Subjective and Mental Health Sequelae among Mexican Refugees

Mark Lusk and Griselda Villalobos

The University of Texas at El Paso

USA

Background & Significance

Intra-Country Violence

Diminished quality of life

Increased burden of disease

Chronic disability

Poor mental health

Affects hundreds of thousands annually

Eisenman, Gelberg, Liu, & Shapiro, 2003; Fortuna, Porche, & Alegria, 2008;

Pedersen, Tremblay, Errazuriz, & Gmarra, 2008; Walker & Barnett, 2007

Contributes to human suffering

Drug-Related Violence

Experiences associated with Intra-Country Violence

• Witnessing or experiencing:

– Threat to life or limb

– Severe physical harm

– Torture

– Loss of a loved one

– Forced disappearance

– Forced separation from family

Eisenman et al., 2003; Steel, Silove, Bird, McGorry, & Mohan, 1999

Drug-Related Violence

Drug-Related Violence

Contributing Factors to Refugee Mental Health

• Pre-migration – Loss of loved one

– The degree of choice to leave

– The ability to plan a move

– The ability to return to see family

– Forced separation from family

– Trauma exposure

– Imprisonment

– Eisenman et al., 2003; Fortuna et al., 2008; Steel et al., 1999; Steel et.al., 2009; Steel & Silove, 2000

Contributing Factors to Refugee Mental Health

• Peri-Migration

– Loss of social status & support

– Deprivation of food, water, & shelter

– Exploitation

– Sexual assault

– Imprisonment

– Fortuna et. al., 2008; Steel et al., 2009

Contributing Factors to Refugee Mental Health

• Post-migration

– Discrimination

– Poverty

– Social isolation

– Homelessness

– Lack of health care access

– Fear of deportation

– Fear for family left at home

– Eisenman et al., 2003; Maldonado et al., 2002; Miller et al., 2002; Silove, Momartin, Marnane, Steel, & Manicavasagar, 2010; Steel et al., 2009

Mental Health Sequelæ

• Depression

– Dose-response effects

• Anxiety

• Post Traumatic Stress

– Number of traumatic exposures

• High rates of disability, chronic pain, mortality, and perceived quality of life

• Eisenman, et al., 2003: Green et al., 2000; Kaltman et al., 2010; Lie, 2002: Lindert, von Ehrenstein, Priebe, Mielck, & Brahler, 2009; Marshal, Schell, Elliott, Berthold, & Chun, 2005; Mollica et al., 1998; Mollica et al., 1999; Pedersen et al., 2008

Variance in Mental Health Sequelæ

• Depression – Cambodian refugees – 68%

– Bosnian refugees – 39%

• Anxiety – Sierra Leone refugees-80%

– Vietnamese refugees – 5%

• Post Traumatic Stress Disorder – Cambodian refugees – 37%

– Sierra Leone refugees – 86% – Fenta, Hyman & Noh, 2007; Mollica et al., 1993; Mollica et al., 1999; Mollica et al., 2001; Silove, Steel, Bauman, Chey, & Cowell, 2007; Steel et al., 2006.

Mexico Drug War

• Declared in December 2006 by Felipe Calderon

• Over 50,000 soldiers and thousands of policemen

• 2,862 killed in 2006; 15,273 killed in 2010

• Total lives lost: Over 35,000

• Victims: Women, children, government officials, uninvolved citizens; US citizens

• Campbell, 2009; Goodman, 2011; Ramos, 2010;

Widespread Corruption

• Only 2% of detainees brought to trial

• 1,100 discarded guns traced to Texas in 2007

• Two-thirds of all homicides concentrated in 5 of 32 States.

• Mexican journalists no longer report on violence: 66 killed and 12 disappeared since 2005

• In 2009 in Juarez, 2,763 murders led to 30 arrests

• Bowden, 2011; Goodman, 2011: Mexican Drug War, 2009

Ciudad Juarez

• 2,763 killed in 2009: Over 3,111 killed in 2010

• 11,000 soldiers and police in Juarez

• As number of military increased, so have killings

• An estimated 125,000 refugees from Juarez in El Paso

• An estimated 7 of 10 businesses closed

• Anecdotal reports from Mental Health Professionals

• Abandonan Ciudad Juarez, 2010; Bowden, 2011; Campbell, 2009; Goodman, 2011

Ciudad Juarez

• By differing measures, Juarez ranks as the most violent city in Mexico, most violent in the Western Hemisphere, or even the most violent in the world, the local newspaper El Diario reported earlier this month (link in Spanish). Juarez, with a current population of 1.3 million, has lost more than 230,000 residents in an "exodus" from the daily barrage of drug-related killings, kidnappings and extortion operations.

Significance

• Experiences of Mexican refugees fleeing violence are understudied and unknown

• Mental Health sequelæ are unknown

• Research question: What are the subjective experiences and mental health sequelæ of Mexican refugees fleeing violence in Mexico?

Research Design

• Mixed methods design

– Beck’s Depression Inventory

– Harvard Trauma Questionnaire

– In-depth Qualitative Interview

• ~ 30 Mexican Nationals seeking refuge and mental health services in El Paso

Preliminary Findings: Pre & Peri-Migration Experiences

• Currently 20 participants completed interviews and questionnaires

• All participants experienced or witnessed multiple pre-migration traumas

• All participants moved for fear for their safety

• Most participants had family/friends in El Paso to assist with housing & transportation

Post-Migration Stressors

• Nearly all have no health care access

• Most have no social affiliations in US

• Overwhelmingly utilize public transportation

• All fear deportation

• All fear assassination

• All fear for family’s safety in Mexico

• All perceive a lower standard of living in the U.S.

Experiences Associated with Violence

• Forced to desecrate bodies

• Witnessed murder/violence

• Identified bodies

• Experienced extortion

• Kidnapped

• Forced separation from family

• Shot 4 times & son murdered

Subjective Experiences

• Tremendous sense of personal loss

• Numbness

• Anger at lack of justice

• Loss of faith in the Mexican Government

• Loss of empathy for others

Subjective Experiences (Cont’d)

• Diminished sense of functioning

• Feeling that no one understands

• Identity/Role confusion

• Increased sense of safety in the US

• Deportation anxiety

Reported Signs & Symptoms: BDI

• Physical complaints: Somatization

• Sleep pattern disturbances

• Changes in appetite

• Observed behaviors: Trembling, guarding, crying, agitation

• Perceive themselves as victims

• Scores indicate mild to severe depression

Reported Signs & Symptoms: HTQ

• Generalized anxiety, phobias, hyper-vigilance

• Sustained fear of capture

• Fear of assassination

• Depersonalization

Salient Themes

• Life in the Shadows

• Deportation Panic

• Suffering

• Human Rights

• Hope versus Despair

Life in the Shadows

• “It is a pity that people stop by my apartment with such sad stories about what is happening, about the persecution, fear of going outside, of living a normal life like any other human being who deserves dignity. In my own case I drive without a license since if I don’t drive I cannot work and my children won’t eat. We are working hidden in the shadows knowing that they could ask us for our documents. We always have that fear.”

Deportation Panic

• “That is the anguish I have. My only anguish. Is that they will deport me. That is my only fear right now. I always live with….I don’t want to think. I try not to think, because I say, “my God if they deport me, what am I going to do? That is my fear.”

Suffering

• “Testimonio de Eva” – Mark

• “Yes I have cried in the last two weeks because when I go give presentations, I realize things, that my parents are also suffering and that has hurt me. Realizing that in reality my parents suffered for the death of my brother and still suffer….they have always suffered because of my situation”

Suffering • “They are very conflicting feelings, because

besides the pain one is feeling for the loss of….someone, of a loved one, they are not only taking away a loved one, they are taking away your life, your home, your customs, of everything you have….not so much material things, but emotionally, they are affecting you too much, because you have to start all over, you have to face new and difficult things like, simply being in a new country, where it is not easy to start from the bottom….it is hate, resentment, it is sadness. Against whom? You don’t even know against whom, because you don’t know specifically who is causing you this pain.”

Human Rights

• “Llegamos a pie, subimos el puente, le dije perdone oficial donde puedo pedir un asilo….. me pusieron las esposas a mi y a mi hijo…..me arrepenti señores porque dije ay Dios mio ahora hasta en la carcel voy a estar despues de todo esto. Pues me pusieron como si fuera la peor de las criminales, cadenas asi en los pies, me subian a carros blindados, ay.”

Human Rights

• “Many of the people who are being arrested in the deserts or on the border are not given due process or fair treatment whatsoever. They are violating their human rights completely. No state, local or federal law should prevail over human rights. That is untouchable. Moreover, all the time they are passing new racists laws. Everyday they are trying to make our lives more difficult so that we are forced to leave this country.”

Hope versus Despair

• “I want to explain something, in reality, I have shelter, I have food, in other words, within all this bad, there is something good. It cannot be a punishment because I am well, I have life, I have food, and I have shelter.”

General Findings

• Massive psychological trauma “Left in a trunk” “Shot, son murdered, mother died”

“Assaulted at gunpoint, raped, lost everything, rebuilding life and giving back to community”

• Cumulative stress “Held two weeks for ransom, tortured and brainwashed”

Remarkable Resilience Through the Mediating Effects of Mexican Culture

Factors:

• Familism

• Religiosity

• Fatalism

• Collectivism

• Personalism

• Dignity

References

• Abandonan Ciudad Juarez 230 mil personal en dos anos. (2010, September 20). Prensa Mexicana. Retrieved from http://www.prensamexicana.com/noticia/26691/registro.php

• Bowden, C. (2011). Murder City: Ciudad Juarez and the global economy’s new killing fields. New York: Nation Books.

• Campbell, H. (2009). Drug war zone: Frontline dispatches from the streets of El Paso and Juarez. Austin: The University of Texas press.

• Eisenman, D., Gelberg, L., Liu, H., & Shapiro, M. (2003). Mental health and health-related quality of life among adult Latino primary care patients living in the United States with previous exposure to political violence. Journal of the American Medical Association, 290(5), 627-634.

• Fenta, H., Hyman, I., & Noh, S. (2007). Health service utilization by Ethiopian immigrants and refugees in Toronto. Journal of Immigrant & Minority Health, 9(4), 349-357.

• Fortuna, L., Porche, M., & Alegria, M. (2008). Political violence, psychosocial trauma, and the context of mental health services use among immigrant Latinos in the United States. Ethnicity & Health, 13(5), 435-463.

• Green, B., Goodman, L., & Krupnick, J. (2000). Outcome of single versus multiple trauma exposure in a screening sample. Journal of Traumatic Stress, 13, 271-286.

• Goodman, S. (2011). Mexican drug war a lost cause as presently fought. The Huffington Post. Retrieved from http://www.huffingtonpost.com/sandy-goodman/mexico-drug-was-a-lost-ca_b_833097.html

• Kaltman, S., Green, B., Mete, M., Shara, N., & Miranda, J. (2010). Trauma, depression, and comorbid PTSD/Depression in a community sample of Latina immigrants. Psychological Trauma, 2(1), 31-39.

• Lie, B. (2002). A 3-year follow-up study of psychosocial functioning and general symptoms in settled refugees. Acta Psychiatrica Scandinavica, 106(6), 415-425.

• Lindert, J., von Ehrenstein, O., Priebe, S., Mielck, A., & Brahler, E. (2009). Depression and anxiety in labor migrants and refugees-A systematic review and meta-analysis. Social Science & Medicine, 69, 246-257.

References

• Maldonado, J., Page, K., Koopman, C., Butler, L., Stein, H., & Spiegel, D. (2002). Acute stress reactions following the assassination of Mexican presidential candidate Colosio. Journal of Traumatic Stress, 15(5), 401-405.

• Marshall, G., Schell, T., Elliott, M., Berthold, S., & Chun, C. (2005). Mental health of Cambodian refugees 2 decades after resettlement in the United States. Journal of the American Medical Association, 294(5), 571-579.

• Mexican drug war: 10 shocking facts. (2009). Huffington Post. Retrieved from http://www.huffingtonpost.com/2009/04/15/mexican-drug-war-10-shock_n_187361.html

• Miller, K., Weine, S., Ramic, A., Brkic, N., Bjedic, Z., Smajkic, A., Boskailo, E., & Worthington, G. (2002). The relative contribution of war experiences and exile-related stressors to levels of psychological distress among Bosnian refugees. Journal of Traumatic Stress, 15(5), 377-387.

• Mollica, R., Donelan, K., Tor, S., Lavelle, J., Elias, C., & Frankel, M. (1993). The effect of trauma and confinement on functional health and mental health status of Cambodians living in Thailand-Cambodia border camps. Journal of the American Medical Association, 270(5), 581-586.

• Mollica, R., McInnes, K., Poole, C., & Tor, S. (1998). Dose-effect relationships of trauma to symptoms of depression and post-traumatic stress disorder among Cambodian survivors of mass violence. British Journal of Psychiatry, 173, 482-488.

• Mollica, R., McInnes, K., Sarajlic, N., Lavelle, J., Sarajlic, I., & Massagli, M. (1999). Disability associated with psychiatric comorbidity and health status in Bosnian refugees living in Croatia. Journal of the American Medical Association, 281(5), 433-439.

• Mollica, R., Sarajlic, N., Chernoff, M., Lavelle, J., Vokovic, I., & Massagli, M. (2001). Longitudinal study of psychiatric symptoms, disability, mortality, and emigration among Bosnian refugees. Journal of the American Medical Association, 286(5), 546-554.

References

• Pedersen, D., Tremblay, J., Errazuriz, C., & Gmarra, J. (2008). The sequelæ of political violence: Assessing trauma, suffering, and dislocation in the Peruvian highlands. Social Science & Medicine, 67, 205-217.

• Ramos, J. (2010). Cisen: 28mil muertos por guerra a narco. El Universal, August 3, 2010.

• Silove, D., Momartin, S., Marnane, C., Steel, Z., & Manicavasagar, V. (2010). Adult separation anxiety disorder among war-affected Bosnian refugees: Comorbidity with PTSD and associations with dimensions of trauma. Journal of Traumatic Stress, 23(1), 169-172.

• Silove, D., Steel, Z., Bauman, A., Chey, T., & Cowell, A. (2007). Trauma, PTSD and the longer-term mental health burden amongst Vietnamese refugees: A comparison with the Australian-born population. Social Psychiatry and Psychiatric Epidemiology, 42(6), 467-476.

• Steel, Z., Chey, T., Silove, D., Marnane, C., Bryant, R., & van Ommeren, M. (2009). Association of torture and other potentially traumatic events with mental health outcomes among populations exposed to mass conflict and displacement: A systematic review and meta-analysis. Journal of the American Medical Association, 302(5), 537-549.

• Steel, Z., & Silove, D. (2000). The psychological cost of seeking and granting asylum. In Shalev, A., Yehuda, R., & McFarlane, A. (Eds.), International handbook of human response to trauma (Chapter 31). London: Plenum Series on Stress and Coping.

• Steel, Z., Silove, D., Bird, K., McGorry, P., & Mohan, P. (1999). Pathways from war trauma to posttraumatic stress symptoms among Tamil asylum seekers, refugees, and immigrants. Journal of Traumatic Stress, 12(3), 421-435.

• Walker, P., & Barnett, E. (2007). Immigrant Medicine. St. Louis, MO: Elsevier Mosby.