VALOR: Cultural considerations when assessing Central American immigrant women in behavioral health settings

Abstract

The topic of immigration is timely yet polarizing. By definition, to be an immigrant implies being in a state of transition and transformation. The eventual outcome is likely to be influenced by a series of contextual factors starting in the country of origin, continuing during the migration journey, and culminating in receiving communities. The authors use a fictional case example of a Central American immigrant woman to illustrate VALOR, the Spanish word for courage, as an acronym that identifies five key areas for clinical consideration in behavioral health settings: Values, Arrival in the United States, Losses, Obstacles to care, and Resources. VALOR offers guidance for a culturally informed assessment critical for mental health clinicians. Implications for culturally affirming treatment directions including advocacy, community linkage, and attention to trauma and unresolved grief are woven into the discussion.

Health disparities occur for a wide variety of reasons, among them, providers’ limited experience and/or biases toward culturally diverse patients or clients which impact treatment engagement and outcomes (Soto et al., 2018; Tucker et al., 2011). While personal biases may be difficult to eradicate, for the many providers that have limited experience and a desire to be part of the solution in reducing health disparities, key information can provide support for improving accessibility, acceptability, and effectiveness of behavioral health interventions (Robert Wood Johnson Foundation, 2014). Unfortunately, the amount of information needed to develop a depth of knowledge can be overwhelming and difficult to synthesize. In addition to training and ongoing supervision and consultation opportunities, culturally informed tools can begin to fill a much-needed gap for providers. The American Psychological Association (2017) released 10 guidelines to inform the provision of multiculturally competent practice, research, consultation, and education. The guidelines developed from a shared understanding that all people are embedded in cultural contexts which shape their experiences, and that varied identities intersect (i.e., being a Latina immigrant) resulting in experiences of oppression and unequal treatment that must be identified and recognized. The present manuscript provides a brief and easy to remember acronym that can help providers recall important assessment components when working with Latina immigrant women in behavioral health settings, specifically, female migrants from the Northern Triangle countries of El Salvador, Guatemala, and Honduras. Based on the authors’ collective clinical experiences, and the commonly shared narratives of extreme violence and repeated traumatic exposures among women from El Salvador, Guatemala, and Honduras, the authors created VALOR (Kaltman et al., 2011; United Nations High Commissioner for Refugees [UNHCR], 2015). VALOR is an acronym that identifies five recommended areas of inquiry when working with these women in behavioral health settings: Values, Arrival in the United States, Losses, Obstacles to care, and Resources. These areas were chosen as they represent unique sources of vulnerability and resilience that can both hinder and facilitate treatment. Grief and loss are familiar experiences among immigrant communities, but for some individuals, self-disclosure may be challenging in a new setting. Through the fictional case example of Señora Heredia detailed below, the authors illustrate the application of the VALOR acronym to gather relevant background data that can complement the traditional outpatient clinical assessment.

Case Example

Flor Heredia (Sra. Heredia) is a 41-year-old, single, employed, uninsured immigrant woman from Honduras. She has been in the United States (U.S.) for four years and was recently reunited with her now 15-year-old daughter. In Honduras, Sra. Heredia lived with her three children, who were ages 11, 12, and 18 at the time of her migration. Prior to leaving, Sra. Heredia discussed her departure with her oldest daughter, Reina, who committed to caring for the younger siblings. Sra. Heredia could not cover the expenses of their journey and promised to send for them within one year. This timeline was significantly extended, and two years after Sra. Heredia’s migration, Reina married her long-term boyfriend. Shortly after the wedding, Reina became pregnant. When the baby arrived, Sra. Heredia noticed that Reina was unable to provide sufficient supervision and care to her younger siblings who still needed significant parenting at 13 and 14 years of age. Sra. Heredia doubled her efforts to bring her younger children to the U.S. She was especially worried about her daughters being vulnerable to commercial sexual exploitation, or sex trafficking, a recognized problem in tourist regions of the country.

Sra. Heredia’s migration was characterized by trauma and hardship, and she traveled 2,500 miles by foot to reach the U.S.-Mexico border. She recounts a journey marked by fear of violence, harsh environmental conditions, and uncertainty. She initially paid $7,000 but once she started the journey North, the coyote (i.e., smuggler) demanded $800 more. Women who did not comply were dragged away at night, beaten, and raped. Sra. Heredia gave the coyotes most of the money she had brought with her to avoid this fate.

Upon arriving in the U.S., Sra. Heredia moved in with her cousin, her cousin’s husband, and their two young children. Initially, Sra. Heredia felt welcomed, but her inability to pay rent made her feel guilty and indebted to her hosts. She noticed that her cousin expected her to cook, clean, and provide childcare in exchange for housing. Sra. Heredia did not feel that she could challenge these expectations, and grew resentful of her cousin. Desperate to reunite with her children, she accepted all employment opportunities she could find and soon found herself working multiple jobs. Two years later, Sra. Heredia had saved enough money to pay for her youngest daughter to make the trip northward. Initially, the two were delighted, enjoying each other’s company and catching up in the rare moments that Sra. Heredia was home. But, after two months, her daughter became oppositional, irritable, and isolated. She blamed her mother for “abandoning” her in Honduras, and on one occasion, told her she “hated” her for it.

During a recent medical visit to a local, free primary care clinic, Sra. Heredia shared her distress. Sra. Heredia was suffering from recurrent nightmares, panic attacks, frequent crying spells, and unexplainable somatic symptoms. She hid her symptoms from others and suffered in silence. She became tearful as she expressed sadness and regret for leaving her children in Honduras and guilt for not having enough time for her daughter. Sra. Heredia’s provider suggested she consider a referral to a local outpatient mental health provider, and although hesitant, Sra. Heredia agreed. At the time of admission to the outpatient community mental health clinic, Sra. Heredia shared that “el dolor en mi corazón” (i.e., “the pain in my heart”) grew stronger after learning that her youngest daughter had been sexually abused by a family member in Honduras while separated from her care. Further inquiry of Sra. Heredia’s history revealed early exposure to domestic violence, rape as a teenager, and a long-standing history of intimate partner violence. She had not previously disclosed any of these experiences, and she minimized their impact on her life, saying “las mujeres nacemos para sufrir en mi país” (translates as “women are born to suffer in my country”). She identified prayer and faith in God as her primary sources of support.

Immigration, Gender, and Behavioral Health

Migration from Latin American countries to the United States (U.S.) is a timely and often polarizing topic. This is particularly the case for immigrants who come from the Central American countries of El Salvador, Guatemala, and Honduras. By definition, to be an immigrant implies being in a state of transition and transformation. The eventual outcome is influenced by a series of contextual factors starting in the country of origin, continuing during the journey, and culminating in the response from receiving communities. Due to home country conditions and systemically rooted violence that include rampant acts of violence with impunity, political corruption, inequality, and poverty, women and children from this region remain among the most vulnerable (Hallock et al., 2018).

People of Latinx¹ origin constitute nearly 19% of the nation’s population, with an estimated 86% of Central Americans coming from the Northern Triangle (i.e., El Salvador, Guatemala, and Honduras; Lopez et al., 2021; O’Connor et al., 2019). Furthermore, data from Mexico’s National Migration Institute highlights an increase in the apprehension of female migrants from 13% in fiscal year 2012 to 25% by fiscal year 2017 (Hallock et al., 2018). Among Central American immigrant women² from the Northern Triangle region, gender-based violence, chronic poverty, and collective sociopolitical histories of civil wars that included death squads, disappearances, and massacres of women and children, often intersect with individual experiences of trauma and translate into significant risk factors for psychiatric distress (Aron et al., 1991; Carranza, 2008; Kaltman et al., 2011). Upon arrival in the U.S., these women are often exposed to additional traumatic events (e.g., family separation) which further compromise their physical, emotional, and psychological well-being, sense of safety, and adaptation to a new environment.

For many Central American women fleeing danger, migration to the U.S. represents relief from the fear and daily threat of persecution. Many of them experience pre-migratory trauma in their home country. Mercado and colleagues (2021) documented that 70 percent of recently migrated families reported crime-related trauma and 50 percent reported physical or sexual trauma before arriving to the U.S. Ongoing exposure to acculturative stressors, however, can exacerbate pre-existing emotional distress and manifest as posttraumatic stress (Goodman et al, 2017; Valenzuela et al., 2013). Studies in primary care settings have revealed the high prevalence of trauma exposure among Central Americans, with one study demonstrating that this subgroup was 76% more likely to have experienced a traumatic event than their non-white counterparts (Eisenman et al., 2003; Holman et al., 2000). Not surprisingly, in one study, only 3% of individuals with exposure to political violence ever shared this experience with a healthcare provider (Eisenman et al., 2003). Identifying traumatic life events and assessing their impact are essential to a comprehensive clinical assessment, yet the collective experiences of inequality, marginalization, and insecurity, often remain invisible and unspoken in healthcare settings. For some women, experiences of violence and loss are consistent with culturally and socially tolerated norms. This reality carries significant treatment implications, as limited attention to the context that led to, and perpetuated mistreatment and abuse of women, risks ignoring what has been termed the “enabling context of violence” and an inadvertent labeling of normative responses to extraordinary circumstances (Blanco et al., 2016, p. 187).

Gender-based violence in Latin America has been recognized as a growing epidemic with acts that include childhood abuse and neglect, domestic violence, and femicide. According to the World Health Organization (2012), femicide is the intentional murder of women and girls because of their gender. Data from early 2021 reveal that a femicide occurred in Honduras every thirty-six hours (Bozmoski, 2021). Despite efforts to raise public awareness of this issue and implement systemic change, the risk for continued victimization and the reality of widespread impunity remains (Wilson, 2014). A 2017 study with Central American migrants from El Salvador, Guatemala, and Honduras, arriving at the U.S. border revealed that 83% reported violence as the precipitant to their migration (Keller et al., 2017). Women often flee to seek safety from sexual assault, extortion, and threats against their lives because the social and governmental structures fail to protect them (Obinna, 2021). The risk of sexual violence among migrant women in transit is also significant. It is estimated that 60% of women are vulnerable to sexual assault during their journey, and a 2017 report from Médecins Sans Frontières (MSF) identified gang members and Mexican security forces as perpetrators (Kaltman et al., 2011; Médecins Sans Frontières (MSF), 2017). Interviews with Honduran women who did not successfully reach the U.S., revealed fears of rape and unwanted pregnancy on the migration journey. Consequently, for some families, the incurred cost of migration can be higher for females transported by coyotes who state that they will offer protection from dangers along the route (Sladkova, 2013).

Behavioral health providers with sensitivity to a shared narrative of suffering, loss, and sacrifice can offer hope, promote resilience, and support the identity transition experienced by many Central American women from Northern Triangle countries arriving in the U.S. Recognition and validation of the courage demonstrated by these women serves as an opportunity to highlight strengths that may have been forgotten. Understanding that there will be significant heterogeneity among the women presenting for treatment, two questions with implications for clinical practice emerge:

1. How well do our behavioral health systems recognize and assess vulnerabilities and strengths among Latina immigrants from El Salvador, Guatemala, and Honduras entering our treatment settings?

2. What domains should be included in a culturally affirming assessment with women from Northern Triangle countries?

Based on the literature, historical accounts, and the collective professional experiences of bilingual/bicultural mental health professionals, the authors promote the use of a resilience-focused framework to conceptualize presenting concerns and identify targets for intervention. The authors propose VALOR, the Spanish word for courage, as an acronym that identifies five key areas of inquiry when working with these women: Values, Arrival in the U.S., Losses, Obstacles to care, and Resources. The authors encourage a culturally humble approach that invites curiosity and elicits a client-centered interaction to gather the context surrounding the migration of these women to the U.S.

VALOR Defined

VALOR represents a guide for gathering a culturally informed assessment that invites a discussion of relevant themes in the lives of many Latina immigrants from El Salvador, Guatemala, and Honduras. Literally, the word can mean value, worth, or courage depending on how it is used. The acronym is intended to trigger thoughts of resilience, strength, and fortitude in the face of struggle, challenge, and uncertainty. Working with marginalized communities carries the vulnerability of focusing on deficits, risk factors, and limited resources. The needs of these communities can be overwhelming, and the available options often feel inadequate, and in some cases, inaccessible. While understanding and accurately assessing contextual challenges is critical in the process of understanding the scope of a problem, a focus on strengths provides the fodder for possible solutions and healing. Below we illustrate VALOR through the case of Sra. Heredia. We first identify and offer rationale for the suggested area of inquiry and follow this description with the examples from Sra. Heredia’s case to contextualize her presentation and offer practice implications.

Values.

Cultural values provide direction and meaning, as well as guide thinking patterns, behavior, and decision-making. Prominent Latinx cultural values have been recognized in the literature and often include constructs that influence the development of interpersonal relationships, communication preferences, and identity formation (Adames et al., 2014; Añez et al., 2005). Attention to cultural values and recognition of how these represent sources of strength have been identified as important components of providing behavioral health services to Latinx communities (Lauricella et al., 2021). For providers working with Central American immigrant women from El Salvador, Honduras, and Guatemala, it is expected that sensitivity to the unique factors that have shaped their choices will contribute to creating non-judgmental spaces that invite more open conversation.

In Sra. Heredia’s story we see evidence of familismo (family orientation), fatalismo (fatalism), and marianismo (refers to a traditional gender role for Latin American women; Añez et al., 2005; Castillo et al., 2010). People hold multiple and intersecting values and therefore, while these are not the only values that Sra. Heredia adheres to, the recognition of these and how they influence her worldview and decision-making, is essential to the therapeutic process. Familismo is characterized by placing the family unit at the center of daily life. The well-being of the collective is prioritized over individual needs with elements of mutual responsibility, obligation, and interdependence (Adames et al., 2014; Añez et al., 2005). For women who adhere to the cultural value of familismo, parenting and caregiving responsibilities can buffer stress in challenging times. A study with mothers in Guatemala during the COVID-19 pandemic identified adherence to familismo as a source of strength and resilience amid uncertainty (Gibbons et al., 2021). In Sra. Heredia’s case, we see her decision to separate from her young children and migrate to the U.S. as motivated by a desire to improve her family’s quality of life. Her work ethic is a strength, but also influenced by her commitment to care for her children and reunite with them. Despite the personal perils associated with a dangerous migration journey and the consequences of working tirelessly, she is placing family well-being over individual well-being. Research with Central American mothers who leave their children behind when migrating to the U.S. revealed a changing definition of motherhood to one of the transnational mother who lives and works away from home, leaving children in the care of others, but still providing emotionally and financially (Hondagneu-Sotelo & Avila, 1997).

Fatalismo refers to a belief that life’s circumstances are predestined and may not be fully under one’s control (Añez et al., 2005). Health research with Latinx populations in the U.S. have suggested that fatalistic views are associated with underutilization of medical and psychiatric services. However, structural barriers that include experiences of discrimination in the healthcare setting and lack of health insurance, should also be considered due to the limited access experienced by some Latinx immigrants seeking care in the U.S. (Abraído-Lanza et al., 2007). In the case of Sra. Heredia, her statement that “las mujeres nacemos para sufrir en mi país” (i.e., “women are born to suffer in my country”), reflects a belief that a life of pain and exploitation is simply part of being a woman and something to be tolerated. This hints at an attitude of resignation and acceptance that suffering is inherent to being a woman in her country. Among Latinx populations, the practices of “controlarse (containment of negative affect)” and “aguantarse (the ability to withstand stressful situations)” have been identified as means of coping with adversity that is beyond a person’s control (Añez et al., 2005).

Finally, a culturally and socially accepted message that women should be self-sacrificing, submissive, and humble underlies the value of marianismo. The value is named marianismo after the Virgin Mary and sets a behavioral expectation for girls and adult women that often clashes with Western values of autonomy and self-sufficiency (Castillo et al., 2010). Adherence to marianismo is theorized to include responsibility for the family’s well-being, moral purity and virtuousness, subordination to others, silencing of self to maintain harmony, and spirituality (Da Silva et al., 2021). In situations where women have adhered to a more traditional gender role in their households, the expanded opportunities in the U.S. can result in conflict. Focus groups with women in Honduras revealed a perceived responsibility to change the tide for future generations. Participants expressed a strong desire for their daughters to be treated with respect by their romantic partners, to be empowered in their choices for family planning, and for their sons to be respectful of women (Giordano et al., 2009). In addition, Latina immigrant women in the U.S. often report more egalitarian gender role attitudes than women in the country of origin. The shift has been associated with greater exposure to accepted views on gender equality, acculturation and time in the U.S., and language, as greater English fluency broadens opportunity to engage with more people and be exposed to different views and attitudes on gender (Villalba et al., 2018). Sra. Heredia’s experiences of intimate partner violence and her expectations that her daughter, Reina, would care for her younger siblings, may signify an underlying expectation of self-sacrifice for the benefit of the family unit. In addition, Sra. Heredia’s preference to suffer “in silence” illustrates selflessness and a tendency to carry and manage problems independent of the family to avoid burdening or disturbing the status quo.

Identifying and understanding relevant cultural values is an essential component of culturally informed treatment planning. Western treatment models often prioritize individual needs and encourage self-care as a path towards healing. For Latinas who adhere to the values of familismo and marianismo, focusing on self may directly conflict with the notion of caring for the collective and result in feelings of guilt. In clinical practice, we have found that recognizing the valued roles of mother, sister, and daughter for some Latina women and reflecting on the strengths and vulnerabilities associated with these culturally sanctioned messages offers space to consider behavioral change. Motherhood itself often drives migration with women fleeing to “save their children” (Ricoy et al., 2022, p. 211). As described in the case of Sra. Heredia, caring for a family member’s children while their own children have been left behind may trigger feelings of betrayal. Clinical assessment that is sensitive to this potential dynamic can identify targets for intervention. Acknowledgment of the immigrant woman’s changing identity in the context of a new country and unfamiliar opportunities, and validation for feelings of ambivalence, grief, confusion, and guilt that may arise, are considered key to treatment. For Sra. Heredia, creating a therapeutic space that integrates her two experiences by both honoring her sense of duty to family and feelings of grief, but also highlighting her innate strength and spirit of overcoming as facilitators, may help her recognize the advantages of her migration for both she and her children.

Arrival in the U.S.

Recognition of possible ambivalence surrounding the decision to migrate is essential to culturally competent practice with all immigrant populations. It becomes particularly important in cases where people are forced to flee due to persecution. A desire for survival may have spurred the migration and therefore readiness to leave their home country cannot be assumed. Additionally, the risks endured on the journey such as vulnerability to sexual violence, kidnapping, and human trafficking, may exacerbate feelings of guilt, shame, and hesitation to initiate the migration journey.

When working with Latina immigrants from El Salvador, Honduras, and Guatemala, the impact of family-related separations must be considered. Women who have made the choice to separate from their families of origin, and particularly from their children, have been found to exhibit depressive symptoms and ambivalence associated with their decision (McGuire & Martin, 2007; Miranda et al., 2005). The length of the separation is often underestimated at the outset, and mother-child ties are strained as children are left with other caregivers, form new attachments, and grow up grieving their absent parent (Conway et al., 2020). Regardless of the circumstances surrounding the migration, it is not uncommon for children and adolescents to experience negative feelings associated with the separation from their caregivers and be at increased risk for depression, anxiety, and behavioral problems (Conway et al., 2020; Mitrani et al., 2004). Findings from a study of Latinx immigrant youth (84% of the sample from El Salvador, Guatemala, and Honduras) revealed that immigrant adolescents with experiences of migration-related parent separations were more likely to report poor relationships with their mothers and fathers (Andrew et al., 2020). Consequently, providers are encouraged to inquire about any migration-related separations from children, the duration of the separation, the circumstances surrounding reunification (if applicable), and the perceived quality of the current parent-child relationship. Provider-initiated curiosity about any parent-child separations can inform the clinical conceptualization, uncover relevant goal areas, and minimize feelings of shame and guilt which may accompany the parent’s decision to migrate.

Sra. Heredia’s narrative depicts the challenge and ongoing uncertainty that characterizes the lives of many undocumented immigrants in the U.S. While there may be compelling reasons to leave and initial psychological safety away from a hostile and dangerous environment in the country of origin, the feeling of relief is often short-lived (Hurtado-de-Mendoza et al., 2014). For example, Sra. Heredia began to feel indebted to her cousin for living in her home and an inability to pay rent. She experienced pressure to contribute financially, but also resentment that her cousin expected her to take care of household duties in exchange for shelter. The reunification between Sra. Heredia and her daughter served as another example of the clash between expectations and reality. After a couple of months, the initial happiness and relief was overshadowed by her daughter’s emerging feelings of resentment, anger, and blame. After learning that her daughter was sexually abused during the separation, Sra. Heredia’s feelings of regret were exacerbated, and possibly magnified by traumatic memories of her own sexual abuse history.

Labeling and validating the experience of disillusionment can prove a powerful intervention when working with Latina immigrants from El Salvador, Honduras, and Guatemala. As indicated in the earlier discussion of cultural values, some women may adhere to marianismo and a belief in self-sacrifice. They may prefer an unassertive communication style that limits their comfort in expressing and owning their negative feelings. A tendency to withhold unpleasant feelings can result in emotional distress and has been linked to greater disempowerment, hopelessness, depression, and anxiety (Da Silva et al., 2021). Therefore, therapeutic spaces that allow women to identify, process, and normalize feelings of anger, frustration, disappointment, and resentment are recommended.

Losses.

The process of migration involves loss, grief, and mourning (Espin, 1987). The loss of language, family, friends, food, traditions, and climate is challenging, but can be addressed in a direct and practical manner. These losses are easily recognized by the individual and those around them. The less-visible losses, however, such as status, future potential, and identity, often remain unseen, but can create the most psychological turmoil. Boss (2010) describes the concept of ambiguous loss as a type of partial or incomplete loss that “complicates grief, confuses relationships, and prevents closure” (Boss, 2010, p. 137). In the case of migration, the experience of loss remains unclear and often difficult to accept, as there is a yearning for people, places, and experiences that often still very much exist, but are no longer readily accessible (Falicov, 2002). In addition, unrecognized losses frequently mean reduced access to support.

For Sra. Heredia, migration carried multiple losses including the loss of her role as protector for her children. Her loss of country and separation from her support system are more easily identified. However, the symbolic loss of her identity as a mother and the resulting grief were ignored. When she learned about her daughter’s sexual abuse, Sra. Heredia experienced physical and emotional symptoms associated with her personal and repressed sexual trauma. She was overwhelmed with feelings of guilt and second-guessed her decision to migrate as she wondered if she could have prevented her daughter’s trauma had she stayed in Honduras.

A grief-informed approach is advisable when working with Latina women from El Salvador, Honduras, and Guatemala to support the process of redefining their identity. Clinical assessment and treatment often focus on immediate needs and facilitating adjustment to living in the U.S. While these goals are important, past experiences, including who and what was left behind, and ongoing caregiving responsibilities, demand attention in the therapy room. Migrant women may be preoccupied with thoughts and fantasies of what could have been had they remained in the country of origin. Therefore, a seemingly simple exercise of identifying the losses and gains associated with the migration journey can offer much needed clarity and solace. This exercise offers an opportunity for women to consider the advantages of their decision and the benefits of migration derived for themselves and their family members. Through this process, an initial narrative of abandonment, self-reproach, and shame can broaden to include themes of resilience and courage.

Obstacles to care.

The process of migration has been recognized as a potential risk factor for psychological distress and a social determinant of health, as immigration impacts social positioning and can affect overall health and quality of life (Castañeda et al., 2015). Among undocumented Mexican immigrant adults in California, Garcini and colleagues (2017) found that 23% were at risk for developing mental health disorders. Some studies estimate that over 75% of Latinx immigrant adults report histories of trauma stemming from experiences in their countries of origin, during the migration journey, and after arriving in the U.S. (Cerdeña et al., 2021). Another study found that 50% of undocumented Central American mothers (98% from El Salvador, Guatemala, and Honduras) experienced clinically significant symptoms of depression (Letiecq et al., 2019). Despite the recognized stressors often experienced by Latinx immigrants in the U.S., Latinas are less likely to have access to care or seek it out even when it is available (Hochhausen et al., 2009). When people do seek treatment, it is often in the primary care setting (Letiecq et al., 2019). Financial costs, lack of health insurance, location of services, time lapse between the initial referral and first appointment, and stigma can affect willingness to engage and overall satisfaction with available care (Doshi et al., 2020; Hochhausen et al., 2009). Restrictive immigration policies and fear of detection are additional barriers to health care among undocumented people (Morey, 2018).

Sra. Heredia’s lack of health insurance, social isolation, a demanding work schedule, and unrecognized trauma represented potential obstacles to her mental health and overall wellness. She had internalized her experiences of abuse as something that happens to women (her belief that “women are born to suffer in my country”) and she did not fully appreciate how these experiences had impacted her present-day life. In addition, limited familiarity with mental health treatment and untreated mental health symptoms may have negatively affected her relationship with her daughter and her ability to successfully engage in daily tasks. Trauma exposure among immigrant women from El Salvador, Guatemala, and Honduras may go unnoticed, but it can impair maternal functioning and the ability to meet their children’s socioemotional needs (Letiecq et al., 2019). Consequently, providers in primary care settings are encouraged to be sensitive to screening for mental health symptoms during routine visits, and to be informed about services available and accessible to the undocumented community. Additionally, providers are encouraged to be attentive to the risk for exploitation which may include limited work-related protections and vulnerability to mistreatment and abuse.

Resources.

Recognition of the resilience, fortitude, and determination characteristic of Latina immigrant women are essential. It is not uncommon for people to lose sight of internal sources of strength in the midst of challenging circumstances. Mental health providers often can identify these personal assets and remind people of how far they have come. In addition, the power of social support, in the US and transnationally, cannot be minimized. Migration disrupts a woman’s support networks and often leads to persistent feelings of sadness and loneliness (Casas et al., 2020). The latter is particularly important, as social isolation has been linked to depression and suicidality (De Oliveira et al., 2017; Fortuna et al., 2007).

Social support has been identified as both congruent with the Latinx cultural value of familismo, and essential to overall health and access to necessary resources (Lee et al., 2020). It can prove a protective factor in times of adversity and provide meaning and purpose in times of suffering. Some Latinx immigrants identify faith, or “la Fe,” as critical to their sense of optimism, hope, and perseverance (Lusk et al., 2021). Among Latina immigrant women, positive social relationships have been associated with reduced symptoms of anxiety (Ryan et al., 2021). Given findings that reduced loneliness and increased social support can contribute to greater resilience among Latinx immigrants, interventions that enhance community and promote religious and/or spiritual connection will likely prove beneficial.

Sra. Heredia’s narrative illustrates multiple examples of resilience. She identified her faith and religious beliefs as essential sources of support and used prayer to navigate difficult life circumstances and find meaning. Tireless dedication to reunite with her children and an ability to remain gainfully employed across multiple jobs were evidence of her internal strength. Despite the hardship, her valued role as a mother was a significant source of motivation. Ensuring access to interventions that attend to rebuilding social support networks, including promoting religious connection and spiritual wellness have been recommended as important to posttraumatic growth (Lusk et al., 2021). Posttraumatic growth has been understood as the positive changes that occur in the aftermath of pain, struggle, and stressful life events (Tedeschi & Calhoun, 2004). Taking an inventory of instrumental sources of support in the receiving community as well as the country of origin can offer women hope and reduce loneliness.

Discussion

Central American immigrant women from El Salvador, Guatemala, and Honduras represent an understudied but growing segment of the U.S. population. Despite the divisive impact of an anti-immigrant sentiment, as behavioral health professionals, we can promote an accurate representation of the immigrant narrative that includes the strengths inherent to this community of women. While the lived experience of the Latina woman cannot be generalized and will certainly vary across race, ethnicity, gender identity, sexual orientation, and social class, the egregious human rights violations and growing insecurity in the Central American region affecting this demographic cannot be ignored (UNHCR, 2015). The threats experienced by women and children are maintained by sociopolitical structures which tolerate gender-based physical and psychological acts of violence and deny responsibility for safeguarding the rights of its citizens (Walsh & Menjívar, 2016).

Querying about cultural values, the context of arrival to the U.S., significant losses, obstacles in access to behavioral health care, and sources of resilience are universally recommended for female migrants from any country. VALOR in its presented form has focused on Latina immigrants from the Northern Triangle countries of El Salvador, Guatemala, and Honduras. However, given the unique sociopolitical histories between the U.S. and other Latin American countries that include supporting oppressive governments, controversial foreign policies, and military invasions, querying about (A) arrival in the U.S. and ( R) resources will likely differ depending on a particular country’s historical and present-day relationship with the U.S., and the perceived reception and support of immigrants from that country in the U.S.

For purposes of this manuscript, the focus on Central American immigrants from El Salvador, Guatemala, and Honduras that are women allows for an inherently intersectional analysis (Crenshaw, 1991). A different case study may have highlighted how VALOR can be relevant and useful in the assessment for nonbinary or transgender persons and/or those with a nonheteresexual orientation. Gender identity and sexual orientation are identity contexts that can greatly impact psychological, physical, and emotional well-being. For example, it has been well-documented that sexual minority individuals are vulnerable to violence and exploitation (Latin American Working Group, 2017; Velez et al., 2014). Data for transgender and gender nonconforming persons is sorely lacking at a global level. In addition, the experiences of indigenous and/or Afro-descendant women from the region demands consideration as they are often targeted due to their gender, race, and indigenous background (Obinna, 2021). Afro-Latina migrants are vulnerable to experiences of racism and discrimination in their countries of origin and the U.S. Their experience of navigating environments that promote anti-Blackness or anti-immigrant sentiment pose additional risks that must be considered in the overall assessment process (Sanchez et al., 2019). As behavioral health professionals, our collective call to action includes: (a) recognizing and verbalizing the impact of systemic violence perpetrated against immigrant women; (b) promoting trauma and grief-informed approaches to care; (c) educating Latina immigrant women who have fled experiences of violence that their individual reactions and feelings about what they have endured are valid; and (d) embracing advocacy as a component to our professional identities. Bringing awareness to the challenges facing this community of women both in their country of origin and in the U.S. is a professional imperative, and an opportunity to promote justice and social change.

Clinical impact statement:

This article uses a fictional case example to offer behavioral health clinicians a series of considerations to complement the evaluation and treatment of Central American immigrant women. Attention to experiences before, during, and after migration are highlighted to reflect sources of vulnerability and resilience.