Recent, high-profile protests directed towards U.S. Immigration and Customs Enforcement (ICE) operations across the United States, including those in Oregon, have raised awareness of immigration policies under the Trump administration. Historically, policies that increase immigration enforcement are known to impact mental health among vulnerable populations in the U.S. (Pinedo & Escobar, 2024). In a time of uncertainty for individuals without U.S. citizenship, psychologists are increasingly likely to encounter patients in acute distress. It is therefore prudent for psychologists to begin reflecting upon the interplay of their ethical obligations and possible conflicts that arise under new directives of the Trump administration. In particular, psychologists may soon face, or may have already faced, complex decisions about how to protect their patients’ well-being in a shifting sociopolitical climate. A review of the American Psychological Association’s Ethical Principles of Psychologists and Code of Conduct (APA, 2017, hereafter referred to as the Ethics Code), specifically the ethical standards that apply to protecting vulnerable patients without U.S. citizenship, is warranted.

As the first sanctuary state in the country, Oregon has served as a model for others since 1987 with laws that block the use of state resources from assisting federal immigration officers and prohibit public bodies from inquiring about citizenship or place of birth (Oregon Department of Justice, 2025a, 2025b). Despite Oregon’s status as a sanctuary state, minoritized individuals who feel threatened by recent immigration policies are likely to experience periods of increased stress, fear, or low mood (Pinedo & Escobar, 2024; Roche et al., 2020). As a result of President Trump’s April 2025 executive order to increase ICE operations in sanctuary jurisdictions as well as the recently enacted H.R. 1 (One Big Beautiful Bill Act, 2025), mental health providers should expect that patients who are directly impacted may experience periods of distress or possible mental health crises. This bulletin presents two case examples which highlight unique ethical considerations that pertain to protecting the well-being of patients with unknown or undocumented U.S. citizenship.

Case Example 1: Public Body: Dr. Davis, a licensed clinical psychologist employed by a public health clinic in Oregon, provides mental health services to adolescents. One of her clients, Sara, a 16-year-old, reports experiencing increased anxiety following a recent ICE raid in her neighborhood. Sara discloses that her parents are undocumented and have been living in fear of deportation. As a result, Sara’s parents have felt unsafe leaving their home, and access to adequate transportation and food has decreased. Sara has been missing school and reports feeling as if she does not have a trusted adult confidant. Her psychological distress has worsened, and she reports feelings of hopelessness and worthlessness. Although she denies suicidal ideation, her functioning is significantly impaired, and she expresses fear that any attempt to seek help might cause her family to be separated.

This case presents several ethical complexities. Though Dr. Davis may consider reporting Sara’s situation, she is not required to report such information if the communication is privileged (under ORS 419B.010; Duty of officials to report child abuse) and should weigh all available information to best protect Sara. A report may trigger child protective services involvement that could indirectly expose the family's undocumented status, potentially resulting in deportation or further trauma. Under Ethical Standard 3.04 (Avoiding Harm) of the Ethics Code, Dr. Davis is required to take reasonable steps to avoid harm and to minimize harm when it is unavoidable (APA, 2017). Moreover, per Standard 4.01 (Maintaining Confidentiality), she must carefully consider how much information to disclose and whether that disclosure is legally required and ethically justified (APA, 2017). Acting within a public body, Dr. Davis is legally prohibited from recording Sara’s citizenship status in her medical record (Oregon Department of Justice, 2025a). This introduces potential tension between her ethical obligations and legal mandates. In such cases, Ethical Standard 1.02 (Conflicts Between Ethics and Law, Regulations, or Other Governing Legal Authority) becomes relevant, guiding Dr. Davis to clarify the nature of the conflict and to take steps to uphold ethical standards while complying with legal obligations to the extent possible (APA, 2017). Additionally, as a public employee, Dr. Davis may face institutional pressures that could conflict with her ethical duties, activating Standard 1.03 (Conflicts Between Ethics and Organizational Demands). Engaging the family in collaborative safety planning, consulting with legal counsel and the OPA Ethics Committee, and documenting her decision-making process are all viable steps in managing this ethically complicated situation.

Case Example 2: Private Institution : Dr. Ruiz, a licensed neuropsychologist in private practice, sees Jonah, a 45-year-old man, for an evaluation of reported memory difficulties, anxiety, and sleep disturbances. Dr. Ruiz notices in the referral for Jonah that citizenship status was marked as a potential contributing factor to Jonah’s mental health, though no additional details were provided. During the clinical interview, Jonah shares that Spanish is his first language and that his formal education was completed outside of the United States. Dr. Ruiz is conscious of his legal rights, as a provider in a private institution, to inquire about citizenship status, but is unsure if this information is relevant to the presenting concern. At the same time, he recognizes that an understanding of psychosocial history can increase the accuracy and culturally informed interpretation of the assessment results.

This scenario also raises important ethical challenges. While Jonah did not provide details about his citizenship status during the interview, the history he did provide suggests cultural context, acculturation, and systemic stressors should be considered. Dr. Ruiz is aware that, as a private provider, he is not legally prohibited from inquiring about citizenship status. However, whether he should ask is an ethical question rooted in client welfare, privacy, and the purpose of the assessment. According to Standard 9.06 (Interpreting Assessment Results), psychologists are required to consider the individual's language, cultural background, and other contextual factors to avoid misinterpretation (APA, 2017). Jonah’s first language and educational history already offer insight into how his test scores should be interpreted, which may lessen the need to inquire about citizenship directly. However, if Dr. Ruiz believes that citizenship status is critical to understanding the source of Jonah’s psychological distress, he must weigh the benefit of asking against the risk of harm that inquiring and recording this information presents. Ethical 4.04 (Minimizing Intrusions on Privacy) cautions that psychologists should only seek information relevant to the service being provided (APA, 2017). Asking about citizenship status, without a clear and clinically justified reason, may violate this principle. Additionally, what Dr. Ruiz chooses to do with the information, should Jonah disclose it, raises questions about confidentiality and privileged communication. If Dr. Ruiz were to record citizenship status in the medical record, he must ensure it is stored securely and not shared unnecessarily, in line with Standard 6.02 (Maintenance, Dissemination, and Disposal of Confidential Records; APA, 2017). Should Jonah’s citizenship status become relevant to advocacy, resource referrals, or safety planning, Dr. Ruiz might consider discussing potential benefits and risks of disclosure with Jonah, emphasizing collaborative decision-making.

Reflections on how to protect vulnerable clients from harm are highly relevant. In June of 2025, the U.S. Departments of Homeland Security sought to extract the medical records of undocumented Medicaid enrollees, an unprecedented request (Kindy & Seitz, 2025). Importantly, Oregon is one of seven states in which individuals without citizenship are eligible to receive full benefits in their state’s Medicaid system. Thus, licensed psychologists in Oregon must reflect deeply on the potential impact of the information they collect, document, and share when working with this particular population. Culturally informed risk assessments that mitigate harm and abide by psychologists’ duty to protect are also more important than ever. During this time, clinicians can spend time with questions such as: 

1. Are broad references to therapeutic discussions of these topics sufficient for medical record documentation? Furthermore, is recording patients’ citizenship status essential to treatment, or could it place the client at increased risk?
2. How can patients' safety and well-being be improved through collaborative problem-solving that is contextually and culturally sensitive? As well, are there unconscious biases present that relate to perceptions of danger or neglect?

Such reflections will aid in psychologists’ ability to balance clinical judgment with a commitment to do no harm. This is particularly relevant in a landscape marked by uncertainty, wherein safeguarding the well-being of individuals who may not have U.S. citizenship remains a vital professional responsibility.

References

American Psychological Association. (2017). Ethical principles of psychologists and code of conduct (2002, amended effective June 1, 2010, and January 1, 2017). https://www.apa.org/ethics/code

Kindy, K., & Seitz, A. (2025, June 14). Trump administration gives personal data of immigrant Medicaid enrollees to deportation officials. AP News. https://apnews.com/article/medicaid-deportation-immigrants-trump-4e0f979e4290a4d10a067da0acca8e22

One Big Beautiful Bill Act, H.R. 1, 119th Congress (2025). https://www.congress.gov/bill/119th-congress/house-bill/1

Oregon Department of Justice. (2025a). Model immigration policies. https://www.doj.state.or.us/oregon-department-of-justice/civil-rights/sanctuary-promise/model-immigration-policies/

Oregon Department of Justice. (2025b). Oregon Department of Justice sanctuary promise guidance. https://www.doj.state.or.us/oregon-department-of-justice/civil-rights/sanctuary-promise/

Pinedo, M., & Escobar, C. (2024). Childhood parental deportations, immigration enforcement experiences, and posttraumatic stress disorder among US-born Latino adults, 2021. American Journal of Public Health, 114(S6), S495–S504. https://doi.org/10.2105/AJPH.2024.307660

Roche, K. M., White, R. M. B., Lambert, S. F., Schulenberg, J., Calzada, E. J., Kuperminc, G. P., & Little, T. D. (2020). Association of family member detention or deportation with Latino or Latina adolescents' later risks of suicidal ideation, alcohol use, and externalizing problems. JAMA Pediatrics, 174(5), 478–486.