Caring for Undocumented Migrants: Significance of Recognition and Respect during Healthcare Encounters

Abstract Undocumented migrants are often in a position of extreme vulnerability and experience many barriers to accessing mental health care. It is crucial that health professionals understand this and quickly establish trust and respect. If the stressful living conditions that contribute to the distress of undocumented migrants are recognized, compassionate and trauma-informed care is enhanced. In this regard, it is important that health professionals understand the fear of being expelled from a country. This paper discusses problems that arise when health professionals interact with undocumented migrants and the need to quickly convey recognition to establish trust and respect. We argue that insights from Axel Honneth’s social philosophical theory of recognition and disrespect can further enhance health professionals strategies to improve their verbal and non-verbal communication and thereby increase access to health care for undocumented migrants. We suggest ideas for codifying this knowledge in health care policies and guidelines.


Introduction
Undocumented migrants' mental distress and their vulnerability when encountering health care systems is often a problem of both public health and human rights.Reluctance to seek health care is common for persons with mental distress, and there are many barriers to accessing health care for migrants as well as for those who are native born (WHO., 2022).However, undocumented migrants are especially vulnerable (Andersson et al., 2018;Myhrvold & Småstuen, 2016).Many live in extremely stressful conditions that can have a detrimental effect on their mental health, which may be further exacerbated by trauma experienced in their country of origin or during migration.One area that could receive more attention when health care providers train their staff is the concept of recognition.In this essay we argue for integrating this social-philosophical concept in the work of health professionals.The objective is to present and discuss problems that emerge when undocumented migrants seek health care, interact with health professionals, and problematize how communication and recognition are central to positive interactions in accordance with medical ethics and human rights.We argue that a deepened understanding of these soft skills and philosophical ideas among health professionals can increase trust among undocumented migrants and advance their access to care.We conclude by providing suggestions for how to reduce barriers to care in health care systems as well as increase informal care in community-based settings, places that undocumented migrants often trust and where they can find support.

The importance of recognition in establishing trust and communication
Ensuring a positive initial interaction is crucial for establishing trust and communication.This is a core competence of the health care profession, but it may be overlooked due to time constraints and other practical considerations (Kerasidou et al., 2020).It may also be thought of as self-evident and therefore overlooked.However, the strategies of interacting with and recognizing undocumented migrant patients' unique needs could be realized more in depth.This may even be the most important aspect of a consultation for an undocumented migrant with mental distress, especially if it is considered that the care needed is not acute and can be deferred.
Ensuring dignity and human rights is at the core of Honneth's social philosophical theory of recognition and disrespect (Honneth, 2003).The concept of recognition has long played an important role in practical philosophy, but in the last thirty years it has become even more significant, given the high migration flows that have characterized this period, because recognition is central for inclusion in a new society (Taylor, 1995).Social and legal recognition, respect, social appreciation, and self-esteem are central concepts in Honneth's theory (Honneth, 2003).Three levels of recognition and disrespect are discussed, alongside the consequences for a person's well-being.The foundation of recognition lies in relationships with others.If a person is neglected in their positive self-relationship by another person, their sense of self and identity will be negatively affected.Each case of such a violation constitutes an act of personal injury that destroys the conditions for the individual's agency, which in turn may lead to psychological damage and mental distress.
The primary level of recognition is relationships with family, friends, partners, etc. (love).These are the relationships through which basic physical and emotional needs are, or should be, fulfilled, in which love, care, and support are expressed and received.In their early life, an individual is recognized as a person by significant others.This creates a sense of security, trust, and also builds a foundation for future self-esteem, self-worth and self-respect, and resilience.The individual is acknowledged by significant others as being a unique and multifaceted person with multiple dimensions and competencies.Opposite to this is to be disrespected and not recognized as a human being; this constitutes a moral violation, which has serious consequences such as loss of a sense of self-worth.
The second level of recognition is moral respect.It is on the moral and legal level that an individual becomes aware of their rights and is shown respect by others in society, as well as the fact that they are a legal subject who should be treated equitably and on the same grounds as everyone else in society (rights).Self-respect, pathos, and morality are developed through this process, as is an expectation of justice.
The third level is recognition in relation to solidarity, loyalty, and appreciation, and this is fulfilled when a person feels respected for their abilities and contributions to society (solidarity).In other words, they are recognized socially as someone who is contributing to the common good of their fellow citizens.This form of recognition is seen in communities when its members show appreciation, solidarity, and respect for a person's integrity, acknowledging that the individual has value, upholds a moral standard, and contributes to the community and its common goals.
Everyone should be respected on the grounds that they are human beings.This relates to the idea of abolishing the notion of an 'illegal migrant' , a derogatory term that has been used to define disadvantaged groups throughout history, and which nowadays has been replaced by the terms 'irregular migrant' or 'undocumented migrant' by the United Nations, the EU, and others such as Platform for International Cooperation on Undocumented Migrants (PICUM) (PICUM, 2010a).The use and understanding of Honneth's theory can help us better understand how to ensure positive interactions and better understandings in health care settings in relation to undocumented migrants' living conditions.
For undocumented migrants, as for anyone else, the first level of recognition is established within caring and supportive primary relationships, which often means the family of origin.However, many undocumented migrants are exposed to marginalization, misrecognition, and abuse in their country of origin due to their ethnic or cultural background, sexual orientation, religion, or political ideas, or as a result of ongoing war or persecution (Andersson et al., 2018).Misrecognition here refers both to violations of the three levels of recognition, and to being neglected and not being seen at all.This may have destroyed relationships with significant persons in their lives and caused psychological damage.Living as an undocumented migrant for a long time can also result in the establishment of new, family-like relationships, especially among younger migrants who have migrated alone, but since migration is a continuous, mobile process, many relationships are also disrupted or lost (Hosseini & Punzi, 2022).These scattered relationships, possibly in addition to past traumas, may result in distrust and insecurity, even if the person initially had high self-esteem and a strong sense of self-worth.
Neglect and disrespect are less obvious forms of maltreatment that are nevertheless devastating.It is however known that exposure to neglect may result in mental distress, poor school performance, and substance abuse among young adolescents (Melander Hagborg, 2019).This acknowledges the need to examine age-specific differences and challenges among undocumented migrants.It should be noted that the adolescents undergo a transition to adulthood and a simultaneous transition to a new country and new living conditions (Zedmak & Medaric, 2022).If their parents have a sense of a connection to the new country, they are more likely to be able to support their children in these transitions (Sun et al., 2020), a task that may become overwhelming if one is denied recognition and endure challenging living conditions.
Undocumented migrants who are denied recognition of their losses and grief and who experience poor living conditions, marginalization, a lack of support, and loss of their sense of meaning may develop mental distress and find it difficult to integrate in a new country (Carswell et al., 2011;Jarlby et al., 2018;Vervliet et al., 2014).The act of listening is powerful yet tends to go unnoticed.To be listened to by health professionals, to feel seen, and to have instances of neglect and mistreatment acknowledged and confirmed are important for overcoming trauma as well as fostering a sense of wellbeing, not least for migrants who have been exposed to misrecognition on numerous occasions (Lindberg et al., 2021).
The second level of recognition, moral respect, relates to self-respect, pathos, morality, and expectations of justice.However, many undocumented migrants struggle to uphold their self-respect because they are forced to live in obscurity.In one study, an undocumented migrant states: "We must ask for permission all the time, to cook or to shower.We must wait for permission from the ones we live with all the time.It is very hard and makes us feel unsafe (Wirehag et al., 2021)." This may be difficult for the person themselves, but it is also difficult in relation to family and friends, either in the country in which they are residing or living abroad.It is difficult to preserve one's dignity in the absence of social status, including a lack of work, education, and social networks, and without the moral respect of the community.
For people who live as undocumented migrants, it is also more difficult to endure life itself due to the constant fear of police, as described in the following quotes: "Fear of the police, that they would come here and arrest and deport us.I check for plain-clothes police every time I go outside" and "A difficult neighbor spies on me all the time, makes me feel unsafe and I struggle to maintain a normal social life (Wirehag et al., 2021)." Children become used to these precautions from an early age: "If my brother and I fight or something, Mum and Dad will tell us to keep quiet and not make noise.The woman who lives above us might alert the landlord or the police if she thinks something is wrong (Wahlström Smith, 2018)." For undocumented migrants, the third level of recognition is diminished since they are not officially able to work (although they may work in the gray market) and therefore cannot contribute to society through their labor, for which they could otherwise be shown respect and appreciation and be valued as a contributing citizen.Undocumented migrants may feel a desire to show other members of society that they appreciate their new country and want to contribute to the common good.In one study, an undocumented migrant described their work experience as "degrading" and "being at the bottom of the bottom (Lowry et al., 2003)." In another study, undocumented migrants reported that treats, verbal insults, and racism by employers were common experiences (Segarra & Prasad, 2024).Many undocumented migrants depend on charity for food and daily necessities.For those who were breadwinners in their country of origin, this situation can take a severe toll on their self-respect.Many lack hope for the future and some experience suicidal thoughts (Andersson et al., 2021).
To live a life of exclusion, to not be welcomed or even accepted within a community, and to not be shown respect as a human being is detrimental for mental health.This can be particularly acute if the reason for someone fleeing their country of origin is disputed, which can be seen as a moral violation in accordance with Honneth's theory.Exposure to prejudice and racism from stakeholders and members of a society is morally degrading.It should also be noted that many undocumented migrants are exploited in the gray labor market, working in dangerous conditions and risking injury with no sick leave insurance and being paid a very low salary or sometimes no salary at all (PICUM., 2010a(PICUM., , 2010b)).This violates all three levels of recognition and, accordingly, affects self-esteem and self-worth.Such humiliation has negative consequences for mental and physical health.Therefore, those who live as undocumented migrants need to be approached by health professional as people who live in extremely precarious emotional, financial, physical, and social circumstances, and their mental distress should be seen as an understandable reaction to these, that further exacerbates the mental distress they may experience in relation to previous trauma.Mental distress also carries a stigma, and this further increases the vulnerability of those who experience it.

Undocumented migrants' encounters with health care systems
Undocumented migrants who seek out health care have needs that are similar to those of other patients as well as needs that are specific to their situation (Barkensjö et al., 2018).It is important to understand these specific needs in relation to the many barriers they face as a result of fear of seeking out health care.In addition to the everyday fear of police, there are several barriers related to interactions with health professionals that prevent undocumented migrants from seeking health care for mental distress, such as communication problems and interpersonal dialogue, including verbal and non-verbal communication (Rocque & Leanza, 2015).Since a sense of security is central for undocumented migrants, it is of paramount importance that health care professionals quickly establish an atmosphere of trust and deliver trauma-informed care.Trauma-informed care means that mental health practitioners are aware that trauma experiences are significantly higher in people within secondary mental health services than in the general population, understand distress in relation to adverse life experiences, ask patients about experiences of trauma and abuse, and strive to provide a sense of safety (McNally et al., 2023).
Health care professionals are persons with knowledge, experience, and capacity to provide compassionate care to patients, and caring, especially the nursing profession (Watson, 1979).Nurses are committed to health and well-being and especially, through communication and information, able to create good conditions for the patients to communicate their problems, to see and understand what the patient is susceptible to and has the ability to do.For this alliance to work, empathy, congruence, warmth is central (Watson, 1979).Trust is established during first encounters, and often has much more to do with non-verbal than verbal communication.Pace, tone, and volume of speech, moments of silence and pauses, physical distance, posture, eye contact, and physical gestures are all crucial for setting expectations and assumptions.How these forms of non-verbal communication are perceived may differ depending on an undocumented migrants' background, and may even cause confusion, so it is important that health care staff authentically engage in therapeutic interaction so as not to cause fear (Ritter & Graham, 2017).
It is important that health professionals constantly reflect on the messages they send and receive, especially with undocumented migrants, since they cannot be reached after they have left a clinic and therefore misunderstandings may be difficult to amend after the fact.Undocumented migrants may leave a health care setting instead of waiting for their appointment if they start to fear that they will be reported (Andersson et al., 2018;Jauhiainen & Tedeschi, 2021;Myhrvold & Småstuen, 2018).Those suffering from mental distress may be restless and even experience paranoia and hallucinations.Hence, verbal and non-verbal communication needs to be clear from the start of any interaction.Understanding and assessing expressions of emotions is a complex process, and there needs to be acknowledgement of different cultural expressions of emotion (Ashton-James et al., 2009).
Mental distress is expressed differently across cultures, which may cause confusion in the clinical encounter.For example, symbolic descriptions may be misinterpreted as hallucinations (Bäärnhielm, 2014).Experiencing voices or visions are important aspects of spirituality in some religious groups and may be perceived as the presence of spirits (Cook et al., 2022).It is important to understand the social and cultural context that an undocumented migrant comes from and lives in, the experiences and relationships that are meaningful to them, and the ways in which they present signs of mental distress.Since undocumented migrants come from all around the globe, these sociocultural contexts are many and may impact clinical encounters in new countries.Religious traditions are part of social and cultural contexts, so it is essential for health professionals who interact with undocumented migrants to consider that religion may represent not only beliefs and/or rituals but a lifeworld (Lucchetti et al., 2021).
In addition to the barriers that may exist within health care systems, a number of barriers exist in relation to mental distress itself, especially the stigmatization of mental distress (Douglass et al., 2022).Undocumented migrants often lack a social network and close loved ones to support them, and as a result they may face increased risk of further suffering and suicidal behavior if they feel they have not been heard or been misunderstood when accessing health care.Therefore, it is important that health professionals quickly covey an atmosphere of trust and compassion when interacting with undocumented migrants so they feel safe, heard, understood, and able to express themselves in ways that are meaningful for them.

Access and barriers to health care for undocumented migrants
Many studies show that there are significant structural, financial, and social barriers to health care for undocumented migrants, such as not knowing where to go, lack of knowledge of their right to seek health care, lack of money for transport and out-of-pocket fees, and fear of being reported to authorities (Biswas et al., 2012;Chauvin & Simonnot, 2012;Jauhiainen & Tedeschi, 2021;Mona et al., 2021;Myhrvold & Småstuen, 2016;Straßmayr et al., 2012;Teunissen et al., 2014;Winters et al., 2018).Other barriers are experiences of not being believed, being denied care, interactions with patronizing and condescending staff, and humiliation and neglect (Barkensjö et al., 2018;Biswas et al., 2012;Cleaveland, 2012;Cuadra, 2012;Dias et al., 2011;Jensen et al., 2011;Larchanché, 2012;Mandroiu et al., 2023).
Health professionals themselves are also sometimes unclear on how they should respond to the needs of undocumented migrants.There may be uncertainty over which staff members are supposed to make the decision over whether an undocumented migrant shall receive care or not: this includes front-line staff, emergency staff, clinical receptionists, nurses, or medical doctors (Jauhiainen & Tedeschi, 2021;Jensen et al., 2011).
When undocumented migrants are denied care at the health facility it may conflict with the ethical codes of the health professionals (ICE, 2021;WMA, 2015) and inflict moral distress.Complex moral dilemmas may impact the emotional well-being of healthcare professionals if they are unable to act consistently with their inherent moral values they hold, since the meeting between the caregiver and the patient for whom they care affects both at the same time (McCarthy & Rick, 2008).The international codes of ethics for nurses states that all nursing has an ethical dimension and that each nurse has a moral responsibility for their judgments and decisions, which may be related to prioritizing care or having to deny an undocumented migrant care.To be able to deal with these conflicting circumstances and maintain a professional approach, support is often required, for reflection and guidance.
Undocumented migrants mental distress is a condition that is likely to be denied care at health clinics, as reported by both health professionals and non-governmental organizations (Doctors Without Borders, 2018).One study reported undocumented migrants' strategies for overcoming denial of health care, including accompanying a friend to a doctor's appointment and asking for an examination or using a friend's identity card at the counter.Other strategies were to avoid the need to access health care, such as to try and stay healthy, exercise, and practice self-care or traditional medicine.The use of religious/spiritual practices, such as prayer, and ignoring symptoms of illness were also mentioned, not least by persons who feared losing their job due to the need to seek health care (Bendixsen, 2018).

Enhancing recognition in the health care sector and in civil society organizations
One way to enhance human rights in health care systems, is to include explicit guidance on the social philosophical notion of recognition in health care policies, guidelines, and training.In the case that an undocumented person is denied care, treatment, or service, due to their legal status, the person shall still feel they were met with dignity, compassion, and respect.For example in Sweden, Act 2013:407 states that undocumented migrants are entitled to care that cannot be deferred, but if deemed deferrable, care is to be denied (Greenbrook, 2023).
Outside the health care sector, voluntary organizations and networks are essential for undocumented migrants, as places where they are met with acceptance and recognition.In these settings, knowledge of rights is enhanced, and educational sessions can increase mental health literacy and strengthen resilience.Social networks and support can help undocumented migrants to find alternative facilities, and staff and volunteers can often accompany them to meetings with health care professionals.Strengthening and supporting community organizations should therefore be part of public health strategies, since undocumented migrants are a hard-to-reach group in disease prevention and health promotion.

Conclusion
The threshold for seeking care for mental distress is high.When undocumented migrants overcome the barriers to seeking health care, health professionals must quickly create a sense of trust and respect, so they feel safe to express their emotions and distress.If this is not expressed, it may be difficult for health professionals to fully understand the needs of the person and intervene.Despite the precarious legal and social situation of undocumented migrants, it is of paramount importance that health professionals quickly ensure a dignified meeting of respect and trust and provide compassionate and trauma-informed care.Honneth's (2003) critical social philosophical theory on recognition, which permeates our entire existence and is the basis on which we build relationships, is useful for health professionals in this context to further enhance their capacity to reach a percipient understanding of how to create a respectful meeting with an undocumented person.It can also help to provide an understanding of why an undocumented migrant may leave a clinic at the slightest suggestion of mistrust or doubt, regardless of whether it is related to the mental distress for which they are seeking treatment.
Undocumented migrants are people who have had their asylum applications rejected or entered the country without documents, but it is important to acknowledge that this legal decision does not set aside society's obligation to recognize them as human beings (United Nations, 1948).The full recognition of every individual as a human being and rights holder is central to any democratic society.Public employees and health professionals have an obligation to reflect on the recognition of others, due to their formal responsibility as duty-bearers representing states, municipalities, health care systems, and human rights laws.From both a human rights and a public health perspective, it is important to include all people residing in a society in the pursuit of 'health for all' (WHO) (Matlin et al., 2022).However, in a time when Europe and North America are imposing stricter border controls and more active searches to expel undocumented migrants, many will likely refrain from seeking health care, possibly resulting in higher rates of severe mental distress and suicidal behavior.It may also result in a higher prevalence of so-called hidden health clinics, where health professionals work voluntarily, for ideological and ethical reasons, to respond to unmet health care needs.However, even here it is likely that undocumented migrants experiencing mental distress will suffer most.On a positive note, undocumented migrants are people with strong capacity and if they are respectfully recognized, their mental distress may be amended or at least mitigated, and resilience strengthened.

Disclosure statement
No potential conflict of interest was reported by the author(s).