





























88

Graduate Student Journal of  Psychology 
2018, Vol. 17

Copyright 2018 by the Department of  Counseling and Clinical Psychology 
Teachers College, Columbia University

Sociocultural Constructs in the Conceptualization of  
Adjustment Disorder in an Undocumented Mexican Female

 Selina Mangassarian, M.A. and Lekeisha Sumner, Ph.D.
Alliant International University

Latino immigrants of  Mexican descent comprise the largest segment of  the undocumented population in 
the United States and experience heightened risk for emotional distress. Despite this knowledge, psychologi-
cal treatment for this group has received limited clinical attention regarding research and treatment options 
specific to this subpopulation. This case study describes the treatment of  a young, undocumented, Mexican 
female diagnosed with adjustment disorder. Treatment was based on a cognitive-behavioral framework, which 
integrated cultural values within a socio-political context. Because treatment methods for adjustment disorder 
were found to be culturally inappropriate, outdated, or lacking empirical evidence, the clinician integrated vari-
ous empirically supported methods. Treatment incorporated cultural values into cognitive-behavioral therapy 
methods. The sensitivity and awareness to culture by the clinician led to a successful treatment outcome.

Theoretical and Research Basis for Treatment

In 2011, Latino immigrants in the United States 
represented 80% of  the approximately 11.2 million 
undocumented immigrants, and more than six million of  
these individuals were of  Mexican descent (Gonzalez-
Barrera, Lopez, Passel, & Taylor, 2013; Passel & Cohn, 
2009). Latino immigrants, especially those who have 
resided in the United States for an extended period of  
time, are at heightened vulnerability for experiencing 
symptoms of  emotional distress (Gonzales, Suarez-
Orozco, & Dedios-Sanguineti, 2013). Furthermore, 
undocumented immigrants are more likely than docu-
mented immigrants to meet diagnostic criteria for 
anxiety and adjustment disorders (AD; Gonzalez-
Ramos & Gonzalez, 2005). While several explanations 
for these findings have been offered, there is general 
consensus among researchers and clinicians that factors 
stemming from immigration-related and acculturative 
stressors (Gonzales et al., 2013).

Among undocumented Latino immigrants, unique 
factors that may complicate treatment and increase risk 
of  AD and anxiety include the legal issues that surround 
undocumented status (Sullivan & Rehm, 2005). Smith 

(2001) reviewed mental health issues among individuals 
who recently immigrated to the United States main-
land and found that many immigrants chose not to 
seek mental health or medical treatment. Smith (2001) 
concluded that this finding was due to fear of  depor-
tation, discrimination, lack of  financial means, limited 
access to healthcare, as well as cultural factors includ-
ing language barriers, stigma of  seeking mental health 
treatment, and lack of  education regarding what treat-
ment entails.

Since mental health professionals vary in their 
case conceptualizations, subjective opinions, and 
creativity, the use of  evidence-based practices (EBP) 
increase effectiveness of  patient services and improve 
public health (Norcross, Beutler, & Levant, 2006). 
Interventions based on EBPs have shown scientific 
evidence of  consistent client improvement (Drake et al., 
2001). Evidence-based practices allow for a level of  
uniformity in providing care to a broad base of  clients; 
therefore, promoting a systematic approach to treatment 
is beneficial for researchers and practitioners in order 
to measure efficacy among various populations (Bernal, 
Jiménez-Chafey, & Rodriguez, 2009). Unfortunately, 
there is currently a lack of  evidence-based research 
to inform the necessary treatment for undocumented 
immigrants of  Mexican descent.

Override (Hidden running head text):
Mangassarian, Sumner
Adjustment Disorder in an Undocumented 
Immigrant

Please address correspondence regarding this article to: 
selina.mangassarian@gmail.com



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ADJUSTMENT DISORDER IN AN UNDOCUMENTED IMMIGRANT

From the available literature, it appears that 
common coping strategies among some people in this 
population are: (a) the internalization of  emotional 
distress, and (b) the avoidance and apprehension 
of  seeking mental health treatment. O’Connor and 
Cartwright (2012) provided general recommendations 
that included symptom relief, restoration of  functioning, 
and the prevention of  developing more serious mental 
disorders. Cognitive-behavioral therapy (CBT) is one 
treatment modality that has demonstrated effectiveness 
in the treatment of  AD (O’Connor & Cartwright, 2012). 
Although additional treatments can be supplemented, 
ultimately, the basic offering of  EBPs should not be 
displaced for interventions of  unknown or lesser effec-
tiveness (Drake et al., 2001).

Cognitive behavioral therapy has been shown to 
be effective for immigrant Latino populations because 
it aligns well with many cultural values, including the 
expectation that treatment leads to immediate symp-
tom relief, a focus on the present, a problem-centered 
approach, and direct and active interventions from 
someone who is considered an expert (Organista, 2006). 
Since CBT approaches quickly orient patients to the 
therapy process, this demystification of  treatment allows 
for Latino immigrant populations to lessen their hesi-
tancy toward treatment (Orlinsky & Howard, 1986). The 
collaborative and engaging approach of  CBT, embodied 
in activities such as psychoeducation and homework 
assignments, may be better received by clients than other 
therapy orientations (Organista & Muñoz, 1996).

Given this emerging knowledge and the limited 
availability of  empirically supported, culturally-tailored 
treatments, there is a pressing need for clinicians to 
consider the unique challenges faced by this popula-
tion. The ethical use of  culturally-tailored treatments 
have been debated because of  the possibility that EBPs 
were developed with a particular linguistic and cultural 
context in mind. Thus, they may not be appropriate 
for ethnocultural groups that do not share the same 
language or cultural values (Bernal et al., 2009). Although 
CBT is most effective for Latino undocumented immi-
grants suffering from AD, not all components of  CBT 
need to be followed. For example, the assertiveness of  
CBT is conceptualized to be based in a more individu-
alistic society as opposed to a collectivist one (Hinton, 
Hofmann, Rivera, Otto, & Pollack, 2011; Organista, 
2006; Organista & Muñoz, 1996).

The subject of  the following case study, Eva, is 
from a collectivist culture, thus treatment. integrated 
cultural values within a cognitive-behavioral perspective. 
The treatment did not strictly adhere to a manualized 
treatment. Given the multi-level societal systems (e.g., 
political, education, occupational, and social) that 
contribute to the marginalization of  undocumented 
immigrants in the United States, especially those of  
color, the role of  socio-political factors was considered 
in conceptualization and treatment. Culturally-modified 
trauma-focused CBT for Latinos is a new treatment 
method that has been shown to improve engagement 
by those who were resistant to previous, non-culturally 
modified therapy options (Hinton et al., 2011). Thus, 
CBT was chosen for several reasons, including the 
client’s desire for immediate symptom relief  and pref-
erence for structured sessions. The purpose of  this case 
study is to increase awareness of  not only the lack of  
EBP methods available for AD, specifically to an undoc-
umented immigrant population, but also to provide 
a framework for determining appropriate treatment 
options when systemized treatments are unavailable.

Case Study Introduction

“Eva,” a 20-year-old undocumented single Mexican-
American female living in Southern California, 
self-referred to individual therapy at a community 
mental health center for symptoms of  anxiety. She 
presented as well-groomed and appropriately dressed, 
with a dark complexion, dark brown hair and eyes, and 
was noticeably overweight for her height. Eva had 
chosen to continue therapy after family therapy at the 
agency had unfavorable outcomes, as her parents felt 
that it was shameful to share their family troubles with 
an outsider. Since she was still living at home, where she 
experienced considerable family conflict, she wanted 
to process her anxiety. In Mexican cultures, seeking 
mental health treatment is viewed to be inappropriate 
due to values like familisimo, which views voicing family 
issues as a betrayal of  loyalty to the family (Flores & 
Kaplan, 2009), and thus a disruption to the collective 
good (Martinez, Polo, & Carter, 2012). However, Eva 
was experiencing a clash between her cultural duties 
and her personal well-being, which was influenced by 
her American ideals. When this interplay of  bicultural-
ism, of  or relating to two distinct cultures, occurs for 



90

MANGASSARIAN, SUMNER

a Mexican-American immigrant youth, vulnerability to 
mental distress is heightened (Gonzales et al., 2013).

Eva was born in Mexico and moved to Southern 
California at age two with her mother and older sister 
to join her father. At the time of  therapy, she lived with 
her parents and younger sister, with whom she began 
to experience considerable conflict. She also described 
financial strain. She had recently deferred from a local 
prestigious university in order to dedicate her time to 
work. She enjoyed her job and had developed strong 
supportive relationships with her co-workers. Her goal 
was to re-enroll in university once she saved enough 
money, as her undocumented status would not allow for 
financial assistance. Eva was diagnosed with adjustment 
disorder, chronic, with anxiety to reflect the severity of  
her psychological distress over the previous six months.

At the community mental health center, Eva was 
assigned to a student clinician, who is the author of  
this case study. The student clinician was a second-
year Caucasian female graduate student supervised by 
a licensed mental health care professional. The clinic 
was located in a main city in Southern California where 
there was a varied client population of  all ages, low to 
moderate socioeconomic income, low to high levels of  
education, and minimal undocumented immigrants. The 
following sections describe the case history, assessment 
of  Eva’s anxiety regarding the situation with her parents, 
course of  treatment, a thought journal plus evidence, 
and assertiveness training.

Case History

Stressors
Eva presented with symptoms of  anxiety, which 

she indicated that she had experienced for the past 
five years. Her adjustment issues began eight months 
prior to therapy when she encountered an unexpected 
stressor regarding her family system: she discovered 
that her father had an affair when she was two years of  
age that resulted in a half-brother for Eva. Her father 
asked that she keep this knowledge confidential. Eva 
respected his wishes for four months until she could no 
longer deal with the guilt of  keeping this secret from 
the rest of  her family. She had been severely affected 
by her family members’ denial, verbal fights, and avoid-
ance about the stressor. For example, with regard to 
her father, Eva felt that he was much kinder and atten-
tive toward her when she was keeping his secret. She 

stated that their family only communicated when they 
were all watching TV together. Her mother, conversely, 
was more extroverted and outspoken about the family’s 
conflicts. Eva stated that her mother had been acting 

“childish,” “immature,” and “pathetically.” Because Eva 
believed that this news would lead to her parents’ sepa-
ration, she deferred from university and began to work 
full-time in order to support her mother and sister if  
needed. Eva’s disbelief  regarding her parents’ decision 
to stay together despite their unhappiness represents a 
common bicultural clash between older and younger 
immigrant generations (Gonzales et al., 2013). She 
coped maladaptively by avoiding interactions with her 
parents, staying at work longer, and spending time with 
co-workers after work hours. Physical manifestations of  
her anxiety reportedly included bodily tension, especially 
in the upper back area, and frequent headaches.

Family Obligations
Eva is the second child of  four children: three 

daughters and one son. Her family moved to Southern 
California from Mexico when she was two years of  age 
to live with her father, who immigrated to the United 
States two years earlier for safety reasons stemming from 
a financial dispute in Mexico. When the family reunited 
in the U.S., there were no reported problems other than 
Eva’s undocumented status, apparently because her 
immigration paperwork had not been completed and 
submitted. Her mother was a homemaker and her father 
had intermittent jobs in construction, which resulted in 
chronic financial strain for the family.

Eva’s family held traditional Mexican beliefs, such as 
a concern for the image of  the family in the community 
and gender-stereotyped machismo and marianismo 
roles of  the father as a physical provider and the 
mother as a caretaker (Flores & Kaplan, 2009). She 
explained that if  her mother were to work, it would 
be considered disrespectful. Because her mother was 
invested in this traditional gender role stereotype, Eva 
felt pressured to assume more financial responsibilities. 
Eva’s impulsive decision to defer her attendance at the 
university was a reaction to what she perceived as her 
parents’ imminent separation. However, her parents 
decided to stay together for the sake of  their family 
image—albeit in a dysfunctional uncommunicative rela-
tionship. Moreover, they continued to depend on Eva’s 
earnings for their expenses.



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ADJUSTMENT DISORDER IN AN UNDOCUMENTED IMMIGRANT

Cultural vs. Personal Goals
Eva disclosed her difficulty establishing and 

maintaining boundaries with her parents and felt 
torn between her cultural obligation to demonstrate 
deference to her parents and her personal, academic, 
and financial goals (Flores & Kaplan, 2009). At the time 
of  treatment, Eva worked at a non-profit human and 
immigration rights organization with undocumented 
high school students who were applying for college. 
Eva had worked with immigration lawyers for many 
years to receive legal status in the U.S., without success. 
Thus, she planned to take classes at a city college while 
she saved money so that she could complete general 
education courses that would transfer to the university 
she previously attended. As an undocumented citizen 
without a social security number, Eva was ineligible to 
receive financial aid for school.

Cognitive-Behavioral Therapy
The psychosocial aspects of  the case made CBT a 

good fit for treatment. Eva had been internalizing her 
emotional distress and avoiding communication with 
her parents. She and her family required direct interven-
tions, which can be obtained using CBT (O’Connor & 
Cartwright, 2012; Organista, 2006). CBT is effective 
when one’s distorted views can be altered by interpreting 
the background of  a misinterpretation, recognizing the 
difference between the self  and the ideal self, and recog-
nizing that some fears are unrealistic (Beck, 1976). This 
internal dialogue of  labeling experiences as positive or 
negative is what Beck (1976) referred to as “automatic 
thoughts,” which are often impulsive and perceived 
as true (McKay et al., 2007). Beck aimed to challenge 
these spontaneous, learned, and idiosyncratic thoughts 
by confronting the limited thought patterns through 
cognitive therapy (McKay et al., 2007) and having the 
clients discover the meanings and functions behind the 
thoughts (Corey, 2009).

Initial Assessment and Conceptualization
Eva was cooperative during the initial assessment 

session. She presented as slightly overweight, generally 
healthy, dressed appropriately, and well-groomed. Her 
movement was unremarkable. Her speech took on a 
soft volume with moments of  slowed speech when 
providing negatively emotionally charged information, 

yet pressured and sarcastic when speaking about 
upsetting and frustrating information. She displayed a 
broad range of  affect that was congruent with thought 
content and her mood was generally anxious. She denied 
the presence of  hallucinations and delusions, suicidal 
and/or homicidal ideation, and her sensorium appeared 
to be intact. She was oriented to person, place, time, 
and situation. Her intelligence and memory appeared 
to be average, and she demonstrated adequate judgment 
and insight. Throughout treatment, Eva was observed 
to be committed to psychotherapy and eager to 
alleviate her distress, as demonstrated by not missing 
any appointments, remaining punctual, open to the 
therapeutic process, and completing assignments.

Throughout the initial intake sessions, the therapist 
assessed for symptoms of  generalized anxiety, depres-
sion, and alcohol use for differential diagnoses and to 
rule out disorders. Eva denied ever experiencing symp-
toms of  anxiety of  this severity before the current 
stressors (e.g., financial strains, deferring from univer-
sity, family communication style). Based upon data 
revealed during the clinical interview, it was determined 
that symptoms reflective of  adjustment disorder along 
with some symptoms of  anxiety were causing the most 
interference and distress in Eva’s life. She was relatively 
relaxed during the clinical interview and demonstrated a 
constricted affect; however, when discussing her family, 
a sharp change in demeanor would occur. For example, 
when discussing her father and her finances Eva became 
animated in her discussion—rolling her eyes, flaying her 
arms about, trembling with her hands, and shaking her 
right leg up and down uncontrollably. Due to the mental 
health center’s policies, the therapist was unable to use 
self-assessment measures to assess for these diagnoses 
further.

Although the situation with her father’s affair caused 
much anxiety, Eva’s behaviors due to her anxiety had 
greatly interfered with her social and academic life. This 
anxiety likely interfered with her ability to create a logical 
plan regarding her university attendance and completion. 
As more people in her family discovered the situation, 
her worries grew and her tendency to want to control all 
outcomes within relationships increased, thus precipi-
tating her issues with adjusting to the stressor further, 
resulting in AD with anxiety.



92

MANGASSARIAN, SUMNER

Course of  Treatment and 
Assessment of  Progress

Goals
The specific goals of  treatment were (a) to provide 

cognitive-behavioral psychoeducation, (b) to learn to 
identify, challenge, and alter automatic thoughts, and 
(c) to engage in assertiveness training in order to set 
boundaries with Eva’s parents in an attempt to decrease 
her financial burden. CBT is a theoretical orientation 
that has been adapted for patients with varying levels 
of  education, socioeconomic status, ethnic and cultural 
identities, and developmental stages (Corey, 2009). 
These were key aspects taken into consideration while 
choosing the best approach for this case since the client 
was an undocumented Mexican immigrant youth from 
a lower socioeconomic background.

Structure of  CBT Treatment
Treatment with Eva was once per week for 

50-minute sessions for four months, totaling sixteen 
sessions with the clinician. Her symptoms were moni-
tored throughout the course of  treatment via clinical 
interview questions at the beginning of  each session. 
The initial sessions were focused on establishing a 
healthy rapport and strong therapeutic alliance between 
Eva and the clinician. She and the clinician discussed 
relevant cultural differences between them; the clini-
cian was Armenian-American, born in America, and 
a second year graduate student from upper-middle 
socioeconomic class, whereas Eva was Mexican-born, 
undocumented, unable to attend university, and from 
a lower socioeconomic class. Once they discussed the 
potential challenge of  cultural dissimilarities between 
the two parties, the therapeutic alliance was easily estab-
lished and was characterized by trust, comfort, and 
ease of  conversation. Eva was rarely hesitant to share 
information and discussed her problems openly and 
effortlessly.

Although CBT methods served as the foundation 
for treatment, a formal treatment guide was not followed 
due to the lack of  empirically supported methods for 
AD. In conjunction with O’Connor and Cartwright’s 
(2012) previously described general guidelines for treat-
ment, the clinician used portions of  Thoughts and Feelings: 
Taking Control of  Your Moods and Your Life Workbook by 
McKay and colleagues (2007). Resources utilized for 

sessions included providing psychoeducational CBT 
worksheets, blank thought journal worksheets, blank 
thought and evidence journal worksheets, and relevant 
and appropriate assertiveness training handouts.

The first phase of  treatment was used to gather 
information regarding symptom frequency and sever-
ity, personal data, and diagnostic information in order 
to determine diagnosis and appropriate treatment. 
Additionally, the clinician and Eva clarified realis-
tic expectations for change from treatment and the 
obstacles that may reroute some planned sessions due 
to the possibility of  refocusing sessions based on her 
needs from that week. The second phase of  treatment 
involved psychoeducation for the CBT orientation, the 
CBT thought triangle proposed by Beck (1976), and 
cultural implications of  CBT. The clinician explained 
the general process of  CBT as one that was structured, 
required homework assignments, and was based on 
the premise that an individual’s behaviors and feelings 
lead to his or her thoughts. Eva displayed excitement 
to begin this plan because she preferred a structured 
treatment.

The third segment of  treatment explored the nature 
and function of  her automatic thoughts and schemas 
and how they informed her symptoms. This segment 
included homework assignments from McKay and 
colleagues’ (2007) workbook, which promoted listen-
ing to the meanings behind automatic thoughts. For two 
weeks, Eva kept a thought journal of  the presenting situ-
ations she encountered, which included (a) a one-word 
description of  the feeling caused by the situation, (b) a 
distress rating from 0–100 (0 = no distress, 100 = most 
distress possible), and (c) the automatic thought she had 
just before and during the unpleasant feeling.

The fourth phase of  treatment focused on how to 
label and challenge automatic thoughts by keeping a 
thought and evidence journal. This included the previ-
ous three thought journal columns (one-word feeling, 
distress rating, and automatic thought) and added three 
more columns that (a) labeled which limited thought 
pattern Eva experienced, (b) identified what techniques 
she could use to balance or alternate the thoughts, and 
(c) re-rated her feelings after working through them. 
Eva was provided with a handout of  the main eight 
automatic thought patterns and their explanations as 
reference along with practice exercises of  sample state-
ments matched to the correct automatic thought.



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ADJUSTMENT DISORDER IN AN UNDOCUMENTED IMMIGRANT

After keeping these records for two weeks and 
processing them for repeated themes and patterns 
in sessions, it was determined that “catastrophizing,” 

“shoulds,” and “personalization” were the most frequent 
automatic thought patterns in which Eva would engage. 
As explained by McKay and colleagues (2007), catastro-
phizing is when an individual assumes that the worst will 
happen, shoulds are the arbitrary rules for behavior that 
one sets for themselves and others, and personalization 
is when an individual compares themselves to others 
or assumes that the reactions of  others always relate 
to him or her.

Automatic thought pattern: Catastrophizing. 
When Eva thought in a catastrophizing manner, she 
would feel anxious, fearful, guilty, and self-loathsome. 
An example of  her catastrophizing was when she felt 
she could never save enough money to go back to 
university because of  her inability to set boundaries 
with her parents about finances, without disrespecting 
them. During treatment, the clinician and Eva decon-
structed the meaning behind this automatic thought: 
Eva was uncertain of  her ability to both support her 
family’s finances and save money for herself  to use to 
return to university. To challenge these thoughts, Eva 
would answer, “what are the odds?” of  her automatic 
thought. Eva realized that she had been making her 
situation catastrophic in her mind when she knew if  
she approached her parents in an appropriate manner 
and voiced her concern, which she had not been able 
to do before, they would understand her struggle and 
decrease the amount of  money they requested from her.

Automatic thought pattern: Personalization. An 
example of  Eva’s automatic personalization thought 
would typically occur when she tried to decrease the 
amount of  money she gave to her family and perceived 
that they acted cold with her when she did not give 
enough. Thus her behavior was to continue to give 
them the exact amount of  money they requested in 
order to avoid conflict. When the automatic thought 
was processed, it was determined that it was a function 
of  her cultural belief  that she was obligated to take 
care of  her family before herself. Fitting with this belief, 
Eva had reported that her reason to achieve a higher 
education degree was not only to gain an education 
for herself  but in order to secure a higher paying job 
and better provide for her family. When Eva explored 
this consideration and combined it with other cultural 

factors, such as her conflicting level of  biculturalism 
with her parents, she realized that the purpose behind 
her desire to give her family less money now was so 
that she could provide more financial assistance to her 
family in the future.

Automatic thought pattern: Shoulds. When Eva 
judged her parents for their dysfunctional communica-
tion style, she would automatically reflect, “I shouldn’t 
be thinking like this about my parents, I’m such a horri-
ble daughter,” indicating some overlap with shoulds and 
catastrophizing. The meaning behind this automatic 
thought was processed to understand that values are 
personal and so her judgment of  her parents as “imma-
ture” and “irresponsible parents,” is her right. She may 
feel guilty for such thoughts; however, the meanings 
behind them were not false accusations. Her avoidance 
of  her parents exacerbated her guilt for judging them 
and led to other shoulds, such as “I should be able to 
handle their issues; my sisters are okay so why am I 
so affected by them?” Regarding comparing herself  to 
her sisters (personalization), the clinician encouraged 
Eva to engage in positive psychological methods that 
would allow her to recognize that all individuals have 
their strong and weak points. She was not expected to 
think and behave like her sisters because she was not 
the same person as her sisters. Also, the clinician and 
Eva discussed the fact that she played a different role 
than her sisters since she was the first to know about 
their father’s affair, as well as being the one to break this 
news to the family.

Assertiveness Program
Although Eva alleviated her adjustment issues using 

these CBT techniques, she still needed to improve her 
financial situation, which would involve reducing her 
financial assistance to her family from $600 to $250 
per month. Thus, the fifth phase of  treatment was a 
10-week module-based assertiveness program developed 
by the Government of  Western Australia’s Centre for 
Clinical Interventions (2008). Although this program 
was created in Australia, it was the only easily avail-
able, empirically based resource for the clinician due to 
the clinic’s limited CBT resources. This program was 
deemed appropriate by the clinician and her supervi-
sor for an undocumented Mexican immigrant in the 
U.S., since its modules were broad, allowing for neces-
sary cultural adaptations. The modules completed by 



94

MANGASSARIAN, SUMNER

Eva consisted of  psychoeducation on the meaning of  
assertiveness, how to recognize and engage in asser-
tive behavior, how to reduce physical tension, and how 
to deal assertively with criticism and disappointment. 
In conjunction with these weekly modules, the clini-
cian and Eva participated in role-playing situations to 
prepare Eva to approach her parents and respond to 
their reactions. The outcome of  this was successful: Eva 
assertively approached her parents with her request to 
reduce the money she gave to them and used a chart 
to show them her budget and her plan for returning 
to university. Eva created this chart as a personal proj-
ect outside of  therapy, but she brought the chart into 
session after she unveiled it to her parents in order to 
process the experience.

During assertiveness sessions the clinician and 
Eva drew attention to the value differences between 
Eva and her parents, contextualized the difference, 
reframed the problem, and previewed the future possi-
ble bicultural challenges (Gonzales Suarez-Orozco & 
Dedios-Sanguineti, 2013). This way, Eva was able to 
present her argument to provide less money to her 
parents in a sensitive and thoughtful manner so they did 
not feel blamed for her struggles. Modifications made to 
the modules to fit cultural considerations included issues 
such as tone of  voice, body language, and eye contact.

Outcome of  Treatment
Eva reached the goals she had set for therapy and 

terminated at the same time that the clinician’s training 
at the clinic was ending. By the end of  treatment, Eva 
was able to identify her limited thought patterns and 
had challenged them by continuing to keep a thought 
and evidence journal. Due to the assertiveness training, 
she was able to limit her financial contributions to her 
family and was able to say “no” when they asked her 
for money that she could not allot from her budget. 
Thus, by saving this money, Eva was able to achieve her 
financial goals and return to university.

Since Eva’s goals for therapy at the time of  treat-
ment were short-term and solution-focused, she did 
not always have the opportunity to process the weekly 
communication that occurred within her household. 
This was not detrimental to treatment because there 
was a mutual agreement that the session goals were 
oriented to solution-focused problem-solving more so 

than a processing style. Although she had a much lower 
amount of  anxiety regarding the situations at home, 
there were some issues that she could not control, such 
as her parents’ employment status. Therefore, it was 
recommended that Eva continue treatment as a transfer 
client to a new student clinician who would be joining 
the clinic in the coming year. She had acquired new tools 
to understand and process her emotions and thoughts, 
but the accountability presented by seeing a clinician, 
especially one trained in multiculturalism, would provide 
a good support system in order to continue to facilitate 
the development of  Eva’s coping strategies.

Case Conceptualization

Eva’s case conceptualization was divided into two 
main domains, which influenced her presentation and 
treatment. The first domain involved Mexican cultural 
norms dictating parenting practices, regardless of  chil-
dren’s age. In Mexican families there is an expectation 
to respect parents, to put the needs of  the family above 
the needs of  the individual, and to be obedient to family 
requests (Luis, Varela, & Moore, 2007). Although it has 
been reported that anxiety manifests itself  as somatic 
complaints among Latinos more so than any other 
ethnic minority in the United States (Martinez et al., 
2012), Eva’s anxiety manifested as avoidance and inter-
nalized self-loathing. Eva’s engagement in her selfless 
accommodating behaviors for her family conflicted with 
her thoughts regarding her own well-being; this reflected 
cognitive dissonance. That said, the clinician incorpo-
rated Eva’s culturally-based inclination to protect her 
mother and sister from financial strain into treatment 
via validation and affirmation. This collectivist value was 
positively reinforced in session and was understood as 
a positive quality—reflective of  Eva’s thoughtful and 
dedicated character. Moreover, the clinician worked to 
help Eva utilize this strength in more adaptive ways that 
would not interfere with her personal goals.

The second domain considered while conceptualiz-
ing Eva’s case involved her self-efficacy. Eva’s diagnosis 
of  adjustment disorder with anxiety was precipitated by 
Eva’s difficulties with her father’s affair and pressure 
to keep the secret. Her automatic thoughts of  person-
alization, catastrophizing, and shoulds, as well as an 
emotional, behavioral, or physiological reaction served 



95

ADJUSTMENT DISORDER IN AN UNDOCUMENTED IMMIGRANT

as the basis for her diagnosis (Beck, 2011). Her symp-
toms were exacerbated by her limited coping strategies 
and self-schemas relating to self-efficacy. More specifi-
cally, she engaged in maladaptive coping (e.g., avoiding 
her parents) and believed that she had limited capacity 
to problem-solve and assert her needs to her family.

Three problematic situations triggered Eva’s 
maladaptive and automatic thoughts. According to 
CBT, these automatic thoughts lead to symptoms of  
anxiety due to feelings of  vulnerability (Beck, Emery, & 
Greenberg, 1985). Beck and colleagues (1985) defined 
vulnerability as the perceived internal or external 
danger a person feels, which cannot be controlled by 
his or her own efforts to feel safe. This vulnerability to 
learned, automatic thoughts leads to cognitive dysregu-
lation, where the increased threat to security results in 
a decreased ability to cope and feel protected (Clark 
& Beck, 2010). Eva’s symptoms were not solely due 
to cognitive processing but also due to a faulty infor-
mation-processing system where situations presented 
were processed to have more meaning and perceived 
threat than necessary (Clark & Beck, 2010). When the 
news of  the affair first broke out in her family, Eva 
would perceive any form of  communication between 
her parents as an opportunity for them to inflict verbal 
and emotional pain on one another, thus affecting her 
as well. In reality, her parents’ communication style at 
the beginning of  this adjustment process was expected 
behavior for a couple working through relational issues. 
Eva attempted to alleviate her anxiety by making plans 
to “fix” her problems, such as mentally rehearsing what 
she would say to her parents about her financial stress. 
However, when those strategies failed, she would cycle 
back to relying on her effortless, involuntary, and auto-
matic information-processing system.

Eva’s compensatory behavioral strategies for 
these automatic thoughts included avoidant behaviors. 
Consistent with the literature, these behaviors served 
as safety measures that shielded Eva from unpleasant 
feelings and feared outcomes; however, they also exac-
erbated symptom severity (Helbig-Lang & Petermann, 
2010). Eva used emotional avoidance strategies to 
escape undesirable emotions, which negatively rein-
forced feelings of  anxiety and adjustment issues since 
they provided temporary relief  (Barlow, Allen, & 
Choat, 2004; Helbig-Lang & Petermann, 2010). More 

specifically, Eva engaged in what Barlow and colleagues 
(2004) defined as preventative and restorative safety 
behaviors. Preventative safety behaviors are those that 
aim to prevent future distressing emotional events. This 
was exemplified in Eva’s case by her act of  deferring 
from university to prevent the financial strains that 
would have occurred if  her mother were to leave her 
father. Restorative safety behaviors include those that 
attempt to control or alleviate emotional responses. This 
was evident in Eva’s avoidance of  her family home due 
to the conflict.

Undocumented immigrants of  Mexican descent 
suffer a paradox because they require treatment for AD 
(Gonzales et al., 2013; Gonzalez-Ramos & Gonzalez, 
2005; Sullivan & Rehm, 2005), but this specific popula-
tion is unlikely to seek mental health treatment (Flores 
& Kaplan, 2009; Martinez et al., 2012; Smith, 2011). 
Moreover, evidence-based practices are necessary for 
effective and systematic treatment of  AD; however, this 
is lacking for an undocumented Mexican immigrant 
population. Thus, this treatment took into consideration 
the cultural norms in Mexican parenting, collectivist 
cultural values, the self-concept and maladaptive coping 
of  the client, and the preventative and restorative safety 
behaviors in which the client engaged. The clinician’s 
sensitivity and awareness to culture led to a successful 
treatment outcome. Eva was able to identify limited 
thought patterns and challenge them, the assertiveness 
training was successful, and as a result, Eva achieved 
her financial goals and was able to return to university.

Treatment Implications of  the Case

Mexican immigrants who have lived in the United 
States for longer than approximately thirteen years are 
at heightened risk for mental health disorders than those 
who have resided in the United States fewer years (Vega 
et al., 1998). Further, the circumstances by which indi-
viduals immigrate may render them socially vulnerable 
to experiencing distress. Eva’s case was unique because 
she presented with a diagnosis for which treatment was 
lacking, especially among undocumented Mexican immi-
grant populations. The presenting case study illustrates 
the successful subjective integration of  varying empiri-
cally supported CBT methods for AD with anxiety for 
an undocumented, immigrant, Mexican female.



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Important considerations made for this successful 
outcome were (a) the awareness and sensitivity to the 
cultural clash, not only within the therapy room but also 
within Eva’s family, and (b) the need to modify CBT 
methods to fit Eva’s cultural background. The clinician 
was constantly aware of  Eva’s people-pleasing tenden-
cies due to her cultural obligation influencing obedience 
to authority. To ensure that Eva would not simply try 
to please the clinician, as an authority figure, the clini-
cian was cognizant of  the directive language she used 
during sessions, especially since CBT sessions tend to 
be instructional. Additionally, when making modifica-
tions to empirically based programs, the clinician had 
to take all measures necessary to not completely alter 
the modules.

Recommendations to Clinicians and Students

It is important for clinicians to thoroughly research 
all available treatment options for diagnoses that lack 
suggested treatment methods. If  research is lacking, it is 
the responsibility of  the clinician to make an informed, 
rational, and competent treatment decision. A limitation 
of  the treatment for this case was the use of  an assertive-
ness training module based on research statistics among 
Australian adults. Given the limitations of  resources to 
the clinician and the treatment setting, this program was 
deemed adequate for the goals at hand, especially since 
the modules left room for professionals to incorpo-
rate relevant factors, such as culture. For students, and 
even licensed clinicians, if  a case is beyond the scope of  
practice, the safety and well-being of  the patient should 
take precedence and consideration should be made for 
a referral to a more experienced therapist.

Although not extreme, the therapist did face 
some countertransference issues that required addi-
tional supervision. In order to maintain sociocultural 
sensitivity and a healthy therapeutic alliance with CBT 
techniques, therapists need to be cognizant of  (a) their 
own reactions to clients, (b) their competence regarding 
sociocultural differences that can influence the thera-
peutic relationship, and (c) their competence concerning 
the specific norms and needs of  the client’s cultural 
background (Wright, Basco, & Thase, 2006). Because 
the therapist in this case was also from a collectivistic 
culture, she could understand Eva’s rationale on many 

issues. However, the therapist had a hard time accepting 
that one’s parents would put their child in a financially 
difficult situation where education would be a secondary 
goal. Since the therapist was raised in an environment 
where education was priority, it was necessary for her 
to come to terms with the differences in cultural expec-
tations of  children within a Mexican-American family.

The cultural factors presented in such a case as Eva’s 
must be given the utmost attention so as not to jeop-
ardize the therapeutic alliance. Issues of  immigration, 
documentation, barriers to education, healthcare, and 
legal systems, biculturalism, conflicting family dynamics, 
and socioeconomic status have important implications 
for treatment. If  the clinician had not considered the 
differences between herself  and Eva, the clash between 
Eva’s Mexican and American values, and the importance 
of  respecting authority figures, Eva may have never felt 
fully understood by her clinician. Lastly, given that ther-
apy may be terminated (in this case, due to the end of  
the clinician’s training), the clinician should be aware of  
and address the patient’s potential feelings of  abandon-
ment and create a plan for continued support outside 
of  therapy. The recommendations to other clinicians 
and clinical students are to research all methods, consult 
with colleagues and experts, and make an informed deci-
sion on the best form of  treatment when limited EBPs 
are available.

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