Teaching DBT Skills to DACA Recipients and their Families: Findings from an ECHO Program

Abstract

Deferred Action for Childhood Arrivals (DACA) offers temporary administrative relief from deportation for undocumented immigrant adolescents and young adults who were brought as children to the United States. Accordingly, DACA has contributed to creating a different landscape of opportunities for this group. However, DACA has been and continues to be highly contested in the national political climate. Threats to DACA give rise to considerable anxiety, fear, and distress among its recipients, who face significant barriers to accessing mental health care services. Thus, a group of psychologists partnered with a leading immigrant rights advocacy organization and formed a reciprocal collaboration to understand and meet the mental health needs of undocumented communities. A major focus of the collaboration is to foster learning and support members of the immigrant community in contributing to their own well-being. The collaborative developed and delivered a stand-alone web-based mental health education session to DACA recipients and their families and practitioners serving this population. The session presented the use of dialectical behavioral therapy skills, three emotion regulation and four distress tolerance skills, as a strength-based approach to managing painful emotions and distress. Session content was adapted to include culturally informed examples for each skill. Quantitative and qualitative findings show that those who participated in the web-based program benefited from the education received. Findings also underscored participants’ need for learning culturally sensitive coping strategies for managing stress. We provide recommendations on the delivery of culturally congruent healing interventions for immigrants with a focus on enhancing access among immigrant communities.

On June 15, 2012, the Obama administration issued a memorandum, establishing a federal program known as Deferred Action for Childhood Arrivals (DACA), which benefits young undocumented immigrants (Department of Homeland Security [DHS], 2012). DACA has created a different landscape of opportunities for undocumented adolescents and young adults. The program offers temporary administrative relief from deportation for undocumented immigrant adolescents and young adults who were brought as children to the United States without legal documentation (DHS, 2012). The program allows eligible individuals to obtain Social Security numbers and apply for temporary work permits. It also allows recipients to access other benefits such as healthcare services. As of December 31, 2021, the U.S. Citizenship and Immigration Services (USCIS, 2021) estimated there were approximately 611,470 active DACA recipients. Latinx youth and young adults comprise the overwhelming majority of these, with individuals of Mexican descent constituting the largest proportion and representing about 80% of the total DACA recipients (USCIS, 2021).

DACA has been particularly significant in supporting immigrant youth’s educational pursuits which in turn translates into many long-term benefits (Anaya et al., 2014; Gonzales et al., 2014). Nationally, there are approximately 181,000 DACA-eligible students enrolled in higher education institutions (fwd.us, 2021). Although DACA does not offer a permanent solution, this program has enabled immigrant adolescents and young adults to feel temporarily safe by removing some of the barriers that maintain undocumented immigrants at the margins of society (Alulema, 2019; Nienhusser & Oshio, 2020). Multiple studies have found DACA to have a positive impact on the physical and mental health of its recipients (e.g., Cho, 2019; Gonzales et al., 2014). Cho (2019) found that among DACA recipients, anxiety resulting from the threat of deportation is lessened even though the DACA program does not offer a permanent pathway to citizenship. Nevertheless, a recent report (Latinx Immigrant Health Alliance & United We Dream, 2021) found significant stress tied to documentation status for undocumented and DACA recipients, with over 50% of the sample reporting clinical levels of distress.

Dismantling DACA

DACA has been highly contested in the national political climate. Beginning in June 2015, and as part of his presidential campaign trail, then-candidate Donald Trump promised that he would terminate DACA if elected (Muzaffar & Bolter, 2017). Indeed, on September 5, 2017, the Trump administration announced its plans to officially end the program (DHS, 2017). The announcement resulted in widespread uncertainty and anxiety among the almost 700,000 active DACA recipients and their families (Asad, 2020). DACA had offered hope and the possibility of obtaining legal employment and attaining an education, but with this executive order, the future of this group became uncertain. Since the rescindment of the program in 2017, active DACA recipients have been able to renew their applications after winning a number of lawsuits, but no new DACA applications have been accepted (Krogstad & Gonzalez-Barrera, 2019).

On June 18, 2020, the United States Supreme Court ruled in favor of DACA, asserting that the reasons cited by the Trump administration to dismantle DACA were inadequate, and suggesting that the termination of the program was invalid (DHS, 2020a). This decision should have restored the program in its entirety, including the acceptance of new applications. However, soon after the Supreme Court announced its decision, the Trump administration once again put the future of the program and DACA recipients in jeopardy. On July 28, 2020, President Trump signed a memorandum whose provisions limited the accessibility of DACA (DHS, 2020b). The memorandum mandated USCIS to deny all first-time DACA applications and to reject applications for advanced parole from current DACA recipients except for extraordinary circumstances. In addition, while the memorandum required USCIS to continue accepting and processing DACA renewal and work permit applications, it stipulated that renewals and work permits would be valid for only one year rather than the previous two-year limit (DHS, 2020b). Even though the dismantling of DACA has been challenged by the U.S. Supreme Court, more recently, on July 16, 2021, a Texas Federal Judge ruled to partially end DACA, and mandated USCIS to deny all first-time DACA applications (USCIS, 2021).

Mental Health and DACA

Research has demonstrated that having DACA status results in immediate, short-term improvements in mental health, reducing or eliminating major chronic and anticipatory stressors such as threat of deportation and the inability to lawfully enter the job market (Gonzales et al., 2014; Siemons et al., 2017; Sudhinaraset, To et al., 2017). On the other hand, the stress generated by the continued threats to the program’s existence may outweigh the positive health benefits it initially afforded its recipients. Indeed, findings suggest that the mental health benefits associated with DACA diminished as the future of the program became uncertain (Benuto et al., 2018; Roth 2019; Siemons et al., 2017). Declines in the mental health status among DACA recipients started to become apparent in mid-2015 (Patler et al., 2019). Researchers surmised that such declines corresponded with increased stress due to the feared dismantling of DACA, uncertainty about their future, and apprehension about returning to an undocumented status under the Trump anti-immigrant national political climate (Benuto et al., 2018; Patler et al., 2019). Nevertheless, it is important to note that DACA instability represents only one source of stress for its recipients who are marginalized and face significant additional environmental stressors such as systemic oppression and racial or ethnic discrimination in the United States.

Threats to the DACA program give rise to considerable anxiety, fear, hopelessness, and distress among its recipients and undermine their feelings of being accepted in the only country they have ever known as home. Mallet and Garcia-Bedolla (2019) found that after the announcement of DACA’s termination, DACA recipients exhibited negative mental and physical health outcomes. Based on interviews with Latinx DACA recipients from California, researchers noted that ongoing uncertainty associated with immigration status can result in more unfavorable health outcomes compared to an unchanging undocumented status. Further, most participants interviewed endorsed feeling “extremely sad” or “depressed” since the Trump administration announced that DACA would be dismantled. Similarly, Sudhinaraset, Ling et al. (2017) observed significant mental health issues among DACA participants in their study, with a large proportion reporting either being diagnosed with, or experiencing, symptoms of depression.

Concerns about DACA termination are also practical and social. Amirkhan and Velasco (2019) noted that DACA recipients worried about potentially losing their financial aid, employment, and access to health services if they were to lose the protection afforded by the program. DACA recipients felt apprehensive about disclosing personal information and their family’s undocumented status to USCIS in their DACA applications (Amirkhan & Velasco, 2019), while also expressing concern for their parents (Terrazas et al., 2020). Though DACA offers provisional protection to its recipients, the program leaves out parents and other family members, creating division within the undocumented population and mixed-status families. Another drawback of DACA is the financial burden of renewal fees it puts on its beneficiaries (Lauby, 2018). Overall, DACA recipients are particularly vulnerable to stress overload.

Access to Treatment

Studies have found that Latinx DACA recipients continue to face barriers to accessing health and mental health care services (Siemons et al., 2017). Barriers include lack of culturally responsive and bilingual health providers, as well as limited financial resources to afford medical care (Raymond-Flesch et al., 2014). Moreover, despite having health insurance and active DACA status, some DACA recipients may avoid health care facilities due to fear and lack of trust (Mallet & Garcia-Bedolla, 2019). In 2020, mistrust heightened as it became publicly known that the Office of Refugee Resettlement had been sharing confidential psychotherapy notes with U.S. Immigration and Customs Enforcement resulting in the denial of asylum to some immigrant youth (APA, 2020). Findings highlight the urgent need to implement programs and interventions that can redress the breach of trust and address the unique needs of DACA recipients and their families.

Reciprocal Collaboration

In response to the ongoing stressors and systemic barriers faced by DACA recipients and undocumented immigrants, a group of Latinx psychologist and an immigrant organization came together to collaborate to understand and meet the community’s mental health needs. The Latinx Immigrant Health Alliance (LIHA) is comprised by a group of psychologists that are actively involved in service delivery, education, and research to meet the mental health needs of immigrants, and most of whom identify as immigrants themselves. United We Dream (UWD) is the largest immigrant youth-led organization in the country and has as its core mission the advancement of immigrant rights through community organizing and policy advocacy (unitedwedream.org). The main goal of this reciprocal collaboration was to support UWD’s UndocuHealth program, which seeks to meet the growing health and psychological needs among undocumented communities in the United States. On the other hand, LIHA benefits from engaging in intervention research seeking to understand the experiences of the immigrant community, with the purpose of informing research, practice, and advocacy.

In line with the collaboration’s objectives, a three-part web-based mental health education and skills-building series was designed and delivered to the community stakeholders and practitioners serving this community. This training program was launched using the Extension for Community Healthcare Outcomes (ECHO) telementoring platform which is was developed to reduce health disparities in rural communities (Arora, 2008) and is commonly used for both healthcare service delivery or knowledge sharing in training programs. The first two stand-alone sessions focused on the development and value of support networks for emotional wellness and intergenerational differences among immigrant families. Presenters included psychologists who summarized findings from the literature and applied evidence-based practices to create practical guidelines; advocates with lived experiences as immigrants and professionals; and immigrant activist youth with real-life case illustrations reflecting the various challenges faced by the community. Following the initial sessions, participants requested strategies to manage daily stressors, and this led to the creation of a single stand-alone tele-mentoring session based on principles from Dialectical Behavior Therapy (DBT; Linehan et al., 1991). The primary goals of this session were to increase awareness, knowledge, and motivation to implement such DBT skills. Additionally, facilitators leading this session chose to conduct a exploratory study measuring increased knowledge following participation in the web-based mental health education and skills-building session and feasibility of this delivery modality.

Everyday Life Skills and Dialectical Behavioral Therapy

Painful emotions and distress can occur when we feel overwhelmed with current circumstances or when stability is threatened as in the case for many DACA recipients and their families. Thus, the immigrant community may particularly benefit from learning and practicing everyday life skills as these can help build resilience against negative emotions and experiences. Everyday life skills strengthen a person’s abilities to cope with daily stressors, to tolerate ambiguity, and to rest the mind, body, and spirit. These strategies are anchored in DBT.

Dialectical behavior therapy is based on cognitive-behavioral therapy and was originally developed by Marsha Linehan (Linehan et al., 1991). DBT represents a holistic approach to mental health, incorporating the mind, body, spirit, thoughts, and emotions. DBT skills are intended to improve functioning and focus on four distinct skills: (a) distress tolerance, (b) emotion regulation, (c) mindfulness, and (d) interpersonal effectiveness (Linehan, 2014). The modular and principle-based nature of DBT allows for flexibility in treatment approach. Components can be added or removed depending on the specific needs of each client and context (Linehan, 2014).

DBT has been found effective in treating various mental health concerns such as substance use disorders, eating disorders, major depressive disorders, anxiety disorders, and bipolar disorders (e.g., Cisler et al., 2010; Courbasson et al., 2012; Linehan, 2014; Van Dijk et al., 2013). While DBT has also been recommended for use with immigrants in detention given the invalidating environment often experienced by individuals in these highly restrictive settings (Brooker et al., 2016), the great majority of the research examining the effectiveness of DBT has been conducted in Western countries with predominantly White samples composed of individuals from European-American and middle-class backgrounds.

The current lack of outcome studies including diverse samples clearly limits inferences about the validity and utility of DBT with racial, ethnic, and cultural minority groups. Moreover, empirically supported treatments like DBT may be not be suited for use with culturally diverse clients because of the potential mismatch in cultural values, particularly pertaining to their identity, interpersonal relations, family dynamics, emotion expression, and conceptualization of mental health and healing (Wendt et al., 2015). The need for culture sensitive adaptations of DBT skills is therefore evident. Clinicians ought to modify DBT skills to make them more culturally congruent for culturally diverse clients while preserving the authenticity of the treatment (Domenech Rodriguez et al., 2012) and keeping in mind that variations occur within cultural subgroups.

Although rather limited, there have been some efforts to develop cultural adaptations of DBT to be implemented with ethnically diverse individuals. For example, Mercado and Hinojosa (2017) explored a culturally adapted DBT skills training program delivered in Spanish for Latinx individuals in an outpatient community mental health setting in a predominantly Mexican American community. This culturally modified DBT intervention integrated several Latinx cultural values, including familismo (familism), personalismo (personalism), fatalismo (fatalism), and respeto (respect) thus furthering DBT’s intervention efficacy. The case study findings suggested that culturally responsive DBT skills can decrease symptoms of depression.

DBT Skills for DACA Recipients

Emotions felt by DACA recipients are valid and justified. The continued threats to DACA along with the new hurdles for renewing DACA status represent very real sources of emotional vulnerability among DACA recipients. The stress is compounded by constant exposure to anti-immigrant rhetoric which compromises an overall sense of belonging. Consequently, it is anticipated that DACA youth and young adults may benefit from acquiring skills to strengthen their emotional armor against negative experiences, feelings of rejection, and painful emotions.

DBT skills drawn from the emotion regulation and distress tolerance modules were selected to teach everyday life skills to DACA recipients. Emotional regulation skills include strategies to reduce emotional vulnerability and how to reduce emotional suffering (Linehan, 2014). Distress tolerance skill are often short-term responses designed to help people navigate difficult experiences where they may feel out of control. The goal is to get through the immediate moment and avoid feeling worse. Even though DACA recipients encompass a wide range of cultures and diverse backgrounds, Latinx youth and young adults comprise the overwhelming majority of DACA recipients. Thus, the session focused on presenting DBT skills adapted to include culturally informed examples relevant to the Latinx culture while being sensitive to individual differences (see Table 1 for skills examples).

Table 1.

DBT Skills: General Definitions, Rationale, and Culturally Sensitive Examples

Skill	General definition	Rationale for use	Example
Building mastery	Offers an opportunity to experience a sense of accomplishment and achievement.	Restrictive policies may limit opportunities and contribute to feelings of helplessness.	Signing up for a class or volunteering at a community event
Taking care of the mind	Helps to take care of one’s body as a way to increase emotional resilience.	An out-of-balance body increases vulnerability to negative emotions.	Achieving a balanced diet by obtaining healthy food items from a local food bank
Self-soothing skills	Refers to being comforting, nurturing, gentle, and mindfully kind to oneself.	Anti-immigrant rhetoric may lead to distressful feelings and poor self-concept.	Engaging the sense of taste by eating some traditional foods
Radical acceptance	Involves acknowledging situations which cannot be changed as they are transpiring and letting go of a fight with reality.	Sometimes painful situations cannot be modified immediately or ever. For example, fighting for immigration policies changes is not always successful.	Using dichos, or traditional sayings such as “que sea lo que Dios quiera” (“it’s in God’s hands”) to help to reach acceptance
Improve the moment	Replaces immediate negative events with more positive ones by making the moment more positive and easier to tolerate.	Particularly useful when one is feeling overwhelmed due to a stressful situation that may be long-lasting such as facing the impending deportation of a loved one.	Finding or creating meaning based on one’s spiritual beliefs (i.e., prayer) or visualizing the support of family and friends during a difficult moment
Distracting with wise mind ACCEPTS	Offers distraction from a problem that cannot be solved immediately, and urgency to solve the problem in the moment is making it very difficult to focus on anything except the crisis.	When emotional pain becomes so great that one is in danger of being overwhelmed by it, it may be more effective to distract oneself from the feelings in the moment instead of fully experiencing them.	Singing a traditional song in one’s head, this can be a song that reminds one of home

Emotion Regulation Skills

Emotion regulation skills are optimally taught in a context of emotional self-validation (Linehan, 2014). This consideration is particularly important when working with immigrant populations as these groups are routinely invalidated by their environment. We believe that the emotional distress experienced by DACA recipients and their families is a result of secondary responses (e.g., intense shame, anxiety, or rage) to primary emotions which are appropriate to the context. Another important consideration to keep in mind when teaching emotional regulation skills to DACA recipients from Latinx backgrounds is that among some Latinx groups individuals experience emotions at a deep level. For some of these individuals, high emotional sensitivity and/or intensity is culturally acceptable; thus, it is important to teach participants clear distinctions between varying degrees of emotions without pathologizing or shaming (Mercado & Hinojosa, 2017).

Building mastery and learning to cope ahead.

This set of skills comprises two strategies. The first strategy consists of engaging in activities that build a sense of self-efficacy, self-control, and competence. Feeling competent and adequately prepared for difficult situations reduces vulnerability to negative and painful emotions. Participants were reminded that even when feeling helpless in the midst of the current political climate, they can build a sense of mastery by participating in activities such as volunteer work or becoming involved in activism in their communities. The second strategy focuses on learning to cope ahead of time with expected difficulties through imagining that one is in the situation and coping effectively. As an example, participants were advised they could come up with a step by step plan in case a family member is detained by immigration or faces deportation.

Taking care of the body (PLEASE skills).

An out-of-balance body increases vulnerability to negative emotions. The healthier a person can become, the more effective they will be in regulating emotions. PLEASE skills highlight the importance of balancing nutrition and eating, getting an adequate amount of sleep, exercising regularly, treating physical illness, and avoiding non-prescribed mood-altering drugs or misusing prescribed medications. Culturally relevant examples were provided for each of these areas. It was also pointed out that although poverty can certainly hinder a person’s ability to access certain resources, such as balanced nutrition and health care, mental health professionals can point out community resources that may be able to facilitate access (i.e., community gardens and free or reduced fee community health clinics). Participants were also reminded that a healthy diet does not have to be restricted to American foods; instead a nutritious diet can incorporate healthy versions of traditional dishes from Latin American countries.

Distress Tolerance Skills

By practicing everyday life skills, DACA recipients and their families can prepare themselves to be effective and mobilize when crises occur. For this community, the reality of unpredictable circumstances and a sense of constant threat predispose people to experiencing repeated crises. For example, in many families with DACA recipients, parents and ineligible siblings or other family members are at high risk of being deported (DHS, 2012). When an actual deportation of a loved one takes place, this creates a transnational family separation. Indeed, many mixed-status families find themselves not only having to live away from their extended families but also being separated from their parents and siblings, split between the United States and their country of origin. For such moments of crisis, distress tolerance skills can help individuals tolerate the situation without making things worse (Linehan, 2014). These skills also teach people how to accept and fully enter a life that may not be the life they hoped for or wanted (Linehan, 2014). Distress tolerance skills underscore the benefits of learning to bear pain in a skillful manner.

Distracting with wise mind ACCEPTS.

Distracting strategies work by reducing contact with emotional stimuli or with the most painful parts of the stimuli. When emotional pain intensifies and begins to affect productivity at work or school, it may be effective to distract oneself from the feelings in the moment instead of fully experiencing them. One can also use distraction when a problem occurs that cannot be solved immediately, and urgency to solve the problem in the moment is making it very difficult to focus on anything except the crisis. There are seven sets of distracting strategies: (a) engaging in activities that are neutral or opposite to negative emotions, (b) contributing to somebody else’s well-being as this refocuses attention from oneself to others, (c) making comparisons since this also refocuses attention from oneself to others, (d) generating different emotions which may distract from the current situation and negative emotions, (e) pushing away from a painful situation which can be done by leaving it physically or by blocking it from one’s mind, (f) distracting with other thoughts, and (g) experiencing intense sensations which can focus attention on something other than the emotional distress. A few examples of distracting strategies provided included dancing to rhythms of one’s home country, watching a TV show or movie with a Spanish-speaking cast, cooking a traditional dish from one’s home country, or singing a meaningful song in the language one speaks at home.

Self-soothing.

Self-soothing refers to being comforting, nurturing, peacemaking, gentle, and mindfully kind to oneself. Self-soothing activities reduce vulnerability to painful emotions and impulsivity. These skills help people tolerate pain and distress without making things worse. Self-soothing strategies engage the five senses: vision, hearing, smell, taste, and touch. Individuals are encouraged to engage their senses in a way that fits them appropriately. For example, DACA recipients may engage the sense of taste by eating some traditional foods or the sense of smell by sniffing scents that remind them of home.

Improving the moment.

Improving the moment is particularly useful when a person is feeling overwhelmed due to a stressful situation that may be long-lasting such as facing the impending deportation of a loved one, or when distracting activities and self-soothing are not working. Improving the moment is replacing immediate negative events with more positive ones by making the moment more positive and easier to tolerate. Improving the quality of the moment can be accomplished through the use imagery, finding or creating meaning, prayer, relaxation, doing one thing at a time, taking a time out to regroup, and providing encouragement or cheerleading oneself. Participants were provided with different culturally relevant examples for each skills such visualizing the support of family and friends during a difficult moment and finding or creating meaning based on one’s spiritual beliefs (i.e., prayer).

Radical acceptance.

Radical acceptance refers to the complete and total acceptance of reality. The goal of acceptance is to reduce suffering when painful situations cannot be modified immediately or ever. For example, fighting for immigration policies changes is not always successful. By engaging in radical acceptance, the person suffering can take a proactive and effective approach to overcoming a crisis. The concept of radical acceptance was adapted to incorporate familismo and family unity. In addition, spirituality and traditional beliefs were also incorporated to drive the concept of radical acceptance home. To this end, group members were taught to use phrases such as “it is what it is” or “it’s in God’s hands” (or “Que sea lo que Dios quiera” for bilingual participants) as a reminder to practice radical acceptance. The latter is a popular phrase among some Latinx that reflects the commonly held cultural belief of fatalismo (fatalism), the belief that life is not under one’s control (Mercado & Hinojosa, 2017).

Method

Participants

Eighty-two individuals joined this telementoring discussion session. Among these were the moderator, the guest panelists, psychologists from the Latinx Immigrant Health Alliance who have expertise working with the target population, psychologists and members of state and national professional psychological associations, advocacy leaders from UWD, and technical support personnel. Even though participation was open, the target audiences were DACA recipients, undocumented individuals, community leaders and organizers that work with undocumented immigrants, and mental health providers who serve this community. At the outset of the webinar, a total of 34 attendees completed the pre-assessment measures. At the end of the webinar, 10 attendees completed the post-assessment measures.

Procedures

The telementoring discussion session titled, “Strengthening Everyday Life Skills of DACA Recipients and Mixed-Status Families to Heal from Painful Emotions and Distress” was held on Thursday, August 27^th, 2020. The session was delivered via the ECHO platform. This was the third stand-alone ECHO session in the ECHO Series titled: Building resilience of DACA recipients and mixed-status families in the face of adversity: An ECHO Program. ECHO sessions are conducted in English on the Zoom web-based platform. During the session, teams of experts and community partners facilitate virtual discussions with the goal of delivering education and relevant resources to traditionally underserved groups.

The format of this ECHO session included a discussion of community agreements or expectations for communication and conduct during the sessions, a brief didactic presentation about the relevance of Everyday Life Skills to heal from painful emotions and distress based on evidence-based data, the presentation of a case study to highlight the psychosocial needs of DACA recipients, an open forum discussion about how to strengthen everyday life skills for this population, and a summary of recommendations and resources to be produced as deliverables. Information generated from this ECHO session, including the live discussion and chat transcript, was used to develop culturally sensitive resources that were distributed among providers and community members, and shared online via collaborating organizations. The information presented in these resources was synthesized and organized by an expert team of psychologists and integrated with feedback provided by UWD representatives.

Participants were recruited to attend the ECHO session by UWD. Invitations were disseminated to all members by email, mass text messages, and social media. In addition, a flyer invitation was shared among psychology networks, including listservs of multiple divisions of the American Psychological Association, National Latinx Psychological Association, and state psychological associations. Participation in the ECHO session was free but required pre-registration and access to basic audiovisual capability, such as a laptop, computer, or smart phone with internet access. Participants had the opportunity to remain off camera or use their first name only to protect their confidentiality. The ECHO session lasted 75 min, including the pre- and post-session evaluation. Evaluation activities were administered by UWD, and data were analyzed and summarized by the Latinx Immigrant Health Alliance partners. All materials related to this webinar can be found on the Open Science Framework at: https://osf.io/8dyw5/

Measures and Sources of Data

Pre- and Post-Assessment Surveys

Participants completed brief and anonymous pre- and post- online surveys to measure the effectiveness of the ECHO session on participants’ knowledge and perceived self-efficacy for mastering the session content. Pre- and post- surveys assessed participant understanding of barriers and facilitators to strengthening everyday life skills (Tables 2). The surveys also included a 5-item scale to measure change in perceived self-efficacy based on the session learning objectives. A modified version of a measure used to assess changes in competency because of training among medical professionals in healthcare settings was selected. The scale rendered a total score denoting overall change in perceived self-efficacy, as well as an individual score denoting changes in perceived self-efficacy for each of the learning objectives of the session. Participants responded on a scale ranging from 0 (not at all) to 7 (extremely), where higher scores reflected higher perceived self-efficacy. We report descriptive data (e.g., M, SD, ranges) on evaluation items tied to specific presentation/discussion goals at the outset and completion of the session. Paired-sampled t tests for pre-post items were performed to examine the statistical significance (i.e., p value) as well as the clinical significance (i.e., Cohen’s d).

Table 2.

Pre- and Post-Session Survey Comparisons for the Key Evaluation Items.

	T1 M	T1 SD	T2 M	T2 SD	t	df	p	Cohen’s d a
I have a clear understanding of the importance for building resistance against negative emotions and experiences.	5.86	0.69	6.29	0.49	−2.12	6	.078	−0.56
I have a clear understanding of the difference between skills to reduce emotional pain and skills to tolerate pain skillfully.	4.71	1.60	6.14	0.69	−2.97	6	.025	−1.33
I am confident in my ability to effectively identify skills to reduce emotional pain and tolerate pain skillfully.	4.57	1.40	5.71	1.11	−2.83	6	.030	−1.02

Chat Room Data

During the ECHO session, participants had access to the Zoom chat function to share real-time reactions and feedback. Chat room transcripts are a useful source of qualitative data (Robinson, 2001). Many participants used the chat room to express their thoughts, and the resulting transcript complemented the quantitative data collected through the session. The chat room transcript was analyzed by two independent, bilingual researchers starting with development of domains, or broad thematic areas of interest (Hill et al., 1997). Independently, and keeping in mind the study goal of meeting the growing psychological needs among undocumented communities, the two members of the analysis team reviewed the chat room transcripts before sharing their coding. After this step was completed, the analysis team convened to discuss emergent topics of interest to ensure that they accurately described the data. During this meeting, the analysis team also developed a list of core ideas, or specific topics of interest within the existing domains. To increase validity, any coding discrepancies were evaluated through discussion between the two researchers before a final coding decision was made. Core ideas were audited to avoid redundancies and excessive specificity. Totals within each domain were tallied and illustrations were provided to deepen the understanding of each domain.

Results

Pre- and Post-Session Survey

Pre-session survey mean ratings for the key evaluation items (see Table 2) were on the mid-point of the 7-point scale, suggesting there was some room to improve on knowledge and skills to reduce emotional pain and tolerate pain more effectively. Post-session survey mean ratings for the key items were at the high end of the scale reflecting improved knowledge and understanding after the ECHO session.

On the post-test, participants provided feedback on the webinar. On the item “Were your training or learning expectations for this workshop session fulfilled?” eight participants said “yes” and two did not provide a response. Additionally, participants rated the perceived value of the workshop with the following question “How would you rate this workshop or training sessions?” using a scale from 1 = not helpful to 7 = extremely helpful. In this regard, participants provided very high ratings (M = 6.6, SD = 0.70). When asked “Would you be interested in attending additional workshops or sessions related to the health needs of immigrant families?” all participants (n = 10) responded “yes.” Participants were also asked about their willingness to recommend this workshop to others. When asked “Would you recommend this workshop to others providing services or leadership to DACA recipients?” nine participants said “yes”, and one did not provide a response. One open-ended item asked participants: “Do you have any suggestions or comments that would make this workshop better? (Please describe).” Only three participants offered a response to this item and all focused on expressing gratitude (e.g., I’m glad I was able to hear different perspectives; Great work!).

Of the people that participated in the webinar, 34 attendees completed the pre-assessment measures and 10 completed the post-assessment measures. However, only seven provided both start-of-webinar and end-of-webinar data, allowing for comparisons between pre- and post-webinar scores. Specific means, standard deviations, t statistics, and statistical significance are found on Table 2. There was statistically significant movement on all items but the first one (see Table 2). The effect size for the first item is considered “medium” and for the next two items, it is considered “large.” The first item had the highest pre-session mean, signalizing that these attendees already understood the importance of building resistance against negative emotions and experiences.

Chat Room Data

In total, 77 participant comments were coded. Comments from panelists and team members were not included. The major domains that emerged were: (a) coping, (b) stress, and (c) gratitude (see Table 3). The coping domain encompasses the core ideas of coping strategies, community, and learning. Most comments in the chat room were within this domain (43%) and most were comments on the coping strategies participants currently practice. One particular comment that stood out was “I feel fairly comfortable coping with most stress- thru exercise and reflection. But there are times when stress can get overwhelming, and I need to do something different or more than my regular practice.” This comment highlighted the necessity for learning additional coping strategies for managing stress. The second most common domain was gratitude (30%) which referred to comments expressing how appreciative participants were for the session. As for stress, 27% of comments were related to stressors and barriers. One participant mentioned “Definitely feeling the anxiety from the upcoming elections.” This comment, among others, revealed the current stressors impacting the mental well-being of the undocumented community.

Table 3.

Qualitative Results.

Theme	Subtheme	Frequency	Percent
Coping		33	43%
	Coping strategies	23	30%
	Community	7	9%
	Learning	3	4%
Gratitude		23	30%
	Gratitude for sharing	23	30%
Stress		21	27%
	Stressors	8	10%
	Barriers	12	17%

Discussion

Responding to the complex mental health and social needs of undocumented communities amid a wave of anti-immigrant policies, a group of psychologists and an immigrant organization joined in a reciprocal collaboration to address the mental health needs of immigrants in the country. In addition to other projects, collaborative efforts resulted in the delivery of a single stand-alone web-based mental health telementoring session for DACA recipients, community leaders, and mental health providers to learn about skills to cope with painful emotions and tolerate pain based on principles from DBT. The goal of DBT skills is to reduce the experience of emotional pain (Linehan et al., 1991). However, it should be noted that the empirical support of DBT efficacy and effectiveness and its many successful adaptations for different psychological dysfunctions is primarily based on DBT outcome studies conducted with overwhelmingly White samples with few trials including culturally diverse samples.

In the recent years, culture sensitive DBT approaches have started to emerge along with studies evaluating their outcomes with culturally diverse samples in the United States (e.g., Mercado & Hinojosa, 2017). Mercado and Hinojosa (2017) assert that cultural adaptation of DBT skills training protocol is warranted for the enhanced treatment of the Latinx population in the United States and can result in reduced clinical symptoms and an increase in coping skills. Thus, this mental health telementoring session, which was delivered using the ECHO framework, focused on presenting DBT skills adapted to include culturally informed examples relevant to the Latinx culture while being sensitive to individual differences.

Findings from this exploratory project show that this stand-alone web-based mental health telementoring session was beneficial, validating, and informative to those who attended as evidenced by pre- and post-assessments and the qualitative data (i.e., chat-room data). In particular, quantitative data reveals a clear increase in perception of increased knowledge among participants. Analyses from the data, particularly qualitative data, also explain just how important and valuable coping strategies can be for undocumented communities to manage painful emotions and tolerate uncertainty such as the future of DACA, as many young adults and their family members often live in a chronic state of uncertainty. An unknown outcome challenges a person’s ability to plan for the long-term and can lead to heightened feelings of stress, anxiety, and fear. Young adulthood is a time of establishing a sense of identity and belonging, and among DACA recipients, their precarious status represents a vulnerability to this task.

Similar promising outcomes were observed following the delivery of the first stand-alone session of this skills-building series. Data from the first session showed that this form of reciprocal collaboration was beneficial for participants as reflected by pre- and post-assessments as well as from qualitative data (Morales et al., 2022). Moreover, our qualitative findings are consistent with research that web-based community interventions foster social support and social identification (Kolawole, 2019). Of significance, our qualitative findings add to the literature on how to build on the strengths of undocumented immigrants during a politically charged climate. Specifically, the web-based skills program implemented aligns with research on the effectiveness of web-based skills programs in the reduction of trauma symptoms as well as improvement in emotion regulation skills for individuals with a history of trauma (Stappenbeck et al., 2021). Finally, the discussed program calls attention to the need for new theoretical models of digital community healing spaces and interventions for vulnerable populations.

Clinical Implications

The accessibility of coping skills in times of uncertainty is essential to fostering resilience against the negative mental health consequences of anti-immigrant legislation and rhetoric. Indeed, research supports the notion that the disproportionate effects of anti-immigrant rhetoric and legislation on the mental health of immigrant communities are mitigated in the presence of strengths and coping strategies (Kam et al., 2021; Moreno et al., 2020). Emotion regulation and distress tolerance skills have been found to be effective in the reduction of negative emotions and increase in ability to cope with stressful life events; however, access to effective emotion regulation and distress tolerance skills has not always been available to vulnerable populations who need them the most. With the appropriate training and support in the delivery of web-based services, mental health professionals are in a position to teach culturally sensitive coping skills and resources to address the mental health needs of undocumented communities.

The need for culturally congruent healing interventions that are strengths-based, accessible, and safe for priority populations, in this case undocumented communities, have encouraged mental health care professionals to explore non-traditional approaches (i.e., web-based) and dissemination of mental health related information (Dominguez-Rodriguez et al., 2020; Seven et al., 2021). Web-based mental health programs that foster a sense of community, validation of lived experience, and empowerment have shown to be beneficial to vulnerable communities (Morales et al., 2022). The implemented web-based mental health program was intended to teach skills to empower communities to cope and heal from stressors, offer a supportive and validating environment, and provide resources to support learning, growth and resilience. Additionally, practical guidance on defining the overall purpose and adapting content of skill building programs was an anticipated deliverable from the ECHO session and resulted in a Spanish and English resource sheet for the community (see Table 1 for culturally sensitive coping skills examples).

Limitations

The present exploratory study has several important limitations that should be taken into account when considering the preliminary findings discussed. First, the number of participants who completed both the pre- and post-assessments was extremely small. While eighty-two individuals joined the telementoring session, only seven provided both start-of-webinar and end-of-webinar data which significantly limits the strength of the comparison analyses presented here. Although attrition almost always happens to some extent, it was much higher than what we would have anticipated for this particular study. Different factors could have contributed to the attrition observed, including having to leave the session early due to time constrains or other commitments and poor internet connectivity. Nevertheless, a better understanding of the motives for participation attrition is still much needed as this information would be useful in developing effective retention strategies for future ECHO sessions.

Second, the post-assessments were administered immediately after the delivery of the coping skills and information on resources that promote strengths and resilience suggesting improved knowledge and understanding of skills; however, no follow-up survey was conducted to assess knowledge retention and actual implementation of skills in everyday life. Although the session was rich in content, the format of a one-time didactic offering, a large number of participants, and the brief duration limited the opportunity for participants to engage in meaningful and supervised practice beyond the session. This setup greatly limits what can be inferred about participants’ growth. Third, even though the team made a thorough effort to culturally adapt each of the DBT skills presented, these efforts may not have fully taken into account the diversity of the cultural characteristics of DACA recipients from different countries. Fourth, while intentional in the protection of participants’ documentation status, we did not collect demographic data, therefore limiting the ability to compare differences across participants. A notable limitation in this regard is that we could not differentiate among participants from different Latin American countries. However, qualitative analyses provided additional data on current use of coping skills by participants and difficulties managing stress. Finally, it is important to note the external and internal validity limitations of the study given its exploratory nature, as a result limiting generalizability.

Conclusion

Even though preliminary in nature, this exploratory study provides evidence that further support web-based and group-based approaches to healing that promote the acquisition of knowledge which can foster the development of strengths and resilience. Mental health providers, in collaboration with community leaders with access to spaces with vulnerable populations, are well positioned to help undocumented immigrants improve their emotion regulation and distress tolerance skills while raising their critical consciousness and understanding of how oppressive systems and experiences of discrimination on the bases of intersecting identities are linked to overall mental health and well-being. Given the expressed interest and receptiveness to skill-building among participants, opportunities to implement programming that allows for ongoing exposure and practice of new skills is strongly recommended. While skill building programs can mitigate negative mental health consequences for priority groups, sustainability and supports for such programs are not always available or considered a top priority among funding agencies. Therefore, scholars, providers, community advocacy groups, and faith-based organizations must continue to collaborate to reduce the burden on individual entities.

Clinical impact statement.

• Collaborative web-based mental health programs can create a supportive and validating environment for teaching and increasing knowledge of culturally congruent coping skills to manage painful emotions and distress among undocumented communities.

• Findings from this exploratory study highlight the promising feasibility of web-based mental health programs for the delivery of coping skills and resources to address the mental health needs of undocumented communities which should continue to be explored.