Welcome, everyone, to our session titled At-Risk, Integrating Mental Health, Law, and Advocacy to Improve the Well-Being of Vulnerable Immigrant Populations. I am Giselle Pilata, PGY-3, psychiatry resident at Garnett Health Medical Center, New York State, and I'll be starting our session with an introduction of our presenters. So to start off, Dr. Atiyah Lima is currently serving as director of consultation and liaison psychiatry at Jamaica Hospital Medical Center. She completed her general psychiatry residency at Nassau University Medical Center and then fellowship in consultation liaison psychiatry at Northwell Long Island Jewish Medical Center. Dr. Lima has a strong interest in improving systems and serving the underserved. Next is Dr. Pamela Montano-Arteaga, who is a clinical assistant professor at New York University. She works as a psychiatrist and director of the Latino Bicultural Clinic at Gouverneur Health NYC Health and Hospitals. She completed her psychiatry residency at Northwell Hofstra School of Medicine at Zucker Hillside Hospital and a fellowship in public psychiatry at Columbia University. She was born and raised in Columbia. As an APA minority fellow, she participated in the Council on Minority Mental Health and Health Disparities and has remained as a consultant member. Within the APA, she has participated in different work groups and initiatives, such as creating a toolkit for providers working with undocumented immigrants and as a current member of the resource work group of the APA Presidential Anti-Racism Task Force. She has worked for the Empower Program for Victims of Human Trafficking and Sexual Trauma as part of the Executive Council of the American Society of Hispanic Psychiatry, co-chair of a new committee on advocacy in the Society for Study of Culture and Psychiatry, and a member of Physicians for Human Rights. Ms. Brenda Opunsky is a former human rights attorney and the advocacy director and senior psychotherapist at Teja Firma, a mental health, medical, legal partnership in New York City that provides services specifically tailored to unaccompanied and asylum-seeking families. Brenda provides trauma-informed psychotherapy, and her expertise includes conducting psychological evaluations and writing affidavits in support of patients' asylum and other immigration cases. Brenda's experience with working with families separated at the border under the Zero Tolerance Policy has been published in the peer-reviewed Journal of Child and Adolescent Trauma, and she has also conducted psychological evaluations of asylum-seekers stranded at the border in Matamoros, Mexico. And then last but not at all least, we'll hear from Dr. Gabrielle Shapiro. She is a clinical professor of psychiatry at the Icahn School of Medicine at Mount Sinai, the collaborative care program director at the Baruch and East Harlem Health Council, and supervising psychiatrist at Union Settlement. She's an active member of APA and ACAP, and is a delegate for ACAP, the Medical Society of the State of New York, and the APA's Assembly representing Area 2. She's a board member of New York Council on Child and Adolescent Psychiatry, New York County Psychiatric Society, and the County Medical Society, and a founding board member of ACAP's Political Action Committee. Dr. Shapiro is the chair of the APA Council on Children, Adolescents, and Their Families, and a member of the APA Foundation Board. She's a passionate advocate for child and adolescent psychiatry. She's involved in working with youth and families seeking asylum from the trauma from their countries of origin. She is bilingual Spanish-speaking and provides therapy in Spanish, and has committed her career to public sector psychiatry and working with immigrants, Native American and Latinx children and families to improve the quality of the psychiatric care they receive. Now I will present Ms. Brenda Punsky to begin our presentation. Hello again. My name is Brenda Punsky, and today I'm going to be talking about the needs and care of unaccompanied immigrant children and asylum-seeking families from a trauma-informed perspective. First, who are unaccompanied immigrant children? The Homeland Security Act of 2002 categorizes them as children that come into the United States while they're younger than 18, who arrive to the United States without an immigration status in the U.S., which means that they're not citizens or residents or have any kind of visa, and that they didn't have a parent or a guardian with them at the time of crossing. Not all children that are designated as unaccompanied actually arrive alone. Many of them arrive with family members such as a cousin or an older sister or an older friend, but because it's not their biological parents, they are determined to be unaccompanied, but as a matter of fact, they were not. And adults with children, which I'm going to refer to as AWCs, are parents or legal guardians that cross the border with a child who is under 18 years old. Immigration trends have changed drastically in the last years, especially since 2014. As you can see in this graph, there has been an increase in the amount of unaccompanied immigrant children that we've seen come in. As you see, in 2019, there was a huge surge again, and 2020 and fiscal year 2021, even with the pandemic, we still see many unaccompanied immigrant children arriving to the country. There has also been a rise in family units that come unaccompanied, on adults with children that arrive to the United States, especially in 2019 and 2020, but mostly in 2019, there was a huge surge in them. I'm going to talk about unaccompanied immigrant children and adults with children or family units, and I'm going to talk about them as a group, because I'm going to be talking about some of their shared experiences as a group, but it's important for you to know that their experiences change greatly, depending on many things. I'm going to be talking about them as a group, but keep in mind that they have different identities, they have different experiences of discrimination, both in their country and in the United States, and they have very specific needs and strengths. To better understand their experiences, I am going to talk about this in kind of four stages of their experience. One, I'm going to first talk about their pre-migration and what happens in the country of origin that makes them migrate to the United States, what happens during the migration and the journey, what happens when they're apprehended and in detention, and afterwards, when they are reunified or released into the community. In order to do that, let's first talk about the context of what happens in the country of origin. In many areas of the Northern Triangle, and this I forgot to say, most of both the unaccompanied immigrant children and the family units that come in are from what's called the Northern Triangle. This is Honduras, El Salvador, and Guatemala. And in many areas of these countries, gangs have become the most present and powerful actors in children's lives. The vast majority of patients of all ages report having experiences or knowledge of things that happened with gangs, either to them or to people they know. Gangs often determine the rules of the town, who violates them, and what punishment they get for violating these rules. And so it is because of insecurity, violence, and fleeing for survival, rather than having a more promising future, that those are the primary reasons for migration. It's estimated that around 90% of crimes go unpunished. And while people may attempt to move to another part of the country to be safer, that often doesn't resolve their security concerns. So why do they come? These are some examples of the push, what pushes them out of their countries, and children are especially vulnerable to some of this. We see a lot of targeted violence for youth, ethnic minorities, girls and women. We work with a very large Garifuna community, which are people that are part of an Afro Caribbean community. I'm going to talk more about that later. But we see also a lot of forced gang recruitment. For example, I had a patient from El Salvador who was threatened several times by a gang leader that if she didn't become his girlfriend, he was going to kill both her and her family. And so the harassment increased and increased. And then there were gang members surveilling their house and surrounding their house more and more each day. And so the intimidation and the fear became so severe that she had to escape hidden inside of a trunk of a car. This patient was 15 years old when that happened. And we also see a lot of forced participation in gang activities. And this is with patients as young as five years old. For example, I have a patient who was 11 years old. He was playing at the beach with his friends. And three gang members approached him and asked him to bring a package to a house nearby. Because he and all his family and all his friends are familiar with gang operations, he assumed that that was something illegal, that the package contained drugs or contained something that was going to get him in trouble. So he said, no, he refused. So the gang member said, OK, we're going to come back in three days and you better have changed your mind. Three days went by, they came back and they asked him, have you changed your mind? And he said, no, I don't want to participate. So they brought him to a nearby alley and they broke his knee with a baseball bat. Very shortly after, he migrated to the United States. We see also a lot of extortion. People are extorted into paying for safety, which is just a threat. There's a lot, as I mentioned, there's lack of protection and corruption, impunity, abject poverty and social exclusion. I have another patient who is, she belongs to an Indigenous community in rural, rural Ecuador, and she lived in extreme poverty from birth. She has epilepsy, which was untreated until she arrived in the United States. People in her town thought that she had a demon inside her and tried to exercise her several times. There were, she had several instances of sexual abuse and discrimination and bullying for being Indigenous and for having this demonic attacks, which were in fact seizures. Her dad migrated to the United States when she was 10 years old and her mom when she was 14 years old. So at that age, she was left in charge of her four younger siblings. So basically at 14 years old, she became the main caretaker of her siblings. Okay, so that's the push. What is the pull? These are some examples of what's attractive to them when they are here. It's a safe haven, haven reunification with family members and education and economic opportunities. So this is a very brief overview of why they come, but how do they come? The journey is around 2000 miles and they come by bus, walking for days. They come in car rides and on a train that's called, it's better known as La Bestia or the beast or the train of death. And there's risk of falling and mutilation constantly there. So oftentimes it's not them. It's not the child who decides to migrate. They are informed of this decision. And even though some have a few days to prepare, there are many others that have to leave without notice for that same night, which leaves no time for goodbyes. So this is going to have an impact later on in their adaptation and how they handle things when they're in the United States. And some, especially when they're younger, they're not even told anything of what's happening until they're already in Mexico. So this doesn't help either for their mental health. So these are some examples of what we constantly hear of the experience that they endure, exploitation, extortion, a lot of sexual assaults and robberies. They're exposed to the elements. There's a lot of heat and rain, et cetera. We also hear of a lot of kidnappings, either by competing drug cartels or other groups. And we have patients from West African countries and they face even more hardship than the ones that come from Central America or other parts of the continent. So after all that, after surviving all of that, many of them go to their goal, arrive to what's called an authorized port of entry. And they express their fears of being returned home, their fears of harm if they're returned home to their country. So many are turned away. They may be told there's no space today or we already reached whatever number or simply no. Others are told, especially with something that was called the Migrant Protection Protocols under the Trump administration was established. They were told, OK, here's your number. You come here asking for asylum. Here is your number to go to court and state your case. But you're going to have to wait your turn in Mexico. And this turn may, you know, this was they were given court dates years after or many, many months after. So they were forced to stay at migrant camps. And I've been to these camps. I can tell you these camps are in very, very bad condition. They're gang infested and people live in extreme fear while there. Others attempt coming through other authorized ports of entry, but they are denied entry and they get desperate. They may run out of money or they may fear for their lives or be sick. So they come in without inspection. They come through the river. They come through the desert. It's estimated that five there are around 500 deaths recorded per year for by dehydration or drowning. And patients report hearing and feeling animals in the middle of the night. They report walking for days at a time, seeing bones and dead bodies along the way, kind of a terror movie, a horror movie. They report seeing ice dogs and chasing that are chasing and attacking people. And all children and adults always say that they are terrified of the animals in the river. After they cross almost immediately, they are apprehended. They're typically apprehended right away or they themselves may look for the border patrol for La Migra to turn themselves in. And the reason why they do this is because they may be extremely thirsty or extremely hungry or ill. So they need help on one side. And on the other side, if especially they're under 18 years old, being apprehended is kind of could be helpful just in terms of setting a record that they enter the country while they were younger than 18 years old, because this may have positive implications later on when they try to regularize their immigration status. After being apprehended, they are sent to immigration detention centers. They're known as La Hielera or Icebox because of the freezing temperatures or La Perrera or Dock Canal because it looks like one. And this is the first placement after apprehension. Initially, children and adults are placed together, but later on they get separated. In addition to the freezing temperatures, patients have reported that there are bright lights at all times. The floor is hard and cold. There are no windows. It's very crowded. There's no privacy. There are children crying and coughing all night long. The food is bad and scarce. And many, many medical assessments are conducted by law enforcement officers and not by medical providers. And they're frequently limited to checking for lice, scabies, and chicken pox. They're usually there for around two to four days. And then in processing centers, it is where asylum seekers get to tell their story for the very first time. They get to explain why they are fearful, why they are fleeing their country. And but because of cumulative and complex trauma, many people are afraid to share their stories and are unable to trust authorities, particularly if those authorities are wearing a uniform. They might be scared that information will get back to their community and endanger the lives of those who stayed behind. And discrepancies are not unusual because of the trauma, but they may negatively impact the determinations made by immigration authorities. After that, they are sent, the children are sent to shelters that belong to the Office of Refugee Resettlement. So at this moment, they stop being under the jurisdiction of the Department of Homeland Security and they become part of, they become the jurisdiction of, or our shelters. And this is a positive thing because here, child welfare is involved. They are provided with dorm style, dorm style rooms, shared bathrooms and showers, educational, medical, mental health services they receive. They have recreational activities, are allowed phone calls, and they're usually surrounded by high fences. And they're here while the ORR is investigating a potential sponsor for them to be released to, the sponsor and the people who live with the sponsor. The experience of many patients, I mean, this, this can be very controversial, but I, I, this can be very controversial, but I, in working with, with patients, I process all their, the experiences, like the reasons why they left, what, you know, their experiences during the journey and their experiences while they were apprehended and at these shelters. And often I ask, what do you think was the worst part about the shelter? And very, very often I get the same answer. I'm told the worst part was leaving the shelter because in the shelters, because child welfare, welfare is involved. There are different kinds of professionals working there and they're able to build relationships, both with other children and also with the adults providing care for this, for these children. And often they get to have a better, not necessarily a better quality of life. This is, I know it's very controversial, but they, for example, get to go to the bathroom. They don't have to walk away. They don't have to go out in the cold or in the heat to go to the bathroom. They live in, in, in a way, a place that has more conveniences than when, where they used to live. Okay. So once the sponsor is approved and the sponsor sends money for the ticket, because it is the sponsor who has to pay for the ticket out, they, unaccompanied immigrant children are sent to the sponsor. They are very often, like parents are the, the majority of the people, of the sponsors of these children are parents, but we see all kinds of relationships, other, other relatives as well, especially with unaccompanied immigrant children from Guatemala, they're very often released to a sibling, one older sibling. And, but the thing is that very often they're released to the sponsors and often they've never met them before. They've, they, we have many cases where they are released to the father and they never met the father because the father left when mom was pregnant with them, or they're released to an aunt or an uncle or a grandparent that may, they may have heard before, but they never really had an interaction with, or they did when they were very young. But the point is that it's not a close relationship. And this is going to have an impact later on in their adjustment in their life post, post release. Every state in the, in the country has received unaccompanied immigrant children and some important factors that may impact the adaptation later on is, for example, the number of years that they were separated, let's say that they arrived, but they reunified with the parents, the number of years they were, they were away from them, the communication that they had. We have patients that there's constant communication with the parents. They call them every day and they know everything about each other's lives while others have a call every couple of months. And this can be due to different things in both personality of the parents, but also resources. If it's a family that doesn't have resources, even for a phone call, the phone calls are not going to be very, very often. And also attachment versus just sending money. We have patients that have this talks with the parents every couple of months. And the talk, the, the phone calls are maybe five minutes long and they're very, you know, very complete. And we have other patients that not only talk to the parents every day, but they actually have to, for example, ask for permission, like the child being in Honduras and the patient, the, sorry, the parents being in New York. And they have to ask the parent in New York for permission to go to a party that night. So it's very like micro parenting. We see both ends of the spectrum. Okay. So once they are released to the sponsor, a new phase begins. And this phase brings, may bring stressors, different kinds of stressors. I'm going to talk about that right now. So initially in the best case scenario, what we often see is that there's a honeymoon phase, which lasts about between three to three weeks to a month, a month and a half. And this honeymoon phase, everybody's happy. I haven't seen you so long. We're finally reunified. I love you so much. I love you too. We're going to be great together. We're going to be a great family. I've been waiting all my life for this moment and everything is beautiful. Soon after reality starts to, to sink in and things change a little bit. They may encounter conflict for many different reasons. For example, they may feel misunderstood. Like the children may feel misunderstood and like they can't trust their parents or their sponsor. And the other way around, the sponsor may be thinking, but why I can't, like, why are you not telling me everything about you? Why are you not trusting me? And may think, I've been working so hard for so many years to be able to send you money. How are you not much more grateful and thankful than you seem? So there start being some clashes in that case. They may also be dealing with abusive caretakers. They may not be accustomed to being parented or often children arrive to find out that they have a younger sibling that they had no idea they had. So they arrive home and they are introduced. This is your seven-year-old sister that you didn't know you have. And even if they knew about them, the fact that those younger siblings had the privilege of growing up with a parent and they haven't can make adaptation more difficult. Stressors that are over in the household include financial stress, food and housing insecurity. Caregivers may fear being deported themselves. Legal, they have to go to court hearings first, usually by themselves. And they have to find a lawyer and convey their story. And there's some feel of deportation. Acculturation, they have to adapt to a completely different lifestyle from wearing different clothes to new weather, new food, different languages, different rules. And there are a lot of restrictions on freedom. Very often they're used to play outside until very late at night. And when they come here for different reasons, parents and sponsors don't allow them out much. Very often they're scared of getting in trouble themselves. But if the child gets in trouble out on the street, they're gonna get in trouble. So very often the outings are limited to you go from home to school and from school home and that's it. And this is very different than what you're used to. School, they often arrive with gaps in their schooling. Many stopped going to school in their home country either to avoid being recruited by gangs who are often outside the schools or because they didn't have enough money to attend school because schools are not free in many places. Many sponsors struggle to navigate the educational system here. So it's difficult to guide the child through the system if they don't understand themselves. Once enrolled in school, sometimes they're often wrongfully placed in either lower or higher grades than they should. And sometimes they have to study and work at the same time to repay the debt. So, or they may have unsupportive parents that, or sponsors who don't value education and don't support them going to school, but they have to be in school for their legal case. So many sponsors oblige, allow them to go to school. Isolation, as I said, very often they don't allow them to go out and they spend a lot of time at home alone. Discrimination, including bullying and hostility at school. If they're from an indigenous community or another socially excluded community, sometimes they already come with internalized discrimination and racism and very low self-esteem. And that only adds to the experiences of discrimination and racism that they may find here. Survivors' guilt is not necessarily for those who reunite with the parents, but for the rest. They often feel like they're the only hope of the family and like they are the ones the family back home depends on to send money. And often there's pressure from the family back home to start sending money right away after arrival. And they worry about the family that stayed. And that's, well, what I mentioned before, they have to, they're worried about what they have to, about repaying the debts that was incurred for them coming here. Okay. All apprehended children and adults are placed in proceedings in court to determine whether they can stay in the United States or not. The most common forms of relief are asylum, which is for people who are persecuted, I'm sorry, in their home country on the basis of identity as part of a particular social group. And there's a one year deadline after they arrive to apply for asylum. And there's also something else called CIGS, which is a Special Immigrant Juvenile Status. It's a visa for children who have been abused, abandoned or neglected by one or both parents. We also have the T visa for traffic, for people that have been trafficked to the United States or after they arrived in the United States. And the U visa for victims of crime. They don't have the right to government appointed counsel. So they must represent themselves in court or find an attorney. Finding an attorney and being represented in court tremendously increases their chances of actually obtaining immigration relief. There is a large network of pro bono attorneys, but it's never enough. Like the need is much more than what there is. And the attorneys who do pro bono work often only take the strongest cases. Access to healthcare can be crucial in supporting both a child or an adult immigration case. We as clinicians can uncover and document key medical and mental health evidence. For example, a bullet lodged in the spine or an intellectual disability or gaps in access to care in their home country that would place them in a particular social group. Mental health clinicians can uncover traumas that would make a case stronger. For example, I've had patients that had experiences of racism and discrimination based on their sexual orientation. That is a good basis for asylum. Or I had a patient who had told the attorney about being harassed by gang members, but she hadn't disclosed that she had actually been raped by a gang member. That is extremely important. That is extremely important in an asylum case. And so it is because of this relationship with the medical or mental health providers that many of these important things can come up. We can also enhance the patient's communication with their attorney, improve their ability to testify in court and reduce the risk of retraumatization. I've had many cases in which, because we, especially as mental health providers, we develop a very close relationship. We provide therapy once a week for sometimes years and years. So of course we're gonna develop a much closer relationship with them than that they've developed with their attorney. So we're gonna learn many more things about them than the attorney. And often we help them communicate things to the attorney or with their permission, we may communicate things to the attorney that may be important for their immigration case. It is important that you learn to identify an unaccompanied immigrant child because you may have had them as patients and not even know it. They have unique medical, psychosocial and legal needs, and they can be found in both healthcare and non-healthcare settings. So these are important questions for you to ask someone that you may suspect that maybe an unaccompanied immigrant child or a part of a family unit, you can ask, where were you born? How old were you when you came to the United States? Who were you with? Were you apprehended by immigration patrol? And you should also ask if they have an attorney and if not, do your best to refer them to one. We can talk about that a little bit. Okay, so what do we do with all this information that I just gave you? I'm gonna now talk about the Terrafirma program, the Terrafirma program, which is where I provide services. Terrafirma is a mental health, medical, legal partnership. These are some of our goals. We try to provide, or our goal is to provide a home away from home, a place where patients feel respected, cared for, understood, where they feel that they belong and they matter. We want to improve their overall health and wellbeing. And the way that we do that is through the Terrafirma model. We provide comprehensive primary care. We provide integrated mental health services. I'm gonna talk about that in a second. We provide co-located pro bono legal services. So we're a partner with a nonprofit called Catholic Charities and they provide the legal aspect. When the program was much smaller and before COVID, an attorney from Catholic Charities would come to the clinic on Wednesdays in particular, and he represented many of our patients. Actually, the attorney from Catholic Charities is one of the founders of Terrafirma. And so many of our patients would be represented by him. Because the program has grown so much, we now provide services to patients that are represented by many other attorneys in many other networks and organizations. And the idea of this medical mental health and legal partnership that is all in the same place is because we thought that it is much more likely that if a patient has to go to a medical appointment and to a mental health appointment and to a legal appointment, there are many more chances that they go to those appointments that they make it to those appointments if they have to go to them in the same place. That's why it's so important that it's co-located. We also provide social services and case management from support with college applications to housing issues to during COVID, we continue to distribute food pantry and clothes to another basic needs to hundreds of patients. We provide affidavits and evaluations to help the judge understand, but this is both medical and mental health providers to provide affidavits to help the judge understand who they have in front of them to understand their trauma story. And we provide oral testimony in their cases as well. We have enrichment programming, which we consider a mental health intervention. And this includes things such as tutoring, English classes, soccer, photography, field trips, et cetera. And we do a lot of advocacy. We've presented in front of Congress. We train professionals like this presentation right now. We've collaborated with the ACLU in litigation and we write public comments to propose changes in legislation, et cetera. This is a snapshot of the demographics of our patients, especially of the unaccompanied immigrant children. Most of them are from Honduras, Guatemala and El Salvador, but we also have people from Ecuador, Mexico, West Africa and others. This, so many of our patients are actually primary care naive. They may not have ever been to the doctor, not even when they were born, or they may have gone only in extreme circumstances. So what we do is introduce the concept of medical home. And these are some of the screeners that we use routinely and some of the screeners that we use for new arrivals in particular. We do mental screeners during the medical visits that assess for PTSD and depression and anxiety. And these are resources that the medical providers use in providing care for this population. In terms of mental health, there is very scarce research on their needs, on the mental health needs. But the research that does exist tells us that there's higher exposure to physical and sexual abuse, that there is five times higher prevalence and severity of PTSD, depression and anxiety, and that they have very high levels of functioning. There are no studies on the efficacy of treatments and the social stressors compound trauma. And trauma makes people respond very differently to different scenarios. Providing a trauma-informed care begins with understanding that one, trauma may cause people to react and behave differently. Two, that responses to trauma may range from internalizing to externalizing as seen in the examples in this slide. And three, that these reactions are likely the result of traumatic experiences and a way for patients to cope with their trauma. So it's not that they're being rebellious or it's not that they are just shy. I mean, they may be naturally shy, but it may also be an internalizing reaction to their trauma. And one of the ways that we address trauma is through trauma-informed mental health, individual, family and group psychotherapy. And for groups, we have pre-thing groups, team groups and sponsors groups as well, because we think that in order to better serve the children, we also need to work with the sponsors that are receiving them in their homes. These are some of the common mental health difficulties that we see. PTSD is of course a huge one, complex and developmental trauma, attachment and acculturated stress are important as depression, anxiety, traumatic complaints. And these are some trauma-consistent observations in patients. Issues with trust and attachment are a very important topic in therapy with this population. We see a lot of difficulties with attention and concentration, recall, little or no elaboration of narrative, story may not be organized, the story may not start from the beginning. And so it's important for you to be knowledgeable about this to know that if they're presenting this way, that may be a reflection of trauma. The behavior and the affect may be incongruent with events described. So they may be laughing hysterically when they're sharing something extremely traumatic. And this is also included in the affidavits that we provide because we help the judge understand who they have in front of them better. And so if this is a patient that uses laughter as a coping mechanism, we include that on the affidavit. We may say, you may be asking questions or the patient may be talking about something extremely traumatic, but the person may present as laughing. But that doesn't mean that they didn't endure the trauma or they didn't suffer and continue to suffer from it. Then we also have the behavioral indicators. These are some very basic pointers on how to work with this population. We have to minimize re-traumatization, promote agency and control, focus on their relationship, destigmatize the symptoms. So if they are, you know, if they say that they've been, if they describe, for example, symptoms of depression, normalize depression, normalize those symptoms as reactions to the things that they have lived in the past and destigmatize therapy as much as you can. Congruent services, ask relevant questions sensitively and be patient and empathic. If you're, I mean, this, of course we have limitations in time today, but if your clinical team works with unaccompanied immigrant children or with recently arrived asylum-seeking families and you're interested or feel that it could be helpful to know more about our experience working with them at Terra Firma, please feel free to reach out to me or to my team for a more in-depth training. As I mentioned before, we strongly believe that training other professionals is part of the advocacy that we do. And finally, resilience. I cannot stress this enough. These kids and these families are the most resilient people I have ever met in my life. The theory of the migration of the fetus talks about how the fact that these children and families have made it to the United States as opposed to the ones that didn't leave their country or the ones that didn't make it out alive from the journey is already a reflection of their internal and external resourcefulness. They have a remarkable capacity for resilience and long-term adjustment, and they tend to identify with narratives of strength throughout adversity rather than victimization. So it's just important to keep that in mind when working with this population. Thank you very much. This is Atia Lima. I am working as a consulting psychiatrist on the medical units at Jamaica Hospital, which is located in Queens, New York. My segment of the presentation is a series of cases that exemplifies the challenges of managing immigrant, undocumented, uninsured patients on the CL service. I talk about some of the strategies that we were able to successfully utilize, and I also talk about issues that we are struggling with to hopefully provide some ideas and also to promote some thought as to how we can do things better. Just a quick summary, Jamaica Hospital is a 402-bed nonprofit teaching hospital. It has 120,000 ER visits last year, about 300,000 ambulatory visits over the last year, as well as 2,000 deliveries of babies in our L&D service, just to give you an idea of the scope of the hospital. Our patient population is very diverse, so we have Asian and Latin Americans, patients that are from West Indies and Americans of African descent. The pandemic has really changed the way we provide care at the hospital to begin with at this time, and over the last three months, the entire medical hospital, except for the L&D service, has been converted to COVID-related care. There remains about 25 psychiatric beds that are still open, but they're accessible for COVID-positive patients with psychiatric needs. Our outpatient mental health services have become primarily telepsychiatry, and only high-risk patients and patients on long-acting injectables are being seen in person. The impact of this change is that we are seeing a lot more decompensated patients and they come into the hospital quite sick, and I'm going to go into talking about these issues. And then finally, our detox, our outpatient and patient chemical dependency services have all been closed. So something to mention is that the pandemic has really, really changed the way psychiatry is providing care on the medical service. So the first case I wanna talk about is a complex medical psychiatry case of a 31-year-old male from El Salvador. He was undocumented, uninsured. He had no prior psychiatric or medical history. He was brought in by the police because his family called 911 due to severe aggression, agitation. He was paranoid, he was hypervigilant. He was in RCPEP for about 24 hours and was medicated continuously with Haldol at Event Benadryl, was restrained. And he was noted to have worsening mentation. And at that time he was transferred to medicine and admitted for a full neurologic workup. He underwent an MRI, EEG, and the LP showed that he had anti-NMDA receptor encephalitis. So the medical workup was quite exciting, but really what I wanna point out is the actual management of the patient such as this financially. So patient was given IVIG, five rounds of this, which ran about $10,000, which was covered by emergency Medicaid. The symptoms got better, but there was still some remaining confusion. And I wanted to do rituximab, which is what classically is given at that stage. However, rituximab was too expensive. So we had to resort to cyclophosphamide, which is another immunomodulator. Cyclophosphamide was covered with emergency Medicaid and the patient recovered. So once he recovered, the problem isn't solved because he continues to have needs. He has to have a repeat EEG. He needs neurologic monitoring. He needs psychiatric management for the Zyprexa and Depakote that we started. And he needs general medical follow-up. He is unemployed, has no insurance, is undocumented. So how do we provide for him? So our hospital has a special financial aid program. It is a counselor that the patient meets with, discusses their limited means. And according to however much they can provide, they're put on a sliding scale. And for our patient, this 31-year-old with anti-MDA receptor encephalitis, we were able to have him go to his mental health visits for $5, his general medical follow-up, $5, his neurology visits for $5, his EEG was $10, physical therapy, cyclophosphamide. So we were able to significantly reduce his cost of outpatient care. So where does this funding comes from? Most of it is absorbed by the hospital. Some of it is covered by the state through grants, but Jamaica Hospital is able to provide this amazing service for this very vulnerable population through this means. So the second case I wanted to talk about is a grieving mother. She's a 56-year-old Chinese-speaking woman who came to the hospital because of shortness of breath and because she couldn't cry. The story is that her 18-year-old daughter passed away the day prior at Jamaica Hospital. So the child passed away at home, was brought to the hospital for resuscitation, then passed away at the hospital. The patient went home and then could not sleep. She couldn't, she felt numb, she felt unwell. So she came back to the hospital. So when I met her, I realized that she was in acute shock. And when I called her husband, the husband or the father of the child was crying uncontrollably on the phone. After further interviewing, we found out that they have no social support. They're this small family that immigrated from China. They're unemployed because of the pandemic and they are in this grieving process. So what can we do for a family such as this? So for this particular patient, she was noted to have COVID-related pneumonia as well, but her pneumonia was not so bad that she required hospitalization, which only meant that she would be discharged home with some need for medical, close medical follow-up. Her only support is her husband, who is also not doing very well, emotionally at least. Well, medically, he's doing a little bit better than her. So we resorted to reaching out to Flushing Hospital. They have an outpatient mental health clinic that has a team that is dedicated to Chinese-speaking patients. This team has a social worker, a psychiatrist, and a psychologist that speaks Chinese, and we were able to engage our patient in the emergency room with this team because they were providing these services via telepsych. So much as we suffered from COVID, I think this telepsychiatry option in this particular circumstance really changed the picture. So we were able to engage them with social work who followed them throughout the next few days through phone calls, and this patient ended up following up with Flushing Clinic for her psychiatric as well as psychotherapy needs. Her husband was engaged in psychotherapy as well. Both the patient and her husband qualified for financial aid and the sliding scale payment that I talked about earlier. And finally, the case I wanna talk about is substance use during the pandemic. I think inpatient services are reporting this across the nation that substance use has gone up. And we have this 49-year-old that I saw in the emergency room from Guatemala who recently lost his job because of the pandemic. He was homeless, he was drinking heavily, and he was frequenting our emergency room due to alcohol intoxication. I was consulted to see him because he was having suicidal ideations while he was intoxicated. Once I was able to interview him, I realized how vulnerable he was. He was living alone in America. He was very ashamed of the fact that he didn't have a job and was addicted to alcohol. He did not reach out to his family for support in Guatemala. So he was just suffering alone with this addiction. Because of the addiction, he couldn't find a job and get back on his feet. Of course, he's also undocumented and uninsured. His needs are clear. He needs an inpatient substance use program. He needs to be taken to a place where he doesn't have to be on the street, where he is detoxed properly from alcohol, and he has support. So like I mentioned earlier, all our inpatient services are closed. So the next best option is the outpatient service, which is provided by telepsychiatry. And the patient has no cell phone or a permanent location. So what we tried to do was establish a shelter for him where he would have a landline and the outpatient clinic would call that landline. This option was presented to this patient, but he was not interested in it. And he actually left AMA shortly after. So I point out three cases that were complex in that they had limited resources, we had limited resources, but we were able to somehow find some care for the complex medical case and the culturally specific Chinese speaking family. But for the substance user, I would have to say that we're still struggling to find resources for this community. I really don't have much more to say. I'll end my presentation here. Hi, everyone. My name is Pamela Montano-Arteaga. I work Governing Your Health, that it's a community center from the New York City Public Health System. And we work with a very diverse population that they don't need to have insurance, but we also have people from all the boroughs in New York City. And I'm Director of the Latino Bicultural Clinic there. And the other presenters have done a great job pointing out different issues that the immigrant populations face. But it's very important to know the immigrant population is very diverse, as you know, and there are many different needs. So it's very important for us to know about different resources, how we can help them, and also partner with others. This is just for, I think, for everyone that is an immigrant. And they say moving from where one has lived for a long time to a new place of residence can have destabilizing effects upon the mind. And this will depend on different factors, like at what age do you immigrate? It's not the same like coming to a new country as when you are 60 years old, then you are seven, even though both ages have their different challenges. Also the depth of attachment, like how close were you from your home, how much you are going to miss that area. The degree of choice is very different. So that if you come here, like you want to study, or like you didn't have a choice because you were like fleeing violence or like internal conflicts, as like Brenda have mentioned, or you were like, they threatened like for kidnapping. So you couldn't decide. And also how much time did you have to plan? It's not the same thing, like have years of planning or like, no, we have to go after one month and then you have to separate from your whole family. Also the tolerability of separation. This is a little more interpsychic, like because some people like have different degree of attachment than others, but it's very important to have into account. And also who we are leaving behind. How different are the places? Are you coming from a rural area to an urban area? Do you speak the language, the host country, like how they look like? And also other like socioeconomic factors that will affect the degree of resources that you have. And also the political context is the host country like welcome you. They want you to be here, or they are like you sense like a self-rejection. And I also want to like, because we talk immediately, we always think about like people who are foreign born, but for example, like in U.S. you have people who are from Puerto Rico and they are like U.S. citizens. However, they are so like, especially the ones who are moving from the island to continental U.S., there are many other factors that are playing to a role, even if they have many other resources and legal status. Here, this is just like an overview that we have like different type of course of immigrants and refugees, of course, they're like similar to us at least with a difference that they get the status overseas. So when they come here, they already have all this like established. From the ISILI population, like Brenda already have talk enough. Well, like, no, no, we never will do it, but she'll give a lot of details. Temporary protected status, you should have given to countries after like a disaster or a violence conflict. So, and usually it's temporary, like for some years, like people like after like, I remember the F way in Haiti, they were allowed to come to U.S. So that's another population. Then of course we have the people who come here on different type of visa, work, students. And then we have people who we call like unauthorized or undocumented immigrants. These could be people who later on could become like ISILIs. But also there are many people who, they meet criteria to be ISILIs, but because they didn't know about the resources, they didn't speak the language, the level of education, or they came here many years ago and their case is no longer applicable. They are in this status and sometimes they have the least amount of privileges. The DACA recipients are also like undocumented immigrants, but that they came when they were like younger. And after like the executive order of president of Obama, they were able to get a work permit. But it's also like we saw like in the past few years was also in debate and they also experienced a lot of uncertainty because they practically like felt like they were like Americans, but they were not born here and they have to feel like different, different difficult situations. And this is just to emphasize, for people to come here like an undocumented way or like without a clear legal status, like and look for resources from another country, sometimes it's like the best available solution that they can have. It's like, even if it's just for economic hardship, like it's because they didn't see that they could give their families or themselves like a viable life. And we have really to take into account and that's when we are exploring like their, like what has been their life, their history of trauma and other factors that affect their mental health and general health in general. Another of the issues, I think also Brenda mentioned about this is that also immigrants of color tend to receive like, or be victim more of discrimination. There have been this story of like, there are many like, there are a small population of undocumented immigrants for Ireland, but usually because they look or like what they people sometimes consider like from United States, they usually are not detected by eyes. So there is this also very important factor. And also many of these immigrants and even people who are legally status, especially when like the political context is attacking them, this increase their sense of fear, identity and also not knowing like, or what is going to happen with their lives. Sometimes they have kids who were born here. So we're talking about miss families and they're worried about their kids and their kids are worried about their parents. So all this is something that we as mental health providers or people who want to advocate for this population need to have into account. I put here like feelings of being a second class person. This could be applicable for many immigrants, but also, as I mentioned, Puerto Rico, because for example, people from Puerto Rico, they can no vote for president. So there are many rights when they are in the island. So there are many issues that can also affect as a social determinant, this into that you can have. And also the lack of sense of belonging, depending also on this way, sometimes some groups, they go where other like people like from their own countries they are, because they're trying to look for that community. And yeah, and there are so many factors. So I just want to this slide, just that there are many social determinants of health and mental health, like income, housing, adverse early childhood experiences, but legal status have been proposed like a social determinant, because it really can make a difference on your opportunities and did affect people in all levels, even professionals. This is just an example, like just to describe like how like social determinants can affect this population. This is more focused on Latinos, but we heard like Latinos and other like also minority population, like African-Americans were more affected by COVID. And this was because of many factors. One was because many of them were like essential workers, or they were working for like service industries, like restaurants. So they were exposed to people. And also they didn't have the choice to work remotely. Housing is also an issue. For example, in New York that with rent is so expensive, many of them like live like three people in a room. So, and 10 people in a two bedroom apartment. So this also contributed to the population being more affected, but also we are talking about like that. Sometimes your zip code matters more than genetic upload. So then if you have diabetes or other conditions, and also you are not going to regular healthcare, you also like something like COVID really highlighted the disparities that they had. And also, for example, like I have many of my patients that they were working and they lost their job, but unfortunately they could not receive like a stimulus check or like unemployment aid. And they really face significantly food insecurity, housing insecurity. They know how to go on. In New York City Health and Hospital, we have a program for people who were affected by COVID and they lost their jobs, that at least like $1,000 could be granted to them. But it's still like, there is a lot of population that are still struggling during this time. They were struggling before, but COVID just highlighted so many things. Brenda mentioned a little bit about this type of visa. So many undocumented immigrants are sometimes very afraid to report when they are victims of violence, domestic violence or of assault. But it's very good that we know the system because also like there are, the law can help to improve their quality of life or to empower them. So as Brenda say, like the U visa is for like victim of domestic violence. The WABA is when like they suffer like domestic violence, but they were married to a US citizen. The T visa for victims of human trafficking. So that's where like history taken and also in a cultural sensitive matter, like trying to understand and like gain their trust because sometimes it's very difficult, it's very important. And as we said, like trying to partner with like, enter a firma, they have legal people on site. At Gouverneur, we are lucky that now we have a New York legal assistant group also on site that help us, but not all the organizations have this. So trying to find like what other non-profits like Center for Families, they have. And also I'm living in New York and we need to be aware that I know that our situation sometimes is more privileged compared to other states where people can no access healthcare at all unless they pay out of pocket and they don't have these resources. So the importance of creating collaborative networks with people within your state or other states that just can want to help is very, I think it's a very important message that I want to do here. And Dr. Shapiro that is going to talk about a lot about advocacy, she will refer to this. And this was something that I was mentioning, like the mistrust or like difficult, like, because there have been like, they are not supposed to, someone to go to a hospital, they're not supposed to be deported, but it has happened. So the fear is there. But, and one thing that I just want to emphasize here is the importance of social support. Many of them are sometimes alone. So just trying to like connecting with peers, with community, with church, you provide a social support in terms of your services or like, or trying to reinforce like that resilience is very important. And yeah, like, and we need to, we may look different, we may be from different areas, but we are just a human race, because race is a social construct. So that part of like, we need to help each other and have compassion. Thank you. So hello, everyone. Right now, I'm here to sort of tie things together and let you know ways that you might make a difference for some of the people we've heard about today from all of our great presenters. So really what I'm going to speak about is advocacy for immigrants. And I have nothing to disclose. And so let's speak about advocacy through the APA. I'm the chair of the APA Council on Children, Adolescents and Their Families. And I'm going to let you know some of the ways we have tried to make a difference for our immigrants. So historically, APA puts out position statements. And position statements, you know, for instance, in 2013, we had one on detaining immigrants and mental health. Then when I came on board, which this was, I came on board in May of 18, and the children were separated from their families shortly thereafter. And so we did a position statement on separation of immigrant children and families. And then the ones I'm going to go over with you and show you are all since that time. There was also one by another council on xenophobia, immigration and mental health. So this is what an APA official action position statement looks like. I just wanted you to get a sense of it. And what you do is you first speak about the issues and then you come up with positions. And I really just wanted you to have a sense of what they look like. And this is one of the drafts of the first one we did. So basically this one, for instance, highlighted that no child should be separated forcibly from their parents and that they should be reunified as soon as possible. No child should be displaced, sent back, or retained in a third country, which we know happened, unfortunately. And that, you know, the APA opposed, the APA opposed any kind of policy law or practice that involved prolonged detention and that, you know, all measures need to be taken to ensure the safety and dignity of families fleeing danger. So, so another position statement we did was about the growing fear over coronavirus spread and mental health impact in ICE detention centers. So in this case, you know, basically the APA spoke about how Homeland Security and ICE should release detainees as soon as possible because of coronavirus. We didn't really get heard very well, but we tried. So all these things ended up in press releases from the APA, which is, so the APA sort of creates these position statements, and then it becomes policy, and then they can send out press releases and also recommendations to governmental agencies regarding these issues. So another one we did was one on, you know, what are the rights of immigrant children, adolescents, and their families, and that we recommended that APA have partnerships with immigration agencies to address trauma and give trauma-informed culturally and linguistically and developmentally and structurally competent care for these children and families. So we also had another one on the mental health needs of immigrants and people affected by forced displacement. Okay. And we talked about how, you know, psychiatrists should be involved. And then we also recently had one regarding sexual abuse of migrants in ICE custody, and that we're really concerned about the risk for sexual abuse of migrants and migrant children, and that, you know, we supported measures to be taken to ensure their safety and humane treatment while in custody. So these position statements basically covered access to care for migrants and immigrants, services and screening tools, advocacy, or how to go out there and try to make these problems heard. We spoke about human rights, you know, rhetoric and communication. Like, for instance, when the change of charge rule or the Flores Amendment was being considered, you know, we sent a lot of press releases and sent a lot of communications to clarify what those things were and why it was really important to, you know, uphold the Flores Amendment and the change of charge rule we felt was inhumane and not fair. And, you know, it also had to do with just providing mental health services to immigrants. And it also gave people that are involved in immigrants resources and education. So what can you do to be an advocate for immigrants? Well, all of you belong to a district branch if you're an APA member and you should get in contact with them and make it known that you're interested in helping immigrants. And if you do do asylum evals, it's really useful to let them know because often the district branch is contacted by someone, by lawyers and by the ACLU who need like an immediate, you know, Spanish speaker or Chinese speaker or Mandarin speaker. So being involved in your district branch is important. Also, if you're involved in a political action committee, you can certainly speak and support legislators that are pro-immigration and pro-immigrant rights. And also, you know, through your DB and your states, you can work with lobbyists that work for APA to try to lobby for fair policy for immigrants. So, and so getting involved in advocacy efforts nationally and locally is what, you know, we need to do. You need to, what you, the best thing you can do is to learn to do asylum evals. It's not that hard. It's pretty easy. You can either get a training through Physicians for Human Rights and they have trainings frequently. And I think there's some online now. And we also have an asylum training at this APA meeting and at the ACAP meeting, we kind of focus on generalized asylum evals in the PHR format, but we also sort of focus on children and adolescents and their special needs for asylum evals. And, you know, one thing that I advocate for is I think that we all need to give a little bit of ourselves and work pro bono with immigrants, especially adults, because they're uninsured and they don't have access to even, you know, usually much, many resources for mental health care. Some resources I've listed here, ACLU, the Immigrant Advocacy Network, RAICES, the United Nations, UNICEF and Catholic Charities, the Refugee Agency. And so basically you can make a difference and you can level the playing field if you get involved. And so I think that's a really important thing and you can level the playing field if you get involved. Thank you so much. ♪♪

At-Risk

Integrating Mental Health

Law

Advocacy

Vulnerable Immigrant Populations

Unaccompanied Immigrant Children

Asylum-seeking Families

Terrafirma Program

Comprehensive Care

Trauma-Informed Care

Advocacy Efforts