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Mental health among Mexican refugees fleeing violence and trauma.

Over the past six years, social development in Mexico has severely declined. The war against drug cartels, undertaken by past president Felipe Calderon, has been accompanied by widespread violence, pervasive government corruption, a decline in participation in civil society, and the emergence of a large group of youth and children who neither attend school nor are employed (Lusk, Staudt, & Moya, 2012). At the same time, six out of ten Mexican workers are employed without benefits, contracts, or retirement plans, and as many as twenty-nine million work in the informal economy, off the books and without protection (Cruz, 2012). As a result of the violence and economic instability related to the drug war, Mexico is losing its social capital and national cohesiveness. A consequence of this is the emergence of a new type of Mexican migrant: the refugee.

Mexican refugees flee their home country because they have been exposed to violence, extortion, rape, torture, arson, and threats on their own lives. They come to the United States fearing for their lives rather than seeking a job. A result of their experience, there are significant, adverse consequences to their mental health, including depression, anxiety, and traumatic stress.

Former president Felipe Calderon declared war on the drug cartels and drug traffickers in 2006, launching an epidemic of nationwide violence that began between drug cartels warring for control of transportation routes into North America (Campbell, 2009). The violence has since escalated to include private citizens, children, women, health-care workers, local business owners, and students (Grissom, 2010; Miroff & Booth, 2011; Weissert, 2010). Tactics have escalated from drive-by shootings to, among other things, the use of explosives, beheadings, and attacks on drug rehabilitation centers, churches, and private homes.

In Ciudad Juarez alone, more than 3,000 persons were killed in 2010, earning it the title of most dangerous city in Mexico (Goodman, 2011). Since 2008, an estimated seven of ten businesses in Ciudad Juarez have closed, 230,000 Juarez residents have migrated to the United States for safety, and 124,000 of those have settled in El Paso, Texas (Abandonan Ciudad Juarez, 2010; Huyen 230 mil personas, 2010). At least 100,000 people have been intentionally killed or disappeared in Mexico over the past six years (Karlin, 2012).

The result of this widespread violence has been a surge in opportunistic crime and a wave of kidnappings, carjackings, extortion of individuals and businesses, rape, interpersonal violence, and murder (Campbell, 2009; Dominguez-Ruvacalba & Corona, 2010).

Refugees from Mexico in El Paso

In our work with local mental health agencies over the past five years, we have seen dramatic increases in the number of people in El Paso seeking mental health services related to the traumatic experiences they were exposed to while living in Mexico--especially in the US-Mexico border region, where drug violence is greatest. Many hundreds and perhaps thousands of migrants have fled Mexico to the United States in search of safety, fearing for their lives, property, and income. They have also migrated because of the direct experience of extortion, kidnapping, murder of relatives, destruction of their homes and businesses, and other severe trauma. In this article we call them refugees, not because they meet the US government's definition of refugee--persecuted members of protected classes such as religious or ethnic minorities, but because they, like other refugees from Guatemala, El Salvador, Rwanda, Colombia, Sudan, and elsewhere, are fleeing for their lives.

In our practice as trauma specialists in the community, we have come across individuals who wished to tell their stories so that people could become aware of the enormous personal and psychological costs associated with the violence in Mexico and the accompanying breakdown of civil society. As border residents who have worked extensively in the metropolitan area of Ciudad Juarez and El Paso, we are very familiar with the ongoing, widespread disorder experienced in Mexico, a violence that extends well beyond battles among cartels to have taken the lives of civilians who have no involvement in drugs or organized crime.

Thus, we studied a group of refugees from violence who had resettled on the northern side of the US-Mexico border in order to understand what they have experienced so that we can formulate evidence-based policies and treatment modalities for the mental health community in the border region. The purpose of this research is to explore and describe the perspectives of Mexican refugees who have fled violence in Mexico, migrated to the United States, and resettled along the US-Mexico border. While refugee experiences are well researched and documented across multiple contexts, the exploration of the perspectives of Mexicans fleeing violence in Mexico provides a unique, within-context perspective of their experiences. This study has implications for all developing nations that are experiencing mass violence.

This is a qualitative study designed to explore significant experiences and mental health sequelae of Mexicans who migrated to El Paso, Texas, because of the decline of trust and social cohesion as a result of rampant violence and insecurity in Mexico. We conducted in-depth, semistructured interviews with refugees who have sought mental health treatment in El Paso, Texas, for violence and related trauma. We conducted a total of twenty-four interviews to better understand the refugee experience and to provide new insight into the unique experiences of Mexican refugees, with the aim of this enhancing culturally sensitive mental health treatment and providing the basis for future clinical research within this population. Refugees were referred to us by partner mental health agencies in El Paso. All interviewees were undocumented migrants who reside in El Paso, and all were victims of violence; some also were victims of extortion, rape, arson, torture, attempted homicide. The interviews, which were in Spanish, were transcribed for qualitative analysis. As part of the interview, we also clinically evaluated each person for posttraumatic stress disorder (PTSD) and depression using the Spanish-language versions of the Harvard Trauma Questionnaire and the Beck's Depression Inventory (Beck, Steer, & Carbin, 1988; Mollica, McDonald, Massagli, & Silove, 2004).

Background

Over the past three decades, in nations such as Colombia, Rwanda, Somalia, Cambodia, Guatemala, El Salvador, and elsewhere, increasing within-country violence and worldwide social upheaval have exposed uninvolved citizens to repeated traumatic experiences associated with violence, political instability, civil armed combat, terrorism, drug trafficking, and the breakdown of civil society (Gabriel et al., 2007; Misra, Connolly, & Majeed, 2006; Mollica et al., 2004; Sabin, Cardozo, Nackerud, Kaiser, & Varese, 2003; Silove, 1999; Steel & Silove, 2000; Walker & Barnett, 2007). Hundreds of thousands of people from impoverished nations have fled their home countries to escape persecution and genocide, becoming internally displaced or refugees to foreign countries (Steel & Silove, 2000; UN High Commissioner for Refugees, 2010; Yasan, Saka, Ozkan, & Ertem, 2009).

The psychosocial effects of war and armed conflict are well documented and known to contribute to human suffering, poor mental health, diminished quality of life, increased burden of disease, and chronic disability (Courtois, 2008; Eisenman, Gelberg, Liu, & Shapiro, 2003; Fortuna, Porche, & Alegria, 2008; Pedersen, Tremblay, Errazuriz, & Gmarra, 2008; Savoca & Rosenheck, 2000; Walker & Barnett, 2007). Experiences that have brought on these effects include witnessing or experiencing a threat to life or limb, severe physical harm and/or injury, torture, exposure to the grotesque, violent and/or sudden loss of a loved one, the causing of death and/or severe harm to another, forced disappearance, threat of abduction, extortion, and forced separation from family (Eisenman et al., 2003; Sinnerbrink, Silove, Field, Steel, & Manicavasagar, 1997; Steel, Silove, Bird, McGorry, & Mohan, 1999; Tol et al., 2010).

In Latin America specifically, over the past three decades, state terrorism, ethnic genocide, and drug-related violence have led thousands of citizens of Colombia, Guatemala, Ecuador, Cuba, Brazil, Venezuela, and El Salvador to seek refuge in other countries (Eisenman et al., 2003; Sabin et al., 2003; Walker & Barnett, 2007). After migrating to escape violence, many have secured permanent visas or attained asylum status in the United States (Eisenman et al., 2003; Fortuna et al., 2008; Kaltman, Green, Mete, Shara, & Miranda, 2010).

Refugee Experiences

Those who flee violence and social upheaval can witness or experience threats to life or limb, severe physical harm and/or injury, torture, and exposure to the grotesque. They also can witness the violent and sudden loss of a loved one, forced disappearances, threats of abduction, extortion, and forced separation from their family (Eisenman et al., 2003; Steel et al., 1999).

Once people make the decision to migrate as refugees, they experience additional physical and psychological trauma and stress. These migration-related stressors include lack of shelter, food, and water; exploitation; physical abuse, including rape; extortion; and police harassment (Mollica et al., 2004; Pedersen et al., 2008). Upon relocation to the host country, many refugees experience post-migration stressors related to detainment, discrimination, unemployment and poverty, homelessness, separation from family, social isolation, and possible deportation (Eisenman et al., 2003; Lie, 2002; Marshall, Schell, Elliott, Berthold, & Chun, 2005).

Mental health sequelae of refugees are closely intertwined with the migration experiences that contribute to depression, anxiety, and symptoms of PTSD (Fortuna et al., 2008; Steel & Silove, 2000; Walker & Barnett, 2007). Refugees who experience migration violence and trauma suffer multiple losses. While the most frequent trauma is the unnatural death of a loved one (Steel et al., 1999), also contributing to symptoms of post-migration anxiety and depression are the degree of choice that a person had in leaving his or her home country and the ability to plan a move or return (Fortuna et al., 2008).

Exposure to violence contributes to depression in a manner similar to a cumulative dose-response effect. The more exposures there are, the higher rates of depression are found in refugee populations, with those who have more than three exposures exhibiting symptoms of comorbid PTSD (Green, Goodman, & Krupnick, 2000; Kaltman et al., 2010; Mollica, McInnes, Poole, & Tor, 1998; Steel et al., 2009). Pre-migration factors that strongly correlate with symptoms of PTSD include forced separation from family, isolation, torture, trauma exposure, and imprisonment. Torture is the strongest predictor of PTSD in refugee populations, and those who survive it exhibit a 46 percent increase in PTSD prevalence (Eisenman et al., 2003; Steel & Silove, 2000; Steel et al., 2009).

Migration experiences that contribute to depression include loss of social status and support, as well as displacement (Fortuna et al., 2008). Frequently, the migration experiences of refugees fleeing violence bring continued violence, as they are dependent on smugglers to assist them in crossing international borders. These experiences of violence include rape; deprivation of food, water, and shelter; and exploitation.

Post-migration experiences of discrimination, poverty, separation from family, social isolation, homelessness, lack of health-care access, sense of loss, and fear of deportation contribute to symptoms of depression and anxiety across ethnic groups (Eisenman et al., 2003; Maldonado et al., 2002; Miller et al., 2002; Silove, Momartin, Marnane, Steel, & Manicavasagar, 2010; Steel et al., 2009). In addition, known post-migratory predictors for PTSD in refugees include separation from family and spouse, fear for family left at home, uncertainty in the new country, poverty, loneliness, boredom, and isolation (Eisenman et al., 2003; Steel & Silove, 2000).

Mexican Refugee Experiences

Mental health professionals in El Paso, Texas, report increasing contact with Mexican refugees. They report that refugees have been subjected to death threats, extortion, kidnapping threats, and carjackings, and/or they have witnessed murders and abductions. Clinicians indicate that the refugees are traumatized by their experiences in Mexico and have voluntarily escaped to the United States, whether documented or not, to seek safety, refuge, and security.

Because of the rapid increase in violence in Mexico from 2007 to the present, and with a particular surge in violence in Ciudad Juarez and the border region, the experiences of Mexican citizens and their reasons for migration have drastically changed. As a result of the border contiguity of El Paso and Ciudad Juarez, large numbers of Mexican refugees have migrated across the border for safety. Their perspectives on violence, migration, and resettlement are known within the border region and have been covered by international and local journalists, but their experiences have as yet been afforded scant assessment by mental health professionals.

Psychosocial Effects

The psychosocial effects of armed conflict and political violence are well documented and known to contribute to human suffering, poor mental health, diminished quality of life, increased burden of disease, and chronic disability in refugee populations (Courtois, 2008; Eisenman et al., 2003; Fortuna et al., 2008; Pedersen et al., 2008; Savoca & Rosenheck, 2000; Walker & Barnett, 2007). Perceived psychological distress depends on the cumulative effects of pre-migration experiences associated with trauma and flight, peri-migration stressors, and post-migration resettlement stress (Mollica et al., 1999). A large body of research has shown that refugees fleeing mass conflict that results in displacement experience symptoms of PTSD, anxiety, and depression (Eisenman et al., 2003; Green et al., 2000; Mollica et al., 1998; Mollica et al., 1999; Pedersen et al., 2008). In addition, psychosomatic disorders, grief disorders, and crises of existential meaning have been reported in multiple refugee populations (Schweitzer, Greenslade, & Kagee, 2007; Silove, 1999).

Perspectives of violence, migration, and resettlement experiences contribute to psychological distress, as well as perceptions of suffering, health, and quality of life in refugee populations. In addition, because these perspectives are culturally bound, each cultural group experiences and expresses trauma and loss uniquely (Mollica, 2006; Silove, 1999; Witztum & Kotler, 2000). Because of the recent wave of Mexican refugees into the United States, the cultural similarity between the border cities of Texas and Mexico, and the ease of crossing into the United States, the migration experiences and perspectives of Mexican refugees are unlike the experiences of other refugee groups. Moreover, research about Hispanic refugees in the United States has focused on those from Latin America in general, rather than Mexico specifically (Eisenman et al., 2003; Fortuna et al., 2008; Mitrani, 2011).

Traditionally, Mexicans have migrated to the United States for economic purposes (Eisenman et al., 2003; Fortuna et al., 2008). The onset of mass violence in Mexico, particularly in the border states of Chihuahua, Baja California del Norte, Jalisco, Coahuila, Sonora, Nuevo Leon, and Tamaulipas has led to a new migration of refugees. Their experiences and situations are poorly understood by mental health providers.

Mexican Refugees

Individuals who flee violence in their home country tend do so in waves. The first wave of immigrant refugees is generally affluent, may have dual citizenship, is educated, and has the resources to reestablish themselves in the host country of their choice. Second-wave refugees tend to be middle class and to hold permanent legal status or work visas. Third-wave refugees tend to be poor and undocumented, and to have access to few resources to be able to reestablish themselves and their families (Fortuna et al., 2008).

The first and second waves of out-migration of traumatized refugees from Mexico occurred in 2007 and 2008, as Mexican nationals fled to Canada. Temporary entry into Canada does not require a visa, and the refugee application process can be completed in as little as six months, compared to eighteen months in the United States. Between 2006 and 2007, Mexican applications for refugee status into Canada increased from fewer than one thousand applications to more than five thousand applications (Nicholas, 2007). In 2007 and 2008, the number of Mexican refugee applicants in Canada increased an additional 33 percent (Day, 2009).

Since 2008, an estimated 230,000 Mexican nationals have fled violence in Ciudad Juarez, and 124,000 of those have settled into El Paso, Texas (Abandonan Ciudad Juarez, 2010; Huyen 230 mil personas, 2010). While some of these people may have permanent residency status, we expect that given the increasing violence against citizens and the lack of employment in Juarez, most of them are poor and undocumented.

Research Design

The purpose of this qualitative exploratory study is to explore the mental health sequelae of refugees from Mexico who have fled because of trauma, including physical violence, extortion, kidnapping, physical threats, rape, assault, torture, and the destruction of personal property. The persons we interviewed had experienced some of the most horrific events one can be subjected to, including torture as well as witnessing the desecration of bodies and the murders of family members. Inclusion criteria for participants were that they be eighteen years of age or older and Mexicans who migrated to the United States within the past five years to find safer living conditions and to escape violence. They may be documented or undocumented immigrants, speak English or Spanish, and they must be able to participate in the informed consent process.

Bearing in mind that trauma is mediated by culture (Witztum & Kotler, 2000), the interviews were conducted in Spanish by culturally competent researchers who have an understanding of the nuances of border-region linguistic, emotional, cognitive, and behavioral expressions of subject situations. The depth interviews were supplemented by the administration of the Harvard Trauma Questionnaire (HTQ) in Spanish and the Spanish-language Beck Depression Inventory, both of which have been validated for research with his population (Daza, Nony, Stanley, & Averill, 2002; Mollica et al., 2004). The HTQ was used to inventory the nature of the traumatic events that subjects had experienced and to assess the extent of PTSD. The Beck Depression Inventory determined the severity of depression. The interview was designed to identify sources of support and resiliency.

Salient themes were identified after carefully reviewing and coding the interview transcriptions. We summarized these themes and connected them to specific quotations.

Witnesses to Trauma

The individuals we interviewed represented all social classes and income groups in Ciudad Juarez. Among the subjects were a middle-class psychologist, a drug dealer and hit man, a shopkeeper, a very poor woman who had been in a violent and abusive relationship, a prominent attorney, a young male mechanic of modest means, and a journalist. The youngest interviewee was in her early twenties and the oldest in his late sixties. All indicated that they had fled in fear of their lives.

The interviewees represent a cross-section of Juarenses, or residents of Ciudad Juarez, except that, on average, they were more affluent and well educated than the general population. In interviews, the refugees were open, forthright, and outspoken, but each reported that he or she still lived in fear. All interviews were conducted in a community mental health center, which afforded the refugees a sense of safety and privacy unavailable in other settings in El Paso.

Each of the refugees was clinically evaluated with the Harvard Trauma Questionnaire and the Beck's Depression Inventory in Spanish. Of importance, all twenty-four respondents experienced mild to severe depression; most were in the moderate range. All respondents had experienced at least one major traumatic event, and all exhibited symptoms of posttraumatic stress disorder.

As we interviewed the refugees over a period of three months, we began to see the commonalities among their situations. We were struck by the severity of the events that they had witnessed. Bearing in mind that they had been exposed to severe traumatic events, including torture, kidnapping, assault, rape, armed robbery, extortion, and beatings, among other things, we were surprised by how remarkably poised and settled many of them seemed while describing their histories, as if they had happened to someone else (depersonalization). Others, still with fresh memories of their trauma, wept; cried out; angrily spoke about their assailants, kidnappers, torturers; and lamented their losses--a murdered son, a burned-out business, a husband sent to an American immigration detention center (prison), and a spouse who had been decapitated.

In this section, we highlight representative case histories to explore the nature of the trauma, the experience of migration, and the process of adaptation and adjustment to living life as a refugee (usually undocumented and in hiding). In the concluding section, we explore the salient themes that emerged from a qualitative analysis of the transcriptions to summarize the broad common elements of being Mexican refugees who have fled to the North for a semblance of comparative safety.

Juanita

Juanita is a young business owner who believes she had a "wonderful life" before becoming a refugee from violence. She owned a beauty salon, ran a beauty school, cared for her husband and children, and owned her own house and car. Her children were happy and doing well in school. She believed her life was full of opportunity.

As the violence escalated, she and her family became victims. It began when her brother, who was involved in the drug business, was killed. She and her husband identified his faceless body. Three months later, her other brother was shot in the head but lived. He went with Juanita to her home briefly and then left town to hide out. In the middle of the night, strangers broke into her home looking for her brother. She said, "They did not shoot us; they just beat us and demanded to know where my brother was." Unable to locate her brother, the strangers robbed the family of all cash, jewelry, and her laptop computer. They guaranteed to return and kill her and her family if the police arrived. The police arrived an hour later. Her father, mother, and brothers split up and fled to different areas in the United States.

Juanita, her husband, and children hid out for days before crossing to "El Norte." They fled their home with no belongings or money and arrived in the United States with only the clothes on their back. At the border bridge, they begged for asylum. Her husband, who had previously been deported, was arrested and incarcerated at the El Paso Detention Center. She and her two daughters were given permission to enter. They stayed in a shelter. She scraped by with one change of clothes for her daughters, who were taunted and bullied at school for being poor immigrants with no English. A bully cut off one of her daughter's hair. Juanita wept for her estranged husband, bullied children, lack of a home, and deep economic insecurity, including hunger. Her situation epitomized despair and suffering.

Maria

Maria was a successful attorney in a major city in the interior of Mexico. While not affluent, she was a comfortable single woman with two children. Told by neighbors that their house was being watched, Maria and her parents and children moved in with her grandparents. Her brother stayed at home to watch the house, but he was kidnapped and held for ransom. While her family assembled the ransom money, her brother was beaten to death. As an attorney, she went to the authorities for assistance and, finding no justice, threatened to take legal action. This led to threats from her brother's murderers, so in fear of her life, she fled to El Paso with her daughters on a temporary visa that has since expired. Unable to work legally, she was exploited by employers and paid less than minimum wage. Eventually finding a minimum wage job, she was able to find a modest flat. Nonetheless, as an immigrant without documents, she was not eligible for Medicaid or any other benefits.

Maria's life is defined by ongoing and profound fear of being caught by immigration authorities. She describes herself as "living in the shadows." If she is arrested, she is certain of her deportation and subsequent death at the hands of her brother's murderers. But unlike Juanita, who is in deep despair, Maria regularly speaks at civil rights events in complete disguise, decrying the injustice of her situation as a victim of structural violence. In her words:
   Many of the people who are arrested in the deserts and on the
   border, many of the people are not given due process or fair
   treatment whatsoever. They are violating their human rights
   completely. I have always deeply believed that no state, local, or
   federal law should prevail over human rights. No one should be
   allowed to violate the individual rights guaranteed to each person.
   That is untouchable. It cannot be, it cannot continue to happen,
   yet it does! Moreover, they are always passing new racist laws.
   Every day they are trying to make our lives here in this country
   even more difficult so that we are forced to leave this country.


So while confronted with death, despair, and alienation, Maria, instead of buckling under the strain, has become a vocal opponent of America's immigration quagmire.

Blanca

Blanca, a nineteen-year-old college student, was born in Ciudad Juarez and has commuted frequently between Juarez and El Paso. Her grandparents still live in Mexico, and before the onset of violence, she spent most of her time there with family and friends. She and her friends enjoyed the food and nightlife of Juarez and went out frequently.

Blanca's parents were divorced, and her mother owned a home in El Paso. When her mother died, the home was willed to Blanca. This simplified her life by eliminating the need for a daily border crossing to attend classes. As the violence escalated in Juarez, Blanca found herself spending more and more time in the United States while her sisters remained in Mexico.

Blanca's father, who also resided in El Paso, continued to commute to Juarez daily to work and socialize. One weekend while she was out of town, she received a call from her sister, reporting that her father had been murdered in Juarez. She and her sister spent hours trying to call her father, with no success. She and her sisters spent hours trying to locate her father or find information without success. Finally, she found a picture of a murder scene in Juarez online that contained her father's car and a report of an attempted carjacking.

Blanca and her sisters went directly to her home in El Paso and were bombarded by ABC, NBC, Univision, and Telemundo news reporters, who were waiting to interview her family. She learned the details of her father's death through the news. The case was highly publicized in the local and national media. The US consulate in Juarez and the Mexican Federal Police in Juarez would not provide any information to the family, so all the information Blanca and her family received was from the media. In addition, because the case was so highly publicized, her father's body was expedited to El Paso within five days rather than the standard two to three weeks.

As a result of losing her father and learning of his fate in this way, Blanca is traumatized, as other victims of violence have been. Her life is full of suffering and despair. She describes her life now as having lost part of herself. She states: "I can't relate to people as I used to. I used to think I could relate well to people and now I feel when people tell me their problems, I can't sympathize with them the way I use to. I think that's a big thing about me that I used to have. I used to be a good listener, and now I can't do that. I am sad all the time. I can't shake the sadness."

Francisco

Francisco was a hired killer, or sicario. After getting caught selling two kilos of cocaine, Francisco was sentenced to five years in El Cereso, the penitentiary in Juarez. A member of a prominent drug syndicate, he was well looked after by his bosses, who plied him with enough money for drugs, women, electronics, and restaurant food. While incarcerated, he began snorting heroin, a habit that quickly grew to twenty doses a day, requiring him to begin to shoot up to get high. Sharing needles with inmates, he contracted HIV, for which his former bosses cut him off. Without protection and with no money, he was regularly assaulted and finally stabbed in prison. His sentence was commuted at three years when he developed AIDS. Francisco returned to the trade, where he committed and was exposed to innumerable atrocities. On the Harvard Trauma Questionnaire, he admitted to the following experiences: being homeless, having his property confiscated, engaging in armed combat, as well as being beaten badly, knifed, tortured, imprisoned, robbed, brainwashed, kidnapped. He also desecrated the bodies of people he had killed; destroyed victims' property; and participated in murder, beatings, and torture. He also had survived murder attempts.

Realizing the peril of his situation and unable to secure the latest AIDS treatment, he drove a load of marijuana to the border and when asked if he was carrying any drugs, he said yes. The federal judge gave him one year in the penitentiary, where he was treated for AIDS and experienced a conversion to fundamental Protestantism. Now sober for four years, Francisco volunteers as an AIDS educator. He seems disconnected from the life he led and describes it with detached objectivity; since his "conversion," he says, he is a different person. He has no signs or symptoms of depression or PTSD despite his criminal past, his former brutality, and his dim future as a person with, he says, "full-blown AIDS." While he lives in the shadows with a pseudonym and new identity, he is absent of the despair and hopelessness he has caused in so many others.

Salient Themes

These cases begin to illustrate the patterns of trauma among Mexican refugees. When we analyzed the twenty-four lengthy interviews in their entirety, five salient themes emerged that tied them together: life in the shadows, deportation panic, human rights, suffering, and hope versus despair.

The feeling of living life in the shadows is reflected in the lives of most of the refugees, in that they feel the need to lie low, keep a low profile, and avoid law enforcement and immigration authorities. Their fears were often well founded; if discovered, their former tormentors may find them and deliver their retribution. Most fear the prospect of being returned to Mexico by force, either by being captured by their antagonists or by being picked up by "la migra." Yet an anonymous life is not a life fully lived. As a refugee, one is outside the space of conventional social safety and support networks. However, we were surprised that small extended networks of relatives and friends sustained and supported the refugees, albeit with scarce resources. As Juanita pointed out:
   It is sad to see the faces of these people, their shoulders slumped
   from fatigue, people who work for hours and hours without fair
   compensation. Why? The greatest compensation one could have is to
   live in a state of liberty. But we cannot even go out on the
   streets freely. We can be among people who appear to be "legal" and
   within the law, but within our hearts is the fear that any
   infraction or minor imprudence could provoke our deportation. One
   cannot live like that! People are afraid to go out and look for
   work. We are afraid that someone of ill will might identify us as
   immigrants and get us deported at any time and live separate from
   our children and with all that goes along with that.


The construct of suffering is as old as humanity. While strongly associated with pain, suffering denotes the affective experience of unpleasantness associated with harm or threat of harm (Amato, 1990). Mexican refugees suffer loss of family, social status, financial stability, safety, and security. Despite feeling safe after migrating to the United States, they express feelings of hopelessness, futility, meaninglessness, and disappointment. The inability to find work, live openly, access health care, and maintain social contacts results in constant emotional pain or suffering because of the experience of violence and migration trauma. Suffering in this population is more than a state of mind; it is an existential state of being.

Although existential suffering has been extensively studied in the elderly and terminally ill patients (Hirai, Morita, & Kashiwagi, 2003), characteristics of this phenomena apply to refugees. The characteristics of existential suffering include experiencing a state of groundlessness or being "shaken to the core" (Bruce, Schreiber, Petrovskaya, & Boston, 2011). Refugees discussed violence and migration experiences as invoking fear, frustration, anger, and dissonance both before and after migration. The refugees' mental anguish was universal, though directed at different aspects of their lives. Linda describes suffering associated with living in fear:
   We came here a few months ago after my pregnant daughter--she's
   seventeen--was mugged in front of my home. After that, my daughters
   wanted to move to El Paso, and I kept saying no. But I was afraid
   all the time because they had to walk to school alone. Now I still
   can't get rid of the fear. I have a driver's license but I don't
   drive. It takes a lot of energy from me. What if the police arrest
   me? That is why I am afraid. I don't want to go back to Juarez.
   That is the anguish I have--my only anguish is that they will send
   me back again. The fear I always live with and don't want to think
   about. Oh God, if they send me back, what will I do?


Other Findings and Discussion

As we have seen from the discussion of salient themes, refugees are afraid of deportation and feel that they are in hiding and living in the shadows. They also are angry at the injustices that they have had to experience. Many of them referred to the impunity with which they have been hurt. They all recounted the experience of suffering--some had witnessed the deepest of despair and yet most had rediscovered hope over time

Consistent with previous refugee research, Mexican refugees have serious mental health sequelae. All the refugees we interviewed had experienced PTSD and clinical depression. Most had made progress in resolving PTSD by becoming integrated into the migrant community of El Paso, where they reported receiving strong support. The near majority continues to experience clinical depression, ranging from mild to profound. Their situations are characterized by an extreme sense of loss. We saw that most had culturally mediated their depression since arrival by becoming embedded in community. Only those who were still living in shelters or extreme poverty continue to be severely depressed.

Of importance to future research and treatment interventions, we saw resiliency in all but a few subjects. This manifested primarily through engagement with the migrant expatriate community, where they found solace and social relationships. Because extended families in the border region often are arrayed across both sides of the border, many found economic and social support among relatives. The most resilient were those with the highest education and income, even though they lost their income and social status when they migrated.

Refugees are a key contemporary issue in global social development. As conflict and migration increasingly shape the world, more research is needed to help understand refugees and their needs.

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Mark Lusk is professor in the Department of Social Work, College of Health Sciences at the University of Texas at El Paso. Jana McCallister is assistant clinical professor in the School of Nursing at the University of Texas at El Paso. Griselda Villalobos is a clinical social worker and therapist in El Paso, Texas. This research project was approved by the University of Texas at El Paso Institutional Review Board, ID No. 241471-1. The project was funded by the Hispanic Health Disparities Research Center.
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Author:Lusk, Mark; McCallister, Jana; Villalobos, Griselda
Publication:Social Development Issues: Alternative Approaches to Global Human Needs
Date:Nov 1, 2013
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