Hispanics and Mental Health
Fellows Sharon Salyer and Alejandro Dominguez's exhaustively-reported series on the mental health challenges facing Hispanics in the Pacific Northwest has won journalism prizes from the Association of Health Care Journalists, National Institute of Health Care Management, Mental Health America and the Society of Professional Journalists of the Pacific Northwest. To see the full series, with multimedia stories, click here.
She was just 13 when the man tried to rape her. She got away.
He came back with a gun, she said, attacking her inside her parents' house in Cuauhtémoc, a town in the state of Chihuahua, Mexico.
He pushed her down, onto a crowbar. She escaped from him again, but this time she was bleeding from a cut forehead and a deep slash running from her lip to her nose.
The man, no stranger to her family, was a neighbor. Although police officers took him away, her family knew he would just be back again.
Fearing for her safety, her mother sent Cristina Mendez-Diaz across the border, to Phoenix, to live with her biological father. The girl had never met or even seen a photograph of him.
It was the first time in her life that circumstance forced Mendez-Diaz to run. It would not be the last.
For 11 years, her life, like that of many immigrants, has been marked by isolation and rootlessness.
Depression and anxiety are frequently part of the experience, as immigrants adjust to a new culture separated from families, social networks and emotional support.
Experts say there is a need for mental health services to help Hispanics, whose numbers are increasing because of immigration, including illegal immigration.
Mental health problems among both legal and illegal immigrants can create social problems that can spill over and affect the rest of the community.
One person's untreated clinical depression can cost everyone when police get more calls on domestic disturbances or when people show up in emergency rooms as a result of alcohol or drug abuse.
In American culture, the widespread stigma associated with mental health problems prevents many people from seeking help.
In Hispanic culture, the stigma is even more deeply rooted and considered not only a problem for the individual, but shameful for the person's entire family. A taunt with the word "loco" -- crazy -- can start a fight or be an early step in an escalating conflict.
Just asking for help becomes a source of shame.
Fewer than one in 11 Hispanic Americans with mental disorders contacts a mental health specialist. Studies have found that Hispanic youth, who can be of any racial background, experience proportionately more anxiety-related problems and delinquency, depression and drug use than do white youth who are not Hispanic, according to a mental health report by the surgeon general.
An estimated one-quarter of Hispanic high school students meet the criteria for clinical depression, according to the National Alliance For Hispanic Health.
Perhaps as a consequence, adolescent Hispanic girls are far more likely to attempt suicide than their African American or white peers, according to the Centers for Disease Control and Prevention.
Another challenge is shared by many American families of all cultural backgrounds: a lack of mental health coverage in medical insurance plans.
This is far more acute among Hispanics. Only 41 percent of Hispanics have health insurance with mental health coverage, which is 20 percent less than the general population, according to a survey by the America Psychological Association. The people surveyed were not asked their citizenship status.
Those without health insurance can face long waits for help at nonprofit counseling services, especially for specialists such as child psychiatrists.
Immigration status also affects mental health. Tighter immigration enforcement has added stress. A survey of Hispanic immigrants, both legal and illegal, found 63 percent saying they feel worse off this year than last year, according to the Pew Hispanic Center in Washington, D.C. At the same time, immigrants believe they would be worse off in the country they left behind.
Razor wire tops the tall fences that surround the Northwest Detention Center in Tacoma, Wash., which houses up to 1,000 detainees who have been arrested by ICE (Immigration and Customs Enforcement).
There is one additional fear shared by the estimated 11.9 million illegal or undocumented workers living in the United States. Many like Mendez-Diaz, who have been living here for years, know they risk being discovered, taken to a federal detention center and being deported.
This year has been record-setting in deportations and arrests made by U.S. Immigration and Customs Enforcement, according to numbers provided by federal authorities.
Nationally, ICE deportations have increased to 345,710 made in the one-year period ending Sept. 30, up from the 205,461 deportations in 2005. Approximately 300,000 people are held in detention each year, including 12,500 at the Northwest Detention Center in Tacoma.
Immigration arrests abruptly separate men and women from their families.
Suddenly, those caught in the crackdown must navigate a complex legal system and immigration laws they may only partially understand. Their lives are instantly regulated.
Everything they do behind a razor-wired federal compound is watched by guards. Within a month, they could be told their days in the United States are over.
"This drastic, all-of-a-sudden event is like a natural disaster," said Jorge Barón, executive director of the Northwest Immigrant Rights Project in Seattle. Many have never been to jail or had an experience "where they've been locked up ... basically in maximum security," he said.
The longer a person is detained, the more their mental health suffers, Barón said.
"I've certainly seen the anxiety. ... It gets stronger," he said.
Nearly 10 percent of the 1,000 men and women held at the Northwest Detention Center in Tacoma are prescribed antidepressants, according to federal immigration officials.
Many people held there have escaped persecution, civil wars or other violence in their home countries. They walk through the door with severe mental health issues such as depression, anxiety and post-traumatic stress disorder, said Claudia Antuña, a social worker who spends about 20 hours a week conducting psychological evaluations on detainees for the Northwest Immigrant Rights Project.
Those problems can intensify with the stress of detention, she said.
In even the simplest of immigration arrests, for instance, women are separated from their children, who perhaps are watched by a baby sitter who is unaware that the mother won't be coming to get them. Fathers suddenly aren't able to provide for their families, so "their rent doesn't get paid, their belongings get thrown onto the street," Antuña said.
"The severity of the shock is enormous," she said. "Every one of these situations is so uniquely different, but they have the same common theme -- they're totally unprepared and there's no one helping them deal with it."
Fear of being seen
The women's area at the Northwest Detention Center in Tacoma has semi-private cells and bunks in the common area. Everything, including bunks and dining tables, is made of steel and is firmly attached to the concrete floor.
Hispanics in general, including citizens and those who immigrated here legally, are feeling more anxiety connected with the rise of activity from ICE and other federal agencies. Nearly one in 10 Hispanic adults -- U.S.-born and immigrants -- reports being stopped last year by police or other authorities and asked about their immigration status, according to the Pew survey.
More than half said they worry that they, or someone they love, may be deported.
Their fear is not unfounded.
In Washington, Oregon and Alaska, deportations have more than doubled since 2005, affecting 10,602 people in the 12-month period ending in September.
At that time, about 52 percent of detainees at the detention center in Tacoma came from Mexico; that figure for Hispanics rises to about 72 percent when Central Americans and South Americans are added in.
This increase in deportations has also come with a wave of criticism about the amount of mental health care detainees are receiving. OneAmerica, a Seattle minority-rights advocacy group, in July published a report in conjunction with the Seattle University law school criticizing the Tacoma detention center.
Based on interviews with 41 detainees, the groups' report estimated one in five detainees suffered from mental health issues requiring attention, including depression, nervousness or fear -- or a combination of disorders.
Regional ICE spokeswoman Lorie Dankers discounted the group's report. "We don't have anything to hide," she said.
Mental health is among the things all detainees are screened for in the medical exam when they are brought in, she said.
Each person answers a variety of questions, such as if they have thoughts of hurting themselves, or if they have been the victim of some kind of abuse. A full-time psychologist and two part-time psychiatrists are on staff in Tacoma.
Throughout the center, signs in English and Spanish remind people to ask for help if they have any of the classic symptoms of depression -- sadness, anger, isolation. The symptoms also are listed in the handbook detainees get when they are brought to the detention center, Dankers said.
Guards and other staff are also expected to report any detainees who start skipping meals or sleeping late. The reports are sent to medical staff for evaluation. Any detainee who tells staff he or she isn't feeling right is immediately sent for a medical screening. In fall 2006, ICE started a suicide prevention and intervention program to train staff to look for warning signs.
There have been no suicides at the Tacoma center, which opened in 2004 and is one of the nation's newer detention centers.
ICE's acting director of immigration health services, who testified before Congress in June, said the agency provides detainees with psychological assessments and follow-up, individual psychotherapy sessions, and evaluations and medication for conditions including stress, depression and anxiety.
It also arranges hospitalization for patients with acute mental health problems and monitors detainees for suicide risk.
The focus is on identifying the most severe mental health problems that detainees may have, said Pat Reilly, a national spokeswoman for ICE.
"What we're going to do is treat the most acute symptoms," she said.
On average, people remain in detention 35 to 40 days, which may not be enough time to help people work through all of their problems.
Often, ICE contacts people in the home country to alert them that someone who is returning has mental health issues or other medical issues so that care can be arranged for them there, she said.
ICE spends about $100 million in medical costs annually for the detainees nationwide, Dankers said.
As far as overcoming cultural barriers or the stigma that may prevent some from even asking for help, Reilly said the overall goal is to make detainees psychologically stable, and help them "realize that they're leaving the country and going back to their home country."
Feeling uneasy in Lynnwood
The fear of being caught by immigration agents is constantly on people's minds. In Lynnwood, some say they don't let their kids play outside on the chance that ICE agents might sweep up their children or other family members, said Emily Yim, Lynnwood's director of neighborhoods and community affairs.
"That level of fear in the community really does exist," Yim said. "It really is real and it really affects people's lives."
Minorities are believed to make up nearly one-third of Lynnwood's population of 36,432. So last spring, the city asked a task force for a report on what was on the minds of immigrants, both legal and illegal. The goal was to build trust and open lines of communication.
The report revealed problems for the city to work on. These included language and cultural barriers, fear and distrust of authorities, and the power of rumors and misunderstandings among immigrants.
One question kept coming up: What was the relationship between Lynnwood Police and ICE, which has an agent at the police station?
Many immigrants believe that the city's police department works with federal immigration and customs officials to seek out undocumented or illegal immigrants, which, Yim said, is untrue.
A federal immigration agent does have a desk in the city's police department, and has for eight years, said Karen Manser, the city's assistant police chief.
"He doesn't ... go out and knock on doors" to find illegal immigrants, she said. His job is to catch illegal immigrants who have committed crimes, she said, and wind up in court or in jail.
Still, people like Blanca, who lives in Lynnwood and is here illegally, used to believe she would be safe from immigration if she did not get in trouble with the law. Now, she said, she doesn't think that will keep her from being sent back to Mexico.
She asked that her last name not be used for this story.
The current activity from ICE has forced her to stay home, leaving only to get to work, Blanca said. That's very different from three years ago when she arrived in Washington from Michoacan.
"Three years ago we went out to faraway places. Now, we stay at home on the weekends to avoid being stopped by the police," said Blanca, 35. Although she hasn't been stopped by police, she has heard that it's happening to more people. In September, her brother was stopped for speeding in Oregon and then was sent to the Northwest Detention Center.
During the month he was held, Blanca said she got very depressed, so much so that she spent the evenings crying about her brother and her own situation.
She knew she had a problem but did not want to seek help because of the costs and her worries about leaving home. She knew she was depressed because her behavior toward her family changed. "I was angry and sad around them," she said.
Yet she keeps going, because she feels there's no choice. She must work and help provide for her family. Talking to people, and being comforted by her children, 13 and 10, is helping.
"The simple thing, to be heard, helps a little, I think," she said.
Hispanics are more than twice as likely to seek treatment from doctors or clergy than from counseling services, according to the National Alliance on Mental Illness, a national grass-roots organization for people with mental illness and their families.
The Rev. Milhton Scarpett is a Colombian-born priest who holds Mass in Spanish at Roman Catholic churches in Mount Vernon, Burlington and Sedro-Woolley. Every chance he gets, he talks to his congregation about depression and anxiety.
He does this because he often sees signs of depression and anxiety in parishioners.
"The immigration situation creates problems in physical and mental stability," he said.
People show depression on their faces. They look powerless or like they've been crying, Scarpett said.
When someone approaches him to talk about their depression, he counsels them as a man of faith and, therefore, someone who has earned the community's trust, he said.
"I try to be a motivational speaker for them in trying to give them self-esteem," he said.
In his conversations, he tries to evaluate the roots of their problem. If the trouble is in their marriage, because the spouse is in detention or in the process of being deported, he then can refer them for psychological and material help from Catholic Community Services, an organization that provides several services, including counseling.
Cultural factors add pressure on immigrants, but the Western Washington climate also triggers depression, especially during the winter, Scarpett said. Holidays are hard, too.
"In December we celebrate holidays with family. They come here to the U.S. and are alone, and start yearning for their family."
Mendez-Diaz lived and worked in the U.S. for a decade without arousing suspicion.
When she arrived in Phoenix, she started going to school. But she attended for only about three months. After that, an aunt helped her learn English.
Isolated and with few strong family ties to support her, she reached out to one person she knew from home, a young man who at the time was living in Colorado but often came to Arizona to visit his family.
At age 17, she gave birth to their son, Adrian. The family crisscrossed the West, led by the promise of temporary jobs. There was construction work for her common-law husband, restaurant and house cleaning jobs for her.
Three years ago, the promise of abundant jobs brought them to the Puget Sound region and eventually to Lynnwood. They rented an apartment, found work and celebrated the birth of their daughter, Camila.
With Adrian in school, their porch scattered with children's toys and a living room with a widescreen TV, the couple finally seemed to have found some fragile sense of security.
Mendez-Diaz's luck ended with several traffic stops by police last year: in Brier; on Highway 99 in south Everett; and finally, in Lynnwood, where she was ticketed on Oct. 10, 2007, for driving with a suspended license.
Her license was suspended because of an unpaid speeding ticket, said Adolfo Ojeda-Casimiro, her former immigration attorney.
Mendez-Diaz went to Lynnwood municipal court on Nov. 1, 2007, to plead not guilty to the charge of driving with a suspended license. With the help of an interpreter, she requested a public defender.
As Judge Douglas Fair was about to release her until her next court date, he was politely interrupted by the prosecutor, according to a recording of the proceeding.
"The city is in a position of a request from Immigration and Customs Enforcement to place an immigration detainer on the defendant," the judge was told.
Through an interpreter, a panicked Mendez-Diaz pleaded with the judge.
"I have my children here, I just don't know what I'm going to do," she said.
"I'm sorry," the judge responded. "You'll need to take a seat up in the jury box."
She waited until a guard came for her.
She was booked into the city jail and held three days. On the fourth day, immigration officials took her away. She was photographed and fingerprinted at a facility in Tukwila, then bused to Tacoma.
At the detention center, women and men are held in separate living areas, which are entered through electronically-locked metal security doors. In the women's quarters, about 80 people share one large room. A staff member is assigned to be in the room at all times.
"We had no name, we were a number," Mendez-Diaz said.
Each woman is assigned a bunk; the bunks are stacked in rows around the back half of the room. Daily head counts occur at 2 a.m., 5 a.m., 11:30 a.m., 4:30 p.m., and 10 p.m., Mendez-Diaz said. "Every day we have to run to our beds when they started counting, one, two, three."
All detainees wear a wristband with their picture, name and identification number.
During any typical 24-hour day, the only moments they aren't monitored are during showers.
There is little to do besides watch TV, play basketball, walk around an enclosed area with a skylight, or work for $1 a day doing laundry or janitorial work at the center.
"I was very depressed," Mendez-Diaz said. "I wanted to get it over with quickly so I could see my children. All the people had similar stories. And in one depressing place, you get more depressed. I heard people crying at night."
Mendez-Diaz was released on $4,500 bail five days after she arrived at the center.
Her wait for a court hearing was cut short after detention center officials learned she was breast-feeding Camila, Ojeda-Casimiro said.
Nevertheless, Mendez-Diaz said, by the time she was released, it was impossible for her to produce milk for her baby anymore.
On Sept. 3, nearly 10 months after her arrest, Mendez-Diaz had her hearing at Federal Immigration Court in Seattle. The 90-minute session would determine whether she could legally remain in the United States. Afterward, she admitted she was not prepared for what awaited her.
Her case was scheduled to begin at 8:30 a.m., but Mendez-Diaz was not in the courtroom. She arrived about 10 minutes late, looking agitated and distracted. There was no time to confer with her attorney.
Someone who had promised to look after Camila had backed out, leaving her scrambling to find a baby sitter.
Her hopes to remain in the United States were pegged on a request for asylum. Her attorney asked that the hearing be closed to the public to try to ease her reluctance to disclose the details, which involved the attacks back in Mexico.
In court, her attorney presented a letter from Mexican police saying that Mendez-Diaz reported the attacks against her in April 1997.
More than a decade later -- in December 2007 -- the same man, now 32, returned to her family home in Mexico and beat her stepfather when he refused to disclose where she was living, her attorney said.
When it was her turn to plead her case, Mendez-Diaz was surprised to learn she would have to leave her seat, next to her attorney, and testify from a chair next to the judge at the front of the courtroom.
When lawyers questioned her about the attack, she couldn't bring herself to talk about it.
Her asylum request was denied.
She was being deported.
Later, on the sidewalk outside, she leaned against a pillar, wiping her eyes, trying to piece together some new family plan for survival.
"I can't leave," she cried out in Spanish.
She wanted to talk about the attack, she said. She is still afraid of the man, of what he did to her, of what he's capable of. But it was too personal; she didn't feel comfortable speaking about it.
The deportation process gives people 30 days to appeal the ruling.
Kent attorney Florian Purganan agreed to handle her appeal. It generally takes the Board of Immigration Appeals, based in Fall Church, Va., six to 12 months to rule in such cases, he said.
Meanwhile, Mendez-Diaz can stay in the country. And she's now working for a group that gives counseling for alcohol, drug and domestic violence problems. Most of the clients are Hispanic, she said.
The need for mental health services for all immigrants is becoming an overwhelming task, according to counseling, legal assistance groups and school districts. All are reaching out to assist immigrant families.
Nationally, efforts are under way to improve conditions in detention centers.
In July, the American Bar Association urged Congress to adopt legislative and regulatory changes "to address the full scope of detainee health care," including mental health, dental care and overall medical care, said Mark Agrast, a Washington, D.C., attorney and chairman of the American Bar Association's national Commission on Immigration.
Locally, Sea Mar Community Health Centers, a nonprofit organization that specializes in serving Hispanics, operates four inpatient treatment centers and 12 outpatient behavioral health programs in Washington.
Its newest counseling centers opened in Lynnwood and Bellevue earlier this year. A great need remains for bilingual and bicultural health care specialists, including psychiatrists and psychiatric nurses, said Claudia D'Allegri, vice president of behavioral health of Sea Mar.
Sea Mar provided mental health services to 3,688 clients last year and helped nearly 2,000 teens and adults with drug and alcohol services.
Hispanics generally do not go to counseling for help with depression or other mental problems. Often, they seek help for a medical problem or drug or alcohol problems.
During treatment, counselors help them understand that the roots of the problems might include untreated depression or other mental illness.
"We can see signs of depression within two weeks in treatment," D'Allegri said.
Sea Mar is not the area's only counseling agency helping Hispanics.
Consejo Counseling and Referral Service, with offices in King County, serves about 700 children, teens and adults annually, said Maria Lopez, associate clinical director for child and family services.
The nonprofit provides domestic violence support, drug and alcohol programs, and family mental health services.
Like Sea Mar, people don't come in seeking help in the early stages of depression, Lopez said. They generally show up when the problem is becoming dangerous, such as when people say they are feeling suicidal, she said.
At that point, when told they need mental health counseling, "it's not that they don't know it," Lopez she said. "But it's a name, a label. They're able to at least say, OK, I can get help for this."
Depression is not unusual even for people who have family living with them. The pace of trying to scratch out a living can hamper interactions where thoughts and feelings can be shared. Within the culture, sometimes feelings are not shared directly, because of roles within a family. Still, understanding increases when family members spend time together.
"A lot of families (here) are working nonstop. Families are in a whirlwind. What is most important is talking to each other, to be there for each other, to be supportive," Lopez said.
Reaching out to families
The Edmonds School District is one of many school districts throughout the state taking steps to help Spanish-speaking parents feel welcome, said Kelly Land, family resource advocate.
At Lynnwood High School, a welcome meeting for families was held in Spanish, she said. Last year, there was a program on how to prepare their kids for college for Spanish-speaking parents of middle school students.
Most important is that parents feel comfortable coming to school to ask for help and know that they will be welcomed, she said.
By establishing this trust, Land is able to refer students and families to a variety of resources, including mental health services, family support centers and medical care.
"We're reaching out so that everyone feels comfortable, not just families who speak English," Land said.
The need continues to grow. "I get calls all the time asking, 'Do you have resources, mentorship programs,'" said Arlie Neskahi, the school district's multicultural and family outreach coordinator. "There's a real lack of culturally specific services in this region."
"We've become more diverse," he said. "We're in this transition phase where community services are now catching up with that diversity."
Wendy Messarina, a Spanish Parent Community Liaison for the Marysville School District, also helps connect Spanish-speaking students and adults with resources and information, and works as a translator in Marysville schools. But she often helps parents from Everett, Arlington and Monroe, too.
Heavy work schedules, with both parents often working two jobs and getting home late, sometimes leave children feeling as if they are being ignored by their parents, she said.
These parents generally don't have time to assist with school meetings because of the demands on their time, Messarina said.
This makes students feel that their parents are not interested in them, she said. "Adolescence is a hard stage. They are thinking of their own world. In their minds, they are the victims," she said, not understanding their parents' hard work is for their benefit.
On the flipside, some parents have not finished their own education and have limited English. This causes shame, because the parent cannot help the student with school or homework, Messarina said.
"This is where children lose respect for their parents," she said.
That can be a seed for bigger family problems.
Her work is aimed at bringing more understanding between parents and their children, and make them proud of their Hispanic traditions and culture.
The goal is to avoid conversations like the one between Mendez-Diaz and her son, Adrian, as they walked in the parking lot of the Lynnwood police department earlier this fall: "Speak English," the 7-year-old told his mother, "so they don't think we're Mexican."