral approaches, IPT is time-limited, present-oriented, active, and collaborative. It is mainly based on attachment theory and communication theory. By aiming to reduce distress and improve clients’ interpersonal functioning, IPT helps clients maintain or develop social support (Stuart, 2006).

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Research on IPT with immigrants and refugees is limited (Meffert et al., 2014). However, IPT can be highly appropriate for depressed immigrants and refugees because it stresses the social tensions that they may experience in a new country. The action orientation is compatible with the treatment expectations of many immigrants and refugees. Problem-Solving Therapy. Problem-solving therapy teaches clients how to manage life stressors. It teaches adaptive skills such as making effective decisions, generating creative solutions, and identifying barriers to reaching goals (American Psychological Association, n.d.). Problem-solving therapy has been demonstrated to be efficacious for depression with immigrant populations (Antoniades et al., 2014). INTERVENTIONS FOR POSTTRAUMATIC STRESS DISORDER Similar to anxiety and depression, interventions for PTSD include psychotherapy, medication, or a combination of both (NIMH, 2016b). Although researchers have suggested several psychotherapeutic interventions for PTSD in general populations, there is limited information about PTSD treatment for immigrants and refugees, who usually experience multiple traumatic events (Drozdek, 2015; Slobodin & de Jong, 2015; ter Heide, Mooren, & Kleber, 2016). PTSD treatment among immigrants and refugees could be more complex due to difficulties of communicating empathy through interpreters or in a second language, cultural differences, and challenges in building trust (Crumlish & O’Rourke, 2010; Drozdek, 2015; Slobodin & de Jong, 2015; ter Heide & Smid, 2015). Moreover, most of the measurement tools for PTSD assessment were not initially designed or validated for immigrants and refugees (Crumlish & O’Rourke, 2010). Effective treatment options for PTSD are trauma-focused cognitive behavior therapy (TF-CBT), eye movement desensitization and reprocessing (EMDR), narrative exposure therapy, and imagery rescripting. The National Institute for Health and Clinical Excellence in the United Kingdom has recommended TF-CBT and EMDR as effective treatments for PTSD (Robjant & Fazel, 2010). These two approaches were identified as superior treatments in a meta-analysis conducted with a mixed population (including immigrants and refugees) diagnosed with PTSD (Bisson et al., 2007). EMDR showed promising results for refugees in a systematic review conducted by ter Heide and colleagues (2014). In two other systematic reviews conducted on refugee populations, narrative exposure therapy and CBT showed promising outcomes in PTSD treatment (Palic & Elklit, 2011;

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Slobodin & de Jong, 2015). Finally, imagery rescripting has shown potential positive outcomes for immigrants and refugees (Arntz, Sofi, & van Breukelen, 2013). Each of these approaches is briefly described next. Trauma-Focused Cognitive Behavioral Therapy. TF-CBT is typically used with traumatized children and adolescents but has also been effectively applied with adults (Bisson, Roberts, Andrew, Cooper, & Lewis, 2013). It shares many of the elements of CBT described previously. Specific elements include psychoeducation, relaxation skills, affective modulation skills, cognitive coping skills, trauma narrative and processing, in vivo exposure, and enhancing safety (Dorsey, Briggs, & Woods, 2011). Eye Movement Desensitization and Reprocessing. EMDR helps reduce PTSD symptoms by processing the memories of the traumatic event and overcoming avoidance. EMDR is based on extinction learning that detaches distress cues from signals of threat, indicating that the trauma no longer exists (Nickerson et al., 2011). In EMDR, clients recall traumatic memories, with the help of the therapist, while simultaneously making horizontal eye movements. In this process, survivors gradually learn that the signals primarily linked to trauma no longer exist, reducing the level of anxiety (Nickerson et al., 2011). Narrative Exposure Therapy. NET is another trauma-focused treatment for PTSD. Narration of traumatic events is the key aspect. NET is rooted in the CBT framework and uses two main means of therapy: learning and improvement of memory distortions (Nickerson et al., 2011). NET is based on evidence that distress can be directly linked to verbal cognitions; thus the narration of events can alleviate emotional distress and distorted thinking (Holmes, Arntz, & Smucker, 2007). Active listening and empathy are the two major components of this process (Nickerson et al., 2011). NET is one of the most cited evidence-based trauma treatments for culturally diverse populations (Stenmark, Catani, Neuner, Elbert, & Holen, 2013). Imagery Rescripting. Like NET, ImRs is rooted in the CBT framework. This intervention is based on the concept that fear is the main cause of the disorder. Extreme fear at the time of the traumatic event has resulted in a strong habituated response. Therefore, successful therapy for survivors is through a learning process that teaches them that the cues associated with that trauma no longer exist (Nickerson et al., 2011). Researchers observed that affective distress could be directly linked to visual as well as to verbal cognitions. ImRs addresses the visual part. It is based on the premise that

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mental imagery has a controlling impact on emotions; therefore, using it can be a powerful psychotherapeutic tool for improving emotional distress and reducing anxiety (Holmes et al., 2007). In ImRs, survivors imagine the traumatic event and then imagine an intervention that changes the course of events so a more favorable outcome is achieved. In imaginal exposure (IE), which is the origin of ImRs, patients usually imagined the full trauma before rescripting was begun. However, ImRs makes the process more tolerable and effective by starting rescripting before imagining the traumatic event. Therefore, the client does not need to imagine all the horrible details and feel helpless. Examples of ImRs include clients imagining that members of their tribe successfully defended their family against an attack by another tribe, or imagining a strong defense against a rapist and being successful (Arntz et al., 2013). Interventions that occur shortly after a trauma can help prevent the development of PTSD, so providing preventive interventions in the transit stage or early in the resettlement phase to traumatized immigrants and refugees can be beneficial. Psychological debriefing and other interventions can treat the acute stress disorder (which occurs right after a trauma) and reduce the early signs of PTSD (Feldner, Monson, & Friedman, 2007). A final issue to be considered in the treatment of PTSD is referred to as countertransference, compassion fatigue, or secondary traumatic stress syndrome (Forester, 2007). These terms refer to the therapist’s reactions to the client’s stories of horror and inhumanity. The therapist may experience symptoms that mirror those expressed by the clients and reflect them in behaviors such as freezing or shocked responses and reactivity to the client’s experiences. Coping with these reactions requires therapists to be aware of their own somatic and emotional symptoms. Therapists should discuss their reactions with colleagues and practice the same techniques of anxiety management and cognitive restructuring that they teach their clients (Forester, 2007). Immigrant and refugee assessments should include assessment for alcohol and other drug use, including traditional herbal substances (CDC, 2015b). Immigrants who have lived in the United States for more than fifteen years are as likely to use illicit drugs as are native-born people (Kandula et al., 2004). When questioning about possible substance abuse, workers should consider cultural norms and acculturation gaps. Male Filipinos, for example, are more likely than

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other groups to use amphetamines or intravenous drugs (Nemoto, Operario, & Soma, 2002). Dual diagnosis (i.e., both substance abuse and mental illness) may also affect assessment when discussing symptoms (Horyniak, Melo, Farrell, Ojeda, & Strathdee, 2016; Saffer & Dave, 2005). One crucial question for substance abuse assessment is whether the client is ready to change. The five stages of readiness to change are precontemplation—client has no intention to change in the near future; contemplation—client is thinking about change but is not committed yet; preparation or determination—client is getting ready to change in the near future; action—client is actively trying to change; and maintenance—client is trying to prevent relapse (Norcross, Krebs, & Prochaska, 2011). After assessing the stage of change and possible use of motivational interventions, the worker should determine the appropriate treatment goals. Complete abstinence is the goal for those using illegal substances, but moderate drinking is a realistic goal for problem drinkers whose use is of low to moderate severity (Witkiewitz & Marlatt, 2006). Unfortunately, there is almost no research on substance use treatment specifically for immigrants and refugees. However, for the general population, the most effective treatments for substance abuse are behavioral therapies (National Institute on Drug Abuse [NIDA], 2012). Addiction is a complex disease, and no single treatment is suitable for all clients. Medication, CBT, motivational enhancement therapy, behavioral therapies, twelve-step programs, psychodynamic and interpersonal therapies, and group and family therapies are all recommended approaches for the general population (American Psychiatric Association, 2006). Also, treatment must be of a long enough duration (NIDA, 2012). As with all other issues discussed in this book, cultural competence in this area is critical. The following text box lists recommended practices for substance use interventions with immigrants and refugees.

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Education about addiction as a treatable illness is needed for clients, their families, the community, and for refugee and immigrant human service staff. Treatment programs must be sited in nonstigmatizing settings. “CONTINUED”

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When possible, domestic violence and addiction treatment should be combined and referrals of addicted clients sought from domestic violence programs, child protective agencies, and the courts. Refugee and immigrant communities establishing substance abuse programs should expect that most of the initial referrals will be of very chronic clients. Full-time programs are preferable due to . . . the . . . auxiliary needs of refugee and immigrant clients. Programs must anticipate that a significant proportion of clients will be dually diagnosed. Securing referrals from other refugee and immigrant organizations is more likely . . . if the substance abuse program establishes subcontracts with these organizations. Utilization of a primarily nonverbal treatment such as acupuncture should be considered as one element of a substance abuse treatment program. Need to provide accessible professional training for members of refugee and immigrant communities so they can be independent providers. . . . Need for systemic change in the delivery of in-patient and residential treatment for refugee and immigrant populations. SOURCE: AMODEO ET AL. (2004).

SUMMARY This chapter has considered numerous issues in the etiology, assessment, and treatment of mental health problems among immigrants and refugees. As noted throughout, we have focused on individuals. Of course, individuals exist within families, to which the next chapter will turn.

8 FAMILY DYNAMICS

THE STRESSORS of the migration process typically lead to changes in family roles and family dynamics, especially in the ways family members relate to one another. Migration can cause disintegration of the role systems and social identities of individuals (Yue, Li, Jin, & Feldman, 2013). These role changes place additional stress on family members, and sometimes migration stressors overwhelm the family’s strengths. Like individuals, families respond to stress with coping resources and protective factors. Some families are highly adaptable, and their members are able to adjust their power structure, role relationships, and relationship rules in response to stress. Supportive community resources are also critical for restoration of the family’s balance. Families may see the change as an opportunity rather than a challenge (Degni, Pöntinen, & Mölsä, 2006; Hyman et al., 2008), but if families lack these internal and external strengths, family conflict may occur. For immigrant and refugee families, family conflict has two dimensions: couple and intergenerational conflict (Chung, Flook, & Fuligni, 2009; Lee, Su, & Yoshida, 2005; Lim, Yeh, Liang, Lau, & McCabe, 2008; Wu & Chao, 2005). Family conflict may result in intimate partner violence, child abuse, or elder abuse (Chang, Rhee, & Weaver, 2006; Lai, 2011; Lee & Hadeed, 2009; Shibusawa & Yick, 2007). Some cultures may regard such family violence as acceptable, especially intimate partner violence. In addition, some family members may experience unique life cycle issues related to migration (Aslund, Bohlmark, & Nordstrom Skans, 2009). For example, children and adolescents in immigrant and refugee families face particular individual issues apart from the issues facing the family as a whole. This is also true for older adult family members (Kim et al., 2011; Reed, Fazel, Jones, Panter-Brick, & Stein, 2012; Yoshikawa & Kalil, 2011).

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In this chapter we discuss various family dynamics issues common to immigrant and refugee families. The focus again is primarily on the resettlement stage, when social workers are likely to be involved with families. Best practices for assessment and intervention with families are also described. Social workers should note that in this context the term family is based on the client’s definition of family, which usually includes a wider group than the Western model of the nuclear family.

FAMILY DYNAMICS ISSUES The common issues faced by immigrant and refugee families are couple conflict, including intimate partner violence; intergenerational conflict, including child abuse and elder abuse; and life cycle issues. Each of these issues is addressed in the following sections.

COUPLE CONFLICT AND VIOLENCE

The most commonly reported source of couple conflict among opposite-sex immigrant and refugee couples is gender role reversals, which are accompanied by shifts in status and power (Hyman et al., 2008; Lee & Hadeed, 2009; Renzaho, McCabe, & Sainsbury, 2011). As noted in chapter 7, most immigrants and refugees come from male-dominated cultures in which men hold most of the power in family decision making. These cultures also typically have clearly defined gender roles: men are responsible for supporting the family by paid work outside the home, and women are responsible for supporting the family by unpaid work inside the home. Because men hold the power, they maintain the status quo of gender roles. Some women may desire to work for pay outside the home, or they may want help from the men with housework and child care. However, the men often do not permit such crossing of the gender lines. Even in countries where women participate in the paid labor force at a high rate, traditional gender roles often still exist inside the home. This “double shift” for women with outside jobs can be a source of conflict. Upon migration to the United States, these gender roles frequently are reversed. It is usually necessary for both partners to work outside the home to support the family. Women who work outside the home may

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need help with the household, but their husbands may resist this role change. Gender role reversals may result, with men losing their traditional positions of power and status. Unemployed or underemployed men may become frustrated, depressed, or angry. They may believe they have lost the respect of their family members and may refuse to assist their wives with work inside the home, or these men may try to reassert their power through physical violence (Akinsulure-Smith, Chu, Keatley, & Rasmussen, 2013; Hyman et al., 2008). Several other factors also contribute to couple conflict (Conger, Conger, & Martin, 2010). One factor is a difference in the desire to migrate. Sometimes, one person had a stronger desire to emigrate, and the partner simply followed. The partner who followed may have preferred to remain in the country of origin and may have followed due to having less power or through a desire to keep the family together. When faced with the stressors of migration and resettlement, the reluctant follower may blame the partner for the difficulties they encounter. Similarly, these partners may differ in their desire to return to the country of origin. One partner may strongly desire to return, but the other may wish to remain in the new country. This difference can reach a crisis point for refugees when political changes occur in their country of origin, making return a real possibility (van der Veer, 1998). Another cause of couple conflict is differential acculturation between the partners. One spouse may adopt the new cultural norms or adjust to changes more quickly than the other. This most often becomes problematic when the woman adapts faster than the man, which can lead to a power shift. Even if this does not lead to more rapid or better employment, the woman will take on more responsibility for interaction with the outside world. Again, this represents a power shift away from the man. Cultural differences can cause conflict if the partners are from different cultural backgrounds. Intermarriage between cultural groups is not uncommon among immigrants and refugees. For example, an immigrant or refugee may marry a member of the host culture. Although cultural differences between the couple may have seemed attractive initially, as time passes these cultural differences can become a source of discord rather than attraction. Couples often fail to recognize the cultural nature of the problem and view it in personal rather than cultural terms (Cheng, 2010). Immigrant and refugee families frequently live in crowded conditions during early resettlement, and this increased physical closeness is another

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possible source for couple conflict. If both spouses are unemployed or employed only part-time, they are likely to be spending more time together than they did before this move. Increased togetherness coupled with a lack of privacy in a crowded home may lead to short tempers. When established methods of conflict resolution are no longer effective in the new situation, couple conflict may increase. For example, support systems that were helpful in resolving conflicts in the past are likely to be absent (Shirpak, Maticka-Tyndale, & Chinichian, 2011). Partners may now have to depend on each other in different aspects of life, which can cause distress and couple conflict (Myers-Walls, Frias, Kwon, Ko, & Lu, 2011). A final cause of couple conflict is simply that partners are convenient targets on whom to displace anger arising from the stressors of the migration process. After migration, partners are usually so close and dependent on each other that distress can easily be expressed as couple conflict (MyersWalls et al., 2011). It is important to recognize that some couples may have experienced conflict before they migrated; not all conflicts are caused by migration stressors. Severe couple conflict and cultural norms are risk factors for intimate partner violence, which is defined as “a pattern of assaultive and coercive behaviors designed to establish control.” This violence may be expressed as a “physical assault, psychological or emotional abuse, sexual assault, progressive social isolation, stalking, deprivation, intimidation and threats.” The definition of intimate partners (same or opposite sex) includes “current or former spouses (including common-law spouses), dating partners, or boyfriends and girlfriends who may or may not be cohabiting” (Runner et al., 2009). Both men and women can be abusers, but most immigrants and refugees come from male-dominated cultures, so the perpetrators of intimate partner violence are most often men. The prevalence of intimate partner violence in immigrant and refugee families is not known, but such violence is widespread throughout the world, across societies, cultures, religions, ethnic groups, and socioeconomic strata (Garcia-Moreno, Guedes, & Knerr, 2012). All the factors that lead to couple conflict also can lead to intimate partner violence. Men may resort to spousal abuse in an effort to regain the power and control they lost in the migration process (Akinsulure-Smith et al., 2013; Hyman et al., 2008). Many cultures condone “wife beating,” so a woman may not get support from her own group (Akmatov, Mikolajczyk, Labeeb, Dhaher, & Khan, 2008; Archer, 2006; Fawole, Aderonmu, & Fawole, 2005; Flood & Pease, 2009). In addition, women may blame themselves for the

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abuse or feel that they do not have the right to oppose such treatment (Flood & Pease, 2009). A past history of violence in the country of origin is a risk factor for subsequent intimate partner violence for both men and women (WHO, 2016a). In all circumstances, intimate partner violence is a violation of internationally recognized human rights. No one should sanction intimate partner violence under the guise of being culturally competent.

INTERGENERATIONAL CONFLICT AND ABUSE

Intergenerational conflict occurs between parents, children, and grandparents, and it is common in immigrant and refugee families (Choi, He, & Harachi, 2008; Lim et al., 2008). Intergenerational conflict can result from the differential acculturation rates between the generations, especially when the children become “Americanized” more quickly than their parents or grandparents (Lim et al., 2008; Ying & Han, 2007). Refugee families, in particular, may experience intergenerational conflicts arising from the traumatic experiences of family members (Westoby, 2008). Exposure to violence and trauma is associated with family conflict (MacDermid Wadsworth, 2010). This discussion of intergenerational conflicts is specific to children and youth, the elderly, and refugee families. A subsequent section addresses life cycle issues that are unique to each generation.

DISCUSSION QUESTION

A Turkish mother is at a preschool event, and she hovers over her child while he is making a project. She takes over the project when she thinks he is doing it wrong. In her collectivist culture, this type of parenting is appropriate. However, the other mothers at the school criticize her: “Back off! Let him do his own thing!” (Yaman et al., 2010). If you were the school social worker, how would you handle this culture clash?

INTERGENERATIONAL CONFLICT AND ABUSE RELATED TO CHILDREN AND YOUTH The major source of intergenerational conflict is differential acculturation. This is particularly true in relation to children and youth.

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Children usually learn the new language and customs before their parents do, and they may take on the role of interpreter, translator, and culture broker within the family’s social environment. This is known as role reversal, and it is fraught with problems for the family. Placing children in an inappropriate position of power over their parents may lead them into premature adulthood. Sometimes the intergenerational role reversal extends to include emotional support. Parents may be so emotionally overwhelmed by the stressors of the migration process that they are unable to provide emotional support to their children, and they may, in fact, turn to their children for emotional support for themselves (Lanuza & Bandelj, 2015). In addition, parents with poor English language proficiency or low socioeconomic status may not participate or provide emotional support for their children when school-related conflicts arise (Lanuza & Bandelj, 2015). Gender role conflicts may arise between children and parents as the children adapt to the new society. Parents’ gender-role expectations for their children may be incompatible with behaviors their children are learning (Qin, 2009). For example, parents may expect girls to be subordinate, but the girls may be learning that a certain level of assertiveness is necessary to be successful (Céspedes & Huey, 2008; Dennis, Basañez, & Farahmand, 2010). When faced with these contradictions, the girls may feel additional distress (Céspedes & Huey, 2008). Girls also may feel resentment when parents place more restrictions on their behavior than on their male siblings because the girls see that this often does not happen in nonimmigrant families (Le Espiritu, 2015). Intergenerational conflict can stem from the way parents discipline their children. Immigrant parents often have to work long hours, and they have less time to be with their children (Tyyskä, 2013). Furthermore, intergenerational role reversals may result in a loss of parental authority over the children. Children tend to become more assertive than is the norm in their culture of origin, and they may rebel against their parents’ efforts to discipline them (Baptiste, 2005). Viewing their parents as too rigid and autocratic, children quickly learn that the term “child abuse” can be applied to some of the disciplinary techniques that were appropriate in their country of origin. They may then threaten to report their parents to the authorities. Conversely, some common child discipline practices in the United States, such as letting small babies cry until they go to sleep, may be unacceptable to immigrants and refugees (Fontes, 2002).

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The stressors of the migration process and intergenerational conflicts place immigrant and refugee children at increased risk of child abuse. Although little is known about the actual incidence and prevalence of child abuse in immigrant families, some cultures do sanction child discipline practices such as beating (LeBrun et al., 2016). Like intimate partner violence, cultural differences are no excuse for child abuse. However, some cultural practices, such as coin rubbing (see chapter 6), are healing methods and are not abuse. In general, social workers should be alert to the increased risk of child abuse in immigrant and refugee families and educate parents about child protection laws in the United States. INTERGENERATIONAL

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ADULTS Understandably, older adults may have more trouble adjusting to a new country. It is more difficult for them to acquire language skills and to adopt new beliefs and behaviors, and older adults may become dependent on younger family members to interpret this new world (Kam & Lazarevic, 2014). Grandparents may disapprove of the parents’ new child-rearing practices and may try to maintain the ways of their country of origin (Conn, Marks, & Coyne, 2013). Their adult children often acculturate more easily—and their grandchildren have even less difficulty adjusting to the new culture—so older immigrants and refugees may begin to feel like strangers in their own families. This differential acculturation can lead to intergenerational conflict and emotional distress (Foner & Dreby, 2011; Mui & Kang, 2006). Many traditional cultures stress filial piety: children are expected to treat parents with high respect and to take care of them in their old age, often putting family interests above their individual needs (Lai, 2010). In these cultures, older adults act as wise advisers. In the new country, they may lose their advisory role and become subordinates (Hossen & Westhues, 2013), and older immigrants may be forced to change their expectations regarding filial piety as well (Dong, Chang, Wong, & Simon, 2012). Many adult children may place more value on their careers and other demands than on responsibility for their parents (Yoo & Kim, 2010). These intergenerational conflicts with the older generation are also a risk factor for abuse. Definitions of elder abuse vary widely across cultures and across nations, and it may be manifest in passive or active neglect, physical abuse, sexual abuse, financial abuse, or psychological abuse. In some cultures, older women are more at risk of abuse and neglect than are men (WHO, 2016b).

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Elder abuse may occur in immigrant and refugee families for many reasons, and this may pose a moral dilemma for social workers as they try to balance respect for cultural values with the obligation to intervene in abuse cases (Felton & Polowy, 2015). The definitional problems arise primarily in the area of psychological abuse. Other types of elder abuse (physical, financial, etc.) should be treated as unacceptable regardless of the family’s cultural background.

LIFE CYCLE ISSUES

Immigrants and refugees face unique life cycle issues within each generation. These issues deserve separate consideration because they involve individuals’ psychological reactions to issues of identity and meaning. Children (especially adolescents) and older adults are most affected by these issues. The major psychological issues for adults are discussed in chapter 7 on mental health. Specific life cycle issues for adolescents and older adults are described in the following sections. A major developmental task of adolescence is identity formation. Immigrant and refugee adolescents frequently experience substantial conflict regarding their ethnic identity. They are caught between two worlds that have competing demands. Parents sometimes encourage their adolescent children to conform to the norms of the country of origin, but peer pressure to fit in at school may demand that immigrant children adopt new norms. Parents may not understand the identity conflicts confronting their children because the psychological impacts of migration on the two generations are different. Adolescents’ reactions to this ethnic identity conflict vary. Some reject one culture or the other, effectively removing themselves from interaction with members of that culture. Others develop a heightened sense of ethnic pride, which may be a reaction to experiencing discrimination from the host society (Berkel et al., 2010). Valuing one’s cultural heritage has been a protective factor in mental health and academic attainment for immigrant adolescents (Berkel et al., 2010; Schultz & Lien, 2014; Schwartz et al., 2010). Alternating periods of identifying more with one culture or the other may occur for some adolescents. Others develop a bicultural identity, LIFE CYCLE ISSUES OF ADOLESCENT REFUGEES AND IMMIGRANTS

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in which they selectively choose those elements from each culture that best fit their circumstances (Schwartz et al., 2010). Research indicates that a bicultural identity is the ideal outcome, but the ethnic identity conflict may persist into young adulthood. This may lead to marginalization in the acculturation process, that is, the feeling that one does not fit in with either ethnic group. Another life cycle issue immigrant and refugee adolescents face is expectations from parents for school success. Some immigrants have high expectations for their children in school, whereas others have lower expectations due to language barriers and the parents’ lack of involvement in school (Yamamoto & Holloway, 2010). Many immigrant and refugee children meet or exceed their parents’ high expectations, others become depressed or suicidal due to these demands, and some underperform in part due to the absence of parental involvement. In addition to these unique life cycle issues, adolescents experience typical stressors of the migration process, such as separation, poor English language knowledge, and acculturation. They also must cope with the developmental tasks of adolescence that are not related to migration (Garcia & Lindgren, 2009; Gudiño, Nadeem, Kataoka, & Lau, 2011). Despite ethnic identity conflicts and other stressors, most immigrant and refugee adolescents adapt well to resettlement (Breslau et al., 2007; Perreira & Ornelas, 2011). Although the “risk factors (poverty, family separation, and political violence), together with low rates of health insurance coverage and health care use, should lead to poorer health among foreign-born children” (Perreira & Ornelas, 2011, p. 198), these are balanced by three other factors that affect their overall health. Avoiding behaviors such as smoking, the increased likelihood of the support of two parents and an extended family, and the possibility of selective migration of children—that is, “parents whose children have physical or emotional health problems could be less likely to immigrate” (p. 199)—limit the health risks of these adolescents. These advantages deteriorate over time and in successive generations (Perreira & Ornelas, 2011). There is great diversity in outcomes based on multiple factors, including histories of migration, family circumstances, and school and neighborhood experiences. And some refugee and immigrant children and adolescents are at risk of developing mental health problems arising from multiple stressors.

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One major developmental task of old age is to find integrity or meaning in and acceptance of the life one has lived. If this is not achieved, despair may result. For elderly immigrants and refugees, a major element of this task is coming to terms with feeling a profound loss of the homeland (Nikelly, 2004). For older adults, migration often represents an end rather than a new beginning. They have no further opportunity to live the life they had known, nor any reminders of that life or that self. The longing for the homeland frequently manifests itself as a longing for its physical surroundings, where a lifetime of memories resides. These older adults may spend time reminiscing about the homeland, which is helpful in decreasing or preventing their despair. Older immigrants and refugees understand that it is unlikely they will ever return to their homeland, or even be buried there. This loss can be extremely difficult to accept because of the spiritual teachings of their religion or the strong cultural values of their country of origin (Lee, 2010). Realizing that they may not be able to return is often associated with a deep sense of grief (Lee, 2010). Older immigrants and refugees frequently experience social isolation (Mui & Kang, 2006; Wong, Yoo, & Stewart, 2006). Stigma may play a role in this isolation because U.S. society does not highly value older adults or foreign-born people (Guruge, Thomson, & Selfi, 2015). Also, the intergenerational role reversals may leave older adults feeling useless, unneeded, and unappreciated (Mukherjee & Diwan, 2016). These factors can compound their sense of despair as older adults struggle with issues of identity and meaning. LIFE CYCLE ISSUES OF OLDER ADULT REFUGEES AND IMMIGRANTS

BEST PRACTICES We now turn to best practices for the various family issues discussed here. The macro- and meso-level interventions described in preceding chapters also apply to the family dynamics issues addressed here, so they are only briefly discussed here before discussion of micro-level interventions.

MACRO INTERVENTIONS

Macro interventions are aimed at preventing problems and increasing clients’ access to services. In the context of families, macro interventions

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include developing policies and programs to serve the needs of families. Here are some recommended actions in this regard.

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Q

Q

Support opportunities for the sharing of practice methods and theories that are developed to address the special needs of immigrant-origin individuals and their families across the life span, recognizing there may be methods of treatment that incorporate culturally syntonic techniques in practice. Advocate for implementation of comprehensive, community- and school-based mental health programs and interventions that have demonstrated clinical effectiveness with immigrant-origin children and adolescents. Support and advocate for federal policy initiatives that assist in the adjustment and self-sufficiency of immigrant-origin adults (including older adults), children and adolescents, and families. Advocate for initiatives that provide case management services for immigrant-origin individuals across the life span that address basic needs and access to essential resources (e.g., physical health care, mental and behavioral health care, job placement, and housing). Support the development of and access to a range of services for unaccompanied immigrant minors, such as physical and mental health services, adequate housing and provision of daily needs, and school placement and support. Support the development and dissemination of culturally and linguistically appropriate evidence-informed practices for prevention, intervention, and treatment of mental and behavioral health problems among immigrant-origin individuals across the life span in both traditional and nontraditional settings (e.g., home, community, school, and detention facilities). SOURCE: AMERICAN PSYCHOLOGICAL ASSOCIATION (2012).

One macro-level intervention is the development of federal policy pertaining to intimate partner violence and child abuse within immigrant and refugee families. Based on the Violence Against Women Act of 1994, victims of intimate partner violence, child abuse, or elder abuse can self-petition for cancelation of deportation and for lawful permanent residency without the cooperation of the abuse perpetrator (American Immigration Council, 2012). Social workers can contribute to the continued development of family supportive policies and programs for immigrants and refugees. For example,

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NASW issued a strong statement against separation of immigrant families at the Mexican border in 2018: A “zero tolerance” immigration policy that would prosecute families who attempt to cross the border and forcibly separate children from parents is malicious and unconscionable and the National Association of Social Workers (NASW) will press lawmakers to rescind this egregious action. NASW (2018B)

DISCUSSION QUESTION

This book was written in mid-2018, when immigration and refugee policies were shifting rapidly. What is the current status of the rights of immigrants, refugees, and asylees? What role (if any) did the social work profession play in fighting for their rights?

MESO INTERVENTIONS

Meso-level interventions aim to enhance the effectiveness of agencies and systems serving immigrant and refugee clients. The techniques for doing this described in preceding chapters are equally relevant to family dynamics issues. In this context, empowerment is especially important. Most of the cultures of immigrants and refugees are male-dominated, but the resettlement stage can challenge traditional gender roles. To better serve families that are struggling with these issues, agencies must explicitly include women from the community in their program planning. The following text box provides a framework for gender equality programming.

BEST PRACTICES FOR GENDER EQUALITY PROGRAMMING Q Q Q

Analyze gender differences. Design services to meet the needs of all. Ensure access. “CONTINUED”

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“CONTINUED”

Q Q Q Q Q Q

Ensure participation. Train women and men equally. Address gender-based violence. Collect, analyze, and report gender disaggregated data. Target action based on gender analysis. Coordinate action with other partners. SOURCE: INTER-AGENCY STANDING COMMITTEE (2006).

MICRO ASSESSMENT AND INTERVENTIONS

This section addresses clinical assessment and interventions specifically for couple conflict and violence, for intergenerational conflict and abuse, for children and adolescents, and for older adults. ASSESSMENT

AND

INTERVENTIONS

FOR

COUPLE

CONFLICT

AND

VIOLENCE Assessment of couple conflict and violence follows the general principles for assessment described in chapter 5. In addition, social workers should assess the language ability of each member of the couple. Abusers frequently use their partner’s limited English as one way to control behavior. For instance, they may silence the partner by acting as the only family member able to communicate in English. Therefore, adequate interpretation is necessary during assessment (Runner et al., 2009). Standardized instruments or structured interview questions may be helpful in assessing the degree of couple conflict or violence. As with individual mental health assessment, these instruments should be short and straightforward. A number of instruments and screening tools exist (Heyman, 2001; Snyder, Heyman, & Haynes, 2005), but these instruments have not been translated and validated specifically for immigrants and refugees. Workers should use them with caution. Couple Therapy. Four evidence-based models of couple therapy provide strong evidence of utility for immigrant and refugee couples: emotionally focused therapy, brief strategic family therapy for couples, traditional behavioral therapy for couples, and integrative behavioral couple therapy (Rastogi & Thomas, 2009).

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Emotionally focused therapy is grounded in attachment theory and family systems theory. This approach consists of three phases (Berg, 2009): 1. De-escalation: establish therapeutic alliance and validate each partner’s experience. 2. Engagement: partners describe their experience to each other: express risky feelings. 3. Consolidation: partners practice new ways of interacting.

In brief strategic family therapy, couples are viewed as part of the larger family system. The goal is to change maladaptive, repetitive interactions between the partners. The intervention is practical, problem-focused, and deliberate (Hervis, Shea, & Kaminsky, 2009). Traditional behavioral couple therapy focuses on specific behavioral goals, overt behavioral change, and maintenance of newly learned behaviors, particularly communication and problem-solving skills. Finally, integrative behavioral couple therapy combines two goals, acceptance and change, as positive outcomes for couples. The approach consists of an evaluation/feedback phase, during which the therapist learns about the couple and provides feedback about their struggles and how therapy may help; and an active treatment phase, during which couples discuss recurrent themes in their struggles and develop alternate communication patterns (Christensen, n.d.). Interventions for Intimate Partner Violence. No evidence-based reports exist on interventions for intimate partner violence for immigrants and refugees. Only general recommendations such as those shown in figure 8.1 are available.

DISCUSSION QUESTION

Your agency is working with a coalition to reduce intimate partner violence in a Latinx immigrant community. When prevention posters go up, however, male community members complain because they feel that they are being stereotyped as violent “macho” men. How would you develop an effective intervention that does not reinforce any ethnic stereotypes?

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1

Provide support for survivors, including emergency shelter and legal assistance

2

Adapt services to address language and cultural barriers

3

Win the survivor’s trust by providing services such as employment assistance

4

Obtain support from ethnic community leaders

5

Emphasize families and communities

6

Integrate interventions with programs such as substance abuse treatment

FIGURE 8.1 Recommendations for intimate partner violence interventions with immigrants and refugees Sources: Runner et al. (2009); WHO (2002a).

Many intimate partner violence programs for the general population exist, but few have been evaluated for their effectiveness (Runner et al., 2009). In general, effective programs should include the following components: action at all levels, including local and national; women’s involvement, which means considering their interests and safety above all; changing the institutional culture for a better response to survivors of violence; and a multispectral approach that works with law enforcement, health care workers, and others (WHO, 2002a). In most cases, the abuser and the victim are treated separately. Group approaches are often used. Groups for perpetrators typically focus on education about patriarchal structures (i.e., sex-role socialization, power, and control) and may employ CBT approaches to anger management and development of communication skills for nonviolent conflict resolution. Groups for victims, in contrast, focus on support and empowerment to leave the relationship (Condino, Tanzilli, Speranza, & Lingiardi, 2016). Treatment for the abuser is often court-ordered. The World Health Organization (WHO, 2002a) report on violence suggests that these treatments are more effective if they continue for longer periods, change the abuser’s attitude to discuss their behavior, sustain participation, and work in collaboration with the justice system to assure compliance. This conclusion likely applies to immigrant and refugee groups as well.

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In contrast to the dominant separate-gender treatment approach, some writers advocate couples treatment (Stith, Rosen, McCollum, & Thomsen, 2004; Stover, Meadows, & Kaufman, 2009). Several rationales support this argument, including the fact that some women want to stay in their relationship. This desire to stay is particularly true for immigrant and refugee women who face cultural, economic, and linguistic barriers to leaving. The couples approach is controversial for two reasons: (1) the victim may faced increased threats of violence after the violence is revealed, and (2) encouragement for the victim to leave the abuser is not supported. The focus on family factors may, however, make it more effective for immigrant and refugee groups due to the high cultural value they place on family. Much more research is needed about the effectiveness of interventions for intimate partner violence (Condino et al., 2016), and this need is even more acute among immigrant and refugee populations.

DISCUSSION QUESTION

A family had migrated from a small village to a large city. The mother was reluctant to leave her homeland, so she is angry and bitter. She constantly criticizes her husband for his low-paying job and inability to find a better place to live. One day they have an argument, and he strikes her. When he is asked about this incident, he says that a man must stand up for himself. What would be an appropriate intervention for this couple?

ASSESSMENT AND INTERVENTIONS FOR INTERGENERATIONAL CONFLICT AND ABUSE One assessment tool that may be useful for immigrant and refugee families is the genogram, which highlights family generational patterns. A related concept is the ecomap, which is helpful in assessing the family’s social network. Lim and Nakamoto (2008) argue that the genogram is a culturally compatible tool for Asian clients because of its focus on family ancestors, which is an important element of Asian culture. The same is true for many other immigrant and refugee groups. Another advantage of the genogram is its visual nature, which can get the family involved in the drawing. It does not require sophisticated language skills and helps the worker to see the family structure and increase engagement (Lim & Nakamoto, 2008).

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This method may not be useful for all clients. For example, “West Indians, because of the nature of their countries’ educational systems, use auditory learning modes better than visual ones. Therefore, the use of drawings and maps, such as the genogram, may not necessarily result in engaging the family” (Gopaul-McNicol, 1993, p. 133). In assessment of child abuse in immigrant and refugee families, the following factors must be considered.

CRITICAL CONSIDERATIONS IN CHILD WELFARE WITH IMMIGRANT AND REFUGEE FAMILIES Q Q Q Q

Q Q

Q Q

Q

Q Q Q

What is the child and the family’s immigration status? Are the child’s needs being met? Does harm or threat of harm result from unmet needs? Whose criteria have been used to determine that the child’s basic needs are not met? What are the caregivers’ expectations of child safety and well-being? Are culturally relevant emergency services needed to keep the child at home (e.g., services for domestic violence, chemical dependence, or poverty-related conditions)? Are conditions related to safety the result of poverty factors? Are there differences between culturally based parenting and maltreatment (e.g., neglect, medical neglect, nutrition, or inadequate supervision)? Has a cultural conflict occurred because of different child-rearing beliefs and behaviors? What is the potential for harm of these cultural differences? Are there mental health or substance abuse issues that can affect parenting? Do children exhibit signs of having been exposed to violence or have other caregivers (such as schools or health providers) indicated that children may be affected by exposure to violence? SOURCE: CENTER ON IMMIGRATION AND CHILD WELFARE (2015).

General Principles of Family Therapy. In working with immigrant and refugee families, some general principles apply no matter which specific therapeutic approach is used. First, therapists should be aware of and acknowledge the traditional family hierarchy, which is typically male-dominated and elder-dominated (Baptiste, 2005; Lee, Mock, McGoldrick, Giordano, & Garcia-Preto, 2005; Paynter & Estrada, 2009). Therapists should find a way to honor the family hierarchy during therapy. Because of the male’s

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PROBLEM AREAS AND BEST PRACTICES

strong position in the family, he should be involved in the therapeutic process if possible (Springer, Abbott, & Reisbig, 2009). If the family comes from a culture that stresses a male-dominated and elder-dominated hierarchy, therapists who are young or female may need to take special steps to establish their credibility (Baptiste, 2005; Sue, 2006). Factors such as race and gender could influence the therapeutic relationship, but the therapist’s confidence will help clients believe that the therapist can provide effective help (Johnson & Caldwell, 2011). Some clients may still choose their therapist based on gender bias and the assumption that male therapists are more analytical or that female therapists are more compassionate (Blow, Timm, & Cox, 2008).

DISCUSSION QUESTION

A Liberian family includes a father, two wives, and eight children borne by both women. This practice was acceptable to their church and society. When the father moves to the United States, he only brings one of his wives and their children. The second family is left behind. The children in both countries are traumatized because they were very attached to each other. Which general principles of family therapy would be helpful for the social worker who is working with this family?

Cultural protocols usually require that workers address the adult family members in a formal manner, using titles and surnames rather than first names. Children should be addressed by their first names. Another general principle is to ensure flexibility in scheduling to accommodate the family’s work and school schedules. Education and work are of critical importance to most families, and they are unlikely to attend a session that conflicts with these schedules. Finally, workers should follow all the principles described in previous chapters for establishing trust, rapport, and preparation for the therapeutic process. Family Therapy. Numerous approaches to family therapy can be effective for immigrant and refugee families; McGoldrick, Giordano, and Garcia-Preto (2005) present detailed family therapy considerations for more than forty ethnic groups. Major family therapies include psychoeducational approaches, behavioral approaches, and family systems approaches.

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Psychoeducational approaches aim to increase family members’ understanding of the migration-related and culture-related causes of their intergenerational conflicts. This method includes a behavioral element aimed at increasing family members’ coping skills, effective communication skills, and problem-solving skills. For example, researchers have reported on psychoeducational components of comprehensive programs for coping with caregiving among Latinx families and Iranian families in the United States. These programs address behavioral management, communication skills training, behavioral activation, cognitive-behavioral approaches, mood/frustration management, relaxation exercises, use of positive self-statements, and assertiveness training (Azar & Dadvar, 2007; Gallagher-Thompson, Arean, Rivera, & Thompson, 2001). Asian immigrants were the target of a psychoeducational program that focused on the acculturation gap and communication skills. The sessions also provided information about conflict resolution to help parents deal with their school-age children. A pilot study of this program suggested that it improved family adjustment and engagement (Yoo, 2011). Behavioral approaches to family therapy aim to change the dysfunctional patterns of reinforcement within the family. This includes a functional analysis of how the problem behaviors occurred. Consistent with general behavioral approaches, the goals of behavioral family therapy are to increase positive behavioral change and decrease the frequency of undesired behavior and to enhance effective communication and problem solving. Family systems approaches are derived from family systems theory, which emphasizes several factors: biological, psychological, social, and the family’s place in society. Interventions aim to change negative interaction patterns. For immigrant and refugee families, these approaches are appropriate because of the focus on the family instead of the individual. Family systems approaches try to maintain balance instead of disrupting the family with too much change too quickly. Also, the concept of hierarchy appears in both the interventions and the family’s own culture. Family systems therapies include Bowen’s systems therapy, structural family therapy, strategic family therapy, and Milan systems therapy. An example of an evidence-based family systems therapy for immigrants and refugees is brief strategic family therapy, which is targeted for families with adolescent behavior problems. The program of twelve to sixteen sessions is conducted at locations that are convenient to the family, such as the home. The program views adolescent symptomatology as rooted in

236

PROBLEM AREAS AND BEST PRACTICES

maladaptive family interactions, inappropriate family alliances, overly rigid or permeable family boundaries, and the parents’ tendency to believe that a single individual (usually the adolescent) is responsible for the family’s troubles. Brief strategic family therapy assumes that transforming how the family functions will help improve the youth’s presenting problem. It emphasizes changing maladaptive family interactions. Brief strategic family therapy has three intervention components: joining, diagnosing, and restructuring. Joining occurs at two levels, individual and family. Diagnosis involves observing how family members behave with one another. Finally, restructuring entails using reframing, assigning tasks, and coaching family members to try new ways of relating to one another (BSFT Institute, 2018).

DISCUSSION QUESTION

One study of Japanese immigrants stressed the communication problems between mothers and daughters. The daughters, who are fluent in English, were often frustrated with their mothers because of their poor English language skills (Usita & Blieszner, 2002). If you were the social worker for one of these families, how would you help them overcome this communication issue?

Interventions for Child Abuse and Elder Abuse. In working with immigrant and refugee families in cases of suspected or substantiated child abuse, social workers must partner with the parents by working to understand the parents’ culture, perspectives, and traumatic experiences. Workers must help parents understand the strengths and resources of the child, the family, and the community, as well as the effects of traumatic stress on children (Center on Immigration and Child Welfare, 2015). The following types of questions are recommended to reduce parents’ natural defensiveness and to open the discussion about parenting approaches: Q

Tell me about your life as a child—what positive things do you remember? What was difficult?

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237

Q

How was your journey to this country?

Q

What about your children (all of them)—what makes them happy? What do they like to do? What are they good at?

Q

Is there anything that worries you about your children?

Q

What do you want for your children?

Q

What is the relationship between you and your spouse or partner? What if your partner is not the parent of your children?

Q

What is the relationship between your children and their father (or mother)?

Q

Other parents tell me that their partner is sometimes mean to their children; do you ever worry about that?

Q

What can I do to I help you, your children, or your family? (Center on Immigration and Child Welfare, 2015, p. 24)

Immigrant and refugee parents’ views about child-rearing often differ from those of the social worker. Confronting parents with warnings, threats of losing their children, or immigration issues will only alienate them. Instead, workers should use a trauma-informed approach to reframe their own perspective from focusing on what is “wrong” with the family to what “happened” to the family. Workers should develop intervention strategies that respect the family’s background and that can be incorporated with their parenting styles. Intensive intervention programs delivered in the home or community by well-trained professionals have documented effectiveness (Center for Immigration and Child Welfare, 2015). Elder abuse presents a substantial challenge for social workers, and a systematic review of available interventions found none that had a significant effect on this problem (Ploeg, Fear, Hutchison, MacMillan, & Bolan, 2009). However, the Health in Aging Foundation (2010) has listed the warning signs of elder abuse. If an older adult refuses to let anyone into the home or appears to be dominated by a caregiver, this should be reported to Adult Protective Services. Elder neglect is another concern, and workers should watch out for older adults who look malnourished or are wearing dirty clothes. The National Committee for the Prevention of Elder Abuse (2013) also advises that older adults should be aware that family or friends may try to exploit them. An adult child with a drug problem, for instance, may want to steal money or medications from the parent. Interventions to reduce intergenerational conflict or to mitigate the many other stressors of migration may prevent child and elder abuse.

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ASSESSMENT AND INTERVENTIONS FOR CHILDREN AND ADOLESCENTS

Assessment with immigrant and refugee youth should include the following issues (Ehntholt & Yule, 2006): Q

Exposure to traumatic events, especially for refugees

Q

Individual characteristics such as previous physical or mental illness

Q

Belief systems such as ideological commitments

Q

Role of family in reducing or increasing stress levels

Q

Amount of family or social support

Q

Post immigration stressors

Workers should assess children for mental health problems by a thorough evaluation that includes interviews with parents, teachers, and other service providers. Interviewing and observing the child is also critical. The problems and caveats that exist regarding mental health diagnosis for immigrant and refugee adults apply to children as well. The problem of diagnosis is compounded in children due to their rapidly changing developmental process, which means that their behaviors may be age-related. Measurement tools for mental health assessment include the Children’s Depression Inventory (Cowell, Gross, McNaughton, Ailey, & Fogg, 2005; Fawzi et al., 2009; Fox, Rossetti, Burns, & Popovich, 2005; He et al., 2012) and the Child Behavior Checklist (Gross et al., 2007; Yaman et al., 2010). Researchers have done little validation of these tools for immigrants and refugees, so workers should be cautious about using these tools. Interventions for Identity Conflict. Ethnic identity conflicts in the context of acculturation are the most commonly reported issue for immigrant and refugee youth. Group interventions have a preventive and educational aim and are often delivered in the school setting. One recommendation is to stress a bicultural identity (Schwartz, Montgomery, & Briones, 2006). This includes teaching about both the native and host cultures (Schwartz et al., 2006). Workers should help youth understand what is happening to them in terms of cultural conflict. Another element commonly used in interventions for immigrant and refugee children and adolescents is social skills training, in which participants learn about effective communication (Yankey & Biswas, 2012). Some authors suggest the use of peer counselors and peer support in intervention programs for these youth (Yohani & Larsen, 2009). The peers are immigrant and refugee youth who have been in the new country longer and are

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239

able to serve as a bridge between the old and new cultures. In one case study, the use of peer counselors was shown to facilitate open discussion and empowerment (Chavoya-Perez, 2014; Twaddle, Lee, Mansfield, Sablan, & Mendiola, 2007). Alternatively, intervention programs may use mutual learning, in which the immigrant or refugee student is paired with a student from the host culture (Goodkind, 2006; Shadduck-Hernández, 2006). This helps the new arrival adjust to the new culture, as well as helping members of the host culture understand the new arrivals. This mutual understanding decreases the number of negative interactions. Further research is needed to determine the effectiveness of these interventions in helping youth resolve their identity conflicts. Interventions for Mental Health Problems. Stressors other than identity conflict can affect immigrant and refugee youth. Consequently, they are at risk of developing some of the same mental health problems as adults, such as depression, anxiety, PTSD, and substance abuse. The problems unique to youth include disruptive disorders characterized by antisocial behavior. Research indicates that multisystemic therapy is effective for both disruptive disorders and substance abuse among youth (Swenson, Henggeler, Taylor, & Addison, 2005). This is an intensive, short-term treatment approach for youth with severe emotional disturbances. The worker intervenes with the youth’s family, peer group, school, and neighborhood by identifying and targeting factors that contribute to the problematic behaviors. This therapy appears to be appropriate for immigrant and refugee families because of its comprehensive nature, its focus on family and community, and its short-term, goal-directed nature. Although it is a promising intervention for this population, workers must consider making cultural adaptations to the intervention. School-based mental health services including counseling have had positive outcomes on school adjustment and distress among refugees (Fazel et al., 2009). Classroom drama therapy showed potential positive effects on the social adjustment of adolescent immigrants and refugees (Rousseau et al., 2007). Also, writing showed promising outcomes for refugee children with PTSD (Kalantari, Yule, Dyregrov, Neshatdoost, & Ahmadi, 2012). ASSESSMENT AND INTERVENTIONS FOR OLDER ADULT REFUGEES AND IMMIGRANTS Mental health assessment in older immigrants and refugees is complicated by the multiple factors previously discussed. Assessment with

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PROBLEM AREAS AND BEST PRACTICES

the elderly, in general, is further complicated by a higher rate of somatization, a high comorbidity with physical disorders, cognitive decline, and stereotypes about aging. Consequently, professionals sometimes fail to identify and treat mental health problems among older adults. Social workers must take extra time in assessing this population and be knowledgeable about gerontology in general. A primary task facing older immigrants and refugees is that of coming to terms with their migration experiences. If they do not succeed at this task, they may fall into despair or depression. Therapies that are effective for adults with depression are also effective for older adults (see chapter 7). In addition, one unique, evidence-based approach for older adults is reminiscence therapy, in which clients reflect on positive and negative past life experiences, which helps them overcome feelings of depression and despair (Hsieh & Wang, 2003). Older immigrants and refugees may benefit from reminiscence therapy because it focuses on the migration experience. Researchers have noted the effectiveness of reminiscence among older immigrants in adding meaning to their lives (Hodges & Schmidt, 2009).

9 LANGUAGE, EDUCATION, AND ECONOMIC WELL-BEING

IMMIGRANTS’ AND REFUGEES ’ English language ability, educational attainment, and economic well-being are interrelated. These issues form the major area of concern with regard to immigration among policy makers and the general public. They are also most often the primary concern among immigrants and refugees themselves. Therefore, social workers working with immigrants and refugees need to be well-prepared to address these issues. In this chapter, we first summarize research findings in this area; this is followed by a discussion of best practices for enhancing the language ability, educational attainment, and economic well-being of refugees and immigrants.

RESEARCH FINDINGS ON LANGUAGE, EDUCATION, AND ECONOMIC WELL-BEING Immigrants’ and refugees’ language ability, educational attainment, and economic status have been extensively studied. The following discussion summarizes recent research findings and includes an examination of the factors that influence each one and the interrelationships among them.

LANGUAGE

English language proficiency is frequently regarded as an important indicator of immigrants’ and refugees’ integration to their new society, and numerous studies have examined the English abilities of foreign-born adults and

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children. Bilingualism has also received a great deal of study. These language issues are addressed in the following sections. People who rate their English-speaking ability as less than “very well,” as classified by the U.S. Census Bureau, are referred to as having “limited English proficiency” (Zong & Batalova, 2015). Among all foreign-born people residing in the United States, approximately one-half do not speak English very well (Gambino et al., 2014). This rate varies substantially by country of origin, as seen in figure 9.1. English ability increases with level of education (figure 9.2) and length of time in the United States (figure 9.3).

LANGUAGE ABILITY OF ADULTS AND CHILDREN

Only English at home 92

Very well

Well

Not well

Not at all

90 79

44 47 35 30 21 19

15

16 10

8

7 1

Total 40,589

0 0

3 1

United Kingdom 676

Canada 795

1

0 0

Jamaica 678

26 24

16 8

4

1 0

0

Germany 589

Korea 1,075

65

Percent

56 39 30 28

23 6

9

6

1

Philippines 1,861

29 21

17

14

11

9 2

India 1,944

26

31

29 30 22 22

18 7

China 2,280

6

9

7

Haiti 603

18

7

Vietnam 1,255

Guatemala 852

41 33 26 19

18 8

6 Colombia 675

24

6

26 19 5

Cuba 1,110

29 21

26 24

19

30

27

5 Honduras El Salvador 520 1,267 Population (in thousands)

31

29 22

15 3

28 21

18

17

3 Mexico 11,520

Dominican Republic 950

FIGURE 9.1 Language spoken at home and English-speaking ability by country of birth, 2012 Note: Percentage distribution is for the foreign-born population age five and older. Countries of birth are shown only for those countries with more than 500,000 people. Percents may not add to 100 due to rounding. Total includes all countries of birth. Source: Gambino et al. (2014).

Total

Less than high school High school graduate or equivalent

15.4

7.2

31.8

11.6

20.9

Associate’s degree

22.0

20.8

10.4

36.5

19.7

25.0

24.3

25.8

26.0

15.9

Some college

Bachelor’s degree or higher

21.6

24.3

39.9

41.8

Only English at home

Very well

11.2

22.6

19.0 Well

2.8

12.0

52.8

20.1

8.1

Not well

2.4

1.4

6.8

Not at all

FIGURE 9.2 Language spoken at home and English-speaking ability by educational attainment, 2012 Note: Percentage distribution of the foreign-born population aged twenty-five and older. Percents may not add to 100 due to rounding. Source: Gambino et al. (2014).

Total

15.4

Prior to 1980

1980 to 1989

34.5

27.8

34.7

15.5

1990 to 1999

12.0

2000 or later

11.3

21.2

18.0

34.9

Only English at home

21.9

21.7 Very well

Well

9.6

13.7

22.5

36.6

32.9

19.3

19.3

20.5

21.3 Not well

5.8

7.7

9.0

12.9 Not at all

FIGURE 9.3 Language spoken at home and English-speaking ability by period of entry, 2012 Note: Percentage distribution of the foreign-born population aged five and older. Percents may not add to 100 due to rounding. Source: Gambino et al. (2014).

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Immigrants and refugees are highly motivated to learn English, and there is increasing demand and wait times for classes in English as a Second Language (ESL), also known as English for Speakers of Other Languages (ESOL) (Center for Applied Linguistics, 2010). It can take adults several years to achieve English proficiency. Many factors affect learning and participation in classes, including work schedules, family responsibilities, opportunities to learn and use English outside of instructional settings, family status, and personal motivation. Program factors include class availability, schedules, locations, settings, length and frequency of courses, and training and expertise of the teachers (Center for Applied Linguistics, 2010). Immigrant and refugee children usually learn English at a faster rate than adults, and they spend hours in ESL classes every week. Approximately 10 percent of all U.S. public school students were English language learners in the 2015–16 school year (U.S. Department of Education, 2018). When children learn English more quickly than their parents, problems can develop. If children become largely monolingual in English, they may lose the ability to effectively communicate with their parents who are less proficient in English (Costigan & Dokis, 2006; Oh & Fuligni, 2010). These communication problems can persist throughout the family members’ lives (Costigan & Dokis, 2006). BILINGUALISM Bilingualism for immigrant and refugee adults is desirable because it facilitates adaptation and integration into the new society without giving up one’s ethnic identity. Experts also encourage bilingualism for immigrant and refugee children. The advantages of bilingualism include better family communication, less family conflict, maintenance of ethnic identity, and a competitive edge in the workforce as adults (Bergman, Watrous-Rodriguez, & Chalkley, 2007; Linton & Jimenez, 2009). For both children and adults, bilingualism does not necessarily mean equal proficiency in both languages. Those who learn English as children and whose educational experiences are in English generally become more proficient in and have a preference for English rather than their native language (Tulloch, 2009). Conversely, those who learn English as adults generally remain more proficient in and have a preference for their native language. Accents are another issue for immigrants and refugees; accents may stigmatize or prevent immigrants and refugees from full social integration. Studies show that people who acquire a new language before puberty do not have a foreign accent in the new language, whereas those who acquire the

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245

new language after puberty have a foreign accent (Abrahamsson & Hyltenstam, 2008; Hopp & Schmid, 2013). Bilingual individuals tend to use the two languages in different situations. They may use the native language with family and close friends and English in other situations. Bilingual speakers also commonly engage in “code switching,” alternating between the two languages for words or sentences (Auer, 2013; Toribio & Bullock, 2012). Code switching may occur because the speaker knows the appropriate expression in one language but not the other, or because an equivalent expression does not exist in both languages (Auer, 2013). When code switching occurs due to unequal proficiency in the two languages, it frequently leads to the invention of new words or expressions that are a combination of the two languages. For example, the amalgamation of Spanish and English in this way is called “Spanglish,” mixed Korean and English is called “Konglish,” and mixed Hindi and English is called “Hinglish.” Such mixed-language use is not uncommon, particularly among second generation immigrants and refugees. Social workers should be aware of the role of language in cultural identity, family dynamics, and social interactions. English language ability can determine both educational achievement and economic well-being.

DISCUSSION QUESTION

Clara is a recent immigrant from Nicaragua. Her English is limited, so she works as a housekeeper with Spanish-speaking coworkers. She attends a church that offers services in Spanish and socializes with other Latinx. She says she has no need to learn English, nor the time or the ability to do so. If you were her social worker, would you encourage her to learn English? Why or why not? If yes, how would you do so?

EDUCATION EDUCATIONAL ATTAINMENT OF ADULTS A substantial proportion of the foreign-born population, compared to the native-born population, has less than a high school diploma (figure 9.4). At the other extreme, a slightly

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Less than High school high school graduate All U.S. born 9%

Bachelor’s or more

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Some college

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15%

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13%

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12% 16%

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31 49% 57%

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FIGURE 9.4 Educational attainment among U.S. immigrants age twenty-five and older, 2016 Source: López & Bialik (2017).

higher percentage of the foreign-born, compared to the native-born, have a graduate degree. As with English language ability, educational attainment varies by country of origin and region. Immigrants with the highest educational levels are from South and East Asia, and those with the lowest are from Mexico and Central America (figure 9.4). A survey conducted by the U.S. Office of Refugee Resettlement (2018b) showed that 13 percent of refugees had a college or university degree upon arrival in the United States, and 32 percent had a high school or technical degree. About 16 percent of those eighteen years old and above continued their education after arrival in the United States. The report did not examine what factors had influenced these refugees to seek to advance their education.

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Children of at least one immigrant parent comprise 26 percent of all children under age eighteen in the United States (Zong et al., 2018). These children may face linguistic and other challenges to their academic success, but their achievement overall is quite high—in some cases even better than that of native-born students (Azzolini, Schnell, & Palmer, 2012; Crosnoe & Turley, 2011; McCabe, 2011; Tienda & Haskins, 2011). For example, adolescents in immigrant families (especially Asian) usually outperform native-born adolescents in math (Crosnoe & Turley, 2011). Consistent with systems theory, research has shown that the academic achievement of immigrant and refugee children is influenced by many factors at the levels of the individual, the family, the peer group, the school, and the community. Most of the differences in academic achievement across the various national origin groups are explained by these factors; in other words, there is nothing inherent about national origin itself that causes some groups to perform better or worse. Individual factors. These include the child’s motivation, aspirations, and expectations; English language proficiency; self-esteem; sense of belonging to the school; time spent studying, doing homework, seeking extra help, and watching television; gender; age at immigration and length of residence in the new country; immigration and refugee status; mental health status and level of stress and anxiety; peer support; bilingualism; and level of acculturation and ethnic identity (Asanova, 2005; Cortes, 2006; Fazel, Reed, Panter-Brick, & Stein, 2012; Feliciano & Rumbaut, 2005; Hatoss & Huijser, 2010; Kao & Tienda, 1995; McBrien, 2005; Myers, Gao, & Emeka, 2009; Rumbaut, 2005). Academic achievement is positively influenced by having higher motivation, aspirations, and expectations; better English proficiency; higher self-esteem; and having a sense of belonging to the school. Negative self-perception and feelings of rejection by peers are associated with school dropout among immigrants and refugees (McBrien, 2005). Academic performance is positively influenced by spending more time studying, doing homework, and seeking extra help and is negatively influenced by spending more time watching television (Rumbaut, 2005). Gender also plays a role in academic success, with girls usually doing better than boys (Rumbaut, 2005). Children who arrive in the new country at younger ages, particularly by age six, have a better chance of learning English well and completing high school (Myers et al., 2009). ACADEMIC ACHIEVEMENT OF CHILDREN

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The relationships between bilingualism, acculturation, ethnic identity, and academic achievement are complex and somewhat controversial. Some studies have shown that bilingual students have better academic achievement than both limited English proficient and English-only monolingual students (Han, 2012; Lutz & Crist, 2009; Rumbaut, 2005). This finding has been used by advocates of bilingual education as an argument in its favor. However, it is important to recognize that the association between bilingualism and academic achievement does not mean that bilingualism leads to better academic achievement; it may be a spurious correlation, meaning that both bilingualism and academic achievement are influenced by another factor. Another study notes that bilingualism has a positive effect on academic achievement only if the parents do not speak English well. Once parents become moderately proficient in English, the apparent positive effect of bilingualism on academic achievement disappears for their children (Lutz & Crist, 2009). The level of acculturation also affects a child’s academic success. In general, assimilation into the mainstream culture leads to a decline in academic achievement (Kao & Tienda, 1995). However, the relationship between acculturation and academic achievement is more complex than this because it also depends on how much parents value education. For instance, Asian parents usually have high expectations for better grades and encourage their children to progress to higher educational levels (Suinn, 2010). The acculturation process has four possible outcomes: integration, separation, assimilation, or marginalization (Rudmin, 2003). No clear line divides these four groups, and an individual might move between the categories during the process (see chapter 5). When individuals have high knowledge about and a strong connection to both their cultural heritage and that of the dominant culture, integration usually leads to better academic outcomes. The other three outcomes can lead to academic problems—especially marginalization, where children feel alienated from both their native culture and the dominant culture (Sam & Berry, 2006). Family factors. The family factors that influence academic achievement include family socioeconomic status, family structure, parent–child conflict, parental expectations and optimism for children’s achievement, and parental education and involvement in educational activities (Capps et al., 2005; Gong, Marchant, & Cheng, 2015; Kao & Tienda, 1995; McBrien, 2005; Okazaki & Lim, 2011; Rumbaut, 2005; Strekalova & Hoot, 2008). Academic achievement is positively influenced by higher

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socioeconomic status, which is indicated by family income and parents’ educational levels and occupations (McBrien, 2005; Rumbaut, 2005). Much of the variation in academic achievement across national origin groups is due to variations in socioeconomic status (Baum & Flores, 2011; Tienda & Haskins, 2011). Children from families in which both parents are present in the home perform better than children in single-parent families or stepfamilies (Tienda & Haskins, 2011). Also, lower levels of parent–child conflict are associated with higher academic achievement (McBrien, 2005; Pumariega & Rothe, 2010). Finally, academic achievement is positively influenced by greater parental expectations and greater parental involvement in educational activities (McBrien, 2005; Okazaki & Lim, 2011). Peer Factors. Peer factors can influence academic achievement. These peer factors include educational expectations, experiences, involvement educational activities, and support (Baum & Flores, 2011; McBrien, 2005; Rumbaut, 2005). Students who have a network of friends who study together and support each other perform better than students without a peer network (Black & McKenzie, 2008). School Factors. The school itself can affect a child’s achievement. School factors that influence academic achievement include the ethnic and socioeconomic composition of the school; stereotypes, prejudice, and discrimination; and the school curriculum (Agirdag, Van Houtte, & Van Avermaet, 2012; Brown & Chu, 2012; Levin & Shohamy, 2008; McBrien, 2005). Although school ethnic composition may affect students’ academic experience, friendship, and peer support, studies show that its effect may be negligible on academic achievement (Brown & Chu, 2012; Hamm, Bradford Brown, & Heck, 2005; Van Houtte & Stevens, 2009). However, the perspectives of schools and teachers toward diversity in schools and attitudes about multiculturalism may have significant impacts. In a school system in which failure of a student is conceived of as due to a racial or ethnicity-related factor rather than a structural issue, stereotyping or discrimination may occur (McBrien, 2005). The relationship between a school’s socioeconomic situation and student achievement is another factor. In overcrowded public schools, minority children may be overlooked and lose opportunities to build positive relationships with teachers or school officials (Gonzales, 2010). Unwelcoming practices in schools, discrimination, and negative attitudes can discourage ambitious immigrant and refugee students, change their

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self-perception and motivation, and affect their achievement in the long term (McBrien, 2005; Strekalova & Hoot, 2008). Conversely, if school officials actively take steps to integrate minority students, they have a better chance for academic achievements. Adapted school curricula designed for children with limited English proficiency also have a positive effect on academic achievement (Calderón, Slavin, & Sánchez, 2011; Capps et al., 2005), and success is more likely. Community Factors. How well the foreign-born are received in the community matters. School partnerships with community-based organizations that provide students with extracurricular support help these students perform better (Sugarman, 2017). Summary. Many children in immigrant and refugee families perform well in school, but many others are disadvantaged due to low family socioeconomic status, limited English proficiency, late entry into the U.S. school system, assimilation into societally disadvantaged minority groups, and so forth. It is these children who need social work interventions to help them achieve their educational goals. Educational attainment is a crucial factor in obtaining economic well-being later in life.

ECONOMIC WELL-BEING

The economic status of immigrants and refugees is of great concern to the general public and to policy makers because of the possible impact on the native-born population. In contrast, social workers are more concerned with the well-being of immigrants and refugees for their own sake. These are two sides of the same coin because the economic well-being of immigrants and refugees in turn influences the economic well-being of the whole society. We first address the research findings on the economic impact of immigrants and refugees. This is followed by a discussion of the findings related to the economic well-being of immigrant and refugee individuals and families, and the factors that influence it. ECONOMIC IMPACT OF IMMIGRANTS AND REFUGEES Contrary to prevailing public perceptions, immigrants are net economic contributors to the U.S. economy. An exhaustive report by the National Academies of Sciences, Engineering, and Medicine (2017) drew the following conclusions:

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ECONOMIC AND FISCAL IMPACTS OF IMMIGRATION Q

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When measured over a period of ten years or more, the impact of immigration on the wages of native-born workers overall is very small. To the extent that negative impacts occur, they are most likely to be found for prior immigrants or native-born workers who have not completed high school—who are often the closest substitutes for immigrant workers with low skills. There is little evidence that immigration significantly affects the overall employment levels of native-born workers. As with wage impacts, there is some evidence that recent immigrants reduce the employment rate of prior immigrants. In addition, recent research finds that immigration reduces the number of hours worked by native-born teens (but not their employment levels). Some evidence on inflows of skilled immigrants suggests that there may be positive wage effects for some subgroups of native-born workers, and other benefits to the economy more broadly. Immigration has an overall positive impact on long-run economic growth in the United States. In terms of fiscal impacts, first-generation immigrants are more costly to governments, mainly at the state and local levels, than are the native-born, in large part due to the costs of educating their children. However, as adults, the children of immigrants (the second generation) are among the strongest economic and fiscal contributors in the U.S. population, contributing more in taxes than either their parents or the rest of the native-born population. Over the long term, the impacts of immigrants on government budgets are generally positive at the federal level but remain negative at the state and local level—but these generalizations are subject to a number of important assumptions. Immigration’s fiscal effects vary tremendously across states. SOURCE: NATIONAL ACADEMIES OF SCIENCES, ENGINEERING, AND MEDICINE (2017), REPORT BRIEF, P. 2.

Immigrants make up around 17 percent of the workforce in the United Sates (Pew Charitable Trusts, 2015). Without their contributions, some industries would not be able to function as they currently do. For instance, a national survey of dairy farms showed that immigrant workers produce about 79 percent of the milk supply in the United States (Adcock, Anderson, & Rosson, 2015). This survey, which was conducted in the fall of 2014, estimated that eliminating immigrants’ labor from dairy farms would increase the milk price by 90 percent (Adcock et al., 2015). Similarly, the crop farm sector relies heavily on the immigrant labor force. Without foreign seasonal

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workers, a study in North Carolina showed that the agriculture sector in the state would collapse (Clemens, 2013).

DISCUSSION QUESTION

One writer who wants to limit immigration states that immigrants are taking away Americans’ jobs and that family reunification is harmful to U.S. interests: “Spouses, children and parents of citizens may be unskilled, uneducated, and thus likely to become ‘public charges,’ the bane of immigration” (Foster, 2014). How would you respond to this?

Despite their overall net positive economic contribution, the economic well-being of individual immigrant and refugee families varies greatly. Legal status is one key factor; undocumented workers are more likely to be exploited and underemployed. Indicators of economic well-being include income, employment, poverty, food security, and homeownership (Deenanath, Lo, Mao, Ballard, & Solheim, 2016; Dodini & Thomas, 2016). Data on these indicators are presented in chapter 1. Additional research findings on economic well-being are summarized in the following text box.

ECONOMIC WELL-BEING OF IMMIGRANTS AND REFUGEES

ECONOMIC WELL-BEING OF IMMIGRANTS AND REFUGEES

Employment and Earnings Q

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For the years 2003 through 2013, the overall male employment rate for all educational levels was slightly higher for first-generation immigrants (86 percent) than for the second-generation (83 percent) or third- and later-generation native-born (82 percent). Among women the pattern is reversed, with a substantially lower employment rate for immigrants (61 percent) than for the native-born (72 percent). Immigrant men with the lowest level of education are much more likely to be employed than comparable native-born men, indicating that they are filling an important niche in the U.S. economy; these immigrants appear to be filling low-skilled jobs for which native-born men are not available or that native-born men are unwilling to take. Foreign-born workers’ earnings improve relative to the native-born the longer they live in the United States. But earnings assimilation is considerably slower for Hispanic (predominately Mexican) immigrants than for other immigrants. “CONTINUED”

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“CONTINUED”

Occupation Q

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First- and second-generation immigrants have robust representation across the occupational spectrum, implying that the U.S. workforce has been welcoming immigrants and their children into higher-level jobs in recent decades. In the highly skilled professions of science and technology, immigrants comprise about one-fifth to one-third of all workers. Immigrant groups who are concentrated in low-status occupations in the first generation improve their occupational position substantially in the second generation, although they do not reach parity with third and later generations. Second-generation children of immigrants from Mexico and Central America have made large leaps in occupational terms: 22 percent of second-generation men from Mexico and 31 percent of second-generation men from Central America were in professional or managerial positions from 2003 to 2013. The occupational leap for second-generation women during this period was even greater.

Poverty Q

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Immigrants are more likely to be poor than the native-born, even though their labor force participation rates are higher and, on average, they work longer hours. The poverty rate for foreign-born people was 18.4 percent in 2013, compared to 13.4 percent for the native-born. However, among adults the poverty rate overall declines over generations, from over 18 percent in the first generation, to 13.6 percent in the second generation, and 11.5 percent in the third generation. SOURCE: NATIONAL ACADEMIES OF SCIENCES, ENGINEERING, AND MEDICINE (2015), REPORT BRIEF, PP. 2–3.

Additional findings include the following. Income. The average yearly income of foreign-born households is lower than that of native-born households. However, these income levels vary among different groups of immigrants. For instance, in 2010 the average yearly income of foreign-born households from Oceania, Asia, and North America was higher than that of the native-born population, but this number was drastically lower for foreign-born households from Mexico and Latin America (Grieco et al., 2012). On average, hourly wages for immigrants are lower than wages of native-born individuals (Capps, Fix, Passel, Ost, & Perez-Lopez, 2003). The median weekly income was about $837 for native-born individuals and about $681 for immigrants in 2015 (U.S.

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Bureau of Labor Statistics, 2016). On average, immigrants earn 12 percent less than their native-born counterparts. The main barriers to higher-paying employment are English language proficiency and education (Deenanath et al., 2016). Employment. About 26.3 million foreign-born individuals were active in the U.S workforce in 2015, accounting for nearly 17 percent of the total labor force. Foreign-born individuals were more concentrated in service occupations; construction, maintenance, and natural resources; and transportation, production, and moving sectors (U.S. Bureau of Labor Statistics, 2016). About 20 percent of immigrants are employed in construction, food services, and agricultural fields, and they make up a third of the workforce in the hospitality industry (Deenanath et al., 2016). Key points about employment also include: Q

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About one in every ten immigrants is self-employed (Batalova & Dixon, 2005). Self-employment among immigrants increased 4.6 times between 1970 and 2000 (Batalova & Dixon, 2005). Latinx, Asians, and whites are more likely to be self-employed (Batalova & Dixon, 2005). Immigrants with higher education levels and work skills are more likely to find jobs with higher wages and stability (Deenanath et al., 2016). Immigrant representation in high-skill industries such as information technology, health care, life science, and technology is close to that of native-born individuals (Singer, 2012).

Finally, some immigrants and refugees, particularly in the early years after arrival, experience underemployment or “status inconsistency,” working in a job that is below their level of education or abilities. Several factors cause underemployment, including poor English language proficiency, the lack of recognition for education, training, or licensure obtained in the country of origin, employment discrimination, or, in the case of refugees, the pressure to find a job in a very short time period. It is difficult to advance one’s career while working at a low-paying job with no opportunities, and many lose their chance for education and training (Deenanath et al., 2016). Food Security. Foreign-born individuals are at much higher risk for food insecurity compared to native-born individuals (Deenanath et al., 2016). The average incidence of food insecurity among immigrant households is

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about twice that of nonimmigrant households (Beaulieu, 2014). The same gap exists among children with noncitizen mothers compared to children with native-born parents (Beaulieu, 2014). This gap could be due to economic hardship, lack of access to social services, lack of English language knowledge, cultural sensitivities, or difficulty navigating through the food supply system (Beaulieu, 2014). Homeownership. In general, immigrant inflows increase rents and housing costs. Although this change can benefit the community, it makes homeownership less affordable for everyone. On average, the foreign-born are less likely than native-born individuals to own a house and more likely to live in overcrowded homes (Deenanath et al., 2016). Opportunities for homeownership usually increase with higher education and longer periods of stay in the United States (Ray, Papademetriou, & Jachimowicz, 2004). An extensive body of research has identified several factors that influence refugees’ and immigrants’ economic well-being: financial capital, human capital, household structure, social capital, and community reception. Most immigrants and refugees arrive in the United States with little financial capital, and it can take years to save money for a home or a business startup. Human capital includes education and familiarity with capitalistic systems such as job hunting (Baum & Flores, 2011; Crea & McFarland, 2015; Muhwezi & Sam, 2004; Naidoo, 2009; Phillimore & Goodson, 2008; Shutes, 2011; Vasey & Manderson, 2012). Clearly, English language proficiency is a prerequisite for attainment of higher education after arrival in the United States; however, it is education itself and not English language proficiency that yields the most economic returns. Furthermore, higher education is crucial for economic advancement in the contemporary labor market, which is focused on high-skilled service and technology industries (Capps et al., 2003; Doty, 2016). Educated or highly skilled immigrants with limited English proficiency are twice as likely to be at risk of unemployment or to be overqualified for their position when compared with proficient English-speaking immigrants (Pew Charitable Trusts, 2015). Familiarity with work and business practices in the new country is an important human capital factor. The practices may be different from those in the country of origin. New immigrants to the United States may not be familiar with the economic system, including managing finances, transactions, and payment systems (Deenanath et al., 2016). Immigrants also may

FACTORS AFFECTING ECONOMIC WELL-BEING

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need briefing sessions and education on homeownership, access to credit markets, and financing (Ray et al., 2004). Two final human capital factors that deserve attention are health and mental health. Poor health and mental health negatively affect economic well-being (Chiappero-Martinetti & Sabadash, 2014). Among recently arrived refugees who are not working or seeking work, 34 percent report poor health or disability as the reason (U.S. Office of Refugee Resettlement, 2018b). Household structure refers to marital status and number of children. A common strategy used by immigrants and refugees to enhance their economic well-being is to live in large households with multiple wage earners (Population Reference Bureau, 2013). Immigrant and refugee households headed by married couples, households that have more workers, and households without children or elderly people have better economic well-being than their counterparts (Adserà & Chiswick, 2007; Landale, Thomas, & Van Hook, 2011; Lobo, Salvo, & Hurley, 2012; Population Reference Bureau, 2013; Williams, 2010). The average income of women with children, including immigrants and refugees, is less than that for women without children (Adserà & Chiswick, 2007; Williams, 2010). For women with children, lack of child care or costs associated with proper child care are major impediments (Karoly & Gonzalez, 2011; Williams, 2010). Social capital also affects economic well-being because it includes social networks, social trust, and norms that enable members of the society to use social connections for mutual benefits (Baiyegunhi, 2014; Saracostti, 2007). Social capital can provide a platform for immigrants and refugees to have better access to information and to the job market (Nicodemo & Nicolini, 2012). In the 1990s, researchers proposed social capital as a new panacea for economic well-being, positing that social connections can solve the problem of poverty. This simplification of social capital has been vastly criticized. Studies have shown that social ties, networking, and existence of trust can be both harmful and helpful (Hawkins & Maurer, 2011). For instance, relying on family and friends can provide a better platform and flexibility for immigrant and refugees to pursue education and employment opportunities (Lamba, 2003). However, immigrants and refugees who rely on low-income communities of foreign-born individuals usually end up alternating between welfare support and low-paid jobs in the service sector (Schneider, 2000). Immigrants and refugees connected with dissimilar groups might face lower levels of trust, obligation, and reciprocity, which

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could require higher levels of effort to create interactions. However, the chances for generating access to resources, information, and opportunities is higher through these networks (Hawkins & Maurer, 2011). Finally, community reception refers to the policies of the receiving government and the conditions of the labor market. The receiving community can limit social spending. In the United States, “welfare” for foreign-born people is an unpopular idea, and policies aim to minimize immigrants’ and refugees’ costs to society. The Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996 and the Refugee Act of 1980 aim to reducewelfare utilization by legal immigrants and refugees, respectively (see chapter 3). However, PRWORA does not contain any provisions for helping legal immigrants reduce welfare usage, but the Refugee Act specifically authorizes a multiservice refugee resettlement program to help refugees become economically “self-sufficient” (i.e., not receiving welfare). These restrictive policies have influenced immigrants’ and refugees’ economic well-being. Empirical data demonstrated that legal immigrants’ enrollment in safety programs decreased following enactment of PRWORA due to confusion or fear (Derose, Escarce, & Lurie, 2007; Kaushal & Kaestner, 2005). However, it has been more difficult to evaluate the effects of the refugee resettlement program on the economic well-being of refugees. The multiservice nature of the resettlement program also makes it difficult to attribute any changes in refugee welfare utilization to specific program components. Another consideration is the labor market in the recipient community. Factors include the state of the economy, required qualifications for specific kinds of labor, employment discrimination, and employer-sponsored health care benefits (Androff, Ayon, Becerra, & Gurrola, 2011; Beets & Willekens, 2009; Pager, Western, & Bonikowski, 2009; U.S. Office of Refugee Resettlement, 2018b). Labor discrimination may include biased job interviews, exploitation, racist remarks, social alienation, and mischaracterizing technical and social problems as racial or cultural traits. Several studies have demonstrated the existence of employment discrimination against immigrants and refugees (Dovidio, Gluszek, John, Ditlmann, & Lagunes, 2010; Pager et al., 2009). Gender discrimination is another type of labor market discrimination. Among refugees, women consistently have lower economic well-being than men (Buzdugan & Halli, 2009), even after controlling for sociodemographic attributes (Buzdugan & Halli, 2009; Semyonov & Gorodzeisky, 2005). Although gender discrimination happens in all populations, immigrant and

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refugee women are particularly vulnerable due to their less powerful position in society. These women are also more vulnerable to sexual harassment on the job. In summary, English language proficiency is a prerequisite for enhancing one’s education in the United States, which in turn is a prerequisite for enhancing one’s economic-well-being. We now turn to best practices for enhancing refugees’ and immigrants’ English language proficiency, education, and economic well-being. As in the preceding chapters, macro, meso, and micro strategies for each area are discussed.

BEST PRACTICES ENHANCING ENGLISH LANGUAGE PROFICIENCY

This section addresses best practice strategies for enhancing the English language proficiency of adult immigrants and refugees. Because children receive ESL training in school, the strategies directed to children are addressed in the education section. The major policies that authorize federal funding for ESL programs for children and adults are Title III of the Elementary and Secondary Education Act, Title II of the Workforce Innovation and Opportunity Act, and the Adult Education Act, respectively (U.S. Department of Education, 2014, 2017a). Additional policies exist at the federal, state, and local levels. As in most macro interventions, funding is the primary issue for ESL programs. The demand for ESL instruction is far higher than available programs can serve (Teranishi, Suárez-Orozco, & Suárez-Orozco, 2011). These programs could be enhanced by tailor-made curricula based on specific needs of immigrants and refugees such as language needs for the job market or academia (Teranishi et al., 2011). Social workers should advocate for increased funding for ESL and related programs. These programs not only help clients but benefit the entire society. Workers with good language skills earn more money and would pay more taxes in the long run. Best practices for effective policy advocacy were discussed in previous chapters. MACRO INTERVENTIONS

Meso interventions (program or organizational level) should focus on ESL program staffing and program design. ESL

MESO INTERVENTIONS

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teachers should not only have college degrees but specialize in adult education or a related field. Like other professional activities, Teaching English to Speakers of Other Languages (TESOL) has become an academic specialty, and many states require certification. Research suggests that program design can enhance adult ESL learning (see text box).

BEST PRACTICES FOR ADULT ESL PROGRAMS Q

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Incorporate principles of adult learning, adult second language acquisition, and ways to work with multicultural groups. Begin with an assessment of learners’ needs and goals (e.g., where and why they use or want to use English) to establish instructional content that is relevant to and immediately usable in their lives outside the language classroom. Employ a number of different instructional approaches to match diverse learner needs, motivations, and goals; and provide opportunities for interaction, problem solving, and task-based learning. Acknowledge and draw on learners’ prior experiences and strengths with language learning. Include ongoing opportunities for language assessment and evaluation of learner progress in becoming proficient English language users. Provide courses of varied intensity and duration with flexible schedules to meet the needs of learners who may be new to this country and burdened with settlement demands or multiple jobs. Use technology to expand or individualize learning inside and outside the classroom in accordance with learners’ language proficiency, preferences, and needs and to reach learners who cannot attend classes (e.g., individualized activity stations, self-access learning labs, and online courses). SOURCE: CENTER FOR APPLIED LINGUISTICS (2010, P. 30).

Specific instructional approaches used in ESL programs are varied. For adults, these include life skills or general ESL classes, family literacy programs, English literacy/civics programs, vocational ESL programs, and workplace ESL classes (Center for Applied Linguistics, 2010). School-based approaches for children include dual-language education, transitional bilingual education, and English-only education (Sugarman, 2018). Best practices for school ESL programs are shown in the text box. Although social workers themselves will not be providing ESL instruction, they may work as part of a team with other professionals in designing programs. Social workers should advocate for the types of innovative and multimethod approaches described here.

BEST PRACTICES FOR K–12 ESL PROGRAMS

Identifying Potential English Learners (ELs) Q Q Q Q

Identify in a timely manner EL students in need of language assistance services. The home language survey (HLS) is the most common tool used to identify potential ELs. An HLS must be administered effectively to ensure accurate results. Parents and guardians must be informed in a timely manner of their child’s English language proficiency level and EL program options, in a language the parents/guardians understand.

Providing English Learners with a Language Assistance Program Q

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EL services and programs must be educationally sound in theory and effective in practice. EL programs must be designed to enable ELs to attain both English proficiency and parity of participation in the standard instructional program within a reasonable length of time. EL services and programs must be offered until ELs are proficient in English and can participate meaningfully in educational programs without EL support. Schools must provide appropriate special education services to ELs with disabilities who are found to be eligible for special education and related services.

Staffing an English Learner Program Q Q

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Schools must provide the personnel necessary to effectively implement EL programs. Necessary personnel include teachers who are qualified to provide EL services, core-content teachers who are highly qualified in their field as well as trained to support EL students, and trained administrators who can evaluate these teachers. Schools must provide adequate professional development and follow-up training to prepare EL program teachers and administrators to implement the EL program effectively. Schools must ensure that administrators who evaluate EL program staff are adequately trained to meaningfully evaluate whether EL teachers are appropriately employing their training in the classroom in order for the EL program model to successfully achieve its educational objectives.

Providing ELs Equal Access to Curricular and Extracurricular Programs Q

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Schools must design and implement services and programs that enable ELs to attain both English proficiency and parity of participation in the standard instructional program, within a reasonable length of time. Schools must provide equal opportunities for EL students to meaningfully participate in curricular, co-curricular, and extracurricular programs and activities. Schools must use appropriate, reliable, and valid evaluations and testing methods to measure ELs’ acquisition of English and core-content knowledge. “CONTINUED”

“CONTINUED”

Creating an Inclusive Environment for and Avoiding the Unnecessary Segregation of ELs Q

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Schools must limit the segregation of ELs to the extent necessary to reach the stated goals of an educationally sound and effective program. Schools should not keep ELs in segregated EL programs (or “EL-only” classes) for periods longer or shorter than required by each student’s level of English proficiency, time and progress in the EL program, and the stated goals of the EL program. Although ELs may receive intensive English language instruction or bilingual services in separate classes, it would rarely be justifiable to segregate ELs from their non-EL peers in subjects like physical education, art, music, or other activity periods outside of classroom instruction.

Addressing ELs with Disabilities Q Q

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Schools must identify, locate, and evaluate ELs with disabilities in a timely manner. Schools must consider the English language proficiency of ELs with disabilities in determining appropriate assessments and other evaluation materials. Schools must provide and administer special education evaluations in the child’s native language, unless it is clearly not feasible to do so, to ensure that a student’s language needs can be distinguished from a student’s disability-related needs. Schools must not identify or determine that EL students are students with disabilities because of their limited English language proficiency. Schools must provide EL students with disabilities with both the language assistance and disability-related services they are entitled to under federal law.

Serving English Learners Who Opt Out of EL Programs Q

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Parents have the right to opt their children out of EL programs or particular EL services. This decision must be voluntary and based on a full understanding of the EL child’s rights, the range of services available to the child, and the benefits of such services to the child. If a parent decides to opt his or her child out of EL programs or particular EL services, that child still retains his or her status as an EL. Schools must continue to monitor the English language proficiency (ELP) and academic progress of students who opt out of EL programs and services. If a student does not demonstrate appropriate growth in ELP or maintain appropriate academic levels, the school must inform the parents in a language they understand and offer EL services.

Tracking the Progress of ELs Q

Schools must monitor the progress of all ELs in achieving English language proficiency and in acquiring content knowledge. “CONTINUED”

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“CONTINUED”

Q

Schools should establish rigorous monitoring systems that include benchmarks for expected growth and take appropriate steps to assist students who are not adequately progressing toward those goals.

Evaluating the Effectiveness of an EL Program Q

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Successful EL programs enable EL students to attain both English proficiency and parity of participation in the standard instructional program within a reasonable period of time. Schools should collect longitudinal data to monitor and compare the performance of current ELs, former ELs, and never-ELs in the school’s standard instructional program. When EL programs do not produce both English proficiency and parity of participation within a reasonable period of time, schools must modify the EL program.

Ensuring Meaningful Communication with Limited English Proficient Parents Q

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Schools must communicate meaningfully with limited English proficient (LEP) parents and notify LEP parents adequately of information about any program, service, or activity called to the attention of non-LEP parents. Schools must have a process to identify LEP parents and provide them with free and effective language assistance, such as translated materials or an appropriate and competent interpreter. Appropriate and competent translators or interpreters should have proficiency in target languages; ease of written and oral expression; knowledge of specialized terms or concepts; as well as be trained on their role, the ethics of interpreting and translating, and the need for confidentiality. SOURCE: U.S. DEPARTMENT OF EDUCATION (2017B).

The best way for a social worker to help clients improve their English proficiency is to encourage and assist them in participating in ESL programs. Research suggests that ESL programs are effective in improving basic English language skills and reading skills; in developing English skills to a degree that is sufficient for participating in job training or for holding a job requiring the comprehension of simple English text information; and in increasing employability and immigrants’ self-esteem (Sandlin & Clark, 2009). Therefore, the major way in which most social workers will be able to affect their clients’ English language proficiency is at the micro level, by encouraging limited English proficiency clients to participate in ESL programs, referring them to such programs, engaging in MICRO INTERVENTIONS

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case advocacy to ensure enrollment, and maintaining follow-up with clients to assist with continued attendance. Several venues offer ESL classes and tutoring, including colleges, libraries, and places of worship. Social workers should be aware of the client’s proficiency level because some classes are basic and others are more advanced.

ENHANCING EDUCATIONAL ATTAINMENT AND ACADEMIC ACHIEVEMENT ENHANCING EDUCATIONAL ATTAINMENT OF ADULTS At the macro level, social workers should advocate for universal benefits designed to help people advance their education. These include tax credits or deductions for educational expenses; employer flextime; and on-site child care at adult educational institutions. Advocates should stress that these policies may cost money in the short-term but that the benefits will outweigh the costs. These benefits include saving on public health and welfare expenditures, increased tax revenues from higher incomes, and an increased likelihood of raising better-educated offspring, which in the long term benefits the overall economy (Holzer, 2011). On the meso level, social workers should collaborate with colleges and universities to improve access and retention of immigrant and refugee students. Best practices for doing so are shown in the following text box.

BEST PRACTICES FOR PARTNERSHIPS BETWEEN IMMIGRANT-SERVING ORGANIZATIONS AND INSTITUTIONS OF HIGHER LEARNING Q

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Organizations should carefully consider potential partners, take the time necessary to develop relationships, and be deliberate about establishing roles and responsibilities. Be deliberate and strategic when selecting partners and building relationships. Commit time for face-to-face communication. Develop memoranda of understanding and very specific work plans. Partners need to invest time in learning about each other’s organizational culture and developing personal and organizational connections. Partnerships require committed leaders who can articulate the value of partnership and who can support dedicated, open-minded, flexible, and creative program staff in implementation. “CONTINUED”

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“CONTINUED”

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Colleges and universities that have not previously targeted immigrant populations should be intentional in designing and implementing strategies for reaching and teaching them. Supportive state policy environments and policies enable this work. Partnerships should consider the role of employers when developing programs. Partnerships see significant value in being part of a national initiative that provides flexible resources, technical assistance, and peer learning opportunities. SOURCE: MONTES & CHOITZ (2016).

The greatest immediate impact that social workers can make is on the micro level. In addition to encouraging immigrants and refugees to further their education, workers can facilitate their efforts by helping with applications, scheduling, transportation, child care, and other issues. Individual development accounts, as described in the section on enhancing economic well-being, are another avenue for clients to achieve their educational goals. ENHANCING ACADEMIC ACHIEVEMENT OF CHILDREN AND ADOLESCENTS

As noted earlier, many immigrant and refugee children perform well academically. However, a substantial proportion of these children are at risk of poor academic achievement due to limited English language proficiency, low socioeconomic status, late entry into the school system, and other factors. School social workers should enhance the academic achievement and overall well-being of at-risk children by referring them to services. These workers not only serve as a link between the school, home, and community but also work as a member of an educational team. They work within the school system to provide psychosocial assessments, counseling, and consultation to enhance students’ emotional well-being and improve students’ academic functioning (NASW, 2010). Because multiple factors affect a student’s performance, school social workers must use numerous strategies beyond the micro level. Macro Interventions. Macro interventions involve action at the level of national, state, and local decision-making bodies. Recommendations for enhancing academic achievement of immigrant and refugee K–12 students are shown in figure 9.5. Social workers also need to be aware of federal law regarding admission of undocumented immigrant children to schools. The 1982 U.S. Supreme

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Evaluating the policies and practices created by teachers and administrators on a provisional basis in response to changing needs and systematizing those that were effective Encouraging district and community-based organization partnerships that include strong coordination among service providers so that students experience coherent and well-targeted interventions

Ensuring that sufficient funding is available for instructional and socioemotional services and that policymakers understand the rationale behind investing resources in newcomer student supports

Tracking the impact of evolving federal, state, and local policies on newcomer student achievement

FIGURE 9.5 Macro interventions to enhance academic achievement of immigrant and refugee K–12 students Source: Sugarman (2017).

Court ruling in Plyler v. Doe guarantees undocumented children the right to a free public education (Benavides, Midobuche, & Kostina-Ritchey, 2012). Consequently, schools may not: Q Q

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Deny access to a student on the basis of legal status or alleged legal status; Treat students disparately for residency determination purposes on the basis of their undocumented status; Inquire about a student’s immigration status, including requiring documentation of a student’s legal status at initial registration or at any other time; and making inquiries from a student or his/her parents that may expose their legal status. (BENAVIDES ET AL., 2012, P. 2305).

School social workers should work with other members of the educational team to protect the legal rights of undocumented children.

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Meso Interventions. Several program elements have been effective in promoting the academic achievement of immigrant and refugee students. Social workers can work with the school team to implement some of the following program elements:

COMPONENTS OF EFFECTIVE SCHOOL PROGRAMS FOR IMMIGRANT AND REFUGEE STUDENTS Q

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Information for both school staff and teachers about cultural sensitivity and diversity training. For instance, some children may have experienced trauma in their country of origin. Less emphasis on standardized exams and more use of broad-based assessment tools that do not discriminate against minorities. Comprehensive services to ensure that the psychosocial needs of children are met. Professional development for all school staff and teachers to help them better serve these children. Proactive engagement with parents to overcome barriers such as language limitations and work schedules. This could include special orientation sessions with interpreters and telephone support regarding school information. Mentoring programs by other families for new arrivals. Community meetings held in places other than the school and with ethnic community members to help with communication. SOURCES: CHEUNG & SLAVIN (2012); EDUCATION DEVELOPMENT CENTER (2011); JOHNSON, (2003); MCBRIEN (2005); SHORT & BOYSON (2012); SUÁREZ-OROZCO, ONAGA, & LARDEMELLE (2010); TAYLOR & SIDHU (2012).

In general, educators believe that one size does not fit all and that different approaches can be successful if implemented well. Social workers should function as team members in helping to select approaches based on a school district’s goals, resources, and the needs and characteristics of its students. Evaluations of existing programs are essential for competent social work practice. Unfortunately, one problem with specialized programs is that students may face stigma when transitioning to mainstream education. Even academically successful immigrant and refugee children may have trouble obtaining equal access to services or advanced education because of their LEP status (Kanno & Varghese, 2010). For example, institutional constraints such as a minimum of four years of English in high school is a barrier

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for immigrants and refugees who arrived in the United States during their high school years. Kanno and Veghese (2010) argue that academically successful LEP students can overcome some language barriers with more work and practice, but this kind of institutional barrier can affect their educational opportunities. Vocational training also may not be available for LEP students and workers. Effective connections with the ESL institutes and larger employers have addressed this problem, and LEP students have received job opportunities with required vocational training. Social workers should work with other school personnel to establish and maintain appropriate connections with the workforce (Kaz, 2014). Social workers can also serve as consultants to teachers in developing and implementing specific instructional approaches for immigrant and refugee students. This may be particularly important in schools without a large population of these students and that do not have specialized programs for them. In fact, these teachers are probably ill-prepared for working with these populations. Like other populations, immigrant and refugee groups have gifted and talented children who flourish in the right setting. However, only 22 percent of newcomer programs include a course option for gifted children (Short & Boyson, 2012). A student struggling to learn English may have an aptitude for math that deserves enrichment despite the language barrier. Teachers must be aware of cultural norms such as a low voice and lack of eye contact indicating respect, not disinterest. Economic barriers also exist for low-income families who cannot afford to pay anything extra for their gifted and talented child (Harris, 2007). Another consideration for gifted and talented immigrant and refugee children is that they may mistrust authorities because of their trauma history. Others may hide their talents to avoid failing and thus disappointing their parents. Peer expectations also affect a student’s willingness to participate in a gifted and talented program, and racial conflict and prejudice can occur between students. Interventions may include narratives and role playing to help students cope with the possible disapproval of peers (Harris, 2007). Some students experience cross-cultural stress and may feel that they are turning away from their heritage culture. Talented students may find it difficult to stay loyal to their heritage culture as they adapt to new and dominant norms in the school environment, which can increase levels of stress. If this is related to intergenerational conflict, outreach to parents and other important figures in the student’s life may resolve the issue. School

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systems must be aware that the academic records of immigrant and refugee students may not be available nor accurately reflect their potential. Identifying gifted and talented students who are immigrants and refugees requires a sophisticated screening process that may include extracurricular activities and knowledge of the child’s culture (Harris, 2007). Micro Interventions. School social workers often engage with immigrant and refugee students in direct practice. Such micro interventions must begin with appropriate assessments of the student, which could affect the student’s academic future. Without an assessment, school staff will not be familiar with the student’s background culture, experiences, and current life stressors (Matthews & Mahoney, 2006). School social workers focus their micro interventions on enhancing the student’s psychosocial functioning for better academic achievement. Typical targets are mental health and family dynamics issues commonly faced by immigrant and refugee students. Figure 9.6 illustrates the best practices for an assessment consistent with holistic, strengths-based principles. Social workers must bear in mind that assessment of immigrant and refugee children in educational settings

Child’s developmental needs • Health • Education • Emotional and behavioral development • Identity • Family and social Relationships • Social presentation • Self-care skills

Parenting capacity • • • • • •

Family and environmental factors • Community resources • Family’s social integration • Income • Employment • Housing • Extended family • Family history and functioning FIGURE 9.6 Child and family assessment framework Source: UK Department of Health (2000).

Basic care Ensuring safety Emotional warmth Stimulation Guidance and boundaries Stability

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is hampered by a lack of validated instruments for these populations, and misdiagnosis of learning disorders and adjustment disorders is common (American Psychological Association, 2012). A particularly relevant micro intervention for immigrant and refugee children is after-school programming focusing on activities such as the arts, sports, and recreation (Greenberg, 2014). These programs can enhance social and emotional development and academic achievement, and they have been shown to be beneficial for EL students. However, immigrant and refugee children participate less in such programs than their native-born peers. Social workers can play a vital role in engaging children and their families in these programs (Greenberg, 2014). To engage children and families in after-school programs, Greenberg (2014) recommends that social workers take the following actions: Q Q Q

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Provide information about after-school options and expectations. Encourage family involvement in the development of after-school programs. Incorporate cultural histories traditions in the programs (e.g., drama, art, cooking, music). Reach out to families through phone calls and home visits. Recognize that family involvement in school may be considered disrespectful of the teachers’ authority in many cultures. Recognize that undocumented parents are likely be fearful of any engagement with the school.

In summary, academic achievement is critical in promoting immigrant and refugee children’s economic success later in life. School social workers, as well as other social workers who encounter immigrant and refugee children and adolescents, should employ the multiple macro, meso, and micro interventions presented here to achieve this goal.

ENHANCING ECONOMIC WELL-BEING

Numerous strategies are available to enhance people’s economic wellbeing. We categorize these strategies based on the major factors previously identified as influencing economic well-being: human capital, household composition, financial capital, social capital, and community reception. Specific strategies often target more than one of these factors; however, we

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present them here based on the major factor being targeted. Within each factor, macro, meso, and micro strategies are described where applicable. Human capital is probably the most important factor in economic well-being. Improving clients’ English language proficiency and helping them to achieve their educational goals are essential for economic well-being. Beyond this, the most widely used strategies for enhancing human capital are employment-related services that enhance clients’ skills in job searching, job attainment, and job retention. One of the fundamental goals of federal refugee resettlement policy is to help refugees obtain employment and become economically self-sufficient as soon as possible after arrival through the provision of employment-related services (Deenanath et al., 2016). All newly arrived refugees are eligible for this program. No comparable program exists specifically for legal immigrants, but they may be eligible for similar programs targeted more broadly at low-income people. Specific employment-related services include job search assistance, job coaching, mentoring, self-employment assistance, vocational education and career counseling, and recertification. Job Search Assistance. Job search assistance is a set of short-term, highly focused activities aimed at helping clients find and get jobs. It is a form of behavioral counseling that teaches clients skills for job searching (Liu, Huang, & Wang, 2014). Critical components of job search assistance include those shown here:

ENHANCING HUMAN CAPITAL

CRITICAL COMPONENTS OF JOB SEARCH ASSISTANCE Q

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Teaching job search skills: This may include identifying available jobs where one’s skills could fit, using social media or social capital to find job leads and to obtain job information. Improving self-presentation: This may include training on how to present one’s skills on résumés or application forms, instruction on body language or dress codes, and teaching techniques for interviews. Boosting self-efficacy: This may include encouraging participants to consider a variety of positions, following up on applications, and offering job-related information to potential employers. Promoting goal-setting: This may include helping participants set a goal for a desired occupation and salary level and follow specific search behaviors such as the number of submissions within a specific period of time. “CONTINUED”

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“CONTINUED”

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Enlisting social support: This may include facilitating peer support among participants/job seekers, encouraging information-sharing among participants, and mobilizing support (emotional and physical) among family and friends. Stress management: Clients must learn how to accept rejection and manage stress caused by the job search and learn resilience skills. SOURCE: LIU ET AL. (2014).

In a meta-analysis by Liu and colleagues (2014), the odds of obtaining employment were nearly three times higher for those participating in a job search program than for nonparticipants. This study also showed that job search programs containing the critical components (see text box) were more effective than those that did not include such elements. Job Coaching. Job coaching involves monitoring and supporting client performance in the workplace. It may include the assessment of work habits and behaviors; managing conflicts between clients, coworkers, or supervisors; and resolving child care or transportation barriers. Mentoring. This entails matching the client with a volunteer who has a job such as the one the client would like to obtain. The mentor works with the client in modeling the necessary skills for the job. Self-Employment Assistance. This consists of programs helping individuals transition between job loss and self-employment. These programs may provide instruction in entrepreneurial training, business counseling, writing business plans, and technical assistance (Kosanovich, Fleck, Yost, Armon, & Siliezar, 2001). For the general population, research suggests that such programs accelerate the transition from unemployment into self-employment (Michaelides & Benus, 2012). Career Counseling. Career counseling assists clients with the following tasks (Boise State University, 2018): Q Q

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Figure out what clients want out of their education, career, and life. Discuss and help organize thoughts, ideas, feelings, and concerns about clients’ career and educational choices. Identify factors influencing clients’ career development, and assess clients’ interests, abilities, and values. Help clients find resources and sources of career information. Help clients determine next steps and develop a plan to achieve their goals.

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Best practices for career counseling with immigrants and refugees are shown in the following text box.

BEST PRACTICES FOR CAREER COUNSELING WITH IMMIGRANTS AND REFUGEES Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q

Explore the client’s career and work background. Examine contextual factors. Address the client’s career transition. Build knowledge about career options. Discuss how to obtain and maintain a job. Explore cultural norms about work. Develop work-related intercultural competence. Discuss opportunities for work and education. Address balancing work and family life. Attend to individual and systemic facilitators and barriers of work and career goals. Challenge personal assumptions. Use a team approach. Use interpreters or work with linguistic limitations. Address the client’s unfamiliarity with the helping process. Create workshops and structured groups. Develop a global perspective. SOURCE: YAKUSHKO, BACKHAUS, WATSON, NGARUIYA, & GONZALEZ (2008).

Recertification. This option applies to refugees and immigrants who had education or training for a specific occupation in their country of origin and who need to be recertified or licensed to practice the occupation in the new country. Recertification typically entails further education and taking examinations to obtain licensure. Social workers can help clients contact the relevant licensing boards and educational institutions to determine the requirements for recertification. In addition, transcripts from the country of origin may need to be translated and evaluated. Recertification is typically a long-term process that requires multiple contacts with relevant agencies and institutions and support for the client by the social worker (U.S. Office of Refugee Resettlement, 2012b). General Considerations. Immigrant and refugee clients are likely to be unfamiliar with employment-related services and may distrust mainstream institutions (Abdelkerim & Grace, 2012). They may not be familiar with

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freedom of choice in making decisions regarding employment options and may expect the social worker to do all the work in obtaining a job for them. Social workers must clearly explain their role to ensure that clients do as much as they can on their own. Workers should concentrate on determining how the client’s prior work experiences, if any, fit into the current labor market in the new country. Interventions should be concrete and directive, assigning specific tasks to the client. Clients should consider their own interests and motivations in seeking specific occupations but be realistic about their options. Clients should understand that the first job they obtain will not necessarily last for the rest of their working lifetime. If placed in a low-level job, for example, they should look toward future advancement. However, it may be extremely difficult to move from a low-paid job to a better-paid position due to lack of time to invest in human capital, skills, and education (Deenanath et al., 2016). Finally, social workers must consider the interrelationships between employment status, health, mental health, and family dynamics. This is particularly important when working with immigrants and refugees (Deenanath et al., 2016). As has been previously described, unemployment and underemployment negatively affect people’s psychological well-being, health, and family relationships. These effects can then diminish their employability, thereby creating a vicious cycle. A holistic approach is critical when helping clients navigate this complex situation. Household composition is another important factor in economic well-being. Some households may be targeted for certain interventions, particularly households with children. Lack of child care is a major impediment to employment, particularly for women, and most immigrant and refugee families have children (Grieco et al., 2012). Thus a logical and necessary intervention is linking families to child care. Affordability of child care may be a barrier for immigrant and refugee families who often have lower levels of income (Karoly & Gonzalez, 2011). Therefore, at the policy level, social workers should be familiar with and advocate for subsidized child care and tax incentives that make child care more cost-effective for families. Social policy in Scandinavian countries, for example, shows that subsidized child care can play an important role in increasing intergenerational mobility and household well-being (Havnes & Mogstad, 2011). At the meso level, social workers should be familiar with child care options in their communities and link clients to them. In some

TARGETING HOUSEHOLD COMPOSITION

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cases, social workers may advocate for on-site child care at companies that employ large numbers of immigrants or refugees. Figure 9.7 summarizes recommendations for immigrant and refugee child care. Two current program initiatives are available for enhancing immigrants’ and refugees’ financial capital: Individual Development Accounts (IDAs) and microenterprise development programs. Individual Development Accounts. IDAs are matched savings accounts designed to support low-income and low-wealth individuals in saving for a specific purchase such as a home, a small business, or a higher education. The participant’s savings are matched with public or private funds. Participants also receive basic financial training on budgeting, saving, credit, and the U.S. financial system (Medina & Snyder, 2014). Evidence indicates that IDAs are successful in helping participants build wealth through asset accumulation (U.S. Office of Housing and Urban Development, 2012). The U.S. Office of Refugee Resettlement grants funds to public or private agencies to establish IDAs with refugee participants. Although no comparable program exists specifically for immigrants, some immigrants may be eligible for IDA programs targeted for the general population of low-income people. Microenterprise Development. Microenterprise development programs help people develop, expand, or maintain their own businesses and become financially independent. These services include business technical assisENHANCING FINANCIAL CAPITAL

Conduct aggressive outreach to educate immigrant and refugee parents about their choices Enhance collaboration between immigrant/refugee agencies and child care providers

Streamline the child care subsidy process Increase community capacity to access close and flexible child care Build capacity with immigrant and refugee communities to offer quality child care

FIGURE 9.7 Recommendations for immigrant and refugee child care to enhance economic well-being Source: Fidazzo, Schmidt, & Bergsman (2006).

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tance, or short-term training, and credit program funds and activities that help low-income people start or expand small businesses. The target population for a microenterprise program is aspiring entrepreneurs and those whose businesses employ five or fewer workers, including the owner, and who need less than $50,000 in financing. These targets fit well with the profile of many immigrants and refugees who have neither financial assets nor U.S. business experience and do not qualify for commercial loans. Microenterprise development programs have been successful in creating self-employment as well as in creating jobs for employees of the business (Edgecomb & Thetford, 2012). As with IDAs, microenterprise programs are available to refugees through the U.S. Office of Refugee Resettlement; some immigrants may have access to these programs through other sources if they qualify. Social capital developed through immigrant and refugee networks may provide employment and housing information (Nicodemo & Nicolini, 2012). More established residents from the same country may mentor recently arrived immigrants and refugees. Another option is for immigrants and refugees to join job clubs or support groups to practice skill building and networking. Social isolation can hinder immigrants’ and refugees’ chances for success, and groups like these could help clients. It would appear most prudent, however, to build social capital between immigrants and refugees and the mainstream population because that is most likely to lead to upward mobility.

ENHANCING SOCIAL CAPITAL

The final consideration on how to enhance the economic well-being of immigrants and refugees involves the community reception. Macro-level interventions should focus on community economic development and planning, job development, union organizing, and antidiscrimination strategies. Community Economic Development and Planning. Community economic development is a community-based process of local and regional revitalization. It emphasizes that the members of the community should be directly involved in pursuing and managing their own economic development (Community Futures, 2014). The principles of community economic development are illustrated in figure 9.8. As members of their communities, immigrants and refugees should be integrally involved in community economic development initiatives:

ENHANCING COMMUNITY RECEPTION

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5 - Self-reliance CED establishes community strength by analyzing the flow of wealth in, out, and within the community, identifying how leaks can be plugged and establishing trade links that benefit all partners.

3 - Participation

1 - Sustainability

CED invites and ensures active and inclusive participation in planning and implementation of strategies.

CED involves analysis and planning to implement policies and practices that will make communities 1 resilient for the long-term.

5 4

3 2

4 - Asset-based

2 - Community-based

CED builds on local community resources and assets as well as meeting needs.

CED facilitates community control utilizing a grassroots, bottom-up process.

FIGURE 9.8 Principles of community economic development (CED) Source: Community Futures (2014).

Immigrant economic development initiatives not only focus on how immigration can positively affect the economics of host communities; they also represent a unique opportunity for immigrants, refugees, and immigrant rights advocates. . . . Although these efforts do not directly target the immigration policy debates, they make a profound case for federal, state, and local laws that welcome immigrants, not drive them away or make it infeasible for communities to tap into their economic contributions. These immigration economic development efforts have much to offer immigrants and refugees in terms of tangibly improving their quality of life. In fact, many of the initiatives embrace enhancing traditional integration services (ESL, citizenship programs, legal services, job training, etc.) as a means of being more welcoming. Many local immigrant economic development initiatives bring new energy and innovation to traditional integration services, approaching the work from an asset-based perspective—viewing immigrants and refugees as opportunities, rather than as struggling victims. The initiatives have developed innovative programs, such as so-called “welcome mats” that guide immigrants and refugees to needed services, as well as a focus on building the capacity of the entire integration services field. (TOBOCMAN, N.D., P. 8)

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Job Development. Job development involves contacting potential employers on behalf of clients. It consists of contact and relationships with employers and networking with those who process job applications (Corbière, Brouwers, Lanctôt, & van Weeghel, 2014; Hagner & Breault, 2010). Job development is a central component of many employment-related services for refugees. Close ties with potential employers are essential, especially for companies that are willing to place large numbers of refugees. Job developers should contact employers on a regular basis to match refugees with available jobs. The following box lists best practices for successful job development.

BEST PRACTICES FOR JOB DEVELOPMENT Q Q Q Q Q Q Q Q Q Q Q

You have two customers: don’t forget the employer. Immerse yourself in the employer’s world: get to know their needs. Make the business case: articulate the value your services add. Get employers talking: a pitch is a dialogue. Get real: set expectations you can meet. Get through the ups and downs: keep employers talking. Involve employers in the organization: it’s a win/win situation. Making the match: understand both customers’ needs. It’s your performance that counts: understand your goals. You are a bridge to the employer’s world: communicate to colleagues what you want. You are unique: cultivate the style that works for you. SOURCE: CLYMER & WYCKOFF (2005).

In recent years, a number of large employers have committed to hiring refugees (Tent Foundation, 2018). The same is not necessarily true for immigrants, however. Furthermore, job developers are available for refugees through the federal resettlement program, but no such federal service is specifically targeted toward immigrants. Union Organizing. Labor unions used to ignore the needs of immigrant workers, but unions are becoming more immigrant-friendly and advocating on behalf of undocumented workers. Unite Here, a California-based union of mostly immigrants, is one example of the new trend for unions. A union leader said, “the power with the union is that if you already have that job, you’re able to keep that job. . . . It’s ensuring people aren’t abused or exploited” (Lee, 2015, para. 9). Social workers can assist in connecting

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immigrant and refugee workers with available unions or help workers organize to form their own unions. Antidiscrimination Interventions. Finally, social workers need to implement interventions aimed at decreasing discrimination against immigrants and refugees, both in the workplace and in society as a whole. This is so important that chapter 10 is devoted entirely to this topic.

10 INTERGROUP RELATIONS

THE NEGATIVE IMPACTS OF PREJUDICE ,

racism, and discrimination are discussed throughout this book. Discriminatory behaviors, practices, and policies adversely affect immigrant and refugee health, mental health, and educational and economic status. Many macro- and meso-level strategies are designed to reduce institutional discrimination by remedying discriminatory social policies and social service delivery systems. In this chapter, we address these issues at a more fundamental level—that is, prejudice, racism, and discrimination among individuals and within society. An antiracist model of social work, as opposed to a cultural competence model, is the appropriate response to fighting racism and discrimination (Social Work Policy Institute, 2014). The prejudiced and racist attitudes and discriminatory behaviors of members of the larger society are indentified by the antiracist model as being the source of ethnic minority problems. This model moves beyond a focus on a small segment of society (i.e., social workers and agencies) to the whole society. Interventions stemming from this model attempt to reduce and prevent these attitudes and behaviors through strategies aimed at the individual, small group, and community levels. We begin with a discussion of key issues in intergroup community relations. Best practices at the macro, meso, and micro levels are then presented before we examine specific antiracist social work practice approaches. Discussion questions throughout the chapter focus attention on specific social work issues.

KEY ISSUES IN INTERGROUP RELATIONS Following a brief review of key concepts, the causes of prejudice, racism, and discrimination are examined. Then we discuss the contemporary state of intergroup relations as it relates to immigrants and refugees.

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REVIEW OF KEY CONCEPTS

Intergroup relations refers to the ways in which the various groups of a society come together and interact over extended periods (Marger, 2015). When different groups come together, adaptations at the societal level must occur. Such structural acculturation has several possible outcomes: genocide (annihilation of one group), melting pot (assimilation), pluralism (distinct cultures are preserved), segregation (separate systems), and stratification (unequal distribution of resources). Contemporary U.S. society is characterized by segregation and stratification. Residential segregation results in separate communities for different racial/ethnic groups, the foreign-born, and native-born populations. This is due, in part, to the desire of immigrants and refugees to settle in areas with existing concentrations of people from similar ethnic or national backgrounds (Bruch & Mare, 2008). These residential patterns are more pronounced among people with low socioeconomic status. Among people with higher socioeconomic status, the foreign-born and native-born are more residentially integrated (Sharp & Iceland, 2013). Social stratification, classifying people based on the privileges and power they have, also occurs in the United States (Schizzerotto, 2011). Additional key concepts are prejudice, racism, and discrimination. Prejudices are attitudes that prejudge people on a basis other than their merit. Prejudice against foreigners may be termed xenophobia, anti-immigrant sentiment, or nativism. Social scientists usually define racism as an ideology that justifies and rationalizes racial and ethnic inequality based on the belief that some racial groups are superior to others (Marger, 2015). Finally, discrimination is the behavioral manifestation of prejudice and racism. Institutional discrimination refers to disparate organizational policies and practices for different groups; and individual discrimination is seen in derogatory comments or violence related to race, ethnicity, or national origin (Marger, 2015).

CAUSES OF PREJUDICE, RACISM, AND DISCRIMINATION

Marger (2015) presents three theoretical frameworks for explaining the causes of prejudice, racism, and discrimination: psychological theories,

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normative theories, and power-conflict theories. Two psychological theories are (1) the theory of frustration aggression, which posits that frustrated people become aggressive and lash out at scapegoats; and (2) the theory of the authoritarian personality, which holds that prejudice, racism, and discrimination are an aspect of a personality type that is highly conformist, disciplinarian, cynical, intolerant, and preoccupied with power. Normative theories stress that people conform because their reference groups desire it. By conforming, they are rewarded with a sense of belonging and a sense of self-identity as a member of the reference group. The normative theories stress the social environment, not the individual, as the cause of prejudice and discrimination. If the social environment changes, attitudes and behavior can change. One example is when civil rights laws caused many Americans to rethink their attitudes about racism.

DISCUSSION QUESTION

When you were growing up, what was one of your reference groups? Did this group teach you to have negative attitudes toward another group?

Finally, power-conflict theories stress the benefits of prejudice and discrimination for the dominant group. These theories include: Q Q

Q

Q

Q

Theory of economic gain—oppressing another group can be profitable. Marxian theory—the capitalist class profits from the working class being fragmented and thus easier to control. Different ethnic groups of the working class are pitted against each other. Split labor market theory—higher-paid workers benefit from prejudice and discrimination. The historic fear of “cheap labor” in the form of new immigrants is a manifestation of this theory. Theory of status gain—regardless of social class, people gain prestige from belonging to the dominant group. Theory of political gain—using prejudice to dismiss a political adversary.

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Empirical evidence provides strong support for the power-conflict theories, but it also supports the psychological and normative theories. Historical evidence clearly demonstrates that anti-immigrant sentiments among the public, and anti-immigrant policies, rise and fall in cycles linked to changing economic and political conditions (Billiet, Meuleman, & De Witte, 2014; Hopkins, 2010; Milner & Tingley, 2011). Anti-immigrant sentiment rises in a poor economy. The backlash against immigrants includes the fear that they have come to the United States to receive welfare benefits. However, immigrants place a high value on work, education, and productivity (Doty, 2016). Others believe that the foreign-born represent a threat to the safety of the community. In fact, however, immigrants have lower crime rates than the native-born (National Academies of Sciences, Engineering, and Medicine, 2015). The irrational nature of anti-immigrant beliefs confirms the psychological theory of frustration aggression, whereby anger is displaced onto inappropriate targets, or scapegoats. The normative theories of prejudice are supported by research into people using consensus information to form opinions about groups with which they have not been in contact (Watt & Larkin, 2010). All three major sets of theories about the causes of prejudice, racism, and discrimination have empirical support.

CONTEMPORARY PUBLIC ATTITUDES TOWARD IMMIGRANTS

A 2018 public opinion survey revealed, contrary to prevailing perceptions, that most of the American public has a favorable attitude toward immigrants; however, substantial differences in attitudes exist between Democrats and Republicans, with Democrats being more favorable toward immigrants than Republicans. The survey also revealed that less than half of the public knows that most immigrants are in the United States legally, and this lack of knowledge has influenced their attitude. Some findings of the survey are illustrated in figures 10.1 to 10.4. We encourage you to consult the Pew Research Center (2018a) survey for additional data regarding political and demographic differences regarding immigrants. In addition, about half of the public believes that the United States has a responsibility to admit refugees (figure 10.5), with variations by party affiliation and demographic characteristics of the respondents (Pew Research Center, 2018b).

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% who say that legal immigration into the United States should be ... Decreased 53 Kept at present level

38 32

29

24

Increased 10 2007

2001

2013

2018

FIGURE 10.1 Public attitudes toward level of legal immigration, 2001–2018 Source: Pew Research Center (2018a).

DISCRIMINATION AGAINST IMMIGRANTS AND REFUGEES

Discriminatory government and institutional policies have been described in previous chapters. Discrimination by individuals can range from microaggressions, “everyday verbal, nonverbal, and environmental slights, snubs, or insults, whether intentional or unintentional, which communicate hostile, derogatory,

% who say that legal immigration into the United States should be ... Republican/Lean Rep

Democrat/Lean Dem

Decreased

Kept at present level

43 38

39 33

40 39

37 36 Decreased

Kept at present level 22 15

20

16

Increased Increased ‘06

‘09

‘12

‘15

‘18

‘06

‘09

‘12

‘15

‘18

FIGURE 10.2 Public attitudes toward level of legal immigration by political affiliation Source: Pew Research Center (2018a).

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Among those who often/sometimes come into contact with immigrants who speak little or no English, % who say they are__by this Not bothered June 2018

Bothered

73

26

March 2006

61

April 1997

60

July 1993

38 39

54

45

FIGURE 10.3 Public attitudes toward immigrants’ English ability, 1993–2018 Source: Pew Research Center (2018a).

or negative messages to target persons based solely upon their marginalized group membership” (Sue, 2010, para 2), to hate crimes, acts of violence committed based on the victim’s race, ethnicity, religion, gender, sexual orientation, or disability. Table 10.1 lists some examples of microaggressions. Surveys of immigrants’ and refugees’ perceptions provide further insight into the discrimination they encounter. One survey found that 41 percent of foreign-born Latinx report having been discriminated against or treated unfairly (Krogstad & López, 2016). Another found that 38 percent of Asian

% who__granting permanent legal status to immigrants who came to the U.S. illegally when they were children Oppose Total

Rep/Lean Rep Dem/Lean Dem

20

36

Favor 73

54 8

89

FIGURE 10.4 Public attitudes toward undocumented immigrant children Source: Pew Research Center (2018a).

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% who say the U.S.__to accept refugees into the country

41

25

22

71

74

43 62 68

56

51 35

Feb May ‘17 ‘18 Total

26

Feb May ‘17 ‘18 Rep/Lean Rep

Feb May ‘17 ‘18 Dem/Lean Dem

Does not have a responsibility Has a responsibility FIGURE 10.5 Increase in partisan gap in public attitudes toward accepting refugees, 2017–2018 Source: Pew Research Center (2018b).

immigrants had experienced one or more types of discrimination in employment, treatment by police, being prevented from moving into a neighborhood, or being treated unfairly at restaurants or stores (Hopkins et al., 2016). And a 2018 survey of Muslims revealed the findings shown in figure 10.6. Hate crimes are the most violent manifestation of discrimination. In 2016, more than six thousand hate crime incidents were reported to the FBI (U.S. Department of Justice, 2018). Hate groups are also a threat. The Southern Poverty Law Center listed twenty-two anti-immigrant groups in 2017 (figure 10.7). Finally, intragroup prejudice can occur within ethnic groups. For example, Cuban refugees who arrived in the United States in the 1960s were usually upper class and highly educated. Twenty years later these immigrants often snubbed the “Marielito” refugees who faced stigma because of their poverty and perceived criminality (Fernández, 2007). Many Marielitos had darker skin than the earlier Cuban refugees and had different life experiences because they had lived under the Castro regime (Eckstein & Barberia, 2008). This example illustrates that no ethnic group is monolithic; “diversity within diversity” exists.

TABLE 10.1 Examples of Microaggressions THEME

MICROAGGRESSION

MESSAGE

Alien in own land

“Where are you from?”

You are not American.

When Asian Americans and Latinx Americans are assumed to be foreign-born.

“Where were you born?”

You are a foreigner.

Ascription of intelligence

“You are a credit to your race.”

Assigning intelligence to persons of color on the basis of their race.

“You are so articulate.”

People of color are generally not as intelligent as whites.

Asking an Asian person to help with a math or science problem.

It is unusual for someone of your race to be intelligent.

“You speak good English.” A person asking a U.S.-born Asian American to teach them words in their native language.

All Asians are intelligent and good in math and science. Color blindness Statements indicating that a person does not want to acknowledge race.

Criminality—assumption of criminal status A person of color is presumed to be dangerous, criminal, or deviant on the basis of race.

“When I look at you, I don’t see color.”

Denies a person of color’s racial/ethnic experiences.

“America is a melting pot.”

Assimilate into the dominant culture.

“There is only one race, the human race.”

A white man or woman clutching a purse or checking a wallet as a black or Latinx approaches or passes. A store owner following a customer of color around the store.

Denies the individual as a racial/cultural being. You are a criminal. You are going to steal. You are poor. You do not belong. You are dangerous.

A white person waits to ride the next elevator when a person of color is on it. Denial of individual racism A statement made when people deny their racial biases.

Myth of meritocracy Statements asserting that race does not play a role in life successes.

“I’m not a racist. I have several black friends.”

I am immune to races because I have friends of color.

“As a woman, I know what you go through as a racial minority.”

Your racial oppression is no different than my gender oppression. I can’t be a racist. I’m like you.

“I believe the most qualified person should get the job.”

People of color are given extra unfair benefits because of their race.

“Everyone can succeed in this society if they work hard enough.”

People of color are lazy or incompetent and need to work harder. “CONTINUED”

“CONTINUED”

Pathologizing cultural values/ communication styles The notion that the values and communication styles of the dominant culture are ideal.

Asking a black person: “Why do you have to be so loud/animated? Just calm down.”

Assimilate to dominant culture. Leave your cultural baggage outside.

To an Asian or Latinx person: “Why are you so quiet? We want to know what you think. Be more verbal.” “Speak up more.” Dismissing an individual who brings up race/culture in work/ school setting.

Second-class citizen A white person is given preferential treatment as a consumer over a person of color.

A person of color is mistaken for a service worker. A taxi cab passes a person of color and picks up a white passenger. Being ignored at a store counter as attention is given to the white customer behind you.

Environmental microaggressions Macro-level microaggressions are more apparent on systemic and environmental levels.

You are likely to cause trouble or want to travel to a dangerous neighborhood. Whites are more valued customers than people of color.

“You people . . .”

You don’t belong. You are a lesser being.

A college or university with buildings all named after white, heterosexual, upper-class males.

You don’t belong.

Television shows and movies that feature predominantly white people, without representing people of color.

You are an outsider.

Overcrowding of public schools in communities of color. Overabundance of liquor stores in communities of color. Source: Sue et al. (2007).

People of color are servants to whites. They couldn’t possibly occupy high-status positions.

You won’t succeed here. You can only go so far.

You don’t exist. People of color don’t/shouldn’t value education. People of color are deviant.

% of U.S. Muslims who say ... Immigrants ... there is a lot of discrimination against Muslims

65%

... they experienced at least one of the incidents below because they are Muslim ... someone acted suspicious around them

... they’ve been physically threatened or attacked

15

25

9 4

... airport security has singled them out ... other law enforcement officers have singled them out

47

20

... they were called offensive names

91%

61%

39%

17

4

19

19

FIGURE 10.6 Discrimination against Muslims in the United States Source: Pew Research Center (2018c).

FIGURE 10.7 Location of anti-immigrant groups in the United States, 2017 Source: Southern Poverty Law Center (2017).

U.S. born

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SUMMARY OF KEY ISSUES

Contemporary interethnic relations in the United States are complex and cannot be adequately described through simplistic frameworks. Anti-immigrant sentiments and discrimination rise and fall over time and have multiple causes, including psychological factors, social factors, and power-conflict factors. The negative consequences of prejudice, racism, and discrimination for immigrants and refugees have been extensively described throughout this book. Being subjected to individual discrimination, such as hostile remarks, inequitable treatment, or physical attacks, and to institutional discrimination that limits access to opportunities and limits the effectiveness of social services has adverse impacts on the health, mental health, family dynamics, and educational and economic attainment of immigrants and refugees (Ayón, 2015). These facts alone provide sufficient reason to combat prejudice, racism, and discrimination, but the primary reason is a moral one. Congruent with the social work value of treating all clients with respect and dignity, the Universal Declaration of Human Rights reinforces the moral imperative to honor all people as being equal (see chapter 2). In addition, social workers have an ethical obligation to act for social justice. Social work interventions should aim to decrease conflict and competition and to increase cooperation and accommodation between groups. We now turn to strategies for achieving these goals.

BEST PRACTICES This section presents strategies to reduce prejudice, racism, and discrimination. Achieving a pluralist and multicultural society means valuing liberty, equality, and fraternity for all groups (Modood, 2015). This is the best possible outcome of intergroup relations and is the least harmful of all the outcome options (e.g., stratification). We begin with a discussion of assessment and goal-setting issues, and follow that with discussions of strategies relevant to these goals directed to the macro, meso, and micro levels.

ASSESSMENT AND GOAL-SETTING

Social work practice in the area of intergroup relations follows the same problem-solving process as practice in other areas. It begins with problem

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identification, assessment, and goal-setting. Here are some community assessment questions to begin the process of improving intergroup relations:

INTERGROUP RELATIONS COMMUNITY ASSESSMENT QUESTIONS Q Q

Q

Q Q

Q

What are the common values shared across new and old residents of this community? What are the opportunities for real listening, sharing, and understanding across differences in perspective and background? As we make programs and services more accessible to those who have traditionally been underserved, can we make them more accessible to a greater number of communities and demonstrate the benefits for all? How do we not only provide excellent services but also foster belonging and participation? What bridge-building efforts already exist in this community and how can we incorporate them? What are the existing assets and who are the trusted leaders? How can we best nurture existing networks, especially those with diverse, crosssector partners that address inclusion? SOURCE: WELCOMING AMERICA (2017).

In targeting individuals, social workers must assess which of these four types is exemplified (Marger, 2015): Q

Q

Q

Q

The unprejudiced nondiscriminator: People who accept the idea of social equality and refrain from discriminating against others. The unprejudiced discriminator: People who adjust their behavior to meet the demands of particular circumstances. For example, a landlord may choose to discriminate against refugees to placate his other tenants. The prejudiced nondiscriminator: People who maintain negative beliefs and stereotypes toward others but do not act on them because of norms. A prejudiced landlord, for instance, may want to discriminate against refugees but does not want to face the consequences. The prejudiced discriminator: People who do not hesitate to turn their prejudicial beliefs into discriminatory behavior when the opportunity arises. Members of white supremacist groups exemplify this.

When fighting prejudice or discrimination, each type of person requires a different strategy. When trying to reduce prejudice, it is not necessary to reduce discrimination because these are two separate dimensions. In fact, reducing discrimination through laws and norms may lead to reductions in prejudice or changes in beliefs (Marger, 2015). The assessment of goals,

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people, and situations lays the foundation for the choice of strategies at the macro, meso, and micro levels.

MACRO PRACTICE

Macro-level best practices include policy advocacy, community development, community education, and nonviolent resistance. Each of these is addressed in the following sections. POLICY ADVOCACY Social workers should advocate for the rights of immigrants and refugees on the federal, state, and local levels. The goals should be equal treatment, equal opportunities, and harmonious intergroup relations. The following text box lists some options for policy advocacy.

POLICY ADVOCACY OPTIONS Q Q Q Q

Q Q Q Q Q Q Q Q Q Q

Organize: Build power at the base. Educate legislators: Provide information on issues. Invite legislators to your facility: Leave a lasting impression. Educate the public about the legislative process: Introduce communities and constituencies to the legislators who represent them. Research: Produce relevant resources that reflect the real story of your community. Organize a rally: Mobilize for your cause. Public education: Educate the community on the issues. Nonpartisan voter education: Inform the electorate on the issues. Nonpartisan voter mobilization: Encourage citizens to vote. Educational conferences: Gather, network, share information, and plan for the future. Litigation: Win in court for your cause or your community. Draft a petition: Demand change. Write an op-ed: Share your expertise on an issue. Lobby: Advocate for or against specific legislation. SOURCE: BOLDER ADVOCACY (2013).

DISCUSSION QUESTION

Select an immigrant or refugee rights issue. Discuss how social workers could address it by advocacy. Which advocacy techniques would work best?

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Community development aims to unite citizens and organizations to address common concerns and to improve their communities. Consensus is a key concept for community development because groups must work together, including social workers who are advocating for their clients. One example of successful community development occurred in Utica, New York. More than ten thousand refugees had settled there between 1989 and 2004, which resulted in a bidirectional process for refugees and the host community. Summer festivals showcase the music, foods, and arts of the different ethnic groups, and local radio and newspapers have specific times or sections for them. Smith (2008) posits that the U.S.-born citizens’ perspective was positive toward refugees because they believed that the refugees had enhanced the quality of life in Utica. How can social workers help communities to achieve a successful model of pluralism like that in Utica? Agencies with immigrant and refugee clients can work with local agencies, governments, NGOs, and social groups. In Oregon, Portland’s administrative organizations deliberately involve refugee and immigrant communities in initiatives for projects relevant to neighborhood economic development and programs for school-aged immigrant children and youth. These efforts help to develop relationships with newcomer communities and promote inclusion (Gambetta & Burgess, 2007; Ray, 2003). Police services and outreach to minority communities facilitate the process of integration. Although immigrants are more likely to carry cash and be at risk of being robbed, they are less likely to trust police. The Newport News, Virginia, Police Department started a Hispanic Outreach Initiative in 2004, which was expanded to include a Hispanic Advisory Committee in 2007. This initiative includes outreach to the immigrant community with regular participation of police in Hispanic radio station programming and cultural training for officers (Gambetta & Burgess, 2007; Ray, 2003). Urban transportation and accessibility to employment and services are essential. For instance, Lowell, Massachusetts, ended public bus service immediately following the afternoon rush hour. This was a barrier for immigrants and refugees who were taking evening classes for ESL and other courses. The One Lowell Coalition of immigrant, refugee, and community organizations has highlighted the need for better public transit if the community as a whole intends to integrate immigrant workers into the life of the city (Gambetta & Burgess, 2007; Ray, 2003). COMMUNITY DEVELOPMENT

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DISCUSSION QUESTION

Is public transportation or one of the other issues mentioned here a problem in your community? Has anyone tried to do something about it already? What is the best way to implement a positive step toward integrating immigrants and refugees into the community development effort?

Another consideration is improving relations between immigrants and refugees and the established residents. Immigrant and refugee integration is a dynamic, two-way process in which newcomers and the receiving society work together to build secure and vibrant communities. Several sectors can engage in these efforts, and stakeholders such as religious institutions and labor unions are critical to the conversation. Pathways to integration mean that barriers such as language and cultural differences can stymie newcomers’ efforts to join the community. Cultural and social interaction are especially important (Petsod, 2006). Figure 10.8 identifies best practices for community development for enhancing intergroup relations.

Engage longerterm residents Implement in partnership Collaboration can leverage new resources and build program capacity.

04

01

Design for equity and inclusion Where, when, and how a person can access services can significantly impact participation and outcomes.

Engaging longer-term residents in immigrant inclusion programs and partnerships reshapes the boundaries of “us” and “them” building more unified and welcoming communities. Set goals, monitor impact, and adjust priorities as needed

03

02

Identifying priorities and allowing for course correction are critical to impact when limited resources are available.

FIGURE 10.8 Community development best practices for enhancing intergroup relations Source: Welcoming America (2017).

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DISCUSSION QUESTION

Some established residents may regard immigrants and refugees as “takers” who do not contribute at all to a community. How would you encourage newcomers to create a sense of mutual responsibility for the community’s well-being?

Communities must also consider how to create a positive response to hate groups. Downs-Karkos (2011) offers these best practices for doing so: 1. Create a moral barrier around hate. Show community leaders the negative impact bigotry has on the community. 2. Provide many opportunities for interaction. Focus on communities’ concerns and help them see their world differently in ways that help them. 3. Avoid demonizing community members. Target the hate leaders, not all community members.

It is important for antiracist groups and other entities to stress community education because it is essential in developing a multicultural society. Empirical evidence indicates that community education is effective in reducing prejudice (Pedersen, Walker, Rapley, & Wise, 2003). Social workers should ensure that the message is received under favorable conditions so it will be looked at or heard. It must attract and hold the attention of the target audience, and the message must be understandable, enjoyable, and painless. Most of all, community education should present factual information to contradict inaccurate stereotyping and information (National Academies of Sciences, Engineering, and Medicine, 2016). Here are some best practices for community education messaging:

COMMUNITY EDUCATION

BEST PRACTICES FOR COMMUNITY MESSAGING ABOUT IMMIGRANTS AND REFUGEES Q Q Q

Address ambivalence about diversity directly. Acknowledge the legitimacy of receiving community member apprehensions. Develop effective unifying messages. “CONTINUED”

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“CONTINUED”

Q Q Q

Q

Q

Q Q

Use positive open-ended statements. Focus on the contributions all community members make. Stay away from language like “a flood of people”; rather, use terms like “new members of the community.” Consider terms like “initiative” rather than “campaign” because campaign sounds political. Use the term “immigrants” less frequently than terms like “families of immigrants” or “people from an immigrant background” and, sometimes, “newcomers.” Focus on “entire community” language as much as possible. Be open to framing the issues differently depending on the audience and the goal. SOURCE: DOWNS-KARKOS (2011).

Social workers may consider nonviolent resistance, a concept practiced by Mahatma Gandhi and Martin Luther King Jr. It is based on Gandhi’s concept of satyagraha, or “truth force” or “soul force.” A dominant group does not want to give up power, and the underlying principle behind nonviolent resistance is that basic human rights cannot be negotiated. Nonviolent resistance challenges the privileges of the dominant group by protests, hunger strikes, boycotts, and other techniques (Mattaini, 2013). The primary advantage of nonviolent resistance is that it does not challenge the force and aggression of the opponent as a violent act would (U.S. Institute of Peace, 2009). It works best when members of the opposition are not unified and perhaps are even ambivalent about their own side. People are more likely to be persuaded by nonviolent resistance when it provides them with an effective argument to cease identifying with the dominant position of their own group. Nonviolent resistance does work. In a study on 323 insurrections over past the century, nonviolent resistance was successful in 53 percent of the cases, whereas violent campaigns only succeeded 26 percent of the time (Zunes, 2009). One example of a successful nonviolent protest was the California grape boycott of the late 1960s led by Cesar Chavez. More than seventeen million Americans stopped buying grapes in protest of the low-wages for mostly Filipino farm workers. Chavez went on a twenty-five-day hunger strike to help win the victory for the workers in the form of a minimum wage, unionization, and security.

NONVIOLENT RESISTANCE

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MESO PRACTICE

Within the context of intergroup relations, meso-level practice consists of activities in which the social worker functions as a bridge between diverse segments of the society. The worker functions at the boundaries between different systems and may take on various roles such as facilitator, broker, mediator, enabler, consultant, or cultural interpreter. Two specific methods of meso practice in this context are structured intergroup contact and conflict resolution. STRUCTURED INTERGROUP CONTACT Structured intergroup contact refers to planned, facilitated activities that bring together people from different groups for increased mutual understanding and decreased prejudice, racism, and conflict (Pedersen et al., 2003). Social workers should carefully structure intergroup contacts to achieve these goals, keeping in mind these four essential conditions: (1) groups should have equal status in the contact situation; (2) no competition should be in place between groups during the contact period; (3) groups should seek superordinate goals during the contact period; and (4) relevant authorities should endorse a decrease in intergroup tensions. Failing to implement these conditions may result in the intergroup contact increasing racism and conflict (Pedersen et al., 2003). Following are some best practices for structured intergroup contact:

BEST PRACTICES FOR STRUCTURED INTERGROUP CONTACT Q

Q

Q

Q

Q

Q

Incorporate discussion into community activities featuring a range of perspectives and personal observations to avoid the polarization that usually results from traditional immigration debates. Personalize the event by including stories from immigrants as well as stories from the receiving communities. Utilize arts and culture to deepen empathy and build awareness of the issues surrounding demographic change. Find specific staff or volunteers who will dedicate a significant portion of their time to planning and following up with the event. Identify a neutral, trained, and experienced facilitator who is not perceived to have a personal or professional agenda regarding the issue at hand. Enlist one or more community partners who have relationships with the receiving community members. “CONTINUED”

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“CONTINUED”

Q

Q Q

Q Q Q

Create personalized invitations to the event. If possible, have invitations come from individuals the participants know and trust. Be clear about the purpose and time commitment for the event. Incorporate premeeting, one-on-one, or caucus work with smaller groups of people who may be hesitant to participate so they can explore their feelings in a supportive environment and feel better prepared for a larger group forum. Create an environment where people feel safe and no one feels exposed. Make the event a personal experience, not one that feels broad and abstract. Be prepared for follow-up and incorporate it into the planning process. Structured intergroup contacts are most effective when they happen more than once. SOURCE: DOWNS-KARKOS (2011).

Conflict resolution is a set of processes utilizing communication skills and creative thinking to develop voluntary solutions acceptable to the parties in a dispute. This technique is frequently used as an intervention in interethnic conflicts between individuals, groups, warring factions within nations, or between nations. Although social workers play an important role in conflict resolution, their work sometimes goes unnoticed due to lack of documentation (Barsky, 2017). One type of conflict resolution is contractual, which involves writing a contract between the disputants and other interested parties. Emergent conflict resolution is most likely to occur when it is not the primary focus of the social work intervention. For example, a school social worker might use emergent conflict resolution when an intergroup conflict arises in the school. A problem-solving process should help resolve the conflict. One individual-based model for problem solving is ADAPT (figure 10.9). Social workers can base their conflict resolution processes on a set of underlying principles, such these suggested by Fisher (2016). Conflict resolution must transform conflicts in an enduring manner rather than settling disputes or suppressing differences. One should distinguish a resolution from a settlement and a conflict from a dispute. Conflict resolution requires a range of complementary methods appropriate to the issues and the stage of conflict escalation. Social workers should be sensitive to the background of disputants to ensure the best possible outcome. Fisher also stresses that conflict resolution must address basic human needs and must build sustainable relationships between groups. If a group feels that its basic needs

CONFLICT RESOLUTION

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PROBLEM AREAS AND BEST PRACTICES

Define

Predict

Define the problem, possible solutions, challenges, and opportunities based on facts.

A

Attitude Participants should express their attitude toward the problem.

D

Predict positive and negative consequences and potential outcomes of the alternatives.

A

Alternatives List alternatives to overcome the problem.

P

T

Try out Try out the alternative with the highest probability of solving the problem and fewest negative consequences.

FIGURE 10.9 ADAPT model of conflict resolution Source: D’Zurilla & Nezu (2010).

are being denied, conflict can result. The suppression and frustration of basic human needs is the primary cause of protracted social conflicts. For instance, a group that is denied decent housing may clash with a group seen to be exploiting them. Negotiation. Negotiation is one way for people to interact when dealing with a conflict. Social workers may be involved in negotiation pertaining to intergroup conflict in two ways: (1) by teaching clients the skills and process of negotiation so they can engage in it themselves, or (2) by directly engaging in negotiation as advocates on behalf of clients (either individuals or groups). The negotiation process works best when people are flexible, able to suspend their own ambitions, have faith in their negotiation abilities, and have had prior success in conflict resolution (Barsky, 2017). However, negotiation may not work if the tensions or emotions are high. Social workers should realize that negotiations are not appropriate for every situation. The goal of negotiation may not necessarily be to reach an agreement but to increase empowerment and recognition between the parties. Negotiating parties may feel empowered when they realize that they have more options than they had realized. As the parties develop their own negotiation skills, they can listen to other opinions and analyze the issue. They gain awareness of resources already in their possession or available to them. Most

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299

important, they reflect and make conscious decisions for themselves about what they want (Barsky, 2017). Mediation. “Mediation is a process where the parties to a dispute are assisted by someone external to the dispute, the mediator, who aids their decision-making about the dispute in various ways” (Boulle, Colatrella, & Picchioni, 2008, pp. 1–2). Mediation is consensual and lets the parties make their own decision as led by the mediator (Boulle et al., 2008). This approach may be particularly valuable for resolving conflicts in new immigrant and refugee communities because it is culturally congruent with many ethnic groups (Barsky, 2017). In cases of intergroup conflict, social workers may act as mediators themselves or may train community members to be volunteer mediators. Many states certify mediators, so social workers should consider using professionals or taking mediation training themselves. When social workers act as mediators, one of the most difficult tasks they face is to become neutral and impartial despite the social work value of advocating for the oppressed (Barsky, 2017). Mediation requires a reorientation from focusing on the interests of the immigrant or refugee clients to focusing on the interests of all parties in the dispute. When using mediation in intergroup conflicts, we recommend that you follow the strategies listed in the text box.

BEST PRACTICES FOR MEDIATION IN INTERGROUP CONFLICTS Q

Q

Q

Q

Q

Use recognition strategies from the transformative paradigm to facilitate understanding, reconcile past miscommunications, and foster mutual respect. Validate different cultural beliefs, values, and ways of doing things because many conflicts do not have a right and a wrong; reinforce the idea that conflict is a part of diversity. Separate interests and values; help the parties understand the conflict between their values and focus the problem-solving component of mediation on satisfying interests that exist regardless of their difference in values. Use cultural interpreters to help each party gain a better understanding of the other. If clients have lived most of their lives in a homogeneous culture, they may have difficulty explaining cultural norms to others in language they can understand. Cultural interpreters have had experience with more than one culture, and they have learned how to translate cultural norms from one culture to another. If the dispute is based on intergroup conflict, consider group approaches rather than mediation between individuals. SOURCE: BARSKY (2017).

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PROBLEM AREAS AND BEST PRACTICES

DISCUSSION QUESTION

A group of Iraqi refugees has recently moved into an apartment complex that was once dominated by Latinx. These two groups are clashing because the Latinx feel they are being edged out of the neighborhood. As a social worker, how would you handle this situation?

MICRO PRACTICE

Micro practice refers to direct practice with individuals or small groups. Two strategies to enhance intergroup relations are education and psychotherapy. Social workers may be involved in school-based programs that teach young people intergroup tolerance. These programs may emphasize conflict resolution by teaching students the skills and processes of conflict management, communication skills, and peer mediation techniques (Turnuklu et al., 2010). Peacekeeping circles also help students learn to communicate with each other and reduce intergroup tensions. Educational approaches may include vicarious experiences, such as films, plays, biographies, novels, and other media that portray the experiences of different ethnic groups (Davis, 2007). This is based on the assumption that such exposure helps students recognize the commonalities between different groups and reduces a “them vs. us” perspective. Antibullying programs are another important strategy in the educational setting. Immigrant and refugee children often encounter bullies. Table 10.2 describes best practices for bullying prevention programs when immigrant and refugee students may be involved.

EDUCATION

DISCUSSION QUESTION

A young Latina immigrant gets into a fight at school. She claims to have been picked on for being a “dirty Mexican.” If you were the school social worker, how would you handle this situation on the micro level? Meso level (i.e., school)? Are there any macro-level issues involved in this case?

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301

TABLE 10.2 Best Practices for Immigrant and Refugee Antibullying Programs CONSIDERATIONS FOR SCHOOLS WITH REFUGEE/ BEST PRACTICE

IMMIGRANT STUDENTS

Focus on the social environment of the school.

Look at the school and the community’s attitude toward refugees and immigrants. Recognize the impact of anti-immigrant sentiment, racism, and religious/political tensions.

Assess bullying at your school.

Translate assessment questionnaires or find other ways, such as focus groups, for students with limited English or literacy skills to provide input.

Garner staff and parent support for bullying prevention.

Identify barriers for refugee and immigrant parent participation and develop a plan to address those. Make sure school leadership is involved.

Form a group to coordinate the school’s bullying prevention activities.

Include ELL/ESL staff as well as representatives from community agencies (refugee resettlement, ethnic community-based, etc.) and community leaders. Their buy in is important.

Train your staff in bullying prevention.

Include information on cultural competence and any additional considerations for dealing with bullying of refugees and immigrants.

Establish and enforce school rules and policies related to bullying.

Most students are bystanders. Many youth, including refugees and immigrants, appreciate being given an opportunity for leadership or to help create change.

Increase adult supervision in “hot spots” where bullying occurs.

Refugee and immigrant students are particularly vulnerable when adults are not around, especially because of language barriers. Include areas outside of school, if possible, such as the bus.

Intervene consistently and appropriately in bullying situations.

Take steps to reduce any barriers to parent involvement for refugee and immigrant parents.

Focus some class time on bullying prevention.

Newcomer students should be invited to share, but they should never be forced to be “cultural spokespersons” for their community.

Continue these efforts over time.

The populations in our schools are ever-changing, so the conversation must be ongoing too.

Source: Bridging Refugee Youth and Children’s Services (n.d.).

For adults, providing accurate information to eliminate false beliefs and invoke empathy and providing cultural awareness and cross-cultural training are among the suggested educational approaches for reducing prejudice, racism, and discrimination (Pedersen et al., 2003). Information-gathering involves group activities aimed at dispelling misperceptions about various ethnic groups by providing accurate information about cultural systems, worldviews, values, and experiences. Cultural awareness emphasizes the distinctiveness of different cultures and reeducates individuals to help reshape society and promote intergroup relations. Finally, cross-cultural training uses the strategies of behaviorism to help people unlearn the learned

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PROBLEM AREAS AND BEST PRACTICES

attitudes and behaviors of prejudice, racism, and discrimination—and to learn empowering behaviors instead. PSYCHOTHERAPY Clients don’t typically come to therapy for treatment of their prejudice or racism; however, these views often do arise in therapy. The social worker is then faced with an ethical dilemma: respecting the client’s self-determination or promoting social justice by addressing the issue (MacLeod, 2014). MacLeod recommends that therapists consider the following issues before deciding how to intervene: Q Q Q Q Q Q Q

Q

Consider the client’s goals and how prejudice is related to these goals. Assess the client’s racial identity. Assess the function these stereotypes and biases serve for the client. Consider how the racist comments relate to cultural racism. Assess what cultural values and strengths maintain these beliefs. Identify cultural strengths the client can use to stop relying on these biases. Clarify your own motivations and reactions in the process of addressing prejudice. Assess the client’s motivation for change in this area.

MacLeod then recommends using a functional analysis approach to determine the origin of the client’s beliefs and what purpose they serve for the client. Helping the client develop alternatives to these maladaptive attitudes is an important consideration. Addressing prejudice and racism in therapy is a critical topic that requires much more research.

SUMMARY OF BEST PRACTICES

Comprehensive interventions are needed at the macro, meso, and micro levels to effectively reduce racism, prejudice, and discrimination and to enhance interethnic harmony. It is essential for social workers to adopt a proactive, antiracist model of practice that directly addresses these causes of social inequity. It is not sufficient to focus solely on enhancing the cultural sensitivity of social workers themselves and social agencies and systems. Finally, much work remains to be done in evaluating the effectiveness of all of these antiracist strategies.

11 ADDITIONAL POPULATIONS OF CONCERN

within the overall population of immigrants and refugees require special consideration. All of the concepts and best practices in the preceding chapters apply to these groups, but social workers need additional knowledge and skills to work with them. Four groups are discussed in this chapter: unaccompanied and separated children; older adult migrants; queer migrants; and international victims of human trafficking. The purpose of this chapter is to highlight the unique circumstances and best practice approaches useful in working with these groups; it is not to “ghettoize” these groups and set them apart from the overall foreign-born population.

SEVERAL SUBPOPULATIONS

UNACCOMPANIED AND SEPARATED CHILDREN DEFINITION OF UNACCOMPANIED AND SEPARATED CHILDREN

The United Nations Convention on the Rights of the Child define a child as a “person below the age of 18, unless the laws of a particular country set the legal age for adulthood younger” (United Nations Children’s Fund [UNICEF], n.d., para. 1). The U.S. definition of unaccompanied alien children “include[s] both children who enter the country without their parent or legal guardian and children who for other reasons have been separated from their parent or legal guardian” (U.S. Office of Refugee Resettlement, 2018c).

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PROBLEM AREAS AND BEST PRACTICES

POPULATION OF UNACCOMPANIED AND SEPARATED CHILDREN

In 2017, more than thirty-six million children, age nineteen or younger, lived as migrants in countries other than their country of origin (United Nations Department of Economic and Social Affairs, 2018). Children made up 13 percent of the total population of international migrants in 2017 (figure 11.2). For refugees and other forcibly displaced people, the ratio of children to the adult population is much greater (figure 11.2). By the end of 2016, more than half of the worldwide 22.3 million refugee population was under the age of eighteen (UN High Commissioner for Refugees, 2017a). Currently, one-third of worldwide migrant children are refugees (UNICEF, 2018). The actual number of migrant children, especially the forcibly displaced, may be higher than these reported numbers because many have not been identified by humanitarian organizations (Hart, 2014). In 2017, most migrant children, including refugee children, lived in Asia (figure 11.2). The main host countries for refugee children in 2015 were Turkey, Pakistan, Lebanon, Iran, and Ethiopia (UNICEF, 2018).

Total population

International migrants

31%

13%

Refugees

0%

12%

57%

17%

70%

51%

20%

3%

46%

40% Under 18

60% 18 to 59

80%

100%

120%

60+

FIGURE 11.1 Age distribution of international migrants, refugees, and total world population, 2015 Source: United Nations Department of Economic and Social Affairs (2018).

ADDITIONAL POPULATIONS OF CONCERN

305

16,000,000 14,000,000 12,000,000 10,000,000 8,000,000 6,000,000 4,000,000 2,000,000

ia an ce O

Am N o er rth ic a

e th Am e er C ic ar a ib an be d an

La

tin

Eu

ro p

a As i

Af ric

a

0

FIGURE 11.2 International child migrants (age nineteen and under) by destination area, 2017 Source: United Nations Department of Economic and Social Affairs (2018).

Children usually migrate with their families. However, an alarming number of children travel unaccompanied or are separated from their parents or primary adult caregivers (UNICEF, 2017a). The total population of unaccompanied minors is unclear, but some regional level data exist. In the Mediterranean, for example, 90 percent of child migrants were unaccompanied in 2016 (UNICEF, 2017b). In the same year, 170,000 unaccompanied or separated children applied for asylum in Europe (UNICEF, 2017a). In the United States, the Office of Refugee Resettlement (ORR) is responsible for caring for unaccompanied and separated children until they can be reunited with family members. Table 11.1 shows the number of unaccompanied minors referred to ORR between 2012 and 2017 as well as their age, gender, and country of origin. Table 11.2 shows the number of unaccompanied minors referred to ORR who were released to sponsors between 2015 and 2017.

TABLE 11.1 Unaccompanied Minors Referred to ORR, 2012–2017 YEAR

Referrals

FY2017

FY2016

FY2015

FY2014

FY2013

FY2012

40,810

59,170

33,726

57,496

24,668

13,625

Demographics (in %) Age 0–12

17

18

17

21

14

11

13–14

13

14

14

16

13

11

15–16

3

37

38

36

40

39

17

32

31

30

27

34

38

Male

68

67

68

66

73

77

Female

32

33

32

34

27

23

Honduras

23

21

17

34

30

27

Guatemala

45

40

45

32

37

34

El Salvador

27

34

29

29

26

27

Mexico