Central American Immigrant Mothers and the Children Left Back Home

Home , There Is More

CALIFORNIA STATE UNIVERSITY, NORTHRIDGE

A graduate project submitted in partial fulfillment of the requirements

For the degree of Master of Science in Counseling,

Marriage and Family Therapy

Blanca C. Chaniago

August 2017

The graduate project of Blanca C. Chaniago is approved:

______Dr. Jefferson Sa Date

______Dr. Shari Tarver-Behring Date

______Dr. Pete Goldschmidt, Chair Date

California State University, Northridge

Acknowledgements

I would not have been able to finish the journey through the completion of my

Master’s Degree without the guidance and support of the people who were involved in it.

I must first express my gratitude to my Project Chair, Dr. Pete Goldschmidt, whose knowledge, understanding and exemplary patience gave me the extra confidence I needed as I overcame the hurdles that hindered the finalization of this project.

I would also like to thank Dr. Shari Tarver-Behring for her consistent support and faith in me.

I would like to give special thanks to Dr. Jefferson Sa for taking time out of his busy schedule to serve as my external reader. His huge knowledge and skill in different areas provided me with valuable comments and inputs for this project.

I wish to extend my gratitude to my good friend Mel Spicer for his consistent availability to proofread my work and for his inspiring words that affirmed my strengths, when I doubted that this endeavor could be completed.

I thank my parents and sisters for their unrelenting emotional support and my husband for his devotion and encouragement.

Finally, I must acknowledge the one who makes all things possible, the almighty

God. I thank God for answering my prayers and giving me the strength to achieve my goal.

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Table of Contents

Signature Page ...... ii Acknowledgments...... iii Abstract ...... viii Chapter 1 Introduction ...... 1 Statement of Need ...... 3 Purpose of Graduate Project ...... 4 Terminology ...... 5 Transition to Next Chapter ...... 6 An Overview of the Seven Nations of Central America ...... 7 Chapter 2 Literature Review ...... 16 Introduction ...... 16 Immigration to North America in Context ...... 16 Immigration Statistics ...... 18 Immigration and Naturalization ...... 20 Migrant Women ...... 21 Current Factors that Motivate Central American Women to Migrate...... 24 Economic Liberalization and the Need for Substitute Earning Sources……………25 Increased Demand for Female Migrant Labor in the United States………………..27 Prevalent Violence against Women in the Region…………………………...... 27 Achieving Family Reunification……………………………………………………31 Seeking Improved Services for Themselves and Their Children…………………..32 Cultural Socialization into the Salvadoran Diaspora……………………………….33 Characteristics of Central American Immigrants in the United States ...... 37 Age………………………………………………………………………………… 37 Education………………………………………………………………………….. 37 Employment………………………………………………………………………...38 Income and poverty…………………………………………………………………..38 A View of the Central American Family Unit ...... 39 Migrant Family Separations ...... 41 Theoretical Frameworks ...... 43 iv

Object Relations Theory ...... 43 Attachment Theory ...... 44 Theory of Ambiguous Loss ...... 46 Other Important Factors Associated with the Family Separation Process ...... 48 Immigration and Trauma ...... 50 What Central American Migrant Women Go Through and the Trauma They Endure ...... 50 Stages of Migration-Related Trauma ...... 52 Experiences of Children who have been Separated from Their Parents due to Migration ...... 62 Situation of Honduran Children whose Parents have Migrated ...... 65 Situation of Guatemalan Children whose Parents have Migrated ...... 67 Situation of Salvadoran Children whose Parents have Migrated ...... 68 Reasons Why Migrant Mothers Leave Their Children Behind ...... 69 Immigration Restrictions and Financial Limitations ...... 70 Safety Concerns ...... 70 The Belief that Children Receive a Better Upbringing in the Country of Origin ..... 71 The Need to Protect Children from Racial and Anti-immigrant Prejudice ...... 72 Transnational Motherhood ...... 73 What it means to be a Transnational Mother...... 75 Remittances ...... 77 Establishing Duplicate Families ...... 78 The Moment of Separation between a Mother and her Children ...... 79 Whom Transnational Mothers Entrust their Children to? ...... 80 The Concerns of a Transnational Mother ...... 80 Mental Health Implications of Migration on Women ...... 81 Studies that have assessed Central Americans and their Mental Health ...... 84 Psycho-biological Consequences of Exposure to Trauma ...... 86 Trauma and Family Life ...... 87 Children’s Mental Health Implications ...... 88 Positive vs. Negative Outcomes of Parental Migration...... 90

Family Separation and Mental Health ...... 91 Obstacles Faced by Migrant Families after Family Reunification ...... 96 Attachment Difficulties ...... 96 Addition of New Family Members...... 97 Discipline Conflicts ...... 97 How to Help Central American Migrants ...... 98 Barriers to Mental Health Care...... 99 Principle of Engagement ...... 102 Clinical Assessment and Diagnosis ...... 102 Working Alliance ...... 106 Therapies/Interventions ...... 107 Cognitive Behavior Therapy ...... 108 Problem-solving Therapy ...... 109 Psychotherapy with children ...... 110 Family therapy ...... 110 Narrative Therapy and Collaborative Narrative Practice ...... 111 Narrative Exposure Therapy and Testimonial Psychotherapy ...... 112 Evidence-Based Practices ...... 113 Brief Strategic Family Therapy ...... 114 Trauma Affect Regulation: Guide for Education and Treatment (TARGET) ...... 114 Familias Unidas Preventive Intervention ...... 115 Synthesis of Literature Review ...... 116 Chapter 3 Project Audience and Implementation Factors ...... 118 Introduction ...... 118 Development of Project ...... 118 Intended Audience ...... 119 Personal Qualifications ...... 120 Environment and Equipment ...... 120 Project Outline ...... 121 Chapter 4 Conclusion ...... 123 Summary ...... 123

Evaluation ...... 125 Discussion ...... 128 Future Work/Research ...... 131 References ...... 133 Appendix A Product/English ...... 146 Appendix B Product/Spanish………………………………………………………..170 Appendix C Program Evaluation Form/English ...... 196 Appendix D Program Evaluation Form/Spanish……………………………………198

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Abstract

Central American Migrant Mothers and the Children Left Back Home

Blanca C. Chaniago

Master of Science in Counseling, Marriage and Family Therapy

The migration movement of women, particularly the migration of Central

American women, was examined in the context of its implications on mental health. Due to the persistent social, economic and political instability present in some of the countries of this region, many migrants from this area entering the United States bring with them the hardships and traumas associated with a life lived in the midst of negatives experiences and limited opportunities. The topic was researched by accessing peer- reviewed and scholarly articles using services like ProQuest, EBSCO, PubMed, and

Medline Plus.

Many Central American migrant women, especially those fleeing poverty, family and social violence, have been found to display one or more traumas related to their experience. This finding suggests that a lot of these women already living in the United

States are at risk of developing anxiety, depression, and post-traumatic-stress disorder, and that not only their chances for a better future is compromised, but also the future of their children and their family as a whole.

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Chapter One

Introduction

Ancient manuscripts document how human emigration movements have taken place since the dawn of time. Seeking shelter, food, safety, cultivable lands, and freedom, people have tried to avoid hunger, persecution, and subjugation of the spirit

(Perez- Foster, 2001). In 2015, 244 million people, or 3.3% of the world's population, lived outside their native countries. Although millions are forced to flee crises, the majority of migrants leave in search of better social and economic opportunities (United

Nations Population Fund, 2016). Different countries have served as a safe shelter in the migratory journey for many of these people. The United States has traditionally undertaken such mission. The United States Immigration Act of 1965 with its emphasis on family reunification has attracted large numbers of migrant women interrupting a history of majority male migration to the nation through the mid-20th century. In 2013 there were 21.2 million immigrant women living in the United States out of a total immigrant population of 41.3 million, representing 51% of the overall foreign-born people. In the United States the female share of the immigrant population is higher than it is in the rest of the world, where it is calculated to be 48% (Ruiz, Zong, & Batalova,

2015). Furthermore, women comprised 46% of the 11.4 million unauthorized immigrants in the United States in the 2008-2012 period, according to the latest estimates from the

Migration Policy Institute (Stoney & Batalova, 2013).

The establishment of transnational families has been reinforced by the feminization of migration and the latest tendency toward the increased migration of women on their own including mothers. There are many inquiries around the formation

1 of transnational families including questions about intra-family dynamics, changing gender roles, effects on children and adults left behind, and family reunification, among others (Schmalzbauer, 2004; Parrenas, 2005). Transnational motherhood, and the associated intergenerational pressures with children left behind, was uncommon among

U.S. immigrants a century ago. In 1910, only 7% of migrant women from all ethnic groups had left their children in their native country when they came to the United States

(Robles & Watkins, 1993). There are no exact figures for the present period; however, experts think they are higher, because, among other factors, there are new norms in the

United States that accept more readily the role of working married women in society

(Foner & Dreby, 2011). Female international labor immigrants frequently experience challenging and painful decisions in order to work in a foreign country. They start a controversial process of altering, restructuring and reaffirming habitual gender relations, as they deal with the intrinsic contradiction of having to leave the family in order to support it (Contreras & Griffith, 2012). Studies on gender and migration have emphasized the often conflicting roles that women assume as they leave their children to be able to provide for them. In the search to provide a better opportunity for children, migration may contribute to the erosion of motherhood, including hurting the foundations for authority and parental discipline. As a consequence, the value of children in terms of their capacities to recognize and respond to role models, guidance and other social elements that rest on authority may be lowered (Contreras & Griffith, 2012). Numerous reasons for the surge in women’s migration have been identified. They range from women’s circumstances in sending nations, including lack of opportunities to engage in paid work, separation or divorce, women’s desire for more autonomy and a reduction in

2 social restraints on women’s mobility, to knowledge of employment prospects in receiving countries (Parrenas 2005).

In recent years, immigrants from the nations of Central America have established growing communities in the United States. This land bridge is made up of fertile rain forests, undulant hills and mountains and sandy beaches. Although the region’s natural beauty might make it look like a paradise, every year tens of thousands of Central

Americans leave for the United States or Canada (Hernandez, 2004). Since 1990 the number of Central American immigrants in the United States has nearly tripled. This immigrant population grew faster than any other immigrant group from Latin America between 2000 and 2010. In the last five decades the Central American migrant population in the United States progressively increased from less than 1% in 1960 to nearly 8% in 2011. Furthermore, of all Central American immigrants residing in the

United States in 2011, 47% were women (Stoney & Batalova, 2013).

Statement of Need

The migration-related experiences and mental health needs of immigrants from

Central America have been understudied despite the fact that many immigrants from this region have been exposed to war-related trauma and other forms of political and social violence (Kaltman, Hurtado de Mendoza, Gonzales, Serrano, & Guarnaccia, 2011).

Furthermore, available data suggests that Central Americans do not access mental health services in the same proportion as non-Latino whites do (Kaltman, Hurtado de Mendoza,

Serrano, & Gonzales, 2016). Given that the population of Latino immigrants, including

Central Americans, is increasing in the United States, it is important for mental health practitioners to understand pre and post immigration contextual factors that affect the

3 psychological health of this heterogeneous ethnic group and how its members view mental health. If current tendencies continue, the Latino population, already the largest ethnic minority group in the United States, will triple in size by 2050 (Dillon, De La

Rosa, Sanchez, & Schwart, 2012).

Purpose of Project

In the light of the above information, the goal of this project is to evaluate and become familiar with the current research in relation to the experiences of Central

American migrant women. Some of the topics that will be reviewed in this paper include the immigration history of the Central American people, factors influencing the decision of Central American women migrants to come to the United States, why some of them leave their children behind and the negative experiences these women endure during the migratory journey. Other subjects that will be considered as well include what it means to be a transnational mother, the experiences of children who are left behind by their mothers and how the migration process can impact mental health. The purpose of the review is to create a final proposal that will be presented in the form of a guidebook which will contain practical information for the Central American migrant woman. The guidebook is intended to show the migrant women that mental health professionals have an understanding of the challenges they have endured, that topics related to mental health can be understood and that mental health services can be trusted and accessed. The significance of this project is that it is intended to increase cultural, psychological and humanitarian competencies needed to implement informed therapeutic services when working with Central American immigrant women and children.

Terminology

The following are the definitions of some terms that will appear in this project.

Latino. The term ‘Latino’ is a short form of the Spanish word ‘Latino

Americano’ (Latin American). The definition now refers to Latin Americans, although the term was originally used in the former Roman Empire (Austin & Johnson, 2012).

According to the Associated Press Stylebook and Briefing on Media Law, usually called the AP Stylebook, the word Latino is an umbrella term that refers to residents or citizens of the United States with Latin American ancestry. It adds that federal policy defines

‘Latino’ not as a race, but as an ethnicity and that Latinos can be of any race. The AP

Stylebook definition of Latino includes not only people of Spanish-speaking ancestry, but also people from, or whose ancestors came from Latin America. This means that

Brazilians and people from the Caribbean region, including those from former Dutch and

British colonies can be considered Latino (The Diversity Style Guide, 2017).

Hispanic. The term ‘Hispanic’ alludes to a person’s place of origin, referring to people from the areas in Latin America that were conquered and settled by the Spanish and which were originally called Hispania, a term coined by Romans to refer to the

Iberian Peninsula. The term Hispanic was first used by the Nixon administration on the

1970 census (Austin & Johnson, 2012). The AP Stylebook limits the concept of

‘Hispanic’, and defines it as an umbrella term that refers to people whose ethnic origin is in a Spanish-speaking country or culture, as well as residents or citizens of the United

States with Latin American heritage, except for those from Brazil, which is not a

Spanish-speaking nation. The AP Stylebook writes that federal policy defines ‘Hispanic’

5 not as a race, but as an ethnicity and that Hispanics can be of any race (The Diversity

Style Guide, 2017).

The terms Latino and Hispanic are used interchangeably in this project when referring to Central Americans.

Immigration. A process by which non-nationals move into a country for the purpose of settlement (International Organization for Migration, 2017).

Migration. The movement of a person or a group of people, either across an international border, or within a country. It encompasses any kind of movement of persons, and any kinds of length, arrangements and causes. Migration can include the movement of refugees, displaced persons, economic migrants, and people moving for other purposes like family reunification (International Organization for Migration, 2017).

Transition to Next Chapter

The following section will present a review of the literature on various topics related to the experiences of Central American migrant women. But first, an overview of the seven nations that form the Central American isthmus will provide a general vision of the main characteristics of this region and the particular details of each country’s history, which has recorded the migration patterns of its nationals. After this, the project will examine what researchers and experts have written on topics such as the particularities of the migration movement from Central America, the circumstances endured by Central

American migrant women before, during, and after the migratory journey, how migration can impact these women’s mental health, and what the mental health field can do to best serve this community. Finally, the last part of this project will have a guidebook that has

6 been created with the intent to reach the Central American migrant woman and which has been based on the results of the current literature review.

An Overview of the Seven Nations of Central America

The Central American isthmus is located between Mexico and South America and it includes the countries of Belize, Guatemala, El Salvador, Honduras, Nicaragua, Costa

Rica, and Panama. The isthmus is approximately 1,140 miles long from the northwest to the southeast. There is no land point in Central America that is any further than 125 miles from the sea (Central America, 2016). The seven countries of Central America vary significantly in population, size and demographic characteristics. Some have their origins in the Spanish Empire, while others share a British heritage. Dozens of

Amerindian dialects are found in the region. English is the native language of Belize, and it is also widely spoken on the Atlantic coast of Nicaragua. However, Spanish is the principal language of six of the seven republics. At least two-thirds of Central Americans have a mixed ancestry. Immigration to the area was officially limited to Spanish citizens until the beginning of the 19th century; therefore Spanish were the only significant

European contributors to the ethnic mixture of the region. Three-fifths of the people of

Central America are of mixed European and Indian descent (called Ladinos in Guatemala and mestizos elsewhere), and one-fifth are Indian. Smaller communities of zambos

(mixed Indian and African descent), mulattoes (people of mixed European and African descent), descendants of Europeans, and descendants of South Asian, Chinese, and

African indentured workers make up the remainder. The majority of the region’s Indian population is in Guatemala (the Maya, making up more than two-fifths of that country’s total population). Many of the remaining Indians live in neighboring Honduras and El

Salvador. Elsewhere, only in Belize do Indians comprise a significant portion (about one-tenth) of the population (Central America, 2016). Religion exerts a very important influence in the lives of individuals and its value is generally strengthened within families. Christianity and in particular Catholicism, has been of paramount importance throughout Central America. This faith’s doctrines and teachings regarding spousal roles, the formation of unions, procreation, and the socialization of children have had deep implications for family life in the region (St. Bernard, 2003).

Belize. Belize gained its independence in 1981, making it the youngest nation in

Central America. There is still a huge income disparity between rich and poor in Belize, although the nation has the second highest per capita income in Central America. Due to the impact of natural disasters and a stagnant economy poverty in Belize has markedly increased in recent years. The latest Country Poverty Assessment indicated that during the 2002-2009 period, the overall poverty rate increased from 34% to 42%, while extreme poverty increased from 11% to 16% (The World Bank Group, 2016). The history of this nation differs greatly from that of the rest of Central America. It was colonized by England instead of Spain. Belize seems to have more in common with

Barbados and Jamaica than with its Central American neighbors (Hernandez, 2004).

Belize has enjoyed a fairly peaceful recent history. While Great Britain has been accused of exploiting the resources of its former colony; it has also been credited with passing on strong educational and political institutions. As a result of this, the effects of poverty have been lessened, and Belize has been given good prospects for stability and economic development (Hernandez, 2004).

Guatemala. Guatemala is Central America’s most populous country with a very troubled recent history. After becoming an independent republic in 1839, the country was ruled by a series of dictators until a revolution in 1944 brought free elections for the presidency. In 1950 a leftist president was elected, however, he quickly found himself in conflict with the U. S. government. American officials became concerned that

Guatemala’s president could afford the Soviet Union with an opportunity to gain influence in Latin America. In 1954 a Central Intelligence Agency backed coup forced the president from office (Hernandez, 2004). What followed was a succession of repressive military regimes and decades of dreadful violence. In the early 1960’s insurgent groups formed to overthrow Guatemala’s government through a guerrilla war.

The belligerent actions raged for more than 35 years. In the 1980’s several guerrilla factions joint to form the Guatemalan National Revolutionary Unity (known by its

Spanish acronym, URNG). In the spring of 1996, the URNG declared a cease-fire and the government suspended military operations. In December of that year, the two sides were able to sign a peace treaty. The long armed conflict in Guatemala claimed the lives of as many as 200,000 people, the majority being civilians, including Mayan Indians

(Hernandez, 2004). Furthermore, an estimated one million Guatemalans fled their homes. The years since 1996 have been challenging. Although the country has seen a measure of political stability, Guatemala is still in the process of rebuilding after the decades of war (The World Bank Group, 2016).

Honduras. Honduras was fortunate enough to escape the bloody civil conflicts that devastated its neighbors. However, during its history, Central America’s second most populous nation has not been a model of stability. In fact, since declaring

9 independence from Spain in 1821, Honduras has experienced more than 300 clashes that have included revolts, coups, and wars (Hernandez, 2004). In 1963 an army colonel moved to block any potential Communist-inspired demonstration, overthrew the elected president and placed the country under military control. This military regime lasted for several decades. In 1969 a war with El Salvador erupted. Even though this war lasted less than a week the economic impact for Honduras was severe and the consequences persisted for many years. In1982 the Honduran military lastly conceded power to a democratically elected civilian government. Still, political repression was rampant and military and police death squads were active in the country during the 1980s. Some of

Honduras’s economic predicaments have been credited to Hurricane Mitch, which struck the region in October 1998. Mitch hit Honduras harder than any other country in the region. The hurricane’s devastating power caused floods and mudslides that destroyed entire villages, a large part of the Honduran highway system, and the country’s banana plantations. It has been estimated that a million Hondurans were left homeless, and the economic destruction amounted to nearly $1 billion (Hernandez, 2004).

El Salvador. El Salvador is the smallest nation in Central America by area, but it has the third largest population in the region. The soil and the climate are optimal for the cultivation of coffee, which has been El Salvador’s main cash crop since the mid-1800s.

Through the years, land, wealth and political supremacy in the country became gradually concentrated in the hands of a few families who ran El Salvador’s coffee industry.

Wages and working conditions which were very poor were established by the coffee growers. During the early 1930s a rebellion among the rural poor was stopped as El

Salvador’s army and National Guard, in conjunction with paramilitary bands serving

10 local landowners, killed nearly 10,000 peasants (Hernandez, 2004). For the next half- century the military kept control of the government, as presidential elections were consistently tampered with. Between 1960 and the mid-1970s, even more rural workers lost the privilege to acquire land. Due to the lack of land reform, small guerrilla groups were established and began plotting to overthrow the government by force. In response, armed factions that supported the government persecuted not only rebel leaders, but also common people with liberal political opinions. In 1980 Oscar Romero, the archbishop of

San Salvador, was murdered. Romero had called for an end of the repression of El

Salvador’s citizens by its leaders. The slaying of the archbishop incited a large demonstration, which was dispersed when police fired into the crowd. By the end of the year, the unrest had become a full-scale civil war. The main insurgency force was supported by Cuba. Fearing the formation of a Communist system in the country, the

United States channeled more than a billion dollars in military and economic assistance to the Salvadoran government (Hernandez, 2004). The civil war raged for 12 years in the country and in the face of the terrible violence, an estimated one million Salvadorans fled their land; many headed for North America. In 1992 peace treaties were signed between the insurgent group and the Salvadoran government and a cease-fire was agreed.

Although political peace and reform are now present in El Salvador, the nation continues to confront massive economic and social problems. To add to the difficulties, earthquakes in 2001 destroyed or damaged one of every four homes in the country. Most worrying is that the inequality in the distribution of wealth (one of the primary causes of the civil war), and elite resistance to inclusionary politics persist to this day (Tardanico,

2008).

Nicaragua. Nicaragua, like its neighbors El Salvador and Guatemala, has also experienced shocking civil strife. Once a fairly prosperous land, the country had by the beginning of the 21st century become Central America’s poorest nation (The World Bank

Group, 2016). The United States has had a decisive role in the modern history of

Nicaragua, which gained its independence in 1838 (Hernandez, 2004). Towards the end of the 19th century, the United States considered building a canal across Central America; however, Jose Santos Zelaya, a dictator who ruled Nicaragua from 1894 until 1909, threatened to sell the rights to build a canal through his country possibly to a U.S. rival.

In 1909 Zelaya was forced out of power due to the pressure of the U.S. government; however, Nicaragua had an enormous debt that was subsided only when the United

Stated arranged loans for the newly formed pro-American regime that ascended to power

(Hernandez, 2004). Despite this, the country's troubles continued. North American president William Howard Taft sent a contingent of U.S. Marines in 1912 when

Nicaragua was about to face a revolution. Except for a brief period, beginning in August

1925, the U.S. Marines maintained an uninterrupted presence in Nicaragua until 1933.

Resentment of the American occupation eventually developed, though. The marines were persistently harassed for years by a guerrilla leader named Augusto Sandino. After the Americans left Nicaragua in 1933, the National Guard, a force created by the U. S. marines, was in charge of maintaining order in the nation. The leader of the National

Guard, Anastasio Somoza, soon positioned himself into the presidency and managed to launch a political dynasty that lasted from 1936 until 1979. Soon after securing control of the presidency, Somoza undertook the role of dictator. He and his two sons who governed after he was murdered pitilessly repressed dissent, and used their position to

12 enrich themselves and their families. Paradoxically, during the long, abusive rule of the

Somoza family, Nicaragua experienced periods of economic improvement. Nevertheless, only the upper and middle classes benefited, while Nicaragua’s peasants reaped very little of the profits of this economic growth (Hernandez, 2004). A deadly earthquake hit the

Nicaraguan capital in 1972 which killed 10,000, left another 50,000 homeless, and strained Nicaragua’s budget.

In 1978 the U.S. administration removed aid to the Somoza regime after allegations of pervasive human rights abuses being perpetrated by the government and the National Guard. By the following year, the regime’s position was compromised.

Different opposition groups joined and on the battlefield the revolutionaries gained important political terrain. In 1979 Anastasio Somoza stepped down from power, and the rebels entered Managua and took the presidency. The revolution left approximately

50,000 Nicaraguans dead and 150,000 refugees who fled the country. Nicaragua’s troubles were far from over, though. A five-member junta integrated by the major opposition groups led the new government. However, one of those groups, the Marxist- oriented Sandinistas progressively instituted its absolute control. In 1981 the U.S. administration blamed the Sandinistas of instigating revolution in neighboring El

Salvador, and approved $119 million to help rebels who sought an opportunity to oust the new Nicaraguan government. Many of these insurgents known as the “contras”

(counterrevolutionary) were former members of the Somoza’s infamous National Guard.

Much of the country’s limited resources that the Sandinista government intended to use towards its formidable social and economic agenda had to be allocated to combating the contras (Hernandez, 2004). Ultimately, the Sandinistas were accused of numerous

13 human rights abuses, including land confiscations, political apprehensions and executions. Many middle-class professionals and other Nicaraguans escaped to the

United States where they were granted status as political refugees. In 1988 the

Sandinistas and the contras agreed to a cease-fire and scheduled national elections for

1990. Although in the last years Nicaragua’s government has attempted new economic and political reforms, daunting economic challenges remain. The country has been struggling with the consequences left by Hurricane Mitch and a banking crisis. Many

Nicaraguans have migrated to Costa Rica, El Salvador, and the United States, and their remittances have been a significant source of income for the country (Nicaragua, 2016).

Costa Rica. This small nation has eluded the dreadful social and political problems that have afflicted its neighbors. Costa Rica has enjoyed a stable democratic government since the late 1800s. This pattern has only being disturbed by a few brief periods of political unrest. Military interference in government and society was always very limited. In fact, Costa Rica abolished its national army in 1950. Most likely due to its political and social stability, relative prosperity, neutrality, and high education levels, emigration has been comparatively low. In 2013 Costa Ricans in the United States numbered 79,000 (Migration Policy Institute, 2015).

Panama. Panama’s political history has not been as stormy as that of most of the other Central American nations. At the end of the 19th century the United States was ready to build a canal across Panama, but American representatives were not satisfied with the course of negotiations with Colombia, which had sovereignty over the isthmus at the time. In 1903 American officials took advantage of a Panamanian revolt against

Colombia and prevented Colombian troops from taking action against the insurrection.

As a result, Panama gained its independence from Colombia and promptly handed over to the United States a 10-mile-wide strip of land through which the canal would be built

(Hernandez, 2004). Panama received an annual rental fee from the United States and benefited from the economic activity generated by the canal. Mainly because of this,

Panamanians enjoyed a higher standard of living than most Central Americans. Although

Panama endured a military coup in 1968 and a brief war in 1989, the country has enjoyed a democratically elected government in the last 26 years. According to the Migration

Policy Institute (2015), the number of Panamanians in the United States in 2013 was

101,000.

Chapter Two

Literature Review

Introduction

The Latino population is the largest single minority group in the United States, and as such, it is substantially represented in the workforce and the school-age community in this country. From a social perspective, mental health professionals have the unique responsibility of addressing the different needs of members of this cultural group (Phipps & Degges-White, 2014). The purpose of the literature review is first to identify the different experiences of Central American migrant women, then to determine what factors and how these impact the mental health of this group and finally to understand how the mental health field can respond to the psychological challenges of this population.

Immigration to North America in Context

Almost a century before the English founded Jamestown in 1607 Spanish settlements proliferated in the Americas. They replicated permanent Hispanic imprints in large areas of the American Southwest, and Hispanicized the southern portion of the continent, later joined by the Portuguese and the French. In this manner, Spain began the first wave of migration to what would become the United States of America and gave origin to a population that would send north massive numbers of immigrants in the future

(Tienda & Sanchez, 2013). The persistent power struggle between England and Spain, which seemed to continue in the Americas, is also important for understanding Latin

American immigration to the United States. By the middle of the 19th century most

Spanish colonies had achieved independence; nonetheless, these new republics were

16 fragile politically and militarily and susceptible to external hostility. Mexico was an easy target for the expansionist objectives of the United States due to their proximity. The

United States obtained almost half of Mexico’s land under the conditions of the Treaty of

Guadalupe Hidalgo, which ended the U.S.-Mexican War (1846–1848). This land annexation is very significant to understanding modern-day immigration from Mexico.

Social bonds persisted beyond the newly delineated political boundary, and economic ties were deepened as Mexican workers were enlisted to fulfill chronic and temporary labor shortages during the 19th and 20th centuries. This unbalanced exchange was facilitated by the maintenance of a permeable border (Tienda & Sanchez, 2013). The Bracero

Program, a guest worker program that was implemented between 1942 and 1964, and which operated on a combination of legal contracts and reliance on unauthorized workers, is an example of U.S. growers’ dependence on migrant labor. The foundations of contemporary immigration from Latin America are also embedded in policy changes intended to regulate permanent and temporary admissions to the country. One of the first

U. S. immigration policy modifications that directly impacted migration from Central

America was the Immigration Act of 1924. Although this Act was openly criticized for establishing a quota system that restricted migration from Southern and Eastern Europe, it also clearly exempted from the quotas the countries of Central and South America

(Tienda & Sanchez, 2013).

In 1997 the U. S. Congress approved a legalization program, the Nicaraguan

Adjustment and Central American Relief Act (NACARA), which granted legal permanent resident ( LPR ) status to registered asylees (and their dependents) from

Nicaragua, Cuba, El Salvador, Guatemala, and nationals of former Soviet bloc countries

(and their dependents). Congress also enacted legislation offering Temporary Protected

Status (TPS) for Central Americans displaced by civil wars or natural disasters as part of its humanitarian goals. TPS is time-limited, does not include a path to permanent resident status and involves the deliberation of Congress for extension. When the period of protection ends, TPS’s recipients are expected to return to their country of origin.

Some beneficiaries affected by civil conflict claim political asylum, but if their cases are denied they too lapse into unauthorized status along with the thousands for whom their

TPS have expired.

Immigration statistics. During the first part of the 20th century a relatively small number of Central Americans settled in the United States. The U.S. government first began keeping immigration statistics in 1820 and for that year, only two new arrivals from Central America were recorded. Until the first half of the 20th century, the number never surpassed 1,000 per decade (Hernandez, 2004). However, during the 1960s the number of Central American immigrants more than doubled from the previous period. In the 1950s and 1960s the Central American population in the United States was very small and consisted mainly of a combination of privileged persons and low-skilled workers. In

1960, of the total 48,900 Central American immigrants the majority were from Panama, followed by migrants from Nicaragua, Honduras and El Salvador. The immigrant population from Central America began its accelerated growth in the late 1970s when different civil wars erupted in the region. Large-scale migration from Central America to the United States, a distinctively post-1980s occurrence, has been motivated primarily, as it was mentioned in the preceding section, by political instability and economic adversity in the region. In 2013, nearly 3.2 million Central American immigrants lived in the

United States representing 7% of the country’s 41.3 million migrants. The majority of these Central Americans were from the so-called Northern Triangle formed by El

Salvador, Guatemala and Honduras (Zong & Batalova, 2015). In response to the repression and violence in their countries thousands of Salvadorans and Guatemalans, many from rural areas with little or no education, fled the area. On the contrary, the immigrants who left Nicaragua came mainly from well-educated elites. As part of the president Reagan administration’s regional foreign policy, Salvadorans and Guatemalans were openly discouraged from applying for political asylum. In 1984 their approval rates were less than 3%, compared to 12% for Nicaraguans, and very distant from the rates for

Poles (32%) and Iranians (60%) for example. Many whose asylum’s applications were denied stayed in the United States without authorization under the protection of local religious organizations in the sanctuary movement (Zong & Batalova, 2015). The

Central American immigrant population has continued to grow despite the fact that migration rates dropped with the cease of the armed conflicts in the early 1990s. The migratory movement initiated for economic reasons is now facilitated by the previously developed social networks that supported those seeking political refuge before. Due to a number of natural disasters that struck Central America, in the late 1990’s unauthorized

Hondurans, Salvadorans and Nicaraguans became eligible for Temporary Protected

Status (TPS), a provisional protection against deportation with work authorization. TPS has been renewed for Honduras and Nicaragua until July 2016, and El Salvador until

September 2016 (Zong & Batalova, 2015).

Since 2011, an increasing number of unaccompanied children, mostly from El

Salvador, Guatemala and Honduras, have arrived at the U.S.-Mexico border. From the

19 start of fiscal year 2014 through July 31, 2015, 72,968 (74%), of the unaccompanied minors apprehended by U.S. Customs and Border Protection at the U.S.-Mexico border were from these three countries. Between the years of 1980 and 2013, the size of the

Central American immigrant population increased nine-fold from 354,000 to 3.2 million.

The population more than tripled in the 1980s, nearly doubled in the 1990s, and continued to raise more than 56% between 2000 and 2013. Immigrants from Guatemala,

El Salvador, and more recently, Honduras were responsible for 90% of the total growth between 1980 and 2013, while other Central American groups showed moderate increases. In contrast, between 2010 and 2013, the number of Costa Rican and

Nicaraguan migrants actually declined (Zong & Batalova, 2015).

Immigration and naturalization. The majority of Central American immigrants who have attained lawful permanent residence in the United States have accomplished it through family reunification immigration policies. Eighty-four percent of Central

American immigrants who became legal permanent residents (LPRs) during the fiscal year 2013 did so through family-based venues. Forty-seven percent of new Central

American LPRs were immediate relatives of U. S. citizens, while 37% were eligible via other family-sponsored preferences. Compare to the total legal permanent resident population in the United States, Central American immigrants were far less likely to become LPRs through employment-based preferences (6%), or as refugees and asylees

(4%). Partially due to the large percentage of TPS beneficiaries and unauthorized individuals ineligible for U.S. citizenship, people from Central America are less likely than the total foreign-born population to be naturalized citizens. In 2013, only 32% of the 3.2 million Central American immigrants living in the United States were naturalized

U.S. citizens, compared to 47% of all immigrants. Between 22% and 31% of immigrants from El Salvador, Guatemala and Honduras were naturalized citizens, while between half and two-thirds of immigrants from Belize, Costa Rica, Nicaragua and Panama had taken the steps to become American citizens (Zong & Batalova, 2015).

According to estimates from the Migration Policy Institute (MPI), during the period 2009-2013 nearly 1.6 million Central American unauthorized immigrants lived in the United States. This represented 15% of the11million total unauthorized population in the country. Guatemala, El Salvador, and Honduras are among the top five sender countries of unauthorized immigrants. In 2015, MPI estimated that almost 118,000

Central American youth were eligible for the 2012 Deferred Action for Childhood

Arrivals (DACA) program. As of June 30, 2015, 72,647 Central American unauthorized immigrants had applied for the DACA program, and 60,677 had been accepted (Zong &

Batalova, 2015).

Migrant Women

According to authors Beneria, Deere and Kabeer (2012), globalization, defined as an increase in the interconnection and interdependence of people and countries

(World Health Organization, 2016), provides the framework in which international migration has been growing, particularly since the 1980s. The acceleration of the movement of labor has been influenced by globalization in different ways. First, massive advancements in communications and technology have contributed to the spreading of information about living standards and social circumstances across countries, and have influenced people’s awareness of life options. Great incentives for people to move have originated from the real and symbolic reduction of time and

21 distance. Second, internal changes in many countries such as rural-urban migration movements and the expansion of informal production, have created immense pressures to look for paid work and better living conditions, frequently leading to international migration. International arrangements such as the North American Free Trade

Agreement (NAFTA) and the Central America Free Trade Agreement (CAFTA) have exacerbated structural transformations within countries as well. Third, Beneria et al.

(2012) continue to write that the United Nations Development Programme’s Human

Development Report of 2010 found that between 1970 and 2010 human development indices indicated considerable progress in most countries; however, this progress did not have any influence in reducing inequalities between poorer and richer nations, on the contrary, the differences increased. This factor created further motivations for international migration. Fourth, the establishment and growth of international networks at the individual, family, or group level has also facilitated the information and support needed to initiate migratory journeys. This involves nonprofit country-based or international organizations, as well as commercial systems which facilitate labor flows at different levels. Family networks have been created with the formation of transnational families, whose members are already living and working in different countries. Lastly, Beneria et al. (2012) say that a fast increase in women’s labor force participation, along with increase life expectancy and decrease fertility rates in high income countries, have contributed to the care predicament in many Northern nations, and produced a high demand for paid care work. This demand has been covered mostly by immigrant women from lower-income countries. The globalization of the labor force has included the global commodification of care, which in turn has been a factor in the

22 feminization of international migration. The term “feminization of migration” describes the shift in migration patterns as more and more women become part of migration movements as labor migrants (Dimmitt, 2013). Economists, geographers, anthropologists and scholars from other fields have been increasingly giving more attention to the study of women’s immigration. Better scrutiny and more detailed data- gathering procedures have shown that the motivations, avenues, and ultimate destinations of migrant women have often been related to conditions that are different from those of male immigrants. These patterns were not noticed before because researchers did not consider that gender differences could play a role in migration

(Wurtzburg, 2010).

Some of the conditions that have been identified as impacting women’s immigration patterns include the need to flee gendered hardships such as domestic violence, economic and educational prospects that are lower for women than for men and political and religious inequalities. Female immigrants are particularly attracted to the United States because women in America have freedoms that are not enjoyed by them in other parts of the world, as demonstrated by legislation, law implementation, and courts that uphold women’s rights. Many women may immigrate to the United

States to work in jobs that are held typically by women, like child care and other domestic work. This factor attracts many immigrants from developing countries. Some immigrants are also drawn by the American demand for foreign-born wives and take advantage of online services or relationship brokers to find prospective partners.

Inattention to gender concerns prevented for a long time the clear recognition of the different push-pull factors that influence the decisions of male and female immigrants.

It was also preventing most scholars from becoming aware that women, rather than men, dominated legal migration movements from the 1930’s until 1980 (Wurtzburg, 2010).

The gender share has fluctuated somewhat during the last three decades in the United

States. Women accounted for 53% of immigrants in 1980, 51% in 1990, and 50% in

2000. In 2014, roughly 51% of immigrants in America were female (Zong & Batalova,

2016).

Current Factors that Motivate Central American Women to Migrate

The majority of women transmigrating Mexico are Central Americans who intend to reach the United States. Women represent 10% to 30% of the Central American migrants in Mexico who are continuing their journey to America (Dimmitt, 2013). There are limited alternatives for many Central American parents to acquire a visa for themselves and their families based on employment because U.S. immigration law does not favor low-skilled workers (service industry workers, farm laborers, domestic workers and others). Also, there are constraints in the immigration system itself in regards to who can grant status to whom and the limit on the number of permanent resident applications the United States can give to each country (Cernadas, 2015, Introduction). Dimmitt

(2013) writes that a large number of Central American migrants in the United States migrate by irregular means and do not have legal status. In fact, she says that 46% of

Salvadoran, 60% of Guatemalan, and 68% of Honduran migrants are undocumented in

America.

According to the literature there are key factors associated with Central American women migration. First, Central American women migrate in response to the lack of acceptable employment opportunities caused by the trade and economic liberalization in

24 the region (Dimmitt, 2013). Second, they migrate motivated by an increased demand for female migrant labor (Beneria et al., 2012). Third, Central American women migrate to escape prevalent violence against women in the region, especially in Guatemala,

Honduras and El Salvador (Prieto & Gammage, 2016). Fourth, women migrate to achieve family reunification with the assistance of family members who are already established in U.S. (Massey, Durand & Pren, 2014). Fifth, they migrate to seek improved services (health care, access to material goods, etc.) and educational opportunities for their children (Musalo, Frydman, & Cernadas, 2015, Executive Summary). A sixth factor proposed by Dyrness and Sepúlveda (2015) specifically related to emigration from

El Salvador will be briefly presented as well. These authors’ research findings seem to indicate that Salvadoran youth’s involvement in the Salvadoran displacement is promoted long before a migrant embarks on the migration movement. This is possible thanks to the many different ways Salvadoran girls and boys are exposed to life in the United States, which culturally socialized them into the diaspora.

Economic liberalization and the need for substitute earning sources. Dimmitt

(2013) writes that Central American economic policies are in part responsible for the increasing female labor migration from the region. Since the Caribbean Basin Initiative in the mid-1980s supported liberal economic growth in Central America, countries in the area have been in a process of economic liberalization. Different countries also put into effect structural adjustment policies, Guatemala in 1986, El Salvador in 1989, and

Nicaragua and Honduras in 1990. These policies were designed to integrate the region’s economies into the world market and facilitate a reduced role for the state. Dimmitt continues to write that these changes coincided with Central America’s transition in the

25 last twenty years from traditional agricultural exports to exporting labor. Liberalization strategies and structural modification in Central America have led to reduced wages and increased unemployment, and to the development of low-pay, low-status processing and packing jobs held by women. The policies have deepened gender inequalities like the further devaluing of women’s labor; women usually work longer hours than men and do not receive remunerative pay. Small-scale agricultural producers, especially women, have also been negatively impacted by the economic reforms, since women have more restrictive access, for example, to credit than men. Recent studies show that the compulsory liberalization of the agricultural sector by the Central American Free Trade

Agreement (CAFTA) with the United States has aggravated hunger and food insecurity, and has disproportionately affected Central American women (Dimmitt, 2013).

Based on a study of migrant women in detention, more than 75% of them left their countries in search of work so they could earn money to send home. The study found that these women were stimulated by the possibility of better earnings and not by unemployment. Before migration, most women worked but had an average annual income of $3,875 US dollars. Almost half of these women were from El Salvador,

Guatemala and Honduras (Dimmitt, 2013). Derived from the economic changes, governmental cuts in public expenditure on social services had the effect of increasing the negative consequences brought by job loss and low wages in many Central American households. This new reality left many households seeking for alternative income sources; however, these new income-generating opportunities often depend upon women.

The new survival strategies include employment in export-zones, informal work, sex work and emigration. Dimmitt (2013) says that the consequences of CAFTA-growth of

26 rural poverty and poor work options have placed enormous pressure on Central American women to join the migration crusade to the United States.

Increased demand for female migrant labor in the United States. Besides the factors that compel women to leave their homelands, circumstances in destination countries, specifically the United States, also offer incentives for international migration.

An important percentage of women’s migration is very much connected with paid work prospects in the care economy. The different factors that can explain the increasing demand for care services in high-income countries during the last decades include the fast rise in women’s labor force involvement, higher life expectancy and exceptionally low fertility rates which has decreased the capacity of families to care for their own relatives.

The outcome has been the further commodiﬁcation of care and the growing dependence on immigrant women for paid care work, including salaried domestic work, nursing and childcare (Beneria et al., 2012). The demand for undocumented workers has increased in the United States as higher revenues are sought by the reduction of labor costs.

Employers frequently hire workers who lack proper legal documentation because they are more willing to accept lower wages and more challenging working environments.

Gender and race discrimination facilitate the employability of migrant women in low- skilled, female-intensive labor trades such as service, healthcare and apparel manufacturing. In the United States the demand for international domestic workers has been filled by migrant laborers (Dimmitt, 2013).

Prevalent violence against women in the region. Central America has been described as the poorest region in Latin America, but also as the most violent and insecure area in the non-conflict world. The countries of El Salvador, Guatemala and

Honduras have attracted international attention due to the elevated levels of violence and severe forms of crimes against women (Ronderos, 2011). These countries rank first, third and seventh, respectively, in the global index of femicides (Prieto &

Gammage, 2016). Femicides (also feminicides) are defined as murders of women, and murders explicitly aiming at women based on their gender (Cernadas, 2015,

Introduction). Femicides in Honduras, for instance, are marked by their level of cruelty. Numerous victims are sexually assaulted before they are executed and their bodies are mutilated in ways that reveal an extreme hatred against women and girls.

Studies have found that in Central America the activities of organized crime, which includes drug trafficking networks, gangs and criminal groups that function locally and internationally, have generated forced displacements. The increased presence of organized crime becomes noticeable through homicides, femicides, massacres, kidnappings, extortions, forced recruitment, strategic control of territory and the generalized fear among the population (Musalo et al., 2015). Widespread government institutions’ loss of legitimacy has deteriorated as a result of the penetration of organized crime into government bodies such as the National Police and the Office of the Attorney General; this situation has weakened these institutions’ law enforcement capabilities (Rivera, Ruelas, Cuello, Flores, & Pinto, 2015, Chapter 2).

In an environment of an imbalanced distribution of wealth, limited resources and weak institutions, impunity wins within the justice system. This negatively impacts women because crimes against them like sexual harassment and assault, domestic violence, labor rights violations (for example, forced pregnancy testing) and femicides, all are repeatedly ignored and left without punishment. Women from poorer and

28 marginalized areas are even less protected as crime in these zones is usually invisible to any form of government intervention (Ronderos, 2011). According to Prieto and

Gammage (2016) the intensifying violence in Central America is revealed by the increasing number of women crossing the border between Mexico and the United States.

Between 2013 and 2014 the number of women detained by the U.S. Border Patrol triple, while more than 68,000 families arrived during fiscal year 2014 and 40,000 during 2015.

Repeatedly, these women are the mothers, wives, sisters and daughters of persecuted family members. Others are the direct recipients of violence or are escaping with their children seeking to prevent their children’s forced recruitment into criminal groups.

Sexual violence. Women are at risk of experiencing sexual violence throughout the world, including Central America. National statistics from Nicaragua (2006), El

Salvador (2008) and Guatemala (2008) showed that about 12% of women aged 15-49 years had been coerced into having sex by an intimate male partner, and that women were often victims of sexual violence inflicted by non-partners (Reyes, Billings, Paredes-

Gaitan & Zuniga, 2012). Risk factors associated with sexual violence in Central America include elevated rates of crime and fragile social mechanisms that create an environment in which violent behavior is highly tolerated. Additionally, since approximately half of the region’s live in poverty, women in violent relationships might be unable to leave and might be more vulnerable to sexual intimidation in exchange for material goods, and/or may be exposed more often to high-risk situations. Social standards that do not facilitate the exposure of child sexual abuse and that legitimize violence against women are also listed as risk factors (Reyes et al., 2012).

Domestic violence. Socio-cultural norms that discriminate against women are

29 present in Guatemala and are associated with structural gender violence. Guatemala’s

National Statistics Institute reported that violence against women (emotional, physical, sexual, and financial) was the crime most commonly denounced in the judicial system.

In 2012, nine out of ten victims of intra-familial violence were female and one was male;

56.2% of the victims were women between 20 and 34 years. Intra-familial violence increased by more than 500% between 2003 and 2012, being females most of the victims

(Paz y Paz, Solorzano, & Gonzalez, 2015, Chapter 3). Regarding El Salvador, this country is a highly patriarchal society in which women are subordinate to men. Official statistics on crimes against women are difficult to find in this nation. One of the reasons is the inconsistent measures used by the different institutions that gather the information.

The 2012 Special Integral Law for a Life Free from Violence for Women tried to solve this challenge by establishing a unified database to be accessed by all the relevant institutions. Nonetheless, in 2014, the database, like other parts of the law, such as the creation of shelters for women fleeing abusive partners, was still not operational

(Amnesty International, 2014). Despite the limitations, in the context of domestic violence a 2008 nationwide government study found that nearly half of Salvadoran women who had been in a relationship had experienced abuse at the hand of their partner.

Of these, a quarter had endured physical violence and almost 10% had suffered sexual violence (Amnesty International, 2014). In Honduras, proliferating intra-familial violence, including child abuse and incest, helps clarify the increase in the number of girls migrating alone. From January through August of 2014, only in Tegucigalpa, 1,155 complaints of domestic violence were heard by the Special Prosecutor for Women, with an average of 144 cases per month and 4.8 per day (Rivera et al., 2015). Contreras and

Griffith (2012) write that for abused women, including Central Americans, ending violent relationships means a desire to take control over their own lives, a willingness to assume the risks of single motherhood, and in most cases, taking the initial steps towards migration and the adoption of an active role as the sole breadwinners in their households.

Achieving family reunification. From a sociological perspective, people also migrate to attain family reunification. Mass emigration from Central America during the

1980’s naturally created social networks linking migrants in the U.S. to relatives who stayed back home. Return migration to Central America has always been very low because the region has remained economically, politically and socially unstable. The political violence that to an important extent ceased during the 1990s has been substituted by gang violence (Massey et al., 2014). In addition to fleeing economic or societal turmoil, family reunification has become another motivation for Central Americans to emigrate to the United States. The links new migrants have in the U.S. provide a source of social capital for them to start the trip. The family networks assist migrant workers with money, the process of entry, information about jobs, housing and overall reduce the costs of migration. The multiple ties connecting Central Americans in the U.S. to relatives at home have created solid networks of regular and irregular transit and entry to the United States. Under these conditions, it can be expected that migration from Central

America will persist and will continue to be dominated by the sons, daughters, spouses and other relatives of the people who left during the mass migration of the 1980s (Massey et al., 2014). Circumstances that strengthen a migrant’s wish or need to reunite with family can foment a permanent migrant identity (Gaborit et al., 2015).

Seeking improved services for themselves and their children. In Guatemala,

El Salvador and Honduras, childhood has become equivalent to experiencing social exclusion and being deprived of opportunities, medical services, education, employment and even food. These circumstances force children and/or their parents to emigrate

(Musalo et al., 2015). As States parties to the Convention on the Rights of the Child, these three nations systematically fail to perform important duties expected of them.

Deficiencies include absence of laws and regulations or failure to enforce them, mismanagement of budgets and resources, poor implementation of public policies and arbitrary procedures that contradict a rights-based approach. These deficiencies accentuate the denial of the basic rights of the child as seen by the statistical information on poverty, school drop-out rates, illiteracy, unemployment and general lack of good prospects among adolescents and youths (Cernadas, 2015, Introduction). As of 2013,

UNICEF (United Nations Children’s Emergency Fund) estimated that Guatemala had a population of about 15.4 million, nearly half of whom were children and adolescents, with more than 17% under 5 years of age (Paz y Paz et al., 2015). Consistent with the

National Survey on Living Conditions of 2011, 53.7% of the population lived in conditions of poverty and 13.3% lived in extreme poverty. Data for 2012 showed that

19% of children 7 to 14 years of age worked in the labor market and that rural areas had the highest rate of child labor. The United Nations Development Program (UNDP) reports that in Guatemala 49.8% of children younger than 5 are afflicted with chronic malnutrition; however among the indigenous community this statistic reaches 65.9%.

The report also says that the average level of education of children and teens is only 4 years (Paz y Paz et al., 2015). El Salvador has a very young population, 63.7% is under

32 the age of 30. Data from UNDP suggests that although net enrollment in basic education in 2013 was 93.7% of children, it was only 35.4% for high school. Also, the percentage of underweight children and adolescents was 5.5%, while the percentage of those with chronic malnutrition was 19%. Among children and teens whose mothers lack an education, the percentage of those underweight was 15.7% and of those with chronic malnutrition was 36.6% (Cernadas, 2015, Introduction). Honduras is one of the lowest- income countries in Latin America and the Caribbean, with a poverty rate, according to the National Statistics Institute, of 60% in 2011. Poverty is more concentrated within the rural population which makes about 53% of the country’s total population. Rural areas experience the most extreme deficiencies in the coverage and quality of social services.

Severe malnutrition negatively impacts more than half of the children between the ages of 1 and 5. In regards to education levels, schooling for Hondurans is calculated to be 4.3 years in rural areas and 7 years in urban regions (Cernadas, 2015, Introduction).

In their study with Central American immigrant women, Sternberg and Barry

(2011) found that more than 50% of participants did not have any form of health care before emigrating. The participants reported that they immigrated to the United States to escape the severe poverty in their country. They also shared that they wished the challenging decision they made to leave their children and their country would allow their children to have a better life than the life they had. Migrant women hope to provide their children with better nutrition, clothing and education. Most of these women can indeed buy these items with money earned in the United States (Hondagneu-Sotelo &

Avila, 1997).

Cultural socialization into the Salvadoran diaspora. Dyrness and Sepúlveda

(2015) argue that beyond the focus on the potential reasons behind Central American migration such as the difficult conditions in the region’s countries, or the attractions of life in the United States, there is a more hidden but influential factor. This factor deals with the reality of a cultural displacement to which girls and boys already belong and which has guided them to identify with the diaspora. Dyrness and Sepúlveda, presenting information specifically on El Salvador, interpret diaspora as the social imaginary that bonds Salvadorans in El Salvador with Salvadorans and other Latinos in the United

States. The authors studied how this transnational relationship was experienced in two very different school communities in San Salvador. One of the communities was a long established private school, Lincoln School, which serves the city’s elite, while the other was a public school that operates in El Rio community, one of the most violent and marginalized areas in San Salvador. Dyrness and Sepúlveda (2015) focused on two different contexts of socialization, homeboy expressive culture and school-based English instruction. They use “homeboy expressive culture” to describe the linguistic, behavioral, and other representative characteristics related to California urban Chicano/

Latino youth culture, or “street style.” Homeboy identities embody peripheral subjectivities in El Salvador which are personified by youth gangs and deported

Salvadorans (gang related or not) from California. According to Dyrness and Sepúlveda, youth deported from Los Angeles walking the streets of San Salvador calling themselves

“homies”, are the representation of a forced transnationality. In El Rio, non-deportees and deportees symbolize this forced transnationality, both socialized in the diaspora. El

Rio youth, both gang and non-gang members, exemplified and performed homeboy expressive culture in their language, dress, gestures and daily interactions. For example,

34 they used the common noncontact greeting of a head not upwards, and hand gestures and movements when talking and sharing. The researchers write that they often heard U.S. mainstream English and vernacular English from Los Angeles Latino barrios spoken around the school, in the streets, in taxicabs and on TV. Words like ‘dólar’ and ‘cora’

(dollar and quarter), ‘fulear’ (to fill a gas tank), or ‘hood’ (neighborhood) were common in the vocabulary of El Rio’s youth. In addition, films such as Boulevard Nights,

American Me and others describing the U.S. urban experience were part of their cultural environment. Dyrness and Sepúlveda (2015) say that students in El Rio community adhered to a marginal social identity that is denounced both in El Salvador and the United

States, as they showed attraction to homeboy language and culture. El Rio’s youth were seen often engaged in conversations about U.S. presidential politics, and often showed a familiarity with both general mainstream U.S. culture and the specifics of Chicano/Latino

California barrio subculture. These youth were also taught at their community school how to apply for the TPS (Temporary Protected Status), as they engaged in different role- playing activities depicting ‘a day in the United States’. These teens were instructed by their teacher to practice how to conduct and interview between a U.S. immigration worker and a Salvadoran migrant. Dyrness and Sepúlveda write that El Rio’s students were highly familiar with the life of undocumented immigrants in the United States, due to their routine contact with deportees and migrants present in their community.

Across town, other Salvadorans, the students at the elite Lincoln School (one of several reputable international schools in San Salvador) lived a very different experience.

As students in an American School, these teens had received all their education in

English since kindergarten. They only took one Spanish language and Literature class

35 and a single course on Salvadoran history in their senior year of high school, as all the emphasis was on American history. They were comfortable speaking both Spanish and

English, but on academic responsibilities they preferred to use English. Students interviewed by Dyrness and Sepúlveda (2015) mentioned that it was very difficult or impossible for them to attend universities in El Salvador or another Latin American country, because they did not know how to do science or math in Spanish. Other students made strong comments when they said that no one knew anything about their country in the school. One interviewed student seemed to have captured with her words what many other Salvadoran teens belief. This student said that all Salvadoran teenagers consumed

American music and movies, and that they should not call themselves Salvadorans anymore because they were not. Dyrness and Sepúlveda explain that this student referenced both, “the illegal immigrants” and U.S. popular culture as tendencies that were changing cultural identity for many Salvadorans. Many students at the Lincoln School were able to see an association between their education in English and their identities as individuals who were detached from other Salvadorans. These students argued that they were unaware of the local Salvadoran realities, not only of negative realities like poverty, but also of local opportunities and Salvadoran cultural wealth.

According to Dyrness and Sepúlveda (2015) such is the socialization into the diaspora for boys and girls in both communities in San Salvador. It connects these youth to new groups of citizen subjects abroad: homeboys in Los Angeles, or college-bound

Latin Americans in the United States. However, this socialization also separates them from other citizen subjects at home: their parents, teachers, and for students at elite schools, non-English-speaking Salvadorans. Dyrness and Sepúlveda (2015) argue that

36 different influences imported from the United States mediate Salvadoran youth’s relationships between America and El Salvador and contributes to the creation of a diasporic space. This space allows the formation of new identities that structure

Salvadoran youth’s relation to the United States and their interpretation of migration.

Characteristics of Central American Immigrants in the United States

Age. Statistics compiled by the Migration Policy Institute show that between

2009 and 2013 the Central American immigrant population was younger than the overall foreign-born population. The average age of Central American immigrants was 38 years, compared to 43 for the foreign-born population overall. In 2013, a greater segment of

Central American immigrants were of working age (18 to 64) compared to both the total foreign and U.S.-born populations. Particularly, about 22% of Panamanian immigrants were ages 65 and older, the highest portion among all Central American immigrant groups (Zong & Batalova, 2015).

Education. Central American immigrants are likely to have low educational achievement compared to the overall foreign and native born adult populations. Data from 2013 show that 49% of Central American immigrants ages 25 and over did not complete high school, compared to 30% of all immigrants and 10% of U.S. born adults.

About 9% of Central American adults had a bachelor’s degree or higher, compared to

28% of the total immigrant population and 30% of U.S. born adults. Immigrants from

Panama (27%), Costa Rica (23%), Belize (19%), and Nicaragua (17%) were considerably more likely to be college graduates compared to those from Guatemala, El Salvador, and

Honduras (around 7% each) (Zong & Batalova, 2015).

Employment. Immigrants from Central America were in the labor force at a higher proportion than the general immigrant and native born populations. In 2013, nearly 75% of Central American immigrants ages 16 and over participated in the civilian labor force, in contrast to 67% and 63% of all foreign and U.S. born, correspondingly.

Central American immigrants were substantially more likely to be employed in service occupations (34%), construction and maintenance occupations (22%), and production and transportation jobs (18%) than both the overall foreign and native born populations.

Additionally, close to one-third of employed immigrants from Belize, Panama, and Costa

Rica worked in business, science, management, and arts occupations, compared to less than 10% of their equals from Guatemala, El Salvador, and Honduras (Zong & Batalova,

2015). When compare with Mexican immigrants, Central American migrants have more labor force experience (17.6 vs. 11.9 years), are less likely to be working in agricultural occupations (6% vs. 40%), and are more likely to be business owners (24% vs. 6%)

(Massey et al., 2014).

Income and poverty. In 2013, the average income of households headed by a

Central American immigrant was $41,000 compared to $48,000 for overall immigrant households and $53,000 for native-born households. All Central American immigrants groups, with the exception of Costa Ricans, had lower average household income than the total foreign-born population. During the same year, 22% of Central American immigrant families lived in poverty, a higher proportion compare to all immigrant (18%) and native-born families (10%). Nearly 28% of immigrant families from Guatemala and

Honduras were in poverty, contrasted with 11% of those from Costa Rica (Zong &

Batalova, 2015).

A View of the Central American Family Unit

From a sociological perspective, the family is a basic social institution formed by different relationships that are joined by a line of shared kinship. Its objectives involve social construction and reproduction, nourishing and care-giving work (Ehrenreich &

Hochschild, 2003). Moreover, these relationships are entrenched in cultural, social, economic and political aspects that shape family forms. ‘Familism’ has been identified as one of the most important culture-specific values of Hispanics (Sabogal, Marin, Otero-

Sabogal, Marin, & Perez-Stable, 1987). The term describes the existence of a solid identification and attachment of individuals with their families (nuclear and extended), and strong feelings of solidarity, reciprocity and devotion among members of the same family (Triandis, Marin, Betancourt, Llisansky & Chang, 1982). According to Keefe,

Padilla and Carlos (1979), the Hispanic family represents an emotional support system which is comprised of a cohesive group of nuclear and extended relatives who help each other and rely on each other more than on external sources of support. It has been proposed that this natural support system promotes healthy psychological growth (Valle

& Martinez, 1980). Although familism has been recognized as a central value, many authors theorize that familism along with other important Hispanic values are changing due to acculturation, urbanization, increasing contact with the U.S. mainstream culture and immigration (Garza & Gallegos, 1985; Mindel, 1980). Keefe (1980) proposed that immigrants from traditional societies who arrive to a more industrialized culture become less dependent on the family linkage and experience more social mobility. In an interesting reference to Central American families, Menjivar (2012) writes that the

Central American family is not a fixed institution analogous to the nuclear family, since

39 this institution has endured many transformations in this region. Menjivar argues that other family forms have co-existed with the idealized notion of a nuclear unit. Central

American women and men have been engaged in different movements of labor migration, and this has led to the formation and maintenance of different family arrangements. In the late 1950s, it was already estimated that ‘free unions’ in El

Salvador constituted 50% of all family formations and families usually included children from previous unions (Menjivar, 2012). Guatemalans, Salvadorans and Hondurans in the

United States have mixt forms of family structures. Some immigrants arrived to the US single and began families here; others came alone and left their families back home. In other situations, the parent or parents and the children live in the US while the other children live in the home country. Some immigrants have established new unions in the

US and therefore have two immediate families in different geographical locations. Some

Guatemalans and Salvadorans took their kids, but due to the unsafe conditions of the neighborhoods where they settled, sent the children back to their home country to be cared for by family members (Menjivar, 2000). It is common for the Central American immigrant families to have diverse arrangements and be separated by huge distances.

In a recent study, Dillon, De La Rosa, Sanchez, and Schwartz (2012) researched hardly considered pre-immigration family cohesion and drug/alcohol use behaviors of

Latino youth adults. Even though the importance of the family unit is found in many cultures (Schwartz et al., 2010), as discussed above, family cohesion in the Latino culture is typically characterized by close relations with nuclear and extended family members throughout the life span. The study sample included 527 recent Latino immigrants in US

(45% female and 55% male). Approximately 70% of participants immigrated legally,

40 while the remaining 30% were undocumented immigrants. Seventeen different nationalities from Latin America were involved including participants from six Central

American countries (Honduras, Nicaraguans, Guatemalans, Costa Ricans, Salvadorans and Panamanians). The researchers write that Caribbean participants reported the highest levels of family cohesion, and Central American participants reported the lowest levels.

Central American participants were the least educated, and the more likely to be undocumented of the group. Central Americans also reported more pre-immigration drug use, hazardous/problematic drinking and quantity of alcohol use than the Caribbean participants, but less frequent engagement in alcohol use than South Americans. Dillon et.al (2012) argue that possibly due to socio-political and economic instability and higher levels of separation from families during undocumented migration in comparison to the other regional groups, Central Americans showed the lowest levels of family cohesion in this study. They also state that potentially, cohesion of the family in Central America is overwhelmed by high levels poverty, violent sociopolitical turmoil, and less coping resources across the life span of individuals. Dillon et.al (2012) argue that these circumstances (socio-political and economic instability, poverty, and family separation during migration, among others) have, in theory, led to a reduced protective influence of family cohesion against problematic drug/alcohol use among Central Americans.

Migrant Family Separations

During the process of migration families go through deep transformations that are frequently aggravated by extended periods of separation (Suarez-Orozco, Todorova, &

Louie, 2002). According to Hondagneu-Sotelo (1992), traditionally the pattern followed by families who migrated involved the father leaving alone, establishing himself and

41 sending remittances back home. After it was financially attainable, the father would help the wife and children immigrate too. More recently, however, the first world’s demand for service laborers has attracted mothers from a variety of developing countries often to care for the children of other people. Whether mothers initiate migration or both parents leave, the children are left in the care of extended family. Hondagneu-Sotelo says that due to financial hurdles or immigration laws, the reunification of the entire family may take many years. These migration separations frequently cause disruptions in attachments, first from the parent and then from the caretaker to whom the child has become attached during his/her parent/parents absence. There is not a lot of research about the immigrant experience and its implications on family separations (Suarez-

Orozco, et al., 2002). A few clinical studies of Caribbean families in Canada and Great

Britain reported significant negative family consequences during reunification (Burke,

1980; Gordon, 1964; Sewell-Coker, Hamilton-Collins, & Fein, 1985). Research has found that children may experience negative repercussions during the time they are separated from their loved ones, but also during reunification. This information will be discussed in detail later in the ‘Children’s Mental Health Implications’ section. Authors

Suarez-Orozco et al. (2002), however, point out that the clinical literature reporting on migrant family separations and reunifications could very easily overemphasize the pathological reactions to separations, because only struggling families are likely to seek treatment. The authors cite two dissertation studies that were conducted with non-clinical populations and which found no distinct connections between separations and effects.

One study of stress responses among Jamaican immigrant families found that although many mothers were depressed, the children who were separated from them did not show

42 higher levels of stress responses compared to children who had not been separated (Hohn,

1996). The other study which involved, both, college-age immigrant students who had been and who had not been separated from their parents during early development, found no correlation between separation and family relations and their capacity for emotional intimacy (Simpao, 1999). Suarez-Orozco et al. (2002) write that these studies could have been limited by the use of standardized instruments not appropriately fitted for the population being researched. Nonetheless, Suarez-Orozco et al. argue that the studies open the possibility to the hypothesis that the connection between separations and negative consequences may not be direct.

Theoretical Frameworks

Different parts of the literature have been used to understand the aspects involved in family separation processes. The most widely used theoretical assumptions are presented next.

Object relations theory. Object relations theorists hold that fractures in parental relationships are followed by substantial developmental challenges. Object relations theory is a branch of psychoanalytic theory that emphasizes interpersonal relations, mainly in the family and particularly between mother and child. ‘Object’ essentially means person, and especially the significant person that is the goal of another's feelings or intents. ‘Relations’ refers to interpersonal relations and includes past relationships that affect a person in the present. This theory emphasizes inner images of the self and others, and how they show themselves in interpersonal situations (Daniels, 2007). Donald

Winnicott, an influential object relations theorist, argued that children mature into secure adults within the context of stable parental relationships (Winnicott, 1958). Object

43 relations theorists generally believe that early relationships give origin to the sense of self and the capacity to relate with others. Any disturbances in primary object relations are assumed to create major pathologies. Suarez-Orozco et al. (2002) argue that this theoretical position may not be applicable to migrant families, since the theory, by emphasizing the mother-child dyad, gives privilege to a Western understanding of the nuclear family. Many migrant families come from cultures that rely on a wide network of family support. Suarez-Orozco et al. say that in the presence of different significant relationships, others besides parents can successfully fulfill the needs of developing children. Therefore, although a child might miss his or her parent when the parent leaves, the temporary loss may not involve trauma.

Attachment theory. Attachment theorists also maintain that ruptures in

‘affectional bonds’ with parental figures have deep developmental and psychological consequences (Ainsworth, 1989; Bowlby, 1973). Recent research has tried to comprehend the experience of immigration from an attachment theory perspective

(Polek, van Oudenhoven, & tenBerge, 2008; Van Oudenhoven & Hofstra, 2006). These studies seem to be motivated by the awareness that attachment-related phenomena, such as the interruption of interpersonal bonds, and the escalation of environmental stress, are also central elements of the immigration experience (Sochos & Diniz, 2012). The theory, introduced by John Bowlby, proposes that from an evolutionary point of view, the attachment system has adaptive importance and is therefore central to human life

(Bowlby, 1973). ‘Attachment’ refers to the natural need to remain physically and emotionally close to trusted others who are anticipated to act as sources of support during challenging times. In addition, according to attachment theorists an individual needs to

44 be exposed to supportive attachment relationships in order to develop competence and mastery. Attachment security is the most important concept of the theory, and is defined as the hope that an intimate other will be available at times of necessity and that the self will be capable of eliciting such caring reaction. Attachment security also involves the feelings of safety and well-being that these expectations convey (Sochos & Diniz, 2012).

Based on research, the differences that people display in mental models of attachment are explained, to an important extent, by differences in childhood experience with the primary caregivers. Individuals who display secure attachment characteristics are believed to have been raised by caregivers who responded appropriately and consistently to the child’s needs for autonomy, care and support. These individuals establish a working model of the self that depicts them as lovable and competent, and views others as caring and receptive. As adults, they would gravitate towards genuinely intimate and reciprocally supportive relationships, and would also deal effectively with stressors and demands from their environment. On the contrary, individuals who grew up with relatively unsupportive caregivers would follow an insecure attachment model and would have severe difficulties in dealing with interpersonal relations and in mastering their environment.

The connection between attachment insecurity and clinical distress has been one of the central findings in attachment research. Different studies have found that attachment insecurity might meaningfully predispose an individual to developing a psychiatric condition (Dozier, Stovall, & Albus, 2008). The cross-cultural validity of attachment theory has generated considerable discussion among researchers. Studies suggest that secure attachment is the ideal adaptive mechanism, as it is universally

45 associated with adequate self-regulation, minimal interpersonal conflict, well-balanced developmental and mental health processes and it is the norm in most cultures (Main,

1990). However, according to Sochos and Diniz (2012) insecure attachment seems to be more apparent in highly stressful environments and cultures that emphasize social approval. They argue that more research is needed in this area. Sochos and Diniz also write that because immigration usually involves the interruption of important interpersonal relationships in the country of origin (relationships in which the individual may have felt cared for, love and respected), all major attachment phenomena has an important stage in the immigration experience. Early attachment theorists would generally hold that the attachment with the mother or primary caretaker is of particular importance. Again, according to Suarez-Orozco et al. (2002) this western model may be overstressing the potential damages cause by splits in the parent-child dyad. Ainsworth

(1989) has found that parent substitutes, siblings and peers also may be extremely important as attachment figures. Therefore, interferences in these extended family social and emotional connections can also create feelings of sadness and loss.

Theory of ambiguous loss. The literature on the experience of loss offers another perspective to understand the possible outcomes related to fractures in family relationships (Boss, 1999; Doka, 1989; Feshbach & Feshbach, 2001). Loss which can be experienced as a result of death or other circumstances is generally a transition that involves a process of adaptation, and may trigger different types of emotional, physical and behavioral reactions (Suarez-Orozco et al., 2002). Some researchers think that it is the loss of the close person or persons that activates such reactions. Other researchers argue that it is the secondary losses, such as loss of routines, financial security, or

46 emotional stability that comes with the initial loss that ultimately bring negative consequences (Goldstein, Wampler, &Wise, 1997). Pauline Boss proposes that an ambiguous loss is a loss in which a loved person is either, physically present but psychologically absent (i.e. a parent with dementia), or physically absent but psychologically present (i.e. an estranged family member). Boss found through research that in ambiguous loss situations, closure is not possible or even therapeutically sensible. She argues that there are some losses that people will simply not overcome.

The healthy way to respond is to learn to live with the unsolved grief and to find meaning in ambiguity itself (Gonzalez, 2016). Suarez-Orozco et al. (2002) write that the response given to what Boss has called ‘ambiguous loss’ is related to parent-child separations during the process of immigration. Since the parent is not dead but simply left for what is often estimated to be a short period of time, ‘permission’ to grieve may not be allowed.

The child’s loss may go unrecognized and may be surrounded by silence which can cause that the child’s grief may be invalidated. Under these conditions, the normal emotions of grieving such as sadness, anger, guilt and hopelessness could be prolonged because there is no legitimate public space in which to express them.

Due to the fact that there is no clear-cut conclusiveness in the relationship in migrant family separations, the reactions to the separation may take the form of subtle chronic symptomatology rather than intense, critical manifestations. It becomes important to understand the manner in which the adults in the child’s environment as well as the wider culture respond to the loss, since grief triggers a crisis in family development that impacts all members as they try to adapt to the absence of the loved one (Shapiro,

1994). If the remaining caretaker does not manage the loss in a balance way, this

47 caretaker may not be available to assist the child in the containment of strong feelings.

The child’s capacity to keep the missing parent or caretaker psychologically present is critical to the child’s wellbeing. Research suggests that the child will be able to make meaning of the loss and adapt to it, if he/she has continuity of care and someone who provides connection (Silverman, 2000). Studies in the field of loss and trauma suggest that people get involved in a process of meaning restoration after experiencing a troublesome life event in which they lose the connection with a loved one. The suffering that loss brings is not minimized by meaning-finding approaches. On the contrary, these approaches place the losses in a more complex perspective that takes into account possibilities for finding value and new significance in what is left after the loss

(Neimeyer, 2001).

Other Important Factors Associated with the Family Separation Process

Authors Suarez-Orozco et al. (2002) explain that object relations theory, attachment theory, and the clinical literature on parent-child separations and loss would suggest that separations cause by immigration and its associated reunifications can potentially be very challenging. However, they state that there is no definite empirical evidence about what percentage of migratory movements involves separations, and whether or not difficulties are as common as the literature would expect. Suarez-Orozco et al. argue that the data on this topic comes largely from clinical populations which focus on families and youth that are in treatment. Therefore, these findings may overemphasize the negative consequences of separations. Suarez-Orozco et al. (2002) analyzed data obtained from the Longitudinal Immigrant Student Adaptation Study (LISA) conducted at Harvard University. This study was based on a nonclinical population and was

48 designed to understand the adaptations of newly arrived immigrant youth coming from different countries. Suarez-Orozco et al. share information obtained from young adolescents from the Dominican Republic, Haiti, Mexico, China, and Central America.

They write that although the data obtained showed an association between separation and higher levels of identified depressive symptoms, interpretations to establish direct causality could not be inferred from the statistical analyses. Suarez-Orozco et al. (2002) argue that most likely other significant elements contribute to the presence of these symptoms. They explain that in order to understand immigrant children’s reactions to family separations, different factors must be considered like the complexity of the separation experience and the conditions that surrounds the separation itself. Perez-

Foster (2001) also believes that it is not only the separation alone what causes clinical psychological distress, but also the associated altering events that occur before, during, or after the disarticulation. Suarez-Orozco et al. propose that some identifiable factors aggravate the separation experience. Trauma derived from a family tragedy, or from warfare, or political, ethnic, religious persecution can intensely amplify a negative response. Associated losses can also intensify responses. Dealing with a parent’s departure will be more difficult if a child loses other important relationships at the same time. Most children highly value established routines, when these routines are dramatically interrupted by the parent’s departure, most likely the experience will be more damaging (Boothby, 1992). Due to the expectation of the migratory journey, relationships may be ruptured; in other situations, a break in the marital relationship can force a parent departure (Simpao, 1999). These are also factors that can make the separation experience more difficult. Suarez-Orozco et al. (2002) say as well that the

49 nature of at least three relationships will significantly impact a child’s adjustment to family separation. These are, the parent-child relationship bond prior to the migration

(Arnold, 1991), the caretaker(s)-child relationship, and the triangle parent-child- caretaker. Challenges may appear if problematic connections exist in any of these relationships. Suarez-Orozco et al. (2002) found in their study that, in fact, for many children the family separation process during immigration is painful, and it causes a sense of longing for the missing parents. They urge that a special emphasis be placed in the context and conditions of the separation as these will greatly impact different outcomes.

Immigration and Trauma

Since researchers propose that the conditions to which migrant mothers and their children are exposed before, during, or after their separation can impact mother’s and children’s reactions to family disarticulation (Perez-Foster, 2001; Suarez-Orozco et al.,

2002), the following sections will examine what women experience before, during and after their migratory journey, and what children endure during their separation from their mothers.

What Central American migrant women go through and the trauma they endure. Once migrants decide they will migrate to the United States, they need to choose how they are going to migrate. Although nearly 80% of immigrants arrive to the

U.S. with legal authorization, many Central Americans have limited access to legal immigration paths and enter more often without authorization. However, entry to the

U.S. without proper permission involves very difficult routes and contact with physical adversities and violence (Perreira & Ornelas, 2013). Even though Mexico’s Migration

Law of 2012 grants legal protection to the human rights of migrants and identifies the

50 vulnerability of women migrants, current restrictive immigration policies continue to increase the precariousness of women labor travelers. These policies continue to force women migrants to take illicit migration passages in which they are easy target of organized criminal groups and corrupt officials. In order to avoid detention, female migrants count on smugglers but this exposes them to human trafficking or forced prostitution (Dimmitt, 2013). The immigrant mental health literature that has been compiled in the last years suggests that there are complex stressors that seem to be common to the immigrant experience. Desjarlais, Eisenberg, Good, and Kleinman

(1995) proposed that the entire course of immigration, from leaving the country of origin to entering the host country, could be a traumatic experience.

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-

5) of the American Psychiatric Association (APA, 2013), defines a directly experienced traumatic event as “exposure to war as a combatant or civilian, threatened or actual physical assault (e.g., physical attack, robbery, mugging, childhood physical abuse), threatened or actual sexual violence (e.g., forced sexual penetration, alcohol/drug- facilitated sexual penetration, abusive sexual contact, noncontact sexual abuse, sexual trafficking), being kidnapped, being taken hostage, terrorist attack, torture, incarceration as a prisoner of war, natural or human-made disasters, and severe motor vehicle accidents” (p. 274). The immigrant mental health literature identifies four stages that describe the process and the potential for immigration-related trauma: pre-migration trauma, trauma during transit, trauma during asylum-seeking/temporary settlement, and trauma during settlement in the host country. During these different stages, migrants

51 endure different levels of vulnerability and are exposed to the directly experienced traumatic events specified in DSM-5 (Phipps & Degges-White, 2014).

Stages of migration-related trauma. The four phases as found in the literature include: pre-migration phase, during transit phase, during asylum-seeking/temporary settlement phase, and settlement in the host country phase.

Pre-migration trauma. Pre-migration trauma can include events that were experienced before making the decision to migrate and that could have influenced this aspiration to relocate (Perez-Foster, 2001). A lot of migrants who have lived in poverty before coming to the U.S. have experienced years of war and political violence and years of continuing stress (Perreira & Ornelas, 2013). As was discussed in previous sections, one of the fastest growing immigrant communities in the United States come from war- torn Central America (Asner-Self & Marotta, 2005). A study conducted by Kaltman et al. (2011) with Latina immigrants in which an important percentage of participants were

Central American women, found high levels of pre-migration trauma. Kaltman et al.

(2011) write that their results are consistent with the outcomes of other researchers like

Eisenman, Gelberg, Liu, & Shapiro (2003) for example. Eighty-nine percent of participants in the study by Kaltman et al., reported that they endured one or more of the following types of trauma: childhood interpersonal violence, adult interpersonal abuse perpetrated by a non-partner, domestic violence, witnessed violence, violent loss, community violence, political violence, among others.

Childhood interpersonal violence. Participants witnessed and/or experienced childhood physical, emotional, and sexual violence in their country of origin.

Commonly, the physical violence was inflicted by the women’s parents or by relatives or

52 other individuals who cared for the participants, in the absence of the parents who had emigrated to the United States. Several women talked about the violence they endured as a typical form of discipline. They also mentioned how their abuser rationalized the violence as preparation for marriage or other adult realities. Participants recognized that the abuse was facilitated by the disintegration of their families due to the separation of parents, death of a parent or immigration. Often, participants were required to work by their caretakers, and their basic physical and emotional needs were unfulfilled. Kaltman et al. (2011) also report that women in their study spoke about their experiences of childhood sexual abuse as traumatic, and many disclosed the abuse for the first time as part of the research. In all the cases, except one, the sex offenders were family members.

Domestic violence and witnessed violence. Physical violence inflicted by a partner in the country of origin was noticeably vicious as it often involved weapons or knives. The participants commented that the violence was sometimes mutual and that children were often exposed to it. Emotional violence involved repeated humiliations and being controlled, which was frequently made easier by financial dependence.

However, even if the participants were not financially dependent on their abusers, the controlling behaviors could still be severe. Some women reported being locked in their houses and having their kids kidnapped by the partners. In many occasions these women looked for support or assistance but people, including family members, law enforcement, or even professionals, saw violence as a common part of the marital relationship. Some participants shared that the partner abuse they were experiencing, triggered their migration. Violence witnessed in the family was often between parents or members of the extended family. Eighty percent of the participants who disclosed that

53 they witnessed violence between family members as children also disclosed that they experienced domestic violence as adults. Some experience partner abuse, both, in their country of origin and in the United States (Kaltman et al., 2011).

Violent loss. Violent loss of loved ones was recurrent in the country of origin.

Close male family members or friends who were lost to murders or suicide were more frequently the victims. The participants shared that the majority of these murders went unresolved, because looking for answers could make the family a target for even more violence.

Community and political violence. Many of the women participating in the

Kaltman et al. (2011) study shared that they experienced armed robbery and witnessed gang violence in their county. Frequently, the women witnessed the violent act itself or the consequences. The violence described usually involved extreme cruelty, for example one participant narrated how she saw a woman being sexually assaulted by a gang formed by more than 16 men. Even though community violence is present in the United States, the narratives shared by the women about the gang activity in their countries revealed its widespread presence and its unusual levels of inhumaneness. In the context of political violence the women in the study spoke about the experience of living in a constant state of fear in their country. They usually felt that danger was imminent and that something negative could happen anywhere or at any time. The woman said they were unable to trust others because it was usually difficult to know which side of the conflict people belonged to. Participants disclosed that they witnessed murders, saw corpses in the streets, and had family members vanish who were apparently kidnapped and murdered.

Other forms of trauma. Kaltman et al. (2011), write that women in their study also reported having experienced negative episodes in their life derived from natural disasters and culturally specific practices. At least one participant was the victim of a practice called ‘robo’. The robo is a cultural tradition which is practiced in Latin

America and other parts of the world and that has different variations depending on where it is still followed. The robo is part of a marriage observance in which men

‘kidnap’ young women, sometimes with their agreement, before the wedding and frequently involves sexual intercourse. After the robo, the women’s parents want their daughters to get married to prevent social vilification. There have been efforts to penalize this practice because studies suggest that frequently women are kidnapped even when they did not consent and exposed to violence and rape (Garcia, 2010).

Trauma during transit. The manner of departure from the country of origin that an emigrant chooses can either add more negative experiences to already potentially existing trauma, or by itself, constitute a frightening attack to the body and mind (Perez-

Foster, 2001). The migratory road through Mexico has been dangerous since Central

Americans began entering the United States during the 1980s. During this time, immigration officials, corrupt Mexican police, and opportunist delinquents chased

Central Americans and carried out human rights abuses against them. During the 1990s and early 2000s, migrants were often assaulted and intimidated by Central American street gangs who had control of the southern train courses through Chiapas. The norther border and the Sonora desert have long been characterized for their anarchy. In the last few years, however, migrants have been encountering violence not just at the borders, but throughout Mexico. Criminal groups now target migrants, kidnap them, and order them

55 and their smugglers to pay for crossing their area (Brigden, 2012). Prevalent violence against women migrant is being facilitated by the existing epidemic of migrant kidnapping. The Mexican National Human Rights Commission (CNDH) reported in

2011 that approximately 18,000 to 20,000 migrants were kidnapped every year. Most victims were from Honduras, El Salvador and Guatemala in this order. Migrants are kidnapped while they are traveling or staying in shelters, and coerced into revealing the names of family members who can pay a ransom for their freedom. Often, kidnappers batter and torture migrants and kill those who cannot pay the ransom. Kidnapped women endure systematic sexual abuse and rape and are sometimes sold into sexual slavery

(Dimmitt, 2013). The migrant’s relatives who are in the United States have to pay from hundreds to thousands of dollars usually incurring into debt. However, sometimes even after paying the ransom migrants still disappear and are never heard of again. A safe approach to initiate the migratory route is to pay a respectable guide who can gain traveling rights through Mexican space by bribing the right gangs and corrupt officials.

Usually family members living in U.S. use their savings or high-interest loans to help migrants. However, even when trip arrangements are previously made, the migratory journey can still end in calamity. Unscrupulous smugglers may sell migrants to their competitors or other delinquents, in order to avoid risks of criminal activity or legal prosecution when problems arise along the passage (Brigden, 2012). The typical idea of the ‘coyote’ (smuggler) has changed in the last years from a figure of the ‘family’ coyote to a system with many players. A ‘family coyote’ is a person who has guided several family members, has shown dependability during successful trips, and has traveled with the migrant from the beginning to the end of the route. Presently, the individual coyote

56 has almost disappeared and has been replaced by an ‘organization of coyotes’ with characteristics that make migrants more vulnerable. In many cases, migrants are handled by different smugglers along the passage and treated as commodities while being dehumanized and exposed to harm (Gaborit et al., 2015). Many migrants become trap in an endless cycle of repeat journey victimization and deportation. When they cannot enter the U.S., but cannot return to their country of origin either, they adapt a transit lifestyle which is creating an international homeless class. These people are anonymous refugees who are living nomad lives along the migratory roads in Mexico (Brigden, 2012).

The routes migrant women use. Migrant women from Central America using the migratory route through Mexico endure long journeys on foot, and in different forms of land transportation; the trips usually last from weeks to months (Kaltman et al., 2011).

Most women do not migrate on cargo trains or following systems of migrant shelters as it is usually documented; they are undertaking more isolated roads and clandestine methods. Women hire the services of smugglers, and often pay with housework, money and with alarming frequency, with sexual favors. Some avoid migration barriers by walking certain parts of the route, while others ride with Mexican truck drivers during parts of trip to the United States. Since there are no migrant shelters along the highway circuits, women need to stay in hotels or guest houses. These lodgings often have armed groups facilitating their operations, and this puts female migrants in a situation in which they do not have the protection offered by religious or civil society institutions. The strategies that most female migrants are using to move through Mexico on their way to their final destination, the United States, seem to be effective. Nevertheless, their trips are exposing them to extreme gendered vulnerabilities (Díaz-Prieto & Gammage, 2016).

Some human rights institutions estimate that six in ten women and girl migrants are victims of rape during their transit. Other service groups in the field say that eight in ten women migrants experience rape and other forms of sexual victimization. In fact, sexual aggressions are so rampant that often smugglers require women to take contraceptives before they start their trip (Dimmitt, 2013).

Female migrants are also at risk of human trafficking, another form of gender- based violence. The International Organization for Migration (IOM) has worked directly with trafficking victims since 2005, and throughout this time women have always accounted for more than 80% of the victims. Most of the affected people were Central

American females between eight and twenty-two years old, the large majority

Guatemalans. Women are victims of sex and labor trafficking; however, those trafficked for labor are frequently also victims of sexual violence which is used as a strategy of control (Dimmitt, 2013). For Central American migrants who are trying to enter the

United States without legal documentation, the actual transmigration trip can be filled with very extreme experiences that can range from sexual assault, and being kidnapped or trafficked, to days spent wandering in precarious conditions with limited food and no shelter. Additionally, migrants face constant threats from their potential encounter with wild animals, severe environmental settings, anti-immigrant patrols and vigilante groups.

All these predicaments meet the criteria for a traumatic event as defined in the DSM-5

[APA, 2013] (Phipps & Degges-White, 2014).

Trauma during asylum application/temporary resettlement. Receiving countries do not always offer the friendliest environment to newly arrived migrants, especially if the country is experiencing economic challenges or if large numbers of immigrants

58 arrive. Migrants who have been apprehended upon entering Mexico or the United States can be placed in detention centers and may face overcrowding, lack of provisions and fear. The application for legal asylum has its own set of severe stressors as migrants can remain in detention centers for months or years without being processed (Phipps &

Degges-White, 2014). Obtaining international protections is particularly challenging in

Mexico. The Commission for Assistance to Refugees (COMAR) does not have the capability to detect cases that could legitimately benefit from refugee status or humanitarian protections. Detained migrants are not offered with the possibility of asking for asylum, and are not interviewed to understand their particular situations. In

2014 Mexico granted only 322 residence permits based on humanitarian reasons, and during the first nine months of 2015 gave refugee status to only 277 people. Of these numbers 43% were women and 4.3% girls and boys. Most petitions are denied based on a lack of enough evidence and migrants are deported. During the time migrants are awaiting their application decision and during deportation, the Mexican state fails to guarantee the adequate protection of families and child migrants (Díaz-Prieto &

Gammage, 2016). In regards to the situation of detained migrants in the United States, this nation has the largest immigration detention system in the world, as the U.S.

Immigration and Customs Enforcement (ICE) operates more than 200 facilities across the country. These facilities keep over 30,000 migrants every day (End Immigration

Detention of Children, 2014). Migrants in these detention centers are also exposed to physical and emotional violence, sexual assault, and are not offered with adequate food, health care or outdoor recreation. There have also been reports of segregation and solitary confinement and death by negligence or suicide. A study conducted in 2003

59 found that 86% of detainees in U.S. detention facilities were depressed, 77% had anxiety, and 50% suffered from posttraumatic stress disorder (Rizzo, 2015). For many migrants the atmosphere and the treatment they endure at the detention facilities stir distressing memories of earlier trauma (Phipps & Degges-White, 2014).

Post-migration trauma. There are unceasing acculturative and socioeconomic hardships of migration which do not end with the physical crossing of the border and that can continue to impact migrants for many years. After migrants are finally able to enter the United States many of them now have to adjust to a new physical environment, new people, language and customs. The migrants who enter without proper documentation have the added challenge of dealing with anxiety and fear related to being discovered and repatriated, and potentially repeating the migration journey again (Cervantes, Mejia, &

Mena, 2010). Studies in the United States have found that inability to find a job, substandard living conditions, the need to rebuild social supports and minority discrimination are crucial factors that contribute to migrants’ psychological suffering

(Perez-Foster, 2001). Phipps and Degges-White (2014) write that Latino immigrants are confronted by distinctive mental health stressors which are intensified by anti- immigration legislation, racial profiling and language discrimination that targets undocumented Latino migrants. Phipps and Degges-White continue to say that strong community based relationships, and strong family ties are commonly valued and promoted within the Latino culture. However, migration dislocates these alliances by physically disconnecting migrants and their main support groups; therefore, many migrants feel secluded and traumatized in their new country. Phipps and Degges-White

(2014) argue that in the Latino culture there is a sensitive awareness of discrimination

60 and injustice which has been stimulated by the history of colonialism in Latin American countries. Many Latino immigrants may find that their resilient work ethic is not enough to surmount discrimination and injustice in the United States, after having been guaranteed that hard work would help them fulfill their dreams. Moreover, the Latino cultural construct of ‘fatalismo’, the belief that fate cannot be change, may contribute to the position many migrants take that all negative post- migration experiences are irreparable.

French and Chavez (2010) found that critical internal culture-related stressors like preoccupation about confirming stereotypes, perceived discrimination, or pressure to conform within one’s own culture, can cause persons in immigrant populations, predominantly Latino youth, to feel that they are continually vulnerable and that they have no control over the situation. According to French and Chavez this experience fits the definition of traumatic stress. Kaltman et al. (2011) found in their study with Latina immigrants that the post-migration trauma these women endured in the United States included emotional and physical abuse in intimate relationships. The women were exposed to controlling behaviors which they thought were motivated by their partners’ jealousy. Kaltman et al. (2011) write that the abuse and jealousy could have been connected to the couple’s new social circumstances in the United States, in which for instance, the women held jobs while their partners did not, creating a change in gender roles from the native country. Women also endured adult interpersonal physical violence and emotional abuse that were inflicted by a non-partner, and that were caused by problems between those already established in the United States and those who were just arriving. Women were also exploited and abused by employers who often made them

61 work long hours with no time off and did not pay them a proper salary. As new immigrants, women usually are forced to depend on others because they have limited financial resources, do not understand English and do not know how to orient themselves in the new environment. These circumstances make them easy prey for violence and other abusive situations (Kaltman et al., 2011). It will be important for clinicians working with Central American migrant women to assess and understand the types of trauma these women have endured, and how this trauma is impacting them and her relationships including the relationship with their children (Phipps & Degges-White

2014).

Experiences of Children Who have been Separated from Their Parents due to

Migration

Migration and mobility has become a prevalent phenomenon which has created unique but intricate connections between migrants and family members left behind.

However, there are no definite answers about how migration and mobility impacts family members who remain back home. In countries with high levels of out-migration the number of children left behind is mathematically important and involves a lot of families; nevertheless, knowing the exact numbers of children impacted by the migration of one or both parents can be challenging, since the methods used by national statistics centers vary making international evaluations almost impossible (Cortes, 2007). The term ‘children left behind’ alludes to those who stay in the country of origin while their parents, legal guardians, or other family caregivers migrate to other nations (Office of the United

Nations High Commissioner for Human Rights, OHCHR, 2012). Nevertheless, this term

‘left behind’ can be problematic since it can be understood as those not lucky enough to be able to migrate, or either as those who were in some way ‘abandoned’ (Cortes, 2007).

Since the development of children and adolescents is closely associated with their family bonds, their right to development in the context of migration can be dramatically altered if the right to family life is not guarantee. Interferences on the right to family unity precipitated, for example, by an irregular migration standing, and the lack of interventions to preserve family life in country of origin and destination, can negatively affect the lives of children and adolescents (Cernadas, 2015, Introduction). Additionally, while it was commonly the father who left, now it is heard more frequently that it is the mother who is migrating first, bringing with this decision profound transformations to the family and consequences for the children that have not been experienced before

(Valtolina & Colombo, 2012). When parents migrate, their children’s care is entrusted to grandparents, aunts, uncles and/or godparents. Usually they are capable substitute caretakers; however, research shows that frequently the adults taking care of left behind children are also part of the local work force. The poverty that compels labor-age adults to migrate also coerces the caregivers left to take care of the children to work when the money sent home is insufficient, leaving children neglected to a certain degree

(Castaneda & Buck, 2011). Children for whom one or both parents have migrated can respond in different ways from a psychological perspective, in order to deal with this tense circumstance. They can develop dysfunctional cognitive processes, adapt inappropriate behaviors, or experience trauma. Such reactions depend on different factors like how the family performed before the actual separation, the closeness of family members, the child’s personality and the support offered by the remaining family

63 members. The emotional difficulties experienced by these children can be linked to the lack of physical contact, kisses, caresses and other clear expressions of warmth. A child who is left behind by parents may experience severe forms of physical and medical neglect (i.e., lack of access to adequate food, lack of access to necessary dental, medical or mental health care). The consequences of this deprivation are expressed by the child in forms such as low school performance, absenteeism, anxiety, aggressiveness, tendency towards depression, lack of motivation, lack of concern about what is happening, low self-esteem, antisocial behaviors and suicidal behavior (Valtolina &

Colombo, 2012).

A survey conducted in 1993 showed that migration considerably raises children’s risks for being abused or exploited, and that the migration of mothers was more highly correlated than that of fathers with the potential for being exposed to physical and sexual abuse. In 2005 another study which used a larger sample confirmed this result (D’emilio et al., 2007). The United Nations High Commissioner for Refugees (UNHCR) Office for the United States conducted individual interviews with 404 unaccompanied children from

Honduras, Guatemala, El Salvador and Mexico arriving to the United States without proper documentation. All the children interviewed were part of the massive children migration that began in October 2011. Twenty-one percent of these children (85 children) disclosed that they had endured abuse or violence (physical, emotional, sexual abuse and abandonment) in their homes at the hands of their caretakers. Twenty-two children said they left their country of origin because their caregivers were ill, had died or were otherwise unable to care for them. Twenty-four percent of children from Honduras said they had experience abuse in the home, along with 23% of children from Guatemala,

20% of children from El Salvador, and 17% of children from Mexico (United Nations

High Commissioner for Refugees, 2015, Chapter 1). Countries most impacted by migration have a large percentage of children left behind, but regularly do not possess the necessary resources to deal with the special needs of these children. Moreover, governmental agencies presuppose that children left behind have already more advantages than other children because they are being economically supported by their parents, and usually exclude them from the protection of existing social policies (De la

Garza, 2010).

Situation of Honduran children whose parents have migrated. Thousands of children from Honduras have been left behind by parents who have emigrated to Mexico or the United States. Although these children are under the supervision of extended family members, nobody has legal responsibility for them. With no parents present to support and protect these children and under the governance of failed or ineffective public social policies, they become even more vulnerable to challenging situations like the influence of gangs; even caregivers may neglect or abuse them (Musalo et al., 2015,

Executive Summary). In regards to access to fundamental rights, children whose parents have migrated experienced the same structural deficiencies that affect most Honduran children. A substantial number of Honduran children have been deprived of their fundamental rights or must exercise them in discriminatory, irregular and fragmented conditions. On the subject of the right to education, for example, children have difficulties accessing it when the caregivers lack the necessary resources. Children whose parents are recent migrants tend to be in the most sensitive situation because of their parents’ fragile financial status. These children usually cannot even get public

65 education in their communities. Nonetheless, children whose parents have established themselves abroad and have regularized their migration status, may have better access to education because their parents may have the income to invest in the children’s schooling

(Rivera et al., 2015, Chapter 2).

Healthcare services for children whose parents emigrated are not different from the inadequate healthcare benefits that the majority of the population has. Moreover, there are no programs in place that focus on the psycho-emotional health of children who have been left behind by their migrant parents. As is the case with education, if the children’s parents are not present, the children’s usage of healthcare services can be inappropriate if the adults in charge do not replicate parent’s duties effectively. In

Honduras teenage pregnancies are very prevalent, especially in rural areas. Girls as young as 11years old can get pregnant because of sexual abuse, lack of support from parents and poverty. Young and adolescent girls without parental protection are easy targets for gang members who in many cases coerce them to provide sexual services.

Children are also victims of domestic abuse or violence by the adults who are entrusted with their care, such as relatives or neighbors, or even the parent who did not emigrate

(Rivera et al., 2015, Chapter 2). The Honduras’ national child welfare institution has a weak organization and ineffective enforcement capabilities, and cannot respond satisfactorily when children are deprived of basic rights. The absence or failure of social policies that can secure social rights for citizens, continue to precipitate the migration of families, children and parents who leave their children behind (Musalo et al., 2015,

Executive Summary).

Situation of Guatemalan children whose parents have migrated. Attempts to study the issues experienced by migrant children began very recently in Guatemala.

However, very little academic research has focused on the impact of migration on the children left behind. Different forms of violence and deprivations experienced by

Guatemalan children are impacting their right to development. Intra-familial violence is occurring with distressing frequency in Guatemalan homes and family separations due to migration aggravates this situation (Paz y Paz et al., 2015, Chapter 3). As it was mentioned previously, the UNHCR study (2015) reports that 23% of the Guatemalan children interviewed disclosed intra-familial abuse inflicted by a family member or other caregiver. A study by Carletto, Covarrubias and Maluccio (2011) evaluated the relationship between migration and child growth in the rural uplands of Guatemala. This region is known for its large migration movement, important influx of remittances, but also for its elevated rates of child undernutrition. The research shows that the relationship between migration and net effect on child growth is positive and significant; nevertheless, it finds no clear support on how migration could be improving child nutritional status. Researchers suggest the effect might involve a combination of factors, including better food security and lower morbidity. The authors continue to say that although migration is possibly playing an important role in regards to children’s nutritional status in the community, undernutrition in the study area is still high, and that this outcome indicates that there are other key factors related to child health care in the area that migration is not adequately addressing. Interestingly, these researchers also found in this study that when the higher levels of per capita expenditures are taking into account, children in migrant households have poorer levels of full vaccination when

67 compare with non-migrant households. Carletto et al., (2011) state that they cannot explain this occurrence, but theorize that it could show “increased value of time for remaining household members” (p. 26). An earlier study by Hildebrandt and McKenzie

(2005) also connects migration with poorer child care as measured by vaccination records.

Situation of Salvadoran children whose parents have migrated. Numerous children from El Salvador have parents living abroad due to migration. This has exposed them to neglect, exploitation and abuse while under the responsibility of extended family members or friends. Some Salvadoran children flee their country to be reunited with their parents and to have the nurture, care and protection that is absent in their lives

(Musalo et al., 2015, Executive Summary). As mentioned before, the UNHCR study

(2015) reports that 20% of the Salvadoran children interviewed talked about having experienced intra-familial abuse at the hands of a family member or other caregiver, with

Salvadoran girls disclosing the highest rate of abuse in the home. The emigration of their parents and the remittances parents send to their families have helped many Salvadoran children who remain home, overcome poverty and have their most basic needs covered.

However, children, especially those living in rural areas, continue to experience social exclusion which deprives them of their right to reach their complete development. Some of the challenges Salvadoran children face include the fragmentation of the child protection system, current family and cultural structures that slow down their development, and social tolerance towards violation of their rights. Regardless of El

Salvador’s reformist laws destine to improve children’s welfare, the government still allows violent offenders to harm children with impunity, and has been either incapable or

68 reluctant to stop the intra-familial and gender-based violence many Salvadoran children suffer (Gaborit, Duarte, Orellana, & Brioso, 2015, Chapter 4).

Reasons Why Migrant Mothers Leave Their Children Behind

The rising demand for care services in high-income countries like the United

States and increased dependence on immigrant women for paid care work (i.e. childcare, paid domestic work, and nursing), has produced new care needs as many migrant women frequently leave their own family care behind (Beneria et al., 2012). When compare with

Mexican migrant women, Central American women are more likely to leave their children in their native country, even if their husbands are with them in the United States

(Hondagneu-Sotelo & Avila, 1997). Some studies have found that Nicaraguan migrants travel primarily to Costa Rica, followed by the United States. More than 40,000

Nicaraguans leave their country every year, with approximately the same male to female proportion of emigrants. Both, male and female travelers are between the ages of 20 and

49 and this can mean that tens of thousands of Nicaraguan children are growing up without one or both parents because they have migrated (Yarris, 2014). Another report states that according to El Salvador’s Ministry of Foreign Affairs, as of 2011 nearly 12% of Salvadoran children were growing up without one or both parents as a result of migration (Rodriguez, 2015). A research project conducted by Hondagneu-Sotelo &

Avila (1997) and which has contributed one of the most significant sets of data on the topic so far, states that of 153 Mexican and Central American migrant domestic works interviewed, 75% were mothers, and of these, 40% had at least one child still living in their country of birth. One of the many reasons that force female labour migrants to leave their own countries is the need to support their family; but what motivates women

69 to assume the seemingly contradictory role of leaving their children in order to contribute to the welfare of their children? (Contreras & Griffith, 2012). Some of the causes listed by Schapiro, Kools, Weiss and Brindis (2013) include immigration restrictions and financial limitations, safety concerns, the belief that children receive a better upbringing in the country of origin, and the need to protect children from racial and anti-immigrant prejudice.

Immigration restrictions and financial limitations. Restricted immigration policies may obstruct the simultaneous migration of parents and children, as visas for them might not be available at the same time (Foner & Dreby, 2011). For those who travel without proper documentation, the absence of platforms for obtaining regular immigration status in the United States blocks completely the possibility for thousands of children to travel with their parents. For migrants who already have a legal status, the family reunification process is characterized by many delays and difficulties (Cernadas,

2015, Introduction). Also, when it is challenging to fulfill their families’ economic needs by living together (Foner & Dreby, 2011), or when parents have to pay an average of

$6,000 per child for crossing the border, migrants must choose to leave without their children (Horton, 2009). Some Latina mothers come to the United States without their children to be able to find stable jobs first, and once they established themselves they may send for their kids (Hondagneu-Sotelo & Avila, 1997).

Safety concerns. Parents may decide to come to the United States first and then bring their children later or when the kids are older, as a protective tactic. Migrating in sequence enables parents to adjust to the new environment, and save money to bring their children to the United States legally, or through a safer manner if entering without proper

70 authorization (Perreira & Ornelas, 2013). Central Americans lacking legal documentation encounter double or triple border crossings to enter the United States, because of this, for example, many Salvadoran women embark on their migratory journey without their children to avoid exposing them to danger (Horton, 2009). Migrating to the

United States without proper entry documentation entails grueling journeys and experiences of severe physical adversities and violence (Perreira & Ornelas, 2013).

Migrant children can face several risks along the route at the hands of security forces, migration agents and organized criminals. Potential dangers include the risk of facing hunger, serious health problems, robbery, kidnapping, human trafficking, sexual violence, arbitrary detention and deportation (Cernadas, 2015, Introduction). Very young migrant children can be particularly sensitive to the difficulties endured during the crossing, and may not have yet the resiliency that could protect them from developing mental health complications (Perreira & Ornelas, 2013).

The belief that children receive a better upbringing in the country of origin.

There are diverse sources of intergenerational conflict in immigrant families and this finding is supported by research. Cultural differences between parent’s motherland values and norms, and American’s mainstream culture, greatly contribute to the challenges between teens and parents in immigrant families in the United States.

Immigrant parents can have an idealized description of traditional values and norms, even when these observances may have changed significantly since they left their homeland

(Foner & Dreby, 2011). Some migrant women who have jobs in the United States are determined to prevent their children from experiencing the multiple perils of adolescence in America (Hondagneu-Sotelo & Avila, 1997). Issues of discipline and respect are one

71 important factor. Immigrant parents usually want to see a level of respect, obedience, and consideration that children growing up in the United States perceive as coercive and authoritarian. The cultural background in the United States promotes early independence and child rearing practices that are usually more lenient than in the immigrant’s country of origin. For example, in many countries corporal punishment is still widely accepted as a form of discipline, and immigrant parents may feel that their authority is challenged when it is not possible for them to reprehend their children the way they belief is effective (Foner & Dreby, 2011).

The need to protect children from racial and anti-immigrant prejudice.

Research shows that immigrants who have particular phenotypical characteristics or religious traditions confront high levels of racial-ethnic discrimination in the United

States. Furthermore, recognized racial-ethnic discrimination works as a social stressor and can make many immigrants and ethnic minorities feel vulnerable and powerless in the United States. As an economically underprivileged group, Latino immigrants in the

United States also tend to be isolated into poorer and high crime neighborhoods and schools where they can be further exposed to violence and discrimination (Perreira &

Ornelas, 2013). Migrants with irregular immigration status are particularly vulnerable as they suffer the continued criminalization of undocumented migration in society (Upegui-

Hernandez, 2011). The types of jobs available in receiving countries to migrant women are jobs that are usually inadequately regulated or are illegal, such as childcare, domestic and sex work among others. These are frequently the only options migrant women without proper documentation have, as they can avoid in this manner immigration state officials (Upegui-Hernandez, 2011). Many migrant women do not wish for their children

72 to repeat the job experiences they have faced in the United States. The daily affronts of paid domestic work, low pay, lack of food, subtle humiliations and invisibility, motivate migrant women to leave their children behind and in doing so, they are safeguarding their children from the discrimination they might be exposed to in the United States

(Hondagneu-Sotelo & Avila, 1997).

Transnational Motherhood

Transnational mothers are those women who migrate from poor to rich nations to escape severe poverty, political oppression, or other repressive social realities. When they choose to migrate, they are knowingly leaving their country, culture, family and children; but they are also incurring into questioning about their maternal duties and responsibilities to provide nurturance and protection to their children who now need to be raised by others (Sternberg & Barry, 2011). For migrant mothers who opt for working abroad, superior motherhood means to provide for their children financially, offering them a better life than the one they have had. The price they have to pay for this is their inability to give emotional support and direct care to their children, consequently generating a tension within motherhood (Contreras & Griffith, 2012). In the present day there is more acceptance toward different mothering arrangements like single mothers, stay-at-home mothers, employed mothers, lesbian mothers, to mention a few; nonetheless, even feminist discourses usually assume that mothers, by definition, will live with their offspring. Transnational mothering alters the idea of a family unit residing in one place and departs uniquely from the traditional concept of motherhood. It challenges the prevailing U.S., white, middle-class prototypes of motherhood and most

Latina concepts of maternity (Hondagneu- Sotelo & Avila, 1997). Thousands of Central

American women have been coming to the United States since the early 1980s, many of them leaving their children behind. A lot of working women, including Latinas like these

Central American mothers, embrace the cultural view of stay-at-home mothering as an ideal. This model is spread through cultural mechanisms of urbanization and industrialization, as well as from preindustrial, rural peasant provisions which permit that women work while taking care of their offspring. White, middle-class principles, and strong Latino traditions and practices (i.e. Catholicism and the Virgin Madonna image) define employment as antagonistic to mothering (Hondagneu- Sotelo & Avila, 1997).

Nevertheless, culture does not conclusively determine what individuals do. Many Latina women need to work, and a lot of them look for different ways to earn income while they care for their children. They sew clothes at home, and include their kids into informal selling to acquaintances, at swap meets, or on the sidewalks. They may clean houses while their children are at school, or include their daughters in their house cleaning jobs.

They may involve their children in their agricultural labor or work only seasonally.

While Latina women have habitually worked with their children close by, the white middle-class model of mothering consists on mother-child isolation in the home. In both cases, mothers are with their offspring. However, the time and distance that comes between transnational mothers and their children appears very different from the mother- child combination in the workplace or the mother-child isolation in the home model.

Hondagneu- Sotelo and Avila (1997) point out that although the model of biological mothers raising their own children is commonly embraced, it is not always observed especially in the wealthy and poor social classes. Affluent people have always depended

74 on nannies, guardians, or boarding schools to raise their children, while poor, urban families habitually count on kin to help with this task.

When men leave their families due to migration, it is usually said that they are fulfilling their breadwinning responsibilities towards their family. When women migrate, however, they are getting into a more fundamental gender-reframing journey. When they start separations of time and space from their homes and children, they stir a wave of criticism from other people and have to deal with stigma and guilt. Often, the separations of distance and time are significant, since 10 years may pass before mothers can see their children again (Hondagneu- Sotelo & Avila, 1997). The 1996 enactment of the Illegal

Immigration Reform and Immigrant Responsibility Act (IIRIRA) doubled the size of the

Border Patrol and gradually criminalized the act of illegal immigration. The intensified militarization of the border has inhibited the circular migratory movements that had traditionally allowed migrants to maintain a ‘transnational circuit’, and has also caused that the separation between migrant mothers and their children be more prolonged

(Horton, 2009).

What it means to be a transnational mother. In their study with migrant

Latinas who worked as nannies and housekeepers in the Los Angeles area, Hondagneu-

Sotelo and Avila (1997) noticed that generally when transnational mothers share their definition of motherhood they stay away from descriptions such as child abandonment, disaffection, or renunciation. In fact, one of their research subjects, a Salvadoran woman, reported that although she had been physically separated from her boys for more than a decade, she continued with her mothering and financial responsibilities to them by sending them money on a regular basis. For this mother, being physically absent from

75 her children did not represent being emotionally absent from them. Hondagneu-Sotelo and Avila (1997) write that transnational mothers seem to be able to expand their definitions of motherhood to include breadwinning that can entail persisting physical separations. A central belief for these mothers is that they can best achieve traditional caregiving duties through the production of income in the United States while their offspring stay ‘back home’. According to Hondagneu-Sotelo and Avila (1997) Latina mothers in their research seemed to support full-time motherhood when adequate financial resources were present. However, they accepted more flexible definitions of motherhood, such as the one that involves physical and time separations between mother and child, when financial adversity, like their own, was a pressing factor. Not all Latina migrant mothers appear to support the concept of transnational mothering, though. Some

Latina mothers in the Hondagneu-Sotelo and Avila study who had their children with them in the United States described transnational mothers as ‘bad women’. One participant who had her child with her and could take her to her work said she would never separate from her daughter. For this participant, transnational mothers were bad mothers and nannies who would not be able to properly care for other people’s children.

Despite these negative concepts, most transnational mothers are aware and worry about the potential negative effects separation can cause on their children, and experience the lack of family life as a painful loss. Most transnational mothers believe that motherhood requires emotional connection and communication with a child, and they strive for harmonizing caregiving and instruction with breadwinning. Although breadwinning may involve space and time separations between mother and child, transnational mothers try to maintain family connections by displaying emotional bonds through phone calls,

76 letters and money sent home (Hondagneu-Sotelo &Avila, 1997).

Remittances. Remittances typically make reference to the money and resources that migrants send to their country of birth; however, remittances also measure the strength and magnitude of the ties between the migrant and the family members left behind. Manifestations of love, physical contact, care and support are usually basic elements that are part of a parent’s role. Distance, therefore, poses a challenge to the relationship between parents and children (Castaneda & Buck, 2011). To alleviate the difficulties and uncertainty of the long-term separations from their children, migrants take advantage of the benefits remittances bring. Remittances not only deliver needed resources for those in the country of origin, they are monetary transactions with key emotional significance through which migrants maintain a sense of family (Menjivar,

2012). Migrants can be described as ‘bad’ parents if they do not remit. If the economic situation prevents them from remitting, many may opt for cutting communication with their families instead of presenting themselves empty handed. Moral distinctions are made between migrants who send remittances and those who do not. Remitting conveys that migrants are still devoted to family and community, and at the same time guarantees loyalty towards them and secures their ability to continue their involvement in their family and community of origin (Castaneda & Buck, 2011). Many migrants remit approximately $150 or $200 monthly. Migrant mothers who leave their children in their home land hardly ever stop sending money, and send remittances for longer periods of time than migrant fathers, despite the fact that women’s earnings in the United States are potentially lower than those of men (Menjivar, 2012). Central American transnational mothers try to safeguard the present and future of their offspring by working in the

United States, and this demands that they separate from them for long periods of time.

They keep their mothering commitments by sending remittances and by communicating and guiding across national borders (Hondagneu-Sotelo &Avila, 1997).

Establishing duplicate families. According to Horton (2009) although different researchers have studied the sending of goods as a common approach of ‘mothering from afar’, the strategy of women starting ‘duplicate families’ to guarantee their ability to support the children they left in their country of birth has been less fully analyzed.

Horton enlightens this topic by presenting the experience of a Salvadoran migrant mother who at the age of 23 was abandoned by her partner. This migrant needed to raise her three children and decided that to be able to do so she had to leave them and emigrate.

Once in the United States she faced new expenses related to food and rent, and even though she found a job, the family member who was supporting her in the United States wanted her to sign her paycheck over to her. The Salvadoran mother decided to move out of the house of this family member, but in doing so she was unable to continue to provide for her children in El Salvador. This migrant found herself alone in the new country and with no family to ask for help. Soon after, she started to date a Salvadoran man and within a year they began their own family. Although they procreated two kids, this man helped this Salvadoran mother pay her rent and provided for her children in her country of origin. The new husband helped this migrant mother solved in part the challenge of how to support her children who were back home. Horton (2009) writes that in her research, for women whose breadwinning determinations fell short of their intended objectives, beginning new families represented a way of obtaining the safety of a male breadwinner who could help support the children they had in their home country.

The moment of separation between a mother and her children. The circumstances that surround the departure of migrant mothers are usually distressing.

During the days before they start their journey, some migrants have tense conversations with their children in which they try to explain why they are leaving. By sharing their reasons with their children, these mothers try to protect them from the emotional pressure of their dilemma. They introduce their decision to migrate within a context of ongoing parental care, clarifying that they have to exchange their physical presence for their children’s welfare. However, grief is intersubjective, and parents and children often negotiate the hardship of jointly survival (Horton, 2009). The days preceding the parents’ departure can be characterized by fervent bargaining between them and their children. Horton documents in her study how children may try to convince their parents that they can take on adult responsibilities so that parents can stay. Children may suggest that they will not eat as much so the family can save money, or that they can volunteer their own ability to work. Children can also bargain to be brought along with their parents, arguing they can labor along with them, or can take care of their siblings while the adults work. Horton (2009) continues to write that such children’s attempts to secure their mother’s physical presence produce an atmosphere in which mothers feel deep moral failure for their inability to physically take care of their offspring. The day a transnational mother is ready to leave her home, she may prefer not to say goodbye to her children in order to avoid painful reproaches. Horton (2009) argues in her study that the limited options migrant mothers have impact their entire family and that transnational separations burden the bond between mother and child.

Whom transnational mothers entrust their children to?. Transnational

Central American mothers entrust their children’s care to close relatives. They may count on their own mothers, godmothers and other female kin; they may also rely on the children’s fathers, and paid caregivers. Support from grandmothers and godmothers for joint mothering is well established in Latino culture and is a tradition that describes a more collectivist approach to mothering. Possibly, this cultural heritage has enabled the development of transnational motherhood (Hondagneu-Sotelo &Avila, 1997).

Transnational mothers strongly prefer that their own biological mothers serve as the main caregivers for their children. If this is not possible, then reliance will be place on the biological grandmothers or on the ceremonially connected godmothers. These preferences appear to be motivated by convenient availability, but they also carry cultural directives. Many Hispanic women would agree with the claim that Hispanic women usually do not believe in entrusting their children’s care to someone outside the family circle. Therefore, biological connections, commonly, guide joint child care arrangements

(Hondagneu-Sotelo &Avila, 1997).

The concerns of a transnational mother. A main concern among transnational mothers is that their children may be neglected or exposed to abuse in their absence.

They worry that their children are not getting adequate nutrition, schooling and educational motivation, and moral guidance. They may be left wondering if their children are benefiting from all the remittances they send home, as sometimes their doubts are reinforced by the comments of the eldest child or the report of a relative who is able to watch the caregiver’s disloyalty. Transnational mothers are constantly thinking if their offspring will have problems during their adolescence, or if they will give their

80 devotion and love to the ‘other mother’. Generally, transnational mothers consider that the person who is supervising and caring for the children has the right to discipline them.

However, when teenagers are being cared for by elderly grandmothers or ineffective disciplinary individuals, the mother may need to get involved. Pre-teens and teens who display rebellious behaviors can be sent north because their grandmothers or paid caregivers may have lost control over them. On the other hand, adolescents who are in the United States can be sent back with the hope that this will help them change their behavior. Transnational mothers worry that children who have grown up without their presence may no longer be sensitive to their authority. Transnational mothers want to offer their children a better nutrition, clothing and educational opportunity. Most of them are able to access these benefits with money earned in the United States; however, they know that their transnational relationships get impacted by an enormous cost

(Hondagneu-Sotelo &Avila, 1997).

Mental Health Implications of Migration on Women

Through migration women can have access to opportunities that would not be available to them in any other way, like labor market experiences and earning prospects, increased participation in education and a broaden participation as decision makers.

Women migrants are often empowered by the autonomy and the physical and economic independence they experience; however, changes in gender roles can bring new responsibilities and new emotional and physical hardships (De la Garza, 2010).

Available data shows that migration can increase chances of survival and can alleviate poverty, but can also lead to exploitation, discrimination, and disruption (D’emilio, et al.,

2007). Migration can represent a crisis in the sense that it can bring rupture and

81 separation, since migrants must deal with the now existing distance from loved ones.

Immigrants who enter illegally must also endure the trauma of the migratory process, and at the same time must be able to find a job and a place to live, while thinking about remitting, adapting to a new language and culture, and parenting from far away. Due to the drastic changes they experience, migrants have a higher risk for developing anxiety, depression, psychosomatic disorders, addictions and other complications that could impact their functioning (Castaneda & Buck, 2011). Almost all research on mental health has been carried out in industrialized countries, while attention on Latina immigrants has been very minimal, even though many immigrants from Central America,

South America, and Mexico have endured war-related trauma, political violence and other forms of mental traumatism. Turbulence in Central and South America have included slayings of women, children and the elderly, killings of civilians by death squads and the murder of prisoners. Recent turmoil along drug-trafficking passages in

Central America and Mexico has resulted in unprecedented high homicide rates and an acute social crisis. Immigrants from these regions come to the United States bringing with them the emotional and physical scars from their traumatic experiences; moreover, they are also at risk of going through more disturbing events during the migratory journey and upon their arrival to their adopted country (Kaltman, et al., 2011). In a study conducted by Sternberg and Barry (2011) the dangers of the migration process were highlighted by the participants as they talked about the vicious crimes they experienced or witnessed. All the transnational mothers interviewed suffered some form of physical, mental and sexual abuse during their migratory journey. Although these migrant women

82 knew that the trip north would be threatening, they all still considered that illegally coming to the United States was the only way to offer their children a better life.

After immigration there are still constant acculturative and socioeconomic pressures that can continue to impact immigrant families for many years. Undocumented immigrants might face additional distress due to the very nature of their undocumented status. They have the additional task of managing fears and anxiety related to being discovered and deported. These are significant emotional stressors particularly for those migrants who have risked their lives to immigrate so they can support the children they left behind.

The psychological construction of undocumented status can become part of an individual’s emotional and behavioral self-image and can negatively impact personal and family identities (Cervantes et al., 2010). Family separation is another independent source of strain on immigrant mental health. Many clinicians working with Latino immigrant patients emphasized the role played by family separation in triggering immigrants’ anxiety and depression (Horton, 2009). Migrant parents usually have to cope with feelings of loss while they are separated from their children. Menjivar (2012) writes that the Central American women in her study experienced guilt about their decision to leave their children in their home countries. This feeling was accentuated when their children blamed them more than they did their fathers for the separation and their incapacity to travel to see them. Even when these mothers sent remittances and gifts to their children, the children still accused the mothers of abandoning them. Many parents who experience anxiety over the separation from their children believe that the mechanisms of ‘not thinking’, ‘overcoming’, or ‘enduring in silence’ can help them deal better with the situation than expressing unhappiness (Falicov, 2007).

Studies that have assessed Central Americans and their mental health.

Kaltman, Green, Mete, Shara and Miranda (2010) conducted a study to evaluate the connections among immigration-related elements, trauma history and mental health status among Latina immigrants. Sixty-four percent of the sample was Central American and

75% reported having being exposed to trauma. Trauma exposure was widespread among this group of Latina immigrants. This finding supports prior research which indicates a high level of trauma experiences in this migrant population. In this study, a higher number of the women with comorbid depression and PTSD (post-traumatic stress disorder) reported having experienced more extreme interpersonal traumatic events than the comparison groups. A considerable proportion of the women with depression only disclosed exposure to one or more potentially traumatic experience, while fewer women displaying no mental disorder reported they had not experienced any traumatic situation.

In the study, the number of types of traumas endured by the participants was connected with having a mental disorder, which was congruent with an extensive body of literature that shows that exposure to trauma is a significant risk factor for different mental health illnesses. After holding key factors constant, study participants were much more likely to be in the depression-only group than the comorbid group if they disclosed no more than three traumatic experiences. When the women reported more than three kinds of traumatic events, there was a higher probability of also having PTSD. According to

Kaltman et al. (2010), these findings suggest that comorbidity is more likely to develop after multiple exposures to trauma. The study found that having lived fewer years in the

United States was also linked to having a mental condition. This result disputes existing literature that proposes that as time in the United States increases, the possibility of

84 getting a mental health disorder also increases. Kaltman et al. (2010) argue that one potential reason behind this result is that new immigrants may be more susceptible to mental problems due to more recent traumatic experiences lived in their home country, or during the migration journey and may be more open to disclose their ordeals.

A few studies report that Central American immigrants residing in the United

States exhibit a high occurrence of trauma and PTSD (Eisenman, Gelberg, Liu, &

Shapiro, 2003; Michultka, Blanchard, & Kalous, 1998). Interestingly, in the Kaltman et al. (2010) study, being from a Central American country was not exclusively connected with mental health status. This trend was not observed probably because there was an elevated incidence of trauma exposure, particularly to interpersonal violence, among the participants independently of their country of origin. In a more recent study conducted by O’Connor, Thomas-Duckwitz and Nuñez-Mchiri (2015) with Central American migrants in an immigration detention center in the United States, the researchers found that almost half of their participants presented sufficiently relevant symptoms to be diagnosed with post-traumatic stress disorder (PTSD). These participants disclosed having experienced multiple traumatic events which merited further clinical evaluation.

However, according to the researchers, PTSD assessment and criteria might not necessarily encapsulate the trauma as it has been endured by these migrants. O’Connor et al. (2015) mention how PTSD criteria may be insufficient to capture what has been described as complex trauma or ‘disorders of extreme stress not otherwise specified’

(DESNOS). DESNOS results from trauma that has been experienced repeatedly and over a long period of time. The researchers continue to explain that the exposure of the women and children in this study to community violence for much of their lives, as well

85 as the sexual violence and other forms of trauma disclosed by several of the female participants, are consistent with the long-term trauma implied in DESNOS. Some of the symptoms of DESNOS include memory difficulties, challenges with emotional regulation, feelings of hopelessness and despair, detachment from others, minimization, and somatic indicators like chronic pain, dizziness, digestive problems and cardiovascular complications. The participants in this study noted that these symptoms were present in their daily experiences, and the researchers were able to observe the signs as well during their interactions with these Central American migrants (O’Connor et al., 2015).

Psycho-biological consequences of exposure to trauma. O'Connor et al. (2015) write that migrants who have been through dreadful experiences are at a higher risk for anxiety, depression and post-traumatic stress. These mental conditions may be the precursors of physical ailments and chronic diseases in people who do not receive adequate mental health attention. The anxiety, depression and post-traumatic stress linked to the migratory experience can increase migrants’ risk for co-occurring chronic physical diseases that are notorious health issues among Hispanics in general, like cardiovascular illness, obesity and metabolic syndrome, diabetes and asthma. There is substantial clinical evidence for the positive correlation between depression and chronic illness, and for the higher risk of mortality from chronic illness in the presence of co- occurring depression. O'Connor et al. (2015) also note that since four out of the five principal causes of death among Hispanics are chronic disorders that research has demonstrated habitually co-occur with depression, understanding and dealing with this condition in the Central American community is of extreme importance. Research has also shown that in PTSD and other stress-related disorders, for which Central American

86 migrants are susceptible to, continual activation and deactivation of the hypothalamic- pituitary-adrenal axis (HPA) interrupts its normal functioning. The HPA regulates stress reactions, mood and the immune system. Sufferers of PTSD or other stress-related ailments lose the capacity to return to a normal state because this biological process becomes oversensitive. Heightened negative feedback sensitivity also places trauma survivors at risk for chronic inflammatory responses.

Research among Central American migrants is necessary as well as the implementation of policies that focus on alleviating their symptoms of PTSD, anxiety, stress-related disorders and depression. The lasting physical consequences of these conditions elevate the risk of metabolic problems such as obesity, diabetes, atherosclerosis, and heart disease as well as cancer. As asylum seekers, many Central

American migrants have a right to fair treatment under international law, and also to legal policies that do not aggravate the trauma and health vulnerabilities they already have

(O'Connor et al., 2015).

Trauma and family life. Since almost all human beings experience life in association with families and groups, the wounds caused, for instance, by political violence do not only impact individuals but also their family members. Research has found that the partners of torture survivors frequently suffer from depression, post- traumatic stress disorder and physical disorders. Also, the parents of children who were exposed to violence have to deal with the guilt of not having been able to protect them.

Consequently, the mental and physical health concerns of one person also bring consequences to the social systems that surround this particular individual (Engstrom &

Piedra, 2005). When the traumas confronted by migrant parents impact the parent-child

87 relationship, these traumas may prevent them from being emotionally equip to parent their children (Castaneda & Buck, 2011). Additionally, there is an enormous probability that traumatic symptomology may be transferred onto their children through the parent- child attachment relationship. Research documents that through micro-level interactions, traumatic symptoms felt by main caregivers can also be felt by their children and that parental mental health status are prognostic of child mental health outcomes. This occurrence is known as the intergenerational transmission of trauma. Moreover, children who endure prolong trauma generally fail to meet their developmental milestones

(O’Connor et al., 2015).

Children’s Mental Health Implications

The harsh realities that are part of the life of many migrants force them to confront an impossible decision: to remain in poverty or to leave their families so they can show how much they care for them. The family members that stay behind, particularly the children also find themselves in a challenging position as they must learn to deal with the absence of a parent and the emptiness that is left in their lives, while they continue to experience the changes generated by their physical, emotional and social development. With migration as the only option to meet the family’s necessities, many parents and their children get separated for many years (Castaneda &Buck, 2011). The length of the parent-child separation and the different conflicts and special adjustments it creates, depend on the specific settings molding international migration structures. For migrant parents from Central America separation can extend for many years, at times even until the child is a young adult. This is due to the legal uncertainties many Central

Americans face in the United States that make them unable to travel or bring their

88 children because they only have temporary protection status, or are waiting for resolutions of their immigration cases (Foner & Dreby, 2011). The parent-child separation disarticulates the family unit and often negatively impacts later parent-child relationships, which can lead to psychological, emotional, and behavioral sequels in the children left behind (Cervantes et al., 2010). Migration can represent a crisis for a family; however, the impact it can have often depends on how the family itself adjusts to the experience and how the family recovers (D’emilio et al., 2007). The empirical research of the influence of migration on children is still in progress and the evidence is often contradictory and limited to the country being studied. Evaluating the impact of migration on left behind children, involves an understanding of the characteristics and causes of their parent’s migration and the reasons why parents did not take these children with them (Cortes, 2007).

When assessing the conditions of children left behind it is important to look closely at the gender factor, since the consequences these children may face can be greater if it is the mother who is migrating compare to a father’s migration (Office of the

United Nations High Commissioner for Human Rights, 2012). The migration of a man or a woman impacts differently the children left behind, because the roles and relations that fathers and mothers have in the life of their children vary and because what society expects from them is different. When a man emigrates, he is usually perceived as leaving to fulfill his breadwinning responsibilities and is typically leaving behind a family whose preservation is secured through the spouse, mother, or sister. When the woman migrates, she leaves behind a family for whom she is supposed to be the caregiver and source of emotional support. Often, upon family reunification, a mother has to face the blame of a

89 fragmented family structure particularly with the presence of children who have disconnected themselves from the family unit (D’emilio et al., 2007).

Positive vs. negative outcomes of parental migration. Migration can elevate the standard of living for the children who are left behind to the extent that migrant mothers direct their remittances towards the investment in children’s health, education and nutrition. In an econometric study of emigration from developing nations, researchers found that the proportion of emigration of very educated women as compared to men was negatively related to both, infant mortality and percentages of secondary school enrollment of girls and boys. The analysis also found that the emigration of women with only a primary education produced positive results on the health and education indicators being studied. This outcome suggests that remittances can make a difference and that the impact depends on household income levels (Beneria et al., 2012).

However, not all the studies on the effects of a parent’s migration on children show consistent conclusions. For example, reviews of the literature on educational progress on left-behind children in developing countries have found mixed figures. Some studies have shown positive effects on school performance, while other empirical research has found that parental absence jeopardizes educational accomplishments (Cortes, 2007). In spite of the economic benefits children who have remained in the country of origin can receive, these children undertake the price of the separation with adverse consequences to their psychological welfare which appears to affect their development, behavior and education. A number of studies have found that left-behind children are exposed, to a greater extent than children who live with their families, to psychological and emotional stress. These kids can experience feelings of abandonment, anxiety, depression and low

90 self-esteem; all these can alter negatively their development and their socialization skills

(Valtolina & Colombo, 2012). Parents considering migration frequently overlook the mental and emotional trials that left-behind children may endure, often because they think that remittances will provide children with economic advantages (Castaneda

&Buck, 2011). Nonetheless, a 2006 UNICEF-United Nations Development Programme desk review on children and remittances, studied the influences of remittances in migrant families in sending countries and established that the migration of parents brought about risks for children and created challenges to children’s rights that could not be counterbalanced by these remittances (Cortes, 2007).

Family separation and mental health. Different researchers use attachment theory as their context to understand the consequences of family separation on children after migration, and agree with what the theory postulates that an important portion of psychopathology originates in painful separations and neglect during childhood. Even when considering culture-specific alternative models of care like the extended kinship care network, scholars argue that if one or more of the primary caretakers leave a child this frequently will end up adversely impacting the child, as attachment theory proposes.

After migration children usually feel that it is their fault that their parents had to leave and may reject other justifications for the departure. These children will experience feelings of abandonment, loss of self and loneliness. These and other feelings may have a decisive role in their identity formation (Castaneda &Buck, 2011).

Psychological well-being. The main studies that have analyzed the effects of the separation from the parents on the mental wellbeing of children left behind have been done in Moldova, the Philippines, Sri Lanka, China, Bangladesh, Mexico, Ecuador and

91 the Caribbean. These studies found that, in general in all age groups, an important percentage of children left behind experienced greater anxiety and loneliness than their peers in the control groups. These children were more likely to experience intense anger, confusion and apathy, and usually felt different from other children, particularly if the mother was the one who had emigrated. One analysis studied children’s responses by age at the time of the separation from the parents. The results showed that those children who were separated from their parents when they were still very young presented more

indicators of depression and anxiety than the other children (Valtolina & Colombo,

2012). A child’s age at the time of parental separation may influence the child’s response to the event. Young children may experience the parent’s departure as a form of abandonment, while teenagers can experience mixed feelings about it. Teens can feel acceptance and respect for the parent’s challenging decision to leave in order to secure a better life for them, or anger and resentment for having been left behind. They can feel pleasure for the material benefits, or intense grief because of the separation. Other emotional-affective symptoms displayed by children left behind included unhappiness, sadness, fantasies about running away from home, suicidal ideation and overall less emotional and psychological resilience.

Researchers argue that the migration of a parent can create in the children who stay behind an ‘emotional incompetence’ and can expose them to a lack of role models, which ultimately may impact their development. Different studies have documented that children left behind tended to be very introverted and withdrawn, demonstrated an unwillingness to communicate with others, displayed lack of interpersonal trust, showed aggressive behavior and reported feelings of fear and lack of interest in life. The

92 psychological and emotional sequels of separation from the parents appear to vary by sex, as boys appeared to face greater challenges with interpersonal relations, and girls experienced more negative mood and lower self-image. Feelings of loneliness, defenseless and abandonment can put left behind children at risk of depression. These experiences can prevent children from building and maintaining positive relationships as adolescents and adults (Valtolina & Colombo, 2012).

Risk behavior. Researchers agree about the existing correlation between parental migration and the involvement of the children left back home in risky behaviors. Various studies conducted in different countries with high external migration have demonstrated how left behind children are at greater risk for drug use, teen pregnancy, inadequate eating habits, violent behavior and lifestyles that are harmful to their health. Drugs become available to these children thanks to the economic benefits brought by remittances. Pregnancies, petty crimes and periods of delinquency and violent behavior can be the outcomes of the psychological and emotional pressures left behind children experience when the parents are absent (Valtolina & Colombo, 2012).

Family interactions, roles and housework obligations. Different studies about the family interactions of children left behind report that it was common to see a break in the bond between parents and children, and that family relationships were not enriched over the migratory course, even when the children’s quality of life had improved.

Frequently, migrant parents and their children keep in touch by telephone or mail, and by sharing gifts and pictures; however, some researchers argue that this is not enough to nurture a close relationship, especially when parents and children have to endure many years of physical separation (Valtolina & Colombo, 2012). Nonetheless, scholars have

93 documented that the stress and challenges connected to the separation of migrant parents and their children can be handled, if the migrant parent, the child and the caretaker maintain an effective, cordial and positive interaction. The dilemma here is that the relationship between caretakers and the children left behind is almost never free of problems. For instance, studies show that often the care of the children is delegated to grandparents, but these grandparents may be elderly and therefore generational gaps can bring severe hurdles to communication and the expression of emotional support.

Commonly, the grandparents’ efforts to take care of the children become more difficult over time. In fact, roles may be reversed and children may take on the housework or other responsibilities that grandparents, due to their age, can no longer perform. After the migration of one or both parents it is not uncommon for children left behind to be in charge of household chores, and the care of younger siblings. In rural areas, many of these children have to work in the fields to replace the work their parents did before they migrated. The workload responsibilities affect children left behind because they do not have as much time and energy to concentrate at school, or to socialize with their peers and this can affect their well-being (Valtolina & Colombo, 2012). According to traditional gender roles, migrant mothers are frequently replaced in parenting obligations by other women. However, when they are substituted by their daughters, this has damaging consequences for the daughters’ educational advancement, replicating in this way the disadvantage of women (Beneria et al., 2012).

Academic challenges. Another area that is impacted by parents’ migration is children’s schooling. Conflict between parents and children can arise if the children are not achieving their educational goals, since this can sabotage the family’s migration plan.

For migrant parents, being able to finance the education of the children they left in their country of origin is a key strategy that, they hope, will help the whole family move upward. Unfortunately, this strategy does not guarantee complete success. While some research has found that educational remunerations can be enjoyed by left behind children thanks to their parents’ migration, several small-scale studies have also shown that family separation can represent a negative catalyst for children’s educational ambitions, as children can show a significant decrease in concentration at school. The emotional ramifications of being separated from their parents contribute to the negative educational results, since left behind children experience feelings of loss during periods of separation from their parents, resentment for not being able to be with them, and physical symptoms of anxiety (Foner & Dreby, 2011). Some commentators believe that money in the form of remittances can reward the family for the adversities experienced after the separation.

However, for others, migration leaves children without a parent and with no psychological, emotional, or physical protection. In spite of the negative consequences of family separation seen after migration, some researchers may opt for not writing much on these topics to avoid being perceived as if they are judging or criminalizing migrant parents (Castaneda & Buck, 2011). Nonetheless, Menjivar (2012) points out that the apparent family breakdown that seems to accompany parental migration cannot be attributed solely to migration, but that the structural conditions that lead to migration in the first place need to be taken into account as well. It is important that further research be devoted to the psychological and social needs of children left behind, since in order to foment economic improvement it is necessary that the children who receive remittances

95 experience upward social progress and at least maintain a basic level of mental wellbeing

(Castaneda & Buck, 2011).

Obstacles Faced by Migrant Families after Family Reunification

Only a handful of studies have evaluated how separation influences the experience of parents and left behind children once they reunite (Castaneda & Buck,

2011). Data shows that in the United States the reunification of parents and children brings different sets of problems (Foner & Dreby, 2011) and is characteristically permeated with disappointment and disillusion (Cervantes et al., 2010). The ambiguous and long separations that Central American parents and children experience between them create great strain when they are finally together (Menjivar, 2012). Parents and children have to habituate to each other, and must get used to living together again in an atmosphere in which they might have unrealistic expectations of each other. Their idealized relationship can be in conflict with the personal difficulties and traumas they might have endured and with their lack of attachment ((Foner & Dreby, 2011). In some cases, these children who are reuniting with their families and who are probably now in their teen years, must confront the triple challenge of entering adolescence, entering a new society with a new language and no social support, and also entering a family very different from the one they knew before their mother’s departure. This new family, most likely, will include new siblings born in the United States, a mother’s boyfriend, or a new stepfather (Hondagneu-Sotelo & Avila, 1997).

Attachment difficulties. Once reunited, children usually miss their caregivers, extended family members and friends and may face obstacles in their new family relations. Rejoining the family system can be complicated by the fact that during the

96 time of separation, the family may have changed so dramatically that has ceased to include the parent who has been absent. When separations have been prolonged, parents and children usually report they feel like strangers (Suarez-Orozco et al., 2002).

Parents may be frustrated if their children are withdrawn, confused, or resentful instead of pleased for the reunion. Nevertheless, over time parents and children readapt to each other and many, probably most, will be able to rebuild close relationships (Foner &

Dreby, 2011).

Addition of new family members. A possible source of trouble for migrant parents and their children is the addition of new family members, including stepparents and stepsiblings. Children who are reuniting with parents after a long separation often feel they do not enjoy of the same amount of their parents’ love, attention and resources as their new siblings or stepsiblings do. The long-term consequences of such feelings of jealousy manifested towards new family members merit additional research (Foner &

Dreby, 2011).

Discipline conflicts. Discipline and parental authority are noticeable causes of conflict for migrant parents, as they often report problems when trying to reassert control over their children. For these parents, disciplining children with whom they have not spent a lot of time, or whom they may not have seen for many years can quickly become a daunting task (Foner & Dreby, 2011). Parental guilt, which may lead to inconsistencies and overindulgence, can make the reestablishment of parental authority even more difficult. A rejection and counter-rejection pattern may be created and this can force families to seek professional help (Suarez-Orozco et al., 2002).

Some immigrant parents recognize that the unfavorable economic conditions they left

97 in their native country and the dangers they came across during the migratory journey, actually seem less shocking when compared to the unanticipated challenges of raising their children in a new culture. Possibly, the greatest challenge is the loss of community and family support, and therefore the loss of the well-known ‘collective’ concept of raising children. For instance, immigrant parents may feel confused by the more lenient posture taken by public schools, at the junior high and high school levels in the United States in which children are required by law to attend school, and yet they can easily leave school premises. When the children of migrant parents begin to display behavioral problems and other difficulties, their parents may be perceived as having abandoned their parental role. The more likely reason is that these immigrant parents are in reality afraid, confused and overwhelmed. Another obstacle for many migrant parents is a lack of understanding of what is considered acceptable discipline strategies in the United States. Many do not know that corporal punishment is widely disapproved as a form of discipline, and are surprised and scared when child welfare agencies speak about bringing potential charges of child abuse. Many immigrant families could benefit from early intervention and prevention policies, as well as from culturally sensitive programs that focus on engaging the entire family (Fleck & Fleck,

2013).

How to Help Central American Migrants

The mental health needs of migrants from Central America should be the focus of more careful consideration since research indicates that they have a high prevalence of exposure to trauma, as it has been discussed previously and yet a very low likelihood of seeking mental health treatment (Kaltman, Hurtado de Mendoza, Serrano, & Gonzales,

2016). Data shows that Latinos in need of mental health services underuse available mental health treatment compared to non-Latino whites; are also less likely to be exposed to established care protocols; and are more likely to prefer primary care settings, where treatment is often insufficient, to address their mental health problems. However, Latino immigrants may not talk about their trauma exposure unless they are motivated to do so by a primary care provider. In a study of Central American immigrants in primary care settings, only 3% of patients who experienced political violence discussed it with a clinician (Kaltman et al., 2010). Although there are regional differences among Latin

American countries, some common shared cultural values have been recognized and are believed to be an important component of the interventions that seek to enhance Latino mental health. Cultural ideals of ‘confianza’ (mutual generosity and trust) and

‘personalismo’ (cordial interpersonal relations) situate the person in a social setting and expand positive connections outside the family circle. Since social support can protect individuals from the negative effects of trauma, including this element as part of the interventions when working with Latinos can be crucial. Research indicates that Latina immigrants, particularly those from Central America, have inadequate social support and face challenges in establishing new supportive and trusting relationships in their new home country (Kaltman et al., 2016).

Barriers to mental health care. Immigrants can face substantial difficulties in accessing mental health services. The different barriers they may encounter can be categorized as social-cultural, contextual-structural and clinical-procedural (Suarez-

Orozco et al., 2012).

Social-cultural barriers. These barriers include variances in the expression of symptoms and the different perspectives about the causes of, and ways of dealing with mental health illnesses. Some immigrants may not comprehend how mental issues can be addressed from a Western viewpoint and may believe that self-help is the best way to deal with mental health distress. Others may opt for healing options commonly sought in their culture of origin (i.e., priests, or other religious figures). Another social-cultural barrier is the stigma some cultures attach to psychological problems (Suarez-Orozco et al., 2012).

Stigma. The established Western literature has long identified the stigma that refugees and migrants feel in relation to mental disorders and how this has become a barrier to prevention and early intervention implementations (Poole & Swan, 2010). One of the major obstacles that prevent Latinos from seeking help is the stigma of having a mental issue. Many in the Latino community link mental problems to violence, loss of control and incurability. Mental illness is perceived as an indication of personal weakness which not only affects the individual but the whole family. Individuals that present psychological symptoms are afraid of being rejected by their families or their social groups. In the Latino community it is very common to deny or conceal mental illness to protect the family reputation (Kramer, Guarnaccia, Resendez, & Lu, 2009).

Poole and Swan (2010) write that concerns about stigma can be in part addressed by:

 Developing culturally sensitive services for new migrants.

 Offering mental health help in a neutral context in the community, like in medical

practices or in centers that have more traditional interventions.

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 Offering community education about stress, depression, loneliness, PTSD. Ideally,

this education should be designed and implemented by ethnic community health

workers.

 Discussing common emotions and practical issues before focusing on pathological

signs.

 Making sure that trust is built early in the therapeutic relationship, and that the beliefs

of migrant clients about mind and body are understood and used during treatment.

Kramer et al. (2009) adds that,

 A biological explanation of mental illness can mitigate stigma, especially when

patients and their families recognize that mental distress is related to biological

neurotransmitter imbalances.

 Collaboration among primary care providers, mental health providers and social

services is crucial when providing psychoeducation about the benefits of early

diagnosis and treatment of mental disorder in Latino communities.

 Referrals to support groups can help individuals and families and can lessen the

feelings of being an outcast.

Contextual-structural barriers. These include lack of access to culturally inform mental health services in the immigrant native language, lack of access to interpreters, scarcity of racial/ethnic minority mental health workers and lack of information about available mental health services and resources. The racial and political environment of the host country impacts immigrants’ sense of security and belonging (whether they are documented or not), and their capacity to trust that the health system will assist them when they are experiencing mental health problems. Unauthorized immigrants face

101 additional difficulties related to their documentation situation. Those who have fears related to their unauthorized status and those migrants who move constantly in search of work usually do not seek help (Suarez-Orozco et al., 2012).

Clinical-procedural barriers. These barriers involve the absence of culturally relevant services, clinician bias, and communication obstacles around language differences and subtle cultural variances. For instance, a client’s cultural values may be overlooked if a clinician deemphasizes the role of spirituality and religion in the client’s life and highlights, instead, autonomy and independence. These barriers also include the misdiagnosis of presenting issues and the failure to identify the appropriateness of tests and assessment strategies (Suarez-Orozco et al., 2012).

Principle of engagement. A human rights approach is gradually being acknowledged as the basis of a solid cross-cultural practice when working with refugee and migrant clients. Under the human rights principle, being able to offer culturally responsive and effective services is a requirement, not only an ideal possibility. Human rights include, but are not limited to, the right to be free from coercion, the right to autonomy and self-determination, the right to be treated in a nondiscriminatory way, the right to informed consent, and the right to receive care and support that address the psychological, physical, spiritual, intellectual and cultural needs of the client. For many refugees or migrants receiving mental health help, this will be the first time they hear that they have rights and that these will be upheld (Poole & Swan, 2010).

Clinical assessment and diagnosis. Immigrants bring with them cultural beliefs, values and perspectives that may or may not accord with those in the United States. This cultural background influences the ways in which they understand and express mental

102 challenges and resilience and how they seek help. Therefore, the role of the sociocultural environment must be taken into account in order to offer ethnical and effective standards of care, diagnosis and treatment in immigrant communities. A big struggle in the assessment of immigrants is the unavailability of valid and culturally fitting diagnostic tools that distinguish cultural differences in the expression of and dealing with psychological problems. This poses a substantial challenge to clinicians who must critically scrutinize tests and assessment instruments developed in a Western middle-class setting before utilizing them with non-Western, non-middle-class clients. Adequate multicultural assessment entails that clinicians compile a solid, accurate and complete description of the client’s psychological presentation by collecting information on familial, historical, social, economic and community matters. This data is important in selecting proper tests and in interpreting the outcomes. It is also crucial that clinicians evaluate their own biases and anticipations that could influence the assessment process.

They should also consult with and get the support of supervisors and colleagues who may be more familiar with a client’s sociocultural background, culture-bound syndromes and the particular diagnostic instruments being considered (Suarez-Orozco et al., 2012).

According to Suarez-Orozco et al. (2012), problematic elements during assessment and diagnosis may include:

 Lack of standardized translations of tests and instruments.

 Lack of adequate norm referenced groups and research on reliability of test scores

with different immigrant communities.

 Failure to give appropriate attention to culture which can lead to misdiagnosis.

Issues in diagnosis may include:

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 The current diagnostic system (Diagnostic and Statistical Manual of Mental

Disorders) which favors Western views of mental illness.

 Indicative data that might have been obtained not using clients’ first language or

properly trained translators.

 Clinician’s failure to assess resilience.

 Failure to recognize the experiences of acculturative stress and cultural adjustment.

Suarez-Orozco et al. (2012) suggest the following guidelines to promote best practices in assessment and diagnosis when working with immigrant clients:

 Understand the amplitude of the linguistic and cultural variances between the clients

and the dominant culture (i.e., Wechsler Intelligence Scale for Children [WISC]/

WISC-III Spanish and the WISC-IV Spanish).

 Contemplate the use of revised culturally responsive versions of classic instruments

(i.e., Tell me a Story [TEMAS] which is a revision of the Thematic Apperception

Test [TAT]).

 Implement a contextual methodology that takes into account the clients’ interpretative

models, and the clinicians’ expectations and biases.

 Use different comprehensive assessment approaches, such as the Multicultural

Assessment Procedure [MAP] (Ridley, Li, & Hill, 1998), and the Multicultural

Assessment-Intervention Process [MAIP] (Dana, 2005).

 Use culturally sensitive assessment interviews with questions about religious

practices, racism and prejudice, cultural values, language difficulties and

acculturation.

 Assess for culture-bound syndromes.

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 Work in collaboration with interpreters, families and community members, when

feasible.

 Consult with colleagues.

Other assessment elements to be considered when working with Latino migrants:

 It is important for clinicians to obtain information about the border crossings that

Latino immigrants moving between Central America, Mexico and the United States

undergo. Trauma and violence, which can include robbery, kidnapping, and/or

physical or sexual assault, may be experienced during their migratory journeys

(Cervantes et al., 2010).

 Also, it is essential to assess the level of trauma migrants might have endured in their

country of origin. Many traumatic events are not typically observed on trauma

history instruments used in the United States (Kaltman et al., 2011).

 Additional assessment should be also conducted to evaluate the level of brutality

involved in the traumatic events clients from this population may have endured. The

level of viciousness in the trauma and violence exposure taking place in the country

of origin for many Central Americans (i.e., types of weapons used, intensity of

injuries to victims, exposure to dismembered bodies) seems much greater than what

can happen in the United States. This may have greater negative repercussions in

mental health given the consistent research findings that correlate the degree of

exposure to worse mental health consequences (Kaltman et al., 2011).

 Family therapists working with immigrant families should be informed about the

phenomenon of family separation in their assessments and treatment because

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separation can alter family relations and development. When taking the family’s

history, clinicians have to find out whether family separation took place. The family

should not be perceived as deviant if family disruptions indeed occurred, since

separations are normative to the migration process (Suarez-Orozco et al., 2002).

 When evaluating undocumented families practitioners should evaluate the following

areas: Who left the country of origin? Under what conditions did the departure take

place? Who remained in the country of origin? What are the patterns of migration?

What is the length of separation? What forms of coping have the individuals or

families displayed? What resources are available? and where there any preexisting

challenges or stressors before migration? (Cervantes et al., 2010).

Working alliance. It has been indicated that the quality of the therapeutic alliance is the basis for conducting effective work with Latinos. Although this is central in all counseling relationships, it merits especial attention when serving a group of migrants who have suffered the levels of war-related trauma as has been the case for many Central Americans. In fact, staged models of trauma interventions propose a three- step recovery approach which begins with the establishment of a safe and solid therapeutic alliance, continues with the reevaluation of the traumatic events in a safe environment, and arrives at the phase where reconnection and integration is sought. This is a very dynamic process and requires that clinicians give close attention to the working alliance by continually assessing the client’s sense of safety and stability (Asner-Self &

Marotta, 2005). Clinicians must recognize that it takes time to establish an effective working alliance that permits the successful implementation of clinical intervention when serving immigrants who are also trauma survivors. It is not recommended to begin the

106 therapeutic interventions with Central American immigrants by focusing on their exposure to trauma; instead, clinicians can make sure clients are being able to find security and stability in their experiences with family, their social relationships and financial status. Furthermore, clinicians need to draw attention to the coping skills and resources immigrants have to deal with acculturation and other difficulties. The clinician can address the elements associated with traumatic experiences once a level of safety, permanence, trust and reliance in internal resources has been obtained (Asner-Self &

Marotta, 2005).

Therapies/Interventions

Erikson (1959, 1964) wrote that consistent with life span developmental theory, humans develop on a predictable, epigenetic path within the limits of their biopsychosocial world, and proposed that humans accomplish different developmental tasks during the course of life. The tasks that need to be addressed include the development of a sense of trust in self and others, a sense of self as an independent individual, and a sense of self in connection with other persons. Furthermore, current developmental theorists state that the course of development is different among individuals and it is influenced by cultural experiences and ethnic associations (Asner-

Self & Marotta, 2005). Migrating to a different culture alters a person’s familial and social networks, socio-economic standing, cultural expectations, behavioral norms and values. The acculturation process can be tense and may be affected by psycho-social factors present prior, during and after the migratory journey. All of these circumstances could influence the unfolding of an individual’s life tasks of trust, identity and intimacy, and could require that the individual makes adjusting changes in the midst of the new

107 events being experienced. Asner-Self and Marotta (2005) suggest that clinicians assisting

Central American immigrant clients need to learn to evaluate, accommodate to, and meet these clients where they are developmentally; they also need to plan and implement therapeutic strategies that facilitate clients’ trust, identity and intimacy growth.

According to Poole and Swan (2010) most of the international research recognizes that a different number of therapeutic models are beneficial in the treatment of mental health conditions. The following section reviews some of these therapeutic approaches and their application for refugees and migrant clients.

Cognitive behavior therapy. Extensive empirical evidence shows that Cognitive

Behavior Therapy (CBT) is a very effective treatment for refugees. This therapy seeks to generate more functional emotional and behavioral reactions through the modification of thought patterns. Sessions are conducted in a very systematic manner and concentrate on the solutions to difficulties. Research has considered refugee communities when evaluating treatment alternatives for post-traumatic stress disorder (PTSD). These studies have found clinical improvements in PTSD indicators, anxiety scores, and culturally-linked physical symptoms relative to control groups (Poole & Swan, 2010).

Cognitive behavior approaches have been found to be effective with different Latino communities (Kanter, Santiago-Rivera, Rusch, & Busch, 2010; Miranda et al., 2003), and have been favorably incorporated into primary care settings (Chavira et al., 2014;

Twomey, O’Reilly, & Byrne, 2014). Culturally adapted CBT produced promising outcomes when it was used to treat symptoms of PTSD, anxiety, and depression in a refugee community. CBT strategies like mindfulness relaxation techniques and specific cultural imagery were implemented. However, specific research to clarify whether

108 cultural adaptation is more effective than non-adapted CBT has not been conducted

(Poole & Swan, 2010). Cultural adaptations refer to the methodical adjustment of evidence-based psychological interventions to take into account culture, language, and context in order to make them relevant to a client’s cultural schemes, significances and ideals (Hwang et al., 2015).

Potential difficulties. Poole and Swan (2010) write that a few important elements of cognitive behavior therapy (CBT) that could discord with some immigrants’ cultural values include:

 The emphasis on individual needs above what is good for the rest of the family.

 The emphasis on developing assertiveness skills.

 The attention given to rational thinking and the search of objective indication with

clients who are intensely spiritual.

Problem-solving therapy. Problem Solving Therapy (PST) is a psychosocial approach centered on the problem-solving model of stress. This model sees depression as being triggered and maintained by daily difficulties and major life predicaments in a client’s life. According to this model, a person’s problem solving capacity regulates the experience of stress. Therefore, an adequate problem solving skill should decrease the possibility of experiencing stress even when confronted with every day or major life troubles (Peeren, 2014). During therapy, conflicts are identified, solutions to these conflicts are crafted, and long-term problem-solving skills are built. Studies involving the general population support the idea that PST is beneficial in the treatment of anxiety, depression, chronic illness, suicidal thoughts and behavior. It is also useful for behavior change and personal growth. Migrant and refugee clients in New Zealand have been

109 treated by clinicians who use different principles of PST and who take cultural elements into account, with reportedly positive clinical outcomes (Poole & Swan, 2010).

Potential difficulties. Research on the efficacy of problem-solving therapy with migrants and refugees is very limited (Poole & Swan, 2010).

Psychotherapy with children. This therapy often uses play, drama and drawing to understand a child’s symptoms, thoughts, emotions or behavior. The children of migrants and refugees may be experiencing PTSD, anxiety, depression, grief and loss.

Therapeutic interventions aim for addressing the symptoms related to these mental health conditions and also potential traumas. One of the goals of therapy is to cultivate resilience by promoting competence in the child. Family therapy techniques can help the child feel included in the family system, and can assist the child’s caretakers to manage him or her. Family therapy strategies can also help migrants and refugees preserve the family unit within their culture. The implementation of art therapy interventions like painting and sandtray work with refuges in New Zealand has been very effective as part of assessment and treatment (Poole & Swan, 2010).

Potential difficulties. Children may not have a basic construct of life prior to refugee status, and may be limited in the way they express themselves. With children, the reestablishment of safety should be a first priority. Challenges with this therapy can include the unavailability of qualified art or child therapist, equipment or training (Poole

& Swan, 2010).

Family therapy. Family therapy is a well-recognized psychotherapeutic methodology that attends to the difficulties individuals face within the context of their relationships with important people in their lives and their social networks. There are

110 different models that share a number of principles and guiding expectations. Some of the shared objectives of family therapy include: enhancement of family functioning, promotion of mutual understanding and emotional support among members of the family, and improvement of the family’s coping skills and problem-solving tactics (Skorunka,

2009). Research in Western cultures has shown that family approaches to therapy can be very useful. Furthermore, family therapy has also been extensively implemented in

Chinese, Japanese, and Indian societies, both in their homelands and in migrant communities. Family therapy can be especially beneficial in migrant populations for the discussion of inter-generational conflict triggered by variances in acculturation and beliefs between migrant parents and their offspring (Poole & Swan, 2010).

Potential difficulties. It is important to examine potential family roles, traditional women’s role, and value differences between members of a family, especially when some family members may be more adjusted to the new host country. Little controlled research studies have been conducted to establish the efficacy of the different family therapy models when implemented with refugee clients (Poole & Swan, 2010).

Narrative therapy and collaborative narrative practice. Narrative methodologies assist clients in recognizing the competencies, beliefs, values and abilities they already have, and in using them to deal with challenges. Narrative therapy encourages the telling and retelling of stories taking into account the personal, social, cultural, and political setting of clients’ experiences (Poole & Swan, 2010). Collaborative therapy facilitates the development of free thinking to achieve progress, by creating a client-consultant relationship in which both parties, the client and the clinician, use experience and knowledge to discern and understand problems and conditions

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(Collaborative Therapy, 2015). Throughout migrant and refugee communities narrative approaches are being found to be useful by clinicians, since these methodologies do not entail that clients understand or have ability to participate in traditional Western methods of counseling. They are implemented with individuals and groups who have been exposed to trauma and torture and who are experiencing stress, anxiety, depression and

PTSD. The use of language, metaphors, and storytelling is beneficial with refugee populations who are familiar with the utilization of story as a manner of personal and communal change and growth. Narrative and collaborative approaches promote substitute discourses of resilience, capability and hope within disclosed experiences of trauma. These models recognize that therapy is not usually part of the cultural practices of most refugee communities and they adjust to it. These models also take into consideration the collective nature of trauma and the social grief that can come when exposed to social injustice. Narrative clinicians work with children, young people, adults, couples and families and with whole communities (Poole & Swan, 2010).

Potential difficulties. Some reviewers suggest that a lack of self-reliance, intellectual ability, or limited articulation skills can be barriers for clients to engage in narrative practices, because of the inhibited self-expression capacity (Poole & Swan,

2010).

Narrative exposure therapy and testimonial psychotherapy. Narrative

Exposure Therapy (NET) is a culturally universal treatment approach that was developed to treat survivors of multiple and severe traumatic experiences, like organized violence, war, rape, torture and childhood abuse. Narrative Exposure Therapy is a standardized short-term intervention based on the precepts of cognitive-behavioral exposure therapy.

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NET adapts the traditional form of exposure therapy to meet the needs of traumatized clients. During therapy, the client is asked to talk about the traumatic experiences in detail while allowed to re-experience all feelings link to the event. Through the process, most clients’ emotional reaction habituates to the traumatic memory. It is stated that this habituation leads to a remission of the symptoms related to trauma (Onyut et al., 2005).

Testimonial psychotherapy is a multi-modal approach that incorporates elements from exposure and desensitization, cognitive restructuring and relaxation training, therapeutic relationship, and ritual and narrative techniques. It is a short individual intervention for clients who have endured torture and severe trauma. One of the goals of therapy is to produce a written attestation that can transform the trauma and pain into a different essence and that allows the clients to embrace their own courage and survival capacity

(Poole & Swan, 2010). Some studies have found that nonprofessional counselors can effectively apply narrative exposure therapy in a natural environment to refugees in developing nations that have limited resources. Research with African refugees also indicated that NET produced the same results as CBT, and was more effective at healing

PTSD symptoms than supportive therapy or brief psycho-education. Testimonial psychotherapy is beneficial in populations where talking therapies are rare and stigmatized (Poole & Swan, 2010).

Evidence-Based Practices

An evidence-based practice (EBP) is the integration of clinical proficiency, research evidence, and clients values into the process of deciding how to best serve the clients. In the field of mental health, an EBP is usually discussed in terms of interventions that are effective in producing positive client outcomes (American

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Psychological Association, 2017). The SAMHSA’S National Registry of Evidence-

Based Programs and Practices (NREPP) (SAMHSA, 2016) lists the following interventions as effective when working with the Latino community.

Brief strategic family therapy. One of the goals of Brief Strategic Family

Therapy (BSFT) is to improve family functioning, including effective parental leadership and management, positive parenting and parental involvement with the child and his or her peers and school. BSFT’s sessions are conducted at locations that are convenient to the family, including the family's home in some cases. Hispanic families have been the principal recipients of BSFT. BSFT considers adolescent symptomatology to be rooted in maladaptive family interactions, inappropriate family alliances, overly rigid or permeable family boundaries, and parents' tendency to believe that a single individual

(usually the adolescent) is responsible for the family's troubles. BSFT operates according to the assumption that transforming how the family functions will help improve the teen's presenting problem. BSFT's therapeutic techniques fall into three categories: joining, diagnosing, and restructuring.

Trauma affect regulation: guide for education and treatment (TARGET).

Trauma Affect Regulation: Guide for Education and Therapy (TARGET) is an educational and psychotherapeutic intervention for adults, adolescents and families. It is designed to prevent and treat traumatic stress disorders, co-occurring addictive, affective, personality or psychotic disorders, and adjustment disorders related to other types of stressors. The program comprises a seven-step sequence of skills based on a psychobiological meta-model, the FREEDOM Steps. This model enables participants to recognize, understand, and gain control of stress reactions by enhancing their adaptive

114 capacities for emotion regulation, mental focusing, executive function, mindfulness, and interpersonal engagement and interaction. The purpose of this skill sequence is to offer a systematic approach to processing current life experiences and trauma- or stressor-related symptoms without intensive trauma-memory processing. However, it can also be used to enhance trauma-memory processing and narrative reconstruction. TARGET has been adapted to be gender-specific, culturally responsive, and attuned to the needs of youths and adults who have experienced specific types of trauma including childhood trauma, sexual trauma, domestic violence, community violence, sexual-identity-related trauma, or military trauma.

Familias unidas preventive intervention. The Familias Unidas Preventive

Intervention is a family-based program for Hispanic families with children ages 12-17. It is designed to prevent conduct disorders; use of illicit drugs, alcohol, and cigarettes; and risky sexual behaviors by improving family functioning. The Familias Unidas Preventive

Intervention is guided by eco-developmental theory, which proposes that adolescent behavior is affected by a multiplicity of risk and protective processes operating at different levels often with compounding effects. The program is also influenced by culturally specific models developed for Hispanic populations in the United States. The intervention is delivered primarily through multi-parent groups, which aim to develop effective parenting skills, and family visits, during which parents are encouraged to apply those skills while interacting with their adolescent. Sessions include problem posing and participatory exercises. Group discussions aim to increase parents' understanding of their role in protecting their adolescent from harm and to facilitate parental investment.

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Synthesis of Literature Review

Central American immigrants to the United States have a high risk of suffering severe experiences before, during and after their migratory journey. Ordeals such as life threats, beatings, rape, imprisonment, torture, and disappearance of family members, are only further aggravated by the critical stress that can be generated in the new host country through conditions like, unemployment, poverty, loss of family support, prejudice, potential repatriation and barriers to obtaining social and clinical services (Perez-Foster,

2001). Because of these severe experiences, researchers like Contreras and Griffith

(2012) write that Central American immigrants need more comprehensive legal and social recognition as refugees and asylum seekers, as opposed to merely labor migrants.

Central Americans do not have access to appropriate social and psychological support that is open for refugees and survivors of violence when they arrive in the United States.

However, data shows that despite the fact that agencies in the United States are available to offer care, services are often not used by the migrant population. This is likely due to the different barriers faced by this vulnerable group including concerns about legal status, and economic hardship (Kaltman et al., 2011). Another major obstacle is the stigma associated with having a mental condition which is very ingrained in the Latino culture in general. Mental illness is perceived as an indication of personal weakness which not only affects the individual but the entire family (Kramer et al., 2009). Poole and Swan (2010) write that concerns about stigma in a cultural group can be in part addressed, among other things, by discussing common emotions and practical issues before focusing on pathological signs, and by offering community education about mental health topics.

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With this information in mind, the final product that is part of this project includes a guidebook that has been created mainly for the Central American migrant woman. The guidebook entitled ‘For a Woman of Courage like You: Your Physical, Sexual,

Emotional, Spiritual and Mental Health is Important; Take Care of It’, has been written to reach the migrant woman who might be experiencing challenges related to her migration process, and who could benefit from knowing that there is support available for her.

First, the guidebook tries to set a tone that shows awareness and understanding of the migrant woman’s experience, by presenting general information about what she might have lived. Second, a link is established between negative experiences and how these can impact mental health. Third, a variety of information about mental health is included in the forms of topics such as what a mental health condition is, how mental problems are usually addressed, what a therapy session is, and how mental health services can be obtained. Lastly, the guidebook offers a comprehensive list of different types of resources available for the migrant women.

A visit to different community organizations in the downtown Los Angeles area, where there is a large presence of Central Americans, showed that educational publications about mental health that might be easily accessed by community members are non-existent. The guidebook ‘For a Woman of Courage like You: Your Physical,

Sexual, Emotional, Spiritual and Mental Health is Important; Take Care of It’

was created with the purpose of being an easy-to-read source of information, but mostly a source that is available where the people who could benefit from its contents gather; that is in the different community agencies that offer various types of services to the

Central American public.

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Chapter Three

Project Audience and Implementation Factors

Introduction

For many years now there has been an influx of migrants from Central America into the United States who have experienced firsthand the consequences of living in an environment of generalized instability. A lot of these migrants are carrying with them the pain and mental and emotional scars of having been exposed to poverty and violence.

Many of them are trying to function now in the American culture, bearing the pressures of past hurting memories, but also facing the realities of what it means to be an immigrant in a new society. Commonly, many people from Central America do not seek mental health services due to the strong stigma present in the Latino/Hispanic culture towards mental health illnesses. Although there are several effective evidenced-base- practices in the mental health field from which Latinos/Hispanics can benefit, this population in general is not motivated to access psychological services or does not know how to do so. Informing and educating members of this population seems to be the key to dispel the myths associated with having a mental health condition and to empower them to find support. The guidebook that is presented in this section was created with the intention to make information concerning the topic of mental health available to the average Central American migrant women, who otherwise may not have access to more formal educational publications.

Development of Project

As a result of what was found during the review of the literature, the need to communicate directly with the average Central American migrant women about her

118 experiences was stirred. The guidebook was created using specialized literature on the subjects of migration from Central America, what migrant women go through before, during, and after a migration journey, what happens with the migrant women’s children who stay behind in the country of origin, how migration can impact mental health, how

Latinos/Hispanics view mental health issues, and how to best serve this population in the field of mental health. Four different consulates were visited in Los Angeles area including the consulates of Guatemala, El Salvador, Honduras and Nicaragua, to check the resources these offices have for their nationals. Only the Nicaragua consulate had a flyer from a local mental health agency displayed in the resources area. Different organizations serving the Pico-Union area in Los Angeles (and area known for its predominantly Central American community) were also visited. These institutions included community health centers, mental health agencies, centers offering legal services, and other community groups. None of these groups had any educational materials on the subject of mental health for the community. However, it was encouraging to learn that most of these agencies would be interested in displaying such educational materials if these were available. Since the literature review pointed at the fact that education and information can alleviate the stigma that certain cultural groups like Latinos/Hispanics feel around mental health problems, the idea about creating an educational guidebook was conceived and implemented.

Intended Audience

The guidebook has been designed with the image of the Central American migrant women in mind. It has been created to achieve mainly three objectives; first, to let the average migrant woman know that there are people who have an idea about what

119 she has gone through, and want to hear her personal story and offer support. Second, to educate this woman about her mental health, about some conditions that can impact her mental functioning and how mental conditions can be treated. Third, to try to persuade the migrant women to view mental health services as another option to deal with her personal struggles. Mainly, the person who can benefit the most from this guidebook is the Spanish-speaking migrant woman, young or not so young, who has experienced severe difficulties, who has been separated from her children due to migration and who is finding it challenging to go ahead in life because of the presence of mental illness symptoms. It is believed that this guidebook can also be used by Spanish-speaking professionals who work in the mental health field and who want to offer some initial support and guidance to a migrant woman client or her family.

Personal Qualifications

The guidebook is for the Spanish-speaking woman who has left her native country in search of a better opportunity and who has experienced challenges in her life. No qualifications are required. If a mental health counselor or therapist, whether with an undergraduate or graduate education, finds it helpful, the only skill needed is that he/she must be able to read and understand Spanish.

Environment and Equipment

Copies of the guidebook will be available at any of the four consulates that approves its distribution (consulates from Guatemala, El Salvador, Honduras, Nicaragua), and at key community agencies in the downtown Los Angeles area. People who are willing to read it will be able to take it with them.

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Project Outline

The guidebook for Central American migrant women introduces 19 different topics with information on the events that usually accompany the decision to emigrate to the United States. It attempts to describe how the various phases of the migratory movement can leave different sorts of problematic memories and attempts to educate about mental health. This is followed by a list of potential resources that can be used to access mental health services.

The Migrant Women

1. Introduction

2. Factors influencing the decision of Central American women to migrate

3. Reasons why children stay behind in the country of origin

4. Saying farewell

5. How migrant women stay in touch with their children

6. The migratory journey and its challenges

The Impact of the Migratory Journey

7. How the struggles experienced can affect migrant women

8. Mental illness and the family

9. The children who stay behind

10. Challenges after family reunification

11. Steps than can be taken during the separation from the children or after

reunification

Mental Health

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12. Discussing mental health issues

13. Definition of a mental health disorder

14. Causes of mental illness

15. Mental health conditions

16. Guidelines for the treatment of a mental health condition

17. Getting the proper help

18. What a therapy session is all about

19. Reasons to participate in psychotherapy

Resources

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Chapter Four

Conclusion

Summary

Immigrants from the nations of Central America have established growing communities in the United States. This immigrant population grew faster than any other immigrant group from Latin America between 2000 and 2010, and of all Central

American immigrants residing in the United States in 2011, 47% were women. Although many migrants from this region have been exposed to war-related trauma and other forms of political and social violence, the migration-related experiences and mental health needs of immigrants from Central America have been understudied. Given that the population of Latino immigrants, including Central Americans, is increasing in the

United States, it is important for mental health practitioners to understand pre and post immigration contextual factors that affect the mental health of this heterogeneous ethnic group. Data shows that the majority of women transmigrating Mexico are Central

Americans who intend to reach the United States. There are limited alternatives for many

Central Americans to acquire a visa for themselves or their families, and because of this a large number of them migrate to the United States by irregular means and are in the country without a legal status.

Among other factors, the first world’s demand for service laborers has attracted mothers from a variety of developing countries often to care for the children of other people. Whether mothers initiate migration or both parents leave, the children are left in the care of extended family. Due to financial hurdles or immigration laws, the reunification of the entire family may take many years. These migration separations

123 frequently cause disruptions in attachments between parents and children and deep transformations in family functioning. A study focusing on pre-immigration family cohesion found that of the different groups evaluated, Central American participants displayed the lowest levels of family cohesion. Researchers argue that these results are possibly due to socio-political and economic instability, high levels of poverty, violent sociopolitical turmoil, less coping resources across the life span of individuals and higher levels of separation from families during undocumented migration experienced by

Central Americans in comparison to the other regional groups.

Some researchers explain that object relations theory, attachment theory, and the clinical literature on parent-child separations and loss would suggest that separations cause by immigration and its associated reunifications can potentially be very challenging. However, others also believe that it is not only the separation alone what causes clinical psychological distress, but also the associated altering events that occur before, during, or after the family is disarticulated by migration. Experts think that if a migrant woman has experienced challenging circumstances in her life, whether related to her migration or not, she might be emotionally handicapped to fulfil effectively the requirements of motherhood and of family life. Regarding this issue, studies show that many Central American women, particularly those from Guatemala, Honduras and El

Salvador are at higher risk of enduring traumatic events before, during, and after their migratory journey. Furthermore, a lot of these migrants have to deal also with the pain associated with being separated from their children and of being a transnational mother.

Due to the different stressors these migrants endure, they have a high risk for developing anxiety, depression, psychosomatic disorders, addictions and other complications that

124 could impact their functioning. Despite this, data shows that in the United States Latinos in need of mental health services underuse available mental health treatment compared to non-Latino whites. One of the major obstacles that prevent Latinos from seeking help is the stigma of having a mental issue. Many in the Latino community link mental problems to violence, loss of control and incurability.

Although there are regional differences among Latin American countries, some common shared cultural values have been recognized and are believed to be an important component of the interventions that seek to enhance Latino mental health. Cultural ideals of ‘confianza’ (mutual generosity and trust), and ‘personalismo’ (cordial interpersonal relations) situate the person in a social setting and expand positive connections outside the family circle. Since social support can protect individuals from the negative effects of trauma, including this element as part of the interventions when working with Latinos can be fundamental. Some therapeutic approaches that have been found to be helpful when working with refugees and migrant clients include: cognitive behavior therapy, problem-solving therapy, family therapy, and narrative therapy and collaborative narrative practice.

Evaluation

The guidebook ‘For a Woman of Courage like You’, which was created as the final product for this project, was reviewed by five Central American women. After the participants read the guidebook, they were given an evaluation form (Appendix C) with questions about the material. Two of the women were from Guatemala and three from El

Salvador. They were randomly approached at the Guatemala and El Salvador consulates in Los Angeles. Before agreeing to review the guide and despite the information shared

125 with them about the purpose of the guidebook and the request for their help, four of the women wanted to be reassured that the information they provided would not be given to police or immigration agents. Once their concerns were addressed, the participants read the guidebook attentively. The evaluation form they answered included different questions about the guidebook. The possible answers were organized on a scale of 1 to 5

(1-Poor---5-Excellent/Appendix C). The following are some of the results obtained. The questions asked about the guidebook’s presentation of information on the experiences of a migrant woman, the experiences between a migrant mother and her children, on what psychotherapy is and what can and can’t be expected during a session, received an average score of four point five (4.5). The questions asked about the guidebook’s explanation of what a mental health condition is, about the description of some of the mental health diagnoses, and about motivating a person to look for mental health services received and average score of four point zero (4.0). Regarding the second set of questions which used a scale of 1 to 5 (1-Strongly Disagree - -5 Strongly Agree), four of the participants stated that they had strongly agreed (score of 5 on the scale) with the question that asked if they had learned that a mental health condition is a common occurrence and that anybody can be affected by one during his/her life time, through reading the guidebook. One participant said she had agreed (score of 4 on the scale) with this question. Regarding the question that asked participants if they had learned that psychotherapy is a good option to treat a mental health condition as a result of reading the guide, one participant chose the option that read ‘no opinion’ (option 3 on the scale).

Two participants said they agreed (option 4 on the scale). Two participants said they strongly agreed (option 5 on the scale). The question that asked if the participants

126 thought there was any important information omitted in the guide was answered only by one of the women. She suggested that information about postpartum depression could be incorporated. The question that asked about the most helpful aspect of the guidebook received different answers from each of the women. One participant said that all the topics were equally important, while the other four women pointed to different sections of the guide. The sections mentioned were: mental health, different experiences of the migrant women, challenges after family reunification and the steps that can be taken after family reunification. When asked how the guidebook could be improved, three participants shared their ideas. They suggested that the guidebook could include more specific information on the following topics: the life of the woman here in the United

States; how to help family members (parents and children) left behind in the country of origin; and how the woman’s partner can support her and the children.

Four of the women who read the guidebook said it was interesting and expressed their belief that the guide could benefit other women as well. Some of these participants shared that they became emotional as they were reading, since some of the topics did describe the experiences they had. These women encouraged the distribution of the guidebook in the community. The guidebook was also read by Dr. Jefferson Sa, PhD, who has had the opportunity to work closely with the Central American community for many years. Dr. Sa provided a positive review and suggested that the topics of social isolation and culture shock be included as part of the contents. He expressed his belief that the guide could be potentially used when working with Central American migrant women. As part of the process of obtaining permission to approach Salvadoran women at the El Salvador consulate in Los Angeles, the guidebook was also reviewed by the

127 current vice consul who was present at the time of the evaluation. The vice consul said the ‘Resources’ section of the guide could be particularly useful for his office and requested a copy of the guidebook.

Discussion

Although there is irrefutable and well-documented data about the levels of stress and trauma among Central American immigrants, this group continues to lack adequate social and health services. Obstacles to the utilization of these services range from macro-level issues such as the role of citizenship and health insurance, to factors like insufficient numbers of trained professionals and confusing institutional bureaucracy

(Engstrom & Piedra, 2005). On the individual level, some barriers to mental health service use reported by Latino immigrants in the United States in general included: lack of knowledge of where to access mental health care, belief that services are unhelpful, fear of deportation, self-reliance, language, cultural incompetency of providers, stigma and conflicting cultural norms in regards to mental health among others (Seraphia, 2016).

A systematic review of the literature on immigrant mental health service utilization showed lower use rates among Latino immigrants compared with U.S.-born Latinos. For instance, 15% of Mexican immigrants with a psychiatric diagnosis used services, compared with 38% of U.S.-born Mexicans with a similar need. Latino immigrants without proper legal documentation had the lower rates of service use than any other group. They had fewer mental health appointments and lower lifetime outpatient and inpatient service use rates than U.S.-born Latinos and Latino immigrants in the United

States with legal documents (Seraphia, 2016).

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Some mental health programs and systems in the United States have made methodical efforts to overcome racial and ethnic disparities in the access of mental health service. The strategy most often implemented has targeted the work force by focusing on recruitment and retention of ethnic minority mental health practitioners. At the organizational level, programs designed to reach identified ethnic communities have proven effective in motivating persons from those communities to enter and remain in treatment. These programs have used strategies that address specific barriers. The strategies include intense outreach efforts and promotion of services, collaboration with community-based organizations, and a flexible design that often involves having weekend and evening appointments or making home or community-based visits. The literature in health services research has documented the employment of community workers as one approach to outreach. Studies of these community health workers, which have included neighborhood workers, indigenous health workers, lay health advisers, consejera (counselors), promotoras (health education workers), record their success in improving ethnic minority access and minority use of health care and preventive services

(Snowden, Masland, Ma & Ciemens, 2006). A study conducted to evaluate the perceived effectiveness of different outreach strategies showed that the only successful method that improved access of mental health services across different racial and ethnic minority groups, was the presence of more practitioners per capita. Having more practitioners per capita was connected to higher penetration rates in approximately equal terms for Whites and members of minority groups. Despite this outcome, activities conducted in the community to promote awareness and encourage referrals produced important results as well. Outreach efforts were significant in increasing penetration rates for Latinos

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(Snowden et al., 2006). Some studies report that for immigrants who did use mental health services, informal avenues such as family, friends, and religious communities played an important role in problem awareness and treatment initiation (Seraphia, 2016).

Different researchers like Kramer et al. (2009), and Poole and Swan (2010) write that offering community education about mental health conditions, discussing common emotions and practical issues before focusing on pathological signs, developing culturally sensitive materials, and giving information about resources can make a positive impact among immigrant communities and can help them overcome deterrents to mental health service use.

Following findings from the literature, the guidebook ‘For a Woman of Courage like You’ was created with the intention to be used as a tool to educate and encourage the

Central American woman, who could benefit from mental health programs, to consider services for herself and her family. The Central America women who read the guide shared that the guide presented information many Central Americans can relate to and considered that they learned new concepts about mental health through reading it. The project stimulated the interest of the people who were introduced to it and, as manifested in the project evaluation, it seemed to have attained the goal of educating about mental health topics. The participants who took the time to read it expressed their belief that the guide could benefit other women. Although only a few people read it and it is impossible to predict its usefulness from the results obtained in this brief and unempirical evaluation, at this point the guide can be distributed in the community as a handy manual to acquire basic information about mental health and how to find resources. In this way, the

130 guidebook can address some of the barriers to mental health service utilization that different studies have identified in the immigrant community.

Future Work

Little existing research assesses the effectiveness of strategies used for increasing ethnic minority access to mental health programs. Further studies could use longitudinal methodological designs to better understand the success of these outreach strategies

(Snowden et al., 2006). Most studies exploring the relationship between migration and mental health service utilization are cross-sectional. This factor makes the establishment of causal links almost impossible. In order to form an empirical understanding of this relationship, research should consider heterogeneous groups, and a longitudinal design or more aggressive case studies that follow immigrants who are new to the United States to evaluate how accessing mental health services develops over time. Research on service use among immigrants should also look into factors such as age, gender diversity, religion, pre- and post-migration experiences of social support, acculturative stress and pre-migration experiences with the mental health service systems in countries of origin.

Research should focus on under researched demographic categories like undocumented immigrants, refugees and asylum seekers, and immigrants from geographically underrepresented areas (Seraphia, 2016). Central American migrant mothers are experiencing different physical and psychological distresses before, during and after their arrival at the U.S.-Mexico border. The number of migrants who have endured traumatic events continues to grow warranting attention of mental health surveillance and intervention efforts. More public health research is needed to better understand and address the health challenges of this growing population (Valdez, Valdez & Sabo, 2015).

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Based on the literature findings and on the positive reviews given to the guidebook ‘For a Woman of Courage like You’, this project could be used as an outreach tool to educate Central American migrant women about mental health conditions and to motivate them to access mental health services. The participants who evaluated the guidebook considered that the topics presented were relevant. They were able to identify themselves with the information provided and found the ‘Resources’ section to be very useful. The initial booklet that was printed would be further developed. The ideas shared by the women who reviewed it, will be researched and included in a revised version. The goal of this project is to reproduce the guidebook for its distribution in strategic places in the community where migrant women from Central America can have access to it and benefit from its content.

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migrating women and children fleeing Central America and Mexico: The Public Health Impact of "Humanitarian Parole". Frontiers in Public Health, 3, 163. doi.org/10.3389/fpubh.2015.00163 Valle, R., & Martinez, C. (1980). Natural networks among Mexicano elderly in the United States: Implications for mental health. In M. R. Miranda & R. A. Ruiz (Eds.) Chicano aging and mental health. Washington, D. C.: U. S. Government Printing Office. Valtolina, G., & Colombo, C. (2012). Psychological well-being, family relations, and developmental issues of children left behind. Psychological Reports: Relationships & Communications, 111(3), 905-928. doi: 10.2466/21.10.17.PR0.111.6.905-928 Van Oudenhoven, J., & Hofstra, J. (2006). Personal reactions to ‘strange’ situations: Attachment styles and acculturation attitudes of immigrants and majority members. International Journal of Intercultural Relations, 30, 783 – 798. Winnicott, D. W. (1958). Through pediatrics to psycho-analysis. London, U K Hogarth Press. World Health Organization (2016). Globalization. Retrieved from http://www.who.int/ trade/glossary/story043/en/ Wurtzburg, S. J. (2010). Women immigrants. In C. Bankston (Ed.), Encyclopedia of American Immigration. Hackensack: Salem. Retrieved from http://online. salempress.com.libproxy.csun.edu Yarris, K.E. (2014). “Pensando Mucho” (“Thinking Too Much”): Embodied Distress Among Grandmothers in Nicaraguan Transnational Families. Culture, Medicine, and Psychiatry, 38(3), 473-498. doi:10.1007/s11013-014-9381-z Zong, J., & Batalova, J. (2015). Central American immigrants in the United States. Migration Policy Institute. Retrieved from www.migrationpolicy.org/article/ central-american-immigrants-united-states Zong, J., & Batalova, J. (2016). Frequently requested statistics on immigrants and immigration in the United States. Migration Policy Institute. Retrieved from http://www.migrationpolicy.org/article/frequently-requested-statistics- immigrants-and-immigration-united-states

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Appendix A

Product

For the reader For a Woman of Courage like You: Your Physical, Sexual, Emotional, Spiritual This guide has been written with the image and the and Mental Health is Important; Take Care of It experiences of the migrant woman in mind. The pages that follow will allow us to better understand some of the A Guide for the Migrant Woman challenges that are endured when a woman decides to leave everything she knows behind, in order to cross borders that divide countries to conquer the land of promise. The guide attempts to capture what many, most likely, already know but that needs to be said again with the purpose of transcending what is merely intellectual and reaching the emotional realm to increase the chance that tangible actions may be taken.

However, who has to be moved to palpable actions? In reality, all of society. The people who are in positions of power and authority and have the right to guarantee the wellbeing of the woman, migrant or not. The people who have been trained to understand the intricacies of the mind and human behavior, and have the responsibility to provide services that include the cultural and social context of those who look for support. Finally, those affected by the pain of migration, whether it was forced or unforced, who are experiencing the possible negative consequences of this process on their mental health, but have the right to live a life free of symptoms.

The guide starts with basic information about the woman who migrates, with a focus on women from Central American countries. Some ideas are presented around the reasons that motivate this departure, why children stay behind and how parents and children stay in touch. Here, the reader can also 146 learn about the difficulties that are commonly experienced Contents during the migratory process from the beginning until the end, and about how these difficulties can impact mental health. The Migrant Women ...... 1

This section is followed by the definition of what a Introduction ...... 1 psychological disorder is and why Latinos/Hispanics do not Reasons why we migrate ...... 1 talk much about this topic. Also, information is presented about different conditions that affect mental health and about Reasons why we leave uur children behind ...... 2 factors such as social isolation and culture shock, which can Saying farewell ...... 3 be brought forth by the stressors of immigration. The guide attempts to clarify for the reader how mental disorders are Staying in touch ...... 3 usually treated, and what can be expected from a The migratory journey and its difficulties ...... 4 psychological therapy session. Finally, the Resources section includes a list of different agencies that offer mental health The Impact of the Migratory Journey ...... 7 services and how they can be contacted. How the struggles experienced can affect us ...... 7

This guide has been created primarily to let the migrant Mental illness and the family ...... 8 woman know that there are people who have a good idea of The children we leave behind ...... 9 what she has endured, and who are eager to listen to her and offer support. It is also written for all those mental health Challenges after family reunification ...... 10 professionals who wish to expand on the information they have about what it is like to be a migrant, about the challenges Things we can do for our children ...... 13 that are suffered and about how to offer some initial support. Mental Health ...... 18

I am certain that this guide can offer some help to the woman Discussing mental health issues ...... 18 who is looking to be heard and appreciated. What is a mental health disorder? ...... 18

I thank you for your interest. What causes mental illness? ...... 19 Mental health conditions ...... 20 Blanca C. C. Treating mental health disorders ...... 28 Getting the proper help ...... 30

What will we find in a therapy session? ...... 31 Copyright: © 2017. Blanca C. C. [email protected]. The content of this guide can be cited or copied for educational purposes or other non- What not to expect from therapy ...... 33 commercial reasons giving appropriate credit to the author.

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For a Woman of Courage like You: When therapy is no longer needed ...... 33 Your Physical, Sexual, Emotional, Spiritual, and Mental Health is Important; Take Care of It Why should I participate in therapy? ...... 34 Resources ...... 35 A Guide for the Migrant Woman References ...... 41

The Migrant Woman

From the dawn of civilization to the present, men, women and

children have been involved in migratory movements with the

hope of finding refuge, security, food, prosperity and freedom.

Perhaps you can identify with this. Perhaps you have even

discovered that this search is far from easy. In reality, leaving

behind family, customs, language and many other important

things can be an extremely overwhelming experience.

Reasons why we migrate

Many Latin American women decide to come to this great

country of the United States for different reasons. Some of us

come because we have heard that there are many job

opportunities taking care of children or elderly people,

opportunities of domestic work, or maybe the potential of

opening our own business. We hear of jobs that will enable us

to become financially independent or grow professionally.

We come because we are motivated to provide our children

with better nutrition, health and education. We also have the

incentive to begin the journey to this country if we have the

opportunity to reunite with family or friends who are already

living here. Many of us leave our country of origin simply

because we are protecting ourselves from partners or family

members who are physically, emotionally, sexually, or

mentally victimizing us.

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For many Latin American countries, including Central to make the decision to become separated from our children? American ones, the alternatives for women to acquire a visa It sounds like a contradiction to separate ourselves from our for themselves or their children are very limited. One of the kids precisely to be able to offer them something better in the main reasons is that the immigration system in the U.S. is future. In reality, very strong reasons compel us. Some of selective and can only give a certain number of applications these include: ongoing immigration restrictions; limited family for visas each year. Because of these realities, hundreds of finances; exposure to extreme dangers during the migratory women like us have to enter the United States without the route; our conviction that our children will grow better and appropriate requirements that could make our experience a will get better education within the culture of our countries of little easier and much less risky. origin; and also our need to protect our kids from potential racial and anti-immigrant discrimination.

Saying farewell

The circumstances that surround our departure are always stressful. Trying to explain to our kids why we have to leave becomes a daunting task. We try to clarify to them that we are leaving for their good and for the good of the whole family. We promise our children that we will always be emotionally close to one another. Many times our kids try to prevent us from departing by offering to find work or take on other adult responsibilities. The children may ask if we can bring them with us so they can help us in the new country where we will Reasons why we leave our children behind be residing. Our children’s determination to prevent us from leaving makes us feel deeply sad, compelling us to question A considerable period of time elapsed before many of us were our maternal abilities. However, if we want to provide a better finally able to make the decision to migrate north. Others future for them, we must stick to our goal. The day we are made the decision rather quickly and began the march as soon finally ready to leave, we might choose not to say goodbye to as it became practicable. However, when we said goodbye to our children just to avoid witnessing their painful reproaches our loved ones it was equally difficult for all of us. For those and grief. of us who have children, the departure was particularly painful. We first had to consider how risky it was for our kids Staying in touch to come with us, and how workable it was for them to travel to a new country that not even we knew. When we realized that Despite the distance that separates us from our kids, we know the negative consequences could outweigh the immediate that we need to maintain an emotional connection with them. benefits the kids would receive, we had to make the hard We strive to secure their wellbeing and to somehow be present decision to leave them behind. What reasons then, can force us for them. The best way we can keep in touch with them is

149 through phone calls, letters, e-mails, texts, gifts, and the years of continuous stress. It is also very likely that some of us remittances that, with so much pride, we are able to send to were physically, emotionally, and sexually victimized when our country of origin. We are convinced that working in the we were kids. Chances are that some witnessed domestic U.S. can make a difference in our kids’ present and future, violence or that we were actually in an abusive relationship even though this means that we will be separated from them, with a partner. Probably, some of us lost a loved one to the often for a long period of time. We do our best to maintain our violence in our communities. In spite of all of this, most of us motherly responsibilities through the financial support we give choose not to talk about these memories. We would rather to our kids, our emotional closeness with them, and through remain silent and suffer alone. the guidance we can provide to them from this side of the border. Events that can take place during the migratory trip

Unfortunately, if we do not have the appropriate documentation to enter the U.S. we find ourselves forced to begin a migratory trip through various points of Central America and Mexico. The journey can quickly turn very dangerous, because we women usually take routes that are more secluded. This leaves us without the protection of religious and social institutions that usually operate throughout the migrant route. We would like to think that crossing the different borders only entails avoiding immigration agents; however, this is never the case.

Entering the migratory route can be, for many of us, a true The migratory journey and its difficulties challenge to our integrity and identity as a woman. While trying to get to our final destination, we can face conditions When we finally begin our journey towards a better future, we such as extreme weather, lack of food or water, or anti- leave behind our children and other loved ones, and our immigrant vigilante groups. We can also get exposed to customs and traditions. However, we may take with us common thieves, corrupt officials, or organized crime groups. confusing and painful memories from past negative experiences. It is not easy to speak about this topic, but sadly the prevailing violence against the migrant women can involve assaults and Events that can take place before the migratory trip sexual defilements, kidnap, extortion, labor trafficking, prostitution, being sold into the world of sexual slavery, organ Before coming to this country, many of us endured the harsh trafficking, and other horrendous crimes. Yes, any of us or realities of living in poverty. We may have suffered years of someone we know could have experienced any of these perils. war, political and social violence. We may have gone through

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Events that can take place once we cross the border many of us could once again fall into abusive and violent relationships here in the U.S. As new migrants we are usually With much effort and determination we overcome the forced to depend on other people because our finances are obstacles and the suffering endured on our journey to the limited, we do not speak English, or we just do not know how United States. We are grateful if we did not face any things work in this country. These factors could make us easy despicable situations during the trip; nevertheless, we cling to prey for unscrupulous people who will not hesitate to take our internal strength, if indeed new wounds were added to the advantage of our situation. ones already present. Despite all that we have been through, it is very likely that our struggles will not end when we cross the In the face of so many challenges, our motivation to achieve border. our dream comes solely from holding on to our faith, and from believing that we have been given the capacity to change The countries that receive immigrants do not always offer a things. We often remind ourselves that this ability is already hospitable environment to them, especially if the country is within us. experiencing economic challenges, or if the number of people that arrive is considerably high. If we are stopped in Mexico The Impact of the Migratory Journey or in American territory, we can be sent to detention centers in which we can face problems like limited supplies or How the struggles we experience during our journey overcrowding, or where we can spend many weeks, months or can affect us even years without being adequately processed. Unfortunately, while we are in these centers there is also the possibility of It is true that when we migrate we increase our possibilities of being exposed to abusive situations that will only get added to finding a job and having our own money. We can improve the negative experiences we already have. our chances for a better education or boost our ability to help our families more effectively. Many of us manage to attain Life in America some autonomy and financial independence; however, this achievement can bring new responsibilities and with them new Once we are in the U.S. we have to get used to the cultural physical and emotional challenges. As residents in a new differences, to the way of life in this country, and to the country, we will have to learn to deal with the facts that we are socioeconomic challenges that come with the establishment in far from our loved ones, that we have a limited social support a new environment. It could take us several years to adapt to and that we need to understand a new language. We also need these changes. If we entered the country without adequate to be prepared to move around in a new environment and authorization, we may also struggle with the anxiety and the social system, to work and send remittances, and to parent our fear of being caught and deported. Several studies have children from afar. If we have wounds and scars from past shown that the inability to find a job, living in substandard emotional injuries, we will also have to deal with this in our housing conditions, the need to rebuild a social support group new homeland. and racial or immigrant discrimination, can all lead to an intense psychological suffering. As if that were not enough,

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Due to the different drastic changes we experience in a If we have suffered a traumatic experience and now face relatively short period of time and the possible presence of mental and emotional consequences, it is very likely that this past emotional injuries, we are at greater risk for developing will alter our relationship with our children, since we may be problems such as anxiety, depression, posttraumatic stress, emotionally and mentally inhibited from being effective psychosomatic disorders, addictions, and other complications mothers to them. Moreover, there is also a huge possibility of that can compromise our well-being. passing our symptoms on to our kids! Scientific investigations show that due to the existing bond between mothers and their children, the symptoms that a mother may be feeling due to traumatic experiences, can also be felt by their children. This means that if for example a mother is feeling sad, anxious, or hopeless, there is a big probability that her children may also be feeling the same way.

The children we leave behind

One of the most important motivations behind our decision to leave our countries is the goal of offering our children a more promising future. Although it may appear like a contradiction, Although it may sound hard to believe, mental health in order to accomplish this we have to get separated from them conditions, if left untreated, can lead to the development of and leave them in the hands of family members, until our physical and chronic diseases such as cardiovascular plans start to materialize. Once we begin to send money home problems, obesity, diabetes, or asthma, among others. In some for our children, they may start to benefit right away because cultures, including the Latino/Hispanic culture, we do not they may begin to get a more balanced diet and better access assign great importance to mental health illnesses or we to education and healthcare. Nevertheless, we must admit that simply choose to ignore these conditions. However, these there is a part about leaving our kids behind that is rarely illnesses are very common and there are effective ways to deal spoken of. That is, the difficulties that many children may face with them. when they are living away from their mothers.

Mental illness and the family The children who are separated from one or both parents because of migration respond in different ways to the stress All of humanity lives life in relation to family or social that this situation causes in them. Many children can develop groups. In association with this experience, it has been unhealthy mental processes, adopt inappropriate behaviors, or demonstrated that the pain that radiates from our emotional can interpret the event as a traumatic experience. These wounds can also negatively impact all of those around us. For reactions can depend on different factors like, the instance, studies have found that the partners of people who characteristics of the family bond before the separation, the have survived physical torture, frequently experience type of relationship family members maintain among depression, posttraumatic stress and physical disorders. 152 themselves, the kid’s personality, and the support that the kids place. It could be that the long and unpredictable separation receive from the people in charge of their care. that we Latinas experience with our kids creates a deep breach that is manifested once we are together again. We, as well as The emotional difficulties these children experience can be the children, must adapt to living together in a family traced back to the lack of affection, lack of healthy physical environment in which, most likely, we have unrealistic contact, such as parental kisses and hugs, or other clear expectations of each other. The ideal relationship that we expressions of love and care. Despite the fact that we might be dreamed of all this time could be in conflict with the personal sending money and helping our kids, unfortunately some difficulties and challenges that we have experienced. The lack children may still not be receiving nutritional food and their of emotional, physical, and psychological bonding between us emotional, health, dental or mental needs may still not being and our children, perhaps the result of years of separation, can taken care of. also make the reunification process more challenging.

Sadly, the consequences of these deficiencies can be expressed by the children in forms like low academic achievement, lack of motivation to study, anxiety, aggressiveness, tendency to depression, low self-esteem, not giving importance to things going on around them, anti-social behaviors, thoughts that they would be better off death, and the wish to be dead.

The challenges we face with our children after family reunification

The long family separation that follows the initial migration is In many cases, our children, who might already be in their never easy for us or our children. Many changes take place adolescence years, must confront the different challenges of during the time we are separated. When we finally see our starting a new stage in their development in a different children again, most of us have a nice time with them and do country, with a new culture and language, with no social not experience any mayor inconveniences, as our kids can get support from close friends, and in a family which is very easily used to our presence and we can get used to theirs. different to the one they knew before we were separated. It However, it is very common for some mothers to discover could be that this family now has new siblings born in the how difficult it can be to live and be able to share with the U.S., and a stepfather. It can be a very burdensome task for children again. our children to try to assimilate all these changes in a brief period of time. Data from different studies conducted here in U.S. show that often family reunification is characterized by disappointment and disillusion. But, why do these complications arise? After all, we have been working hard for this reunification to take

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The challenge to emotional bonding behaviors and can create fear about being reported to child protective services. Once our children are reunited with us there is still the possibility that they miss the people who were taking care of What can we do if we are separated from our them in our country of origin, other family members or children or if we are living together again? friends. They may find it difficult to establish a relationship with the new members of the family here is the U.S. In the magazine Ser Padres the expert Carola Suárez-Orozco tells us that we can do a few different things to maintain a When the separation has been prolonged, it is common that good relationship with our kids even when we are far apart. mothers and children feel like complete strangers toward each other. We may get easily frustrated if our children do not open These are some of her recommendations: up to us, or if they appear sad or resentful instead of happy for our reunification. Sometimes it takes effort, understanding,  Explain to them once again why you left and some professional help to reestablish a solid and respectful relationship with our children. Usually it is less painful if we prepare our kids for our departure and we explain to them why we are The challenge to disciplining leaving. If you left without giving an explanation, offer one to them now, and remind them how It can be very difficult to discipline and to reestablish parental much you love them. authority with our children after reunification. After being physically absent from them for so long, we may feel guilty  Make sure your children do not blame when it is time for us to correct and teach our children. The themselves for your absence guilt we feel can lead us to be too lenient with them and to apply discipline interventions inconsistently. Sometimes kids feel responsible for what happens to the family. They may be telling themselves “if I We must remember that once we are in the U.S. we lose the would have been more loving, mom would not extra help we usually receive from family and friends when have left”. Tell your children how much you love we are raising our children, as it is customary in the Latino them and that despite your long separation, the culture. It is important to understand that in this country the family will benefit in the long run. discipline that involves corporal punishment, the form of discipline that was most likely used with us, is not acceptable  Maintain a good relationship with the person as it still is in many countries. The differences that we find in charge of the children’s care between our customs and the rules of this country regarding children’s discipline, can make us feel a bit confused, can Be sure to support this person and to affirm her make us feel powerless when confronted with our children’s authority over the kids. Always remind your kids how much you love them. Tell them words like”

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mom misses you a lot”, “I am always thinking are struggling with the new language, if they have about you and planning to send you the things you to get used to the new members of the family, or if need” and “I will bring you here with me as soon they do not have the lifestyle they dreamed of. as I can.” Speak with them about what they are experiencing. Listen to your children and explain  Maintain constant contact with your kids to them that what they are feeling is very normal.

Call them, send them e-mails, and if possible buy  Occasionally allow yourself to spoil your a camera for your computer so you can see each children, but in doing so establish a healthy other. Send them symbolic gifts that show that limit you are thinking about them, always ask about their activities, and demonstrate that you are Try to please your children, but do not interested in the details of their daily life and their compensate for all the time you were not future plans. physically present by granting them privileges without a limit. Reestablish your parental  Get yourself ready for the reunification authority around the most important aspects.

Make friends with people with children of the  Understand your children’s reactions same age as yours, find out about available community programs and foment stability in your You must understand that sometimes it is normal personal and family life. if your children experience feelings of intense anger or abandonment. If it is hard for you to deal Things we can do once we have our kids with us again: with this alone, do not hesitate to get the support of an expert in family matters. Carola Suárez -Orozco continues to say: Other available options we can take advantage of:  Talk about how you feel  Parenting classes It is almost certain that once we are together again, we and our children will experience During these classes you can learn about different confusing feelings. It is possible that although the topics that are important for raising a child. You children are happy to be with us, they will still can be educated on the different stages of miss the people that took care of them, their development, and how a child’s behavior changes friends, and the freedom they had before. Perhaps accordingly. You can also learn about effective the children feel disappointed with their new life disciplining techniques and how to manage a if they are spending too much time indoors, if they child’s challenging behavior. During parenting

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classes you reaffirm your knowledge on how to raise happy and healthy kids, and how to achieve a balance between respect and responsibility in your family.

 Individual and family therapy

Psychological therapy can help you develop new forms of thinking and new strategies to face everyday situations, serious issues, and all of those matters that bring discomfort to your life.

Psychological therapy can help you find solutions Without a doubt, we as migrants confront an endless series of to depression, anxiety, phobias, grief, and in personal and family challenges before and after we make the general to almost any mental condition. You learn decision to leave our countries of origin. In spite of our pains to be the master of your own thoughts and and difficult memories, our inner strength and resilience sensations, and this can benefit all aspects of your impulse us to go forward. However, there is a reality we life, even your physical health. Therapy can help cannot afford to ignore. It has been demonstrated that an your family overcome the problems that are accumulation of unresolved challenging situations can impacting its functioning. Almost everyone can ultimately overwhelm our physical, mental, emotional, and take advantage of psychological therapy. There is spiritual health. no age limit, gender, job, profession, economic

status, or anything that prevents someone from If we have faced frustrating and painful circumstances, we reaping the benefits of this resource. might be feeling defeated and worthless. We may get involved

with people that hurt us, or we may be feeling angry all the  Information from schools, health centers, time. We may not be able to enjoy our accomplishments; we community agencies, or helplines about may be constantly arguing with our kids; or we might always available programs for us and our children. be emotionally unavailable for others, including our own

children. Programs from non-lucrative organizations like

Avance, which helps parents establish a strong We have the right to express our pain if we believe that life bond with their kids, and Abriendo Puertas, that has been unfair to us; however, we cannot allow the helps parents communicate high academic consequences derived from this pain to wound those around expectations to their kids, are a good start to us, especially our kids. acquire guidance and social support. Find out if

your children’s school has a partnership with one If you feel you are being oppressed by past or present hurtful of these agencies. memories, there are people who want to hear you; but you

156 have to make the decision to share your story. We know it is presence of an acute stressor or incapacity in a person’s social not easy, but it can turn into a liberating experience. You must or professional life or in other important areas for the first overcome the fear, the discomfort, or the shame that you individual. feel when you realize you might be dealing with a mental health condition. What causes mental illness?

Mental Health Currently, many experts believe that mental disorders do not develop from one single cause, but instead can be the result of Discussing mental health issues a combination of different factors that are present in an individual at the same time. These factors usually include: an It is not that common within the Latino community to talk alteration of the chemistry of the brain, or a poor functioning about mental health problems. In fact, one of the major of brain structures or other organs in the body; negative obstacles that prevents many Latin American women from behavioral patterns that have been learned; the presence of accessing mental health services when feeling sad, despair, or illogical thinking processes and maladaptive assumptions; the desolated, is our belief that mental health problems are presence of traumatic memories and relational conflicts that something to be ashamed of, or that only weak people develop were established early in life; or the inability to achieve a such conditions. This belief is called “stigma” and is present in fulfilling self-reality. various cultural groups. Many in the Latino community place all the mental health conditions under the term “craziness”, and equate them to loss of control and incurability. Many people who display psychological symptoms may be afraid of being rejected by their family or social group. In the Latino community it is very common to try to hide or deny mental health conditions, in an attempt to protect the reputation of individuals or families. Due to this strong stigma, studies show that Latinos who need mental health services simply do not use the treatments that could be available for them.

What is a mental health disorder? Other factors equally important may include possible social and cultural pressures, and problems within the family system. A mental disorder is a significant change in a person’s Some specific examples of these factors may be: a thinking process, emotional regulation, or behavior, which compromised family’s medical history or genetic makeup, a gets manifested as a disturbance in the performance of brain injury, or a history of prolong exposure to stress or psychological, biological, or developmental mechanisms that abuse. A pregnant woman’s exposure to viruses or toxic are responsible for the optimal functioning of the mind. chemicals can also play a key role. Other conditions that Usually, most mental disorders are associated with the

157 increase the risk of developing a mental disorder include illicit Generalized Anxiety Disorder (GAD) drug use, or physical illnesses like cancer. Generalized Anxiety Disorder is a condition of ongoing We should not feel alone if we are dealing with a mental anxiety that is not related to a particular event or situation, or health condition. The American Psychological Association that is out of proportion to what a person would expect. For writes that according to published studies around 25% of all example, a person who has GAD may be constantly worried adults in the U.S. suffer from a mental illness, and that 50% of about a child who is perfectly healthy. It usually begins to all the adults in the U.S, will deal with at least one mental affect people when they are in their early 20s. condition in their lifetime! A person with GAD worries so much that it affects her day-to- Some conditions that can affect our mental health day life. This person feels tense and worried more days than not. Other signs of GAD include the following: It is worth knowing some basic information about some of the most common conditions that can affect our mental health.  Trouble falling or staying asleep These conditions include: anxiety disorders, depressive  Muscle tension disorders, trauma and stressor related disorders, bipolar  Irritability disorder, obsessive-compulsive disorders, personality  Trouble concentrating disorders, or schizophrenia and other psychotic disorders. In  Getting tired easily the following section a few of these conditions are examined.  Restlessness, or feeling “keyed up” or on edge  Trembling Anxiety Disorders  Shortness of breath  Fast heartbeat Fear and anxiety are part of life and are beneficial up to a  Dry mouth point, since these feelings allow us to be alert and careful.  Dizziness Usually, these feelings cease once the situation that triggered  Nausea them gets under control or disappears. However, for millions of people in the United States these feelings do not go away; Panic Disorder (Also known as Panic Attack) on the contrary, they get worst over time. Most likely, these people have developed an anxiety disorder. Experts have According to Medline Plus, a panic attack is a sudden identified a few different types of anxiety disorders like: sensation of terror that appears even when there is not an generalized anxiety disorder, panic disorder, social anxiety, apparent situation of danger. A person can experience a panic agoraphobia and other specific phobias. attack at anytime, anywhere, and without a warning signal. A person can be scared about having a panic attack and may avoid places where one episode was experienced before. This condition sometimes begins when an individual is under intense stress. It is more common among women, and its onset

158 usually takes place in early adulthood. During an episode, a Depression person can feel like she is losing control. Other physical symptoms are: Depression (which is the main feature of the different depressive disorders) refers to the condition in which a person  Palpitations, fast heart rate, or pounding heart feels sad, melancholic, unhappy, dejected, or defeated. Many  Chest pain or discomfort of us have felt this way, most likely, for short periods of time.  Sensation of shortness of breath or smothering However, clinical depression is a mood condition in which  Dizziness or feeling faint feelings of sadness, loss, anger, and frustration interfere with  Feeling of chocking daily life activities during several weeks or longer.  Numbness or tingling in the hands, feet, or face Depression can affect us at any age, but its clinical onset  Fear of dying usually begins during adolescence or in early adulthood. The condition is more common among women. The different types of depressive disorders can include: major depressive disorder, Post-Traumatic Stress Disorder (PTSD) persistent depressive disorder, premenstrual dysphoric disorder, or disruptive mood dysregulation disorder. A person can develop Post-Traumatic Stress Disorder (which is under the category of trauma and stressor-related Some of the major symptoms of depression are: conditions) after having experienced or witnessed a traumatic event. A person with this condition undergoes severe anxiety  Feeling sad or “empty” and fear even after the initial danger is over. PTSD symptoms  Loss of interest in favorite activities can start immediately after the traumatic incident takes place;  Overeating, or not wanting to eat at all however, new and more serious symptoms could appear  Not being able to sleep, or sleeping too much months or even years later, all depends on the person. Adults  Feeling very tired as well as children can suffer PTSD.  Feeling hopeless, irritable, anxious, or guilty  Aches or pains, headaches, cramps, or digestive Post-Traumatic Stress Disorder can cause problems such as: problems  Thoughts of death or suicide  Flashbacks, or feeling like the event is happening again  Trouble sleeping or nightmares Psychotic Disorders  Feeling alone  Angry outbursts These are mental conditions that cause atypical ideas and  Feeling worried, guilty, or sad perceptions, and that commonly make a person lose touch with reality. Two of the main symptoms are delusions and hallucinations. Delusions are false beliefs, such as thinking that someone is plotting against the person, or that the TV is

159 sending secret messages. Hallucinations are false perceptions, Social Isolation such as seeing, hearing, or feeling something that is not there. Some of the types of psychotic disorders are: schizophrenia, Newly arrived people to this country can face social isolation brief psychotic disorder, and schizoaffective disorder. and challenges to find relevant information and support that will allow them to get established comfortably and safely. Some early warning signs of psychosis: Social isolation describes the experience of being or feeling separated from others, and of lacking social contact with  Worrisome drop in grades or job performance others. Social isolation is different from the experience of  New trouble thinking clearly or concentrating solitude, which is simply the state of being alone, usually by  Suspiciousness, paranoid ideas or uneasiness with choice. The desire to take time to be alone can be healthy others since it allows us to reconnect with our own needs, feelings,  Withdrawing socially, spending a lot more time alone beliefs, values, and goals. Nevertheless, when a person than usual experiences too much solitude or feels socially isolated, this  Unusual, overly intense new ideas, strange feelings or person can develop feelings of loneliness, social anxiety, having no feelings at all helplessness, or depression, among others.  Decline in self-care or personal hygiene  Difficulty telling reality from fantasy  Confused speech or trouble communicating

Any one of these signs by itself may not be significant, but someone with a number of these symptoms should consult with a mental health professional. It is very important to get help if we notice that some of these behavioral changes appear and if they become more severe or do not go away with time. Early diagnosis and effective treatment can increase the probability of living a satisfying lifestyle.

If you want to know more about other mental health conditions visit Medline Plus website online. Socially isolating oneself can mean staying home for days without talking with friends or acquaintances and avoiding Other conditions that can potentially compromise our contact with others. If the person has any form of contact, is emotional and mental stability are social isolation and culture likely to be brief and superficial, while more meaningful and shock. continued relationships are practically nonexistent.

Social isolation is typically considered unhealthy, as it can exacerbate a person’s feelings of low self-worth, loneliness, shame, or depression. Social isolation by itself is not a

160 diagnosis, but it can be the cause or the symptom of other  Feeling inadequate or vulnerable mental health issues.  Loneliness  Avoiding social situations Culture Shock  Sleeping problems  Getting very angry over minor matters Migration involves a loss of different things that are familiar  Nervousness and fatigue to us including the language, attitudes, values, social  Family conflict structures, and social support. Also, there are post-migration  Dissatisfaction with life in general stressors, like culture shock, that can trigger mental issues. Culture shock is the troublesome feeling of uncertainty that Despite all of this, there is good news. According to different many people experience when they enter an unfamiliar studies, as a person begins to adapt and get used to the new environment in which they are not sure about the acceptable country, all the original changes start to appear less norms of behavior, or what to expect from others. Other challenging. Adapting to the new culture can help reduce the factors that can affect a new migrant are: racism, feelings of grief and loss that were felt initially. discrimination, lack of employment, discrepancy between expectations and what has been accomplished, financial Some strategies to deal with culture shock and facilitate the hardship, legal issues, substandard living conditions, and in adaptation process: general, the feeling that it is difficult to find opportunities for advancement.  Be patient. Do not try to understand everything at once Experiencing affliction and the sensation of loss is usually a  Evaluate your situation and your reactions. Be common reaction, and a natural consequence of the migration flexible; try to tolerate ambiguity. Accept the things process. But, if there are signs that are causing a significant that are just different discomfort and are impairing the person for a considerable  Identify ways to think positively. Use your sense of period of time, it is always a good idea to find help. humor. Give yourself permission to fail  Gather information that can help in your situation The following signals can help us understand if we might be  Do not criticize the host culture experiencing culture shock:  Make friends with people from this country  Do not fall into self-pity. Believe in yourself and in  Sadness the host country  Guilty feelings over leaving behind country of origin  Stay healthy. Be active mentally, physically and  Homesickness socially  Stereotyping host nationals  Use your friends and family as an emotional support  Irrational fears related to the host country group  Loss of identity  Learn how things work in this country (try to learn the  Loss of sense of humor language and become familiar with local customs)

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 Ask for help when necessary, and do not feel bad psychotherapy treatment can be extremely beneficial for the about asking for it; all of us need support and Latino community. guidance Medication: Treating mental health disorders There are different types of medications to treat mental First we need to understand that mental disorders can be illnesses. Our psychiatrist (doctor of medicine who specializes successfully treated and that in most cases people recover and in the functioning of the brain and the mind) can help us find live a typical lifestyle. The National Alliance on Mental the appropriate medication for our condition in particular. It is Illness (NAMI) offers the following treatment guideline: very common that people try a few medications before they find the most effective one for their condition. Education and social support:

A significant step towards recovery is to have as much information as possible about the mental condition that afflicts us, and to learn how the condition can be dealt with. As far as it is within our reach, it is also important to be able to establish a support group that includes family, friends, people who share a similar experience to us, and mental health professionals. Institutions like NAMI offer educational classes and free support groups for people with a mental condition and for family members. To find a NAMI agency, visit www.nami.org or call 1 (800) 950-NAMI (1 800 950-

6264). Other recovery options:

Psychotherapy: Other practices that can contribute to our recovery include: faith and prayer, art (music, dance, plastic arts, etc.) and This intervention allows us to talk with a mental health meditation. A healthy and active lifestyle that incorporates a professional (therapists, psychologists, counselors) and share balanced diet and an exercise regime will facilitate an optimal our concerns and dilemmas. These professionals help us response from our body and mind. understand the situation we are going through and clarify the mental conditions we might be facing. They show us how Hospitalization: different advances and studies have found ways to manage mental disorders, to control stress, and to solve adequately a Sometimes it becomes necessary that we be hospitalized if we variety of challenges. Currently, there are several enter into a crisis caused by our mental condition. By being psychotherapy modalities. Studies have demonstrated that

162 hospitalized we will be safe and stable, and we will receive We persevere until we obtain adequate treatment competent assistance to overcome the impasse. Finding effective services can be hard. It is important that we Getting the proper help know as much as we can about our mental condition, available treatments, our rights and other pertinent things. This What can we do if we need help managing our mental health information can help us understand the mental health system condition? of this country and to persevere until we obtain the right treatment plan for our mental concern. Our primary physician NAMI recommends that: can be a first point of contact to get information on mental health, and organizations like NAMI can guide us as well. We openly talk about the topic We contact NAMI If we have noticed any sign that indicates that our mental health has been compromised, we need to share this with our We must know that we are not alone. Organizations like family or someone close to us and ask them to help us find NAMI, which is an agency for people and families who live professional support. If we suspect that a loved one could be with mental health problems, offer information, education, facing a mental health concern, we should talk to this person help, and support. To find a NAMI agency we can visit about the changes we have noticed, and patiently and www.nami.org or call 1 (800) 950-NAMI (1 800 950-6264). respectfully address the topic with her. When talking to this person, we must keep in mind that many will feel confused or What will we find in a therapy session? ashamed about what is happening to them. Psychotherapy involves a learning experience with the goal of We visit a mental health professional becoming better able to manage and reduce physical, mental, and emotional ailments. Usually, during the first therapy The sooner we look for help and answers to the doubts we session the mental health professional collects information have about what we are experiencing, the better. NAMI about the client and allows her to express how she wants to be recommends that we make a list of all the changes that we helped. The evaluation and assessment of the difficulties the have noticed and that worry us. We need to be open and client is bringing to the therapy room is often completed in transparent with the mental health professional, since a two or three meetings. After this, the client’s goals are complete and honest description of what is taking place will defined, and the best psychotherapeutic treatment is help determine what the potential issue could be. Mental determined. At this point, the client can judge if this is the health professionals include psychiatrists, psychologist, intervention she is looking for to deal with the mental health marriage and family therapists, and social workers. concern.

After the initial evaluation and during the following sessions, the client and the therapist will work together to identify and

163 change the thinking patterns and behaviors that are preventing What not to expect from psychotherapy the client from feeling well. Alternative ways to perceive the circumstances will be proposed, and the client will be  Do not expect a miraculous cure. The solutions motivated to appropriate and utilize the skills and knowledge will come, but you have to commit to work she has rediscovered within herself and in her environment to through the process. confront her dilemmas.  Do not allow the psychotherapist to do or ask for In most psychotherapy styles, the therapist and the client sit something that is against your moral principles. face to face and the therapist asks questions about thoughts Phrases like “I know what’s best for you” should and feelings. If you are participating in therapy, do not worry never be used by the professional. Like in other if you find it hard to open up to a total stranger. Your careers, there is a small percentage of therapists therapist will help you feel safe and comfortable. If you are that could use their influence in a negative way. not feeling at ease with the therapist, do not compromise with You should never feel compel to do anything the rest of the course of therapy; seek the help of another contrary to your values. therapist. It is important that you feel you are in a safe place, so trust can be fomented and you maintain your motivation to  A therapist should not touch you without your engage in the therapy process. permission. Occasionally, a professional may rest his/her arm on your shoulder or arm as a sign of The information you share is confidential support or closeness; any other type of physical contact is unnecessary. If your therapist constantly The information obtained from you during the therapy looks for physical contact, this constitutes sessions helps the mental health professional have a better inappropriate and unethical behavior. understanding of the situation and the problem. Most of the information shared by you is confidential. Some specific  Experiencing a difficulty or disagreement with the situations represent legal exceptions, like presenting an therapist is uncommon, but if it happens it is imminent threat of harm to yourself or others, or indication of crucial to clarify the issue as soon as possible. abuse of a child, dependent adult, or elderly adult. If you have Ignoring the impasse will negatively impact the any questions about confidentiality talk to your therapist. therapeutic relationship. Do not hesitate to discontinue with a therapist who does not give Duration of the therapy session adequate attention to your concerns and discomfort. A therapy session usually lasts about 50 minutes. The duration of the entire therapy process varies from person to person, When therapy is no longer needed since each person’s life experience is unique. The treatment can take some weeks, months, or more. However, most clients At the end of the treatment you will notice that you have obtain some benefits after a few sessions. managed to confront the problem that motivated you to look

164 for help, and that you have discovered new abilities to face stressors, but it also foments self-efficacy and self- challenges more effectively. You and the therapist will decide esteem, which in turn facilitates healthy behavior together when you will be ready to finish your psychotherapy  Because you are already here, in the country in which sessions. One day you will observe that you no longer wake you always believed you would be successful; up feeling worried about the difficulty that led you to look for therefore you deserve to be ‘free of symptoms’. If professional help, and you will receive positive comments your mental health is optimal you will increase your from other people about your demeanor. You and the therapist chances of reaching your full potential and of will evaluate if you have accomplished the goals you functioning at your best in your new home country. established at the beginning of the process.

Next you can find different resources that could help you find mental health services.

Resources

Agencies That Offer Mental Health Services

Amanecer Community Counseling Services 1200 Wilshire Blvd #500

Los Angeles, CA 90017 (213) 481-1792 Why should I participate in therapy? Casa de la Familia

3550 Wilshire Blvd #670 You may be asking yourself why you should participate in Los Angeles, CA 90010 psychological therapy. Maybe some of these ideas will (213) 384-8494 convince you:

East Los Angeles Women’s Center  Because you deserve to be heard and supported 1431 S. Atlantic Blvd  Because life was given to you to live it with mental Los Angeles, CA 90022 peace and emotional stability (323) 526-5819  Because your family deserves to have a mother, wife,

daughter, sister, aunt who can share with them healthy Eisner Pediatric & Family Medical Center thoughts and positive feelings 1530 S. Olive St.  Because you can strengthen your social support Los Angeles, CA 90015 system. Social support not only protects us from

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(213) 747-5542 Los Angeles Child Guidance Clinic 4401 Crenshaw Blvd #300 Institute for Multi-Cultural Counseling & Educational Los Angeles, CA 90043 Services (323) 290-8360 3580 Wilshire Blvd #2000 Los Angeles, CA 90010 Children’s Hospital LA (213) 381-1250 3250 Wilshire Blvd # 3,5,6 Los Angeles, CA 90010 Pacific Clinics (323) 361-7827 520 S. Lafayette Park Pl. #300 (323) 361-3189 Los Angeles, CA 90057 (213) 252-2100 Domestic Violence/Abuse

Southern California Counseling Center Peace Over Violence 5615 W. Pico Blvd 1015 Wilshire Blvd #200 Los Angeles, CA 90019 Los Angeles, CA 90017 (323) 937-1344 (213) 955-9090

Sunrise Community Counseling Center Strength United 537 S. Alvarado St 14651 Oxnard St Los Angeles, CA 90057 Van Nuys, CA 91411 (213) 207-2770 (818) 787-9700 Hotline, Resources & Crisis Intervention: (818) 886-0453/ NAMI (661) 253-0258 4305 Degnan Blvd # 104 Los Angeles, CA 90008 Hotlines (800) 950-6264 / (323) 294-7814 Domestic Violence: 1(800) 978-3600 Agencies that offer mental health services for children Mental Health: 1(800) 854-7771 Substance Abuse: 1(800) 564-6600 Children’s Institute Inc. Women’s Health: 1(800) 793-8090 711 S. New Hampshire Ave Suicide Prevention: 1(888) 628-9454 / 1(877) Los Angeles, CA 90005 727-4747 (213) 385-5100 Youth Hotline: 1 (800) 852-8336 Youth Crisis Hotline: 1 (800) 843-5200 Los Angeles County Human Resources Line: 211 (24/7)

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Health resources for people without appropriate 2533 W. Third Street, Suite 101 documentation Los Angeles, CA 90057 Tel: (213) 353-1333 Ventanilla de Salud Los Angeles http://www.chirla.org/ 2401 W. 6th St Los Angeles, CA 90057 El Rescate (213) 351-6826 Provides information and free legal representation to members of the Central American community in Los Angeles.

Martin Luther King Jr-Macc th 2021 Wilmington Ave 1501 W. 8 St #100 Los Angeles, CA 90059 Los Angeles, CA 90017 (310) 668-4321 (213) 387-3284 www.elrescate.org St. Johns Well Child & Family Center Clinic 808 W. 58th St L.A. County Bar Immigration Project Los Angeles, CA 90037 Provides information in all areas of immigration law, and (323) 541-1411 offers assistance with different application processes.

USC-Eisner Family Medicine Center at California 300 N. Los Angeles St., Room 3197 Hospital Los Angeles, CA 90012 1400 S. Grand Ave, # 101 (213) 485-1872 Los Angeles, CA 90015 www.lacba.org (213) 741-1106 Legal Aid Foundation of Los Angeles Hollywood-Wilshire Health Center Advises on family reunification matters, and offers assistance 5205 Melrose Ave to migrant women who have suffered domestic violence. Los Angeles, CA 90038 (323) 769-7800 5228 Whittier Blvd. Los Angeles, CA 90022 Legal Assistance (323) 801-7991 http://www.lafla.org/ Coalition For Humane Immigrant Rights of Los Angeles (CHIRLA) Public Counsel Non-profit organization that fights for the human and civil Offers assistance to migrants who have been victimized by rights of immigrants and refugees in Los Angeles. partners who are American citizens or permanent residents, and to human trafficking victims or victims of other crimes.

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610 S. Ardmore Ave References Los Angeles, CA 90005 (213) 385-2977, ext. 600 American Psychological Association. (2017). Data on Behavioral www.publiccounsel.org Health in the United States. www.apa.org/helpcenter/data- behavioral-health.aspx. Azor, F. (2017). Cómo es una psicoterapia. Gabinete de Psicología. Other organizations www.gabinetedepsicologia.com/sesion-de-terapia-psicologos- madrid-tres-cantos. Beneria, L., Deere, C. D., & Kabeer, N. (2012). Gender and American Psychological Association international migration: Globalization, development, and www.apa.org/centrodeapoyo/ governance. Feminist Economics, 18(2), 1-33. The support center is an online resource where users can find Bhugra, D., & Becker, M. A. (2005). Migration, cultural information about psychological challenges that can affect a bereavement and cultural identity. World Psychiatry, 4(1), 18–24. person’s well-being. US National Library of Medicine. www.ncbi.nlm.nih.gov Brigden, N. K. (2012). ‘Like a war’: The new Central American NAMI refugee crisis. NACLA Report on the Americas, 45(4), 7 www.nami.org Castaneda, E., & Buck, L. (2011). Remittances, transnational Here users can access a variety of topics about mental health parenting, and the children left behind: Economic and psychological implications. The Latin Americanist, 55(4), 85-110. doi: and how to get support and guidance. 10.1111/j.1557-203X.2011.01136.x Cernadas, P. C. (2015). Childhood and migration in Central and National Alliance for Hispanic Health North America: Causes, policies, practices and challenges. Center www.hispanichealth.org for Gender and Refugee Studies, Introduction. A good physical and mental health is crucial for the enjoyment www.refworld.org/docid/54e5c3574.html of life. On this site, users can find tools and ideas to take Ching, J., Londoño-McConnell, A., Molitor, N., & Ritz, M. (2017). control of their health. Entendiendo la Psicoterapia. Asociación Americana de Psicología. www.apa.org/centrodeapoyo/entendiendo-la-psicoterapia.aspx. Medline Plus Cummings, S. B. (2008). Cuando los Padres se van y los Hijos se https://medlineplus.gov/spanish/mentaldisorders.html Quedan. Ser Padres Magazine. www.parents.com/parents- magazine/cuando-los-padres-se-van-y-los-hijos-se-quedan/. This site offers a variety of information about mental health. Danish, E. (2017). Parenting Classes: Pros and Cons. Health Guidence. www.healthguidance.org/entry/16109/1/Parenting- Classes-Pros-and-Cons.html. D’emilio, A. L., et al. (2007). The impact of international migration: children left behind in selected countries of Latin America and the Caribbean. www.unicef.org/socialpolicy/files/The_Impact_of_ International_Migration_LAC.pdf De la Garza, R. (2010). Migration, development and children left behind: A multidimensional perspective. UNICEF Policy and

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Practice. www.unicef.org/socialpolicy/files/Postscript Nazario, S. (2013). Madre e Hijo: El trauma de la separación. Baby _Formatted__Migration_Development_and_Children_Left_Behind. Center Blog. www.espanol.babycenter.com/blog/mamas/madre-e- pdf hijo-el-trauma-de-la-separacion/. Desjarlais, R., Eisenberg, L., Good, B., & Kleinman, A. (1995). O’Connor, K., Thomas-Duckwitz, C., & Nuñez-Mchiri, G. G. world mental health. New York, NY: Oxford University Press. (2015). No safe haven here: Mental health assessment of women Dimmitt, A. L. G. (2013). Mexico’s missed opportunities to protect and children held in U.S. immigration detention. Unitarian irregular women transmigrants: Applying a gender lens to migration Universalist Service Committee (UUSC). law reform. Pacific Rim Law & Policy Journal, 22(3), 713-749. www.uusc.org/press_release/new-report-complex-trauma-disorder- Engstrom, D. W., & Piedra, L. M. (2005). Central American in-detained-refugee-mothers-children/. survivors of political violence: An examination of contextual factors Pena-Alfaro, L. Y., Rodríguez, M. Q. (2017). Terapia Psicológica. and practice issues. In M. J. Gonzalez and G. Gonzalez-Ramos www.terapia-psicologica.com.mx/. (Eds.), Mental health care for New Hispanic immigrants (pp. 171- Perez-Foster, R. M. (2001). When immigration is trauma: Guidelines 190). NY: The Haworth Press. for the individual and family clinician. American Journal of Foner, N., & Dreby, J., (2011). Relations between the generations in Orthopsychiatry, 71(2), 153-170. immigrant families. Annual Review of Sociology, 37, 545-564. Perreira, K. M., & Ornelas, I. (2013). Painful passages: Traumatic García, J.R. (2012). Mental Health Care for Latino Immigrants in the experiences and post-traumatic stress among U.S. immigrant Latino U.S.A. and the Quest for Global Health Equities. Psychosocial adolescents and their primary caregivers. International Migration Intervention, 21, 305-318. http://dx.doi.org/10.5093/in2012a27 Review, 47(4), 976-10005. doi: 10.1111/imre.12050 976 Good Therapy. (2015). Isolation. www.goodtherapy.org/learn- Phipps, R. M., & Degges-White, S. (2014). A new look at about-therapy/issues/isolation. transgenerational trauma transmission: Second-generation Latino Hondagneu-Sotelo, P. (1992). Overcoming patriarchal constraints: immigrant youth. Journal of Multicultural Counseling and The reconstruction of gender relations among Mexican immigrant Development, 42, 174-187. doi:10.1002/j.2161-1912.2014.00053.x women and men. Gender and Society, 6, 393-415. Spectrum Feel at Home. (2017). Overcoming Social Isolation as a Horton, S. (2009). A mother’s heart is weighed down with stones: A Migrant. www.spectrumvic.org.au/overcoming-social-isolation- phenomenological approach to the experienced of transnational migrant/. motherhood. Culture, Medicine and Psychiatry, 33, 21-40. doi University of New Hampshire. (2017). Cultural Adjustment and 10.1007/s11013-008-9117-z Immersion. www.unh.edu/global/cultural-adjustment-immersion. Medline Plus. (2017). Información de salud para usted. University of Texas Counseling and Mental Health Center. (2017). Enfermedades Mentales. Biblioteca Nacional de Medicina de los Cultural Adjustment: A Guide for International Students. Estados Unidos. www.medlineplus.gov/spanish/mentaldisorders www.cmhc.utexas.edu/cultureadjustment.html. .html Valtolina, G., & Colombo, C. (2012). Psychological well-being, Menjivar, C. (2012). Transnational parenting and immigration law: family relations, and developmental issues of children left behind. Central Americans in the United States. Journal of Ethnic and Psychological Reports: Relationships & Communications, 111(3), Migration Studies, 38(2), 301-322. 905-928. doi: 10.2466/21.10.17.PR0.111.6.905-928 NAMI. (2013). Compartiendo Esperanza: No hay salud sin salud emocional. www.nami.org/getattachment/Get-Involved/What-Can-I -Do/Engage-Your-Community/Speaking-with-Latinos-about- Mental-Health/Esperanza_There-Is-No-Health.pdf

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Appendix B

Product

Para la lectora Para una Mujer de Valor como Tú: Tu Salud Física, Sexual, Emocional, Espiritual Esta guía ha sido escrita con la imagen y la experiencia de la y Mental es Importante; Cuídala mujer migrante en mente. Las siguientes páginas nos permitirán entender un poco más personalmente algunos de Una Guía para la Mujer Migrante los retos que se viven cuando se decide dejar todo lo que conocemos atrás, para cruzar líneas que dividen países y querer conquistar una tierra con promesa. Aquí se trata de plasmar lo que muchos, muy seguramente, ya saben pero que tiene que volver a ser dicho con el propósito de sobrepasar lo meramente intelectual y llegar a lo emocional para así incrementar el chance de que acciones tangibles sean tomadas.

Pero quién tiene que ser movido a acciones palpables? En realidad todos como sociedad. Los que están en posiciones de poder y autoridad y tienen el deber de garantizar el bienestar de la mujer migrante o no migrante. Los que han sido entrenados para entender las intrincaciones de la mente y el comportamiento humano, y tienen la responsabilidad de proveer servicios que incluyan el contexto cultural y social de los que buscan suporte. Finalmente, los que han sido afectados por el dolor de la migración forzada, o no forzada, y el posible impacto de este proceso en su salud mental y que tienen el derecho a vivir una vida libre de síntomas.

La guía comienza con información básica acerca de la mujer que emigra, especialmente de países Centroamericanos. Algunas ideas son presentadas alrededor de las razones que motivan esta partida, porqué se dejan los niños atrás, y cómo se mantiene el contacto con ellos. Aquí también se puede leer 170 acerca de las dificultades que en general se viven durante el Contenido proceso migratorio, desde el comienzo hasta el final, y se describe cómo todo lo vivido durante el viaje puede impactar la salud mental. La Mujer Migrante ...... 1 Introducción ...... 1 Esta sección es seguida por la definición de lo que es un trastorno psicológico, y porqué los Latinos/Hispanos no Razones por las cuales emigramos ...... 1 hablan mucho acerca de este tema. Se presenta información Razones por las cuales dejamos a los niños atrás ...... 2 sobre diferentes condiciones que afectan la salud mental, y se escribe acerca de factores como el aislamiento social y el Momento de despedida ...... 3 choque cultural, que en muchas ocasiones son parte de la Manteniendo el contacto con nuestros hijos ...... 4 inmigración. Aquí se puede entender con un poco más de claridad cómo usualmente se tratan los trastornos mentales y El viaje migratorio y sus dificultades ...... 5 en que consiste una sesión de terapia psicológica. Finalmente, en la sección de Recursos, se puede encontrar información Impacto del Viaje Migratorio ...... 7 variada acerca de cómo encontrar servicios de salud mental. Maneras en que podemos ser afectadas ...... 7

Esta guía ha sido creada principalmente para que la mujer Las condiciones mentales y la familia ...... 8 migrante sepa que hay personas que tienen una buena idea de Los niños que se quedan atrás ...... 9 lo que ella ha atravesado y que están dispuestas a escucharla y apoyarla. También está escrita para todos aquellos, Retos después de la reunificación familiar ...... 10 profesionales de la salud mental o no profesionales, que de Lo que podemos hacer si estamos separadas de los niños o cierta manera desean ampliar un poco más los conceptos que si ellos ya están con nosotras ...... 13 tienen de lo que es ser una migrante, de los retos extras que se experimentan, y de cómo ofrecer una ayuda inicial. Salud Mental ...... 18

Estoy segura que esta guía puede brindar algo de apoyo y Hablando de condiciones mentales ...... 18 ánimo a la mujer que está en la búsqueda de ser oída y Qué es un trastorno de salud mental? ...... 19 apreciada. Cuál es la causa de los trastornos mentales? ...... 19 Agradezco el interés. Condiciones que pueden alterar la salud mental ...... 20

Blanca C. C. Cómo se tratan los trastornos de salud mental? ...... 29 Qué se puede hacer si se necesita ayuda ...... 31 Derechos de Autor: © 2017. Blanca C. C. [email protected]. El contenido de esta guía puede ser citado o copiado para propósitos de Qué pasa durante una sesión de terapia psicológica ...... 32 educación u otras razones no comerciales dando el crédito debido al autor.

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Qué no hay que esperar de una psicoterapia? ...... 34 Para una Mujer de Valor como Tú: Cómo sé que ya estoy lista para terminar la terapia? ...... 35 Tu Salud Física, Sexual, Emocional, Espiritual Por qué debería acudir a terapia psicológica? ...... 36 y Mental es Importante; Cuídala

Recursos ...... 37 Una Guía para la Mujer Migrante Referencias ...... 43

La Mujer Migrante

Desde muy temprano en la historia de la humanidad, hombres, mujeres y niños se han envuelto en movimientos migratorios con la esperanza de encontrar refugio, seguridad, alimentación, prosperidad o libertad. Tal vez tú te identifiques con esto. Tal vez también ya te has dado cuenta de que esta búsqueda no es nada fácil. En realidad, dejar atrás familia, costumbres, lenguaje, y muchas otras cosas importantes puede llegar a ser una experiencia extremadamente abrumadora.

Razones por las cuales emigramos

Muchas mujeres Latinas decidimos venir a este gran país de los Estados Unidos por diversas razones. Algunas venimos porque hemos escuchado que hay muchas oportunidades de trabajo cuidando niños o personas mayores, oportunidades de trabajo doméstico, o quizás que existe el potencial de abrir nuestro propio negocio. Escuchamos de otros trabajos que nos permitirán independizarnos financieramente o crecer profesionalmente. Otras venimos porque nuestros hijos nos inspiran y queremos esforzarnos para ofrecerles a ellos la posibilidad de una buena nutrición, salud, y educación. Si tenemos la ventaja de reunirnos con familiares o amigos que ya están viviendo en este país y nos pueden ayudar, también nos vemos motivadas a emprender el viaje a Estados Unidos. Muchas también tenemos que salir de nuestros países de origen simplemente porque nos estamos protegiendo de

172 relaciones sentimentales y familiares en donde se nos maltrata tan riesgoso era para los niños venir con nosotras, y que tan y victimiza física, emocional, sexual, y mentalmente. El hecho factible era pare ellos viajar a un nuevo país que ni siquiera de que hayamos crecido en comunidades en donde la nosotras mismas conocíamos. Cuando entendimos que las migración es muy común y hasta esperada es otra razón que cosas negativas sobrepasaban a los beneficios inmediatos que influye en la decisión de muchas de emigrar. los niños recibirían, tuvimos que tomar la dura decisión de dejarlos atrás. En varios países Latinoamericanos, incluyendo nuestros países Centroamericanos, hay muy pocas alternativas de adquirir una Pero qué razones nos llevan a tomar la difícil decisión de visa para nosotras y para nuestros hijos, entre otras razones, separarnos de nuestros niños? Parecería contradictor que porque el sistema migratorio de Estados Unidos es selectivo y tengamos que separarnos de nuestros hijos para buscar solo puede conceder cierto número de aplicaciones para precisamente su bienestar. En realidad muchas razones muy residencia permanente cada determinado periodo de tiempo. fuertes alimentan esta decisión. Algunas de estas incluyen: Estas realidades hacen que cientos de mujeres tengamos que restricciones migratorias existentes y limitaciones financieras entrar a este país sin los requerimientos adecuados que hagan familiares, peligros extremos a los que los niños se pueden de nuestra experiencia un poco más fácil y mucho menos exponer durante la ruta migratoria, las convicciones que riesgosa. tenemos de que ultimadamente los niños van a crecer mejor y van a recibir mejor educación en la cultura de nuestros propios países, y también porque sentimos la necesidad de protegerlos de posibles maltratos antinmigrantes y raciales.

Momento de despedida

Las circunstancias que rodean nuestra partida son usualmente estresantes. Tratar de explicarles a nuestros hijos las razones por las cuales nos tenemos que ir resulta ser una tarea muy difícil. Intentamos explicarles que lo estamos haciendo por su propio bienestar y el de toda la familia, y les garantizamos que siempre estaremos cercanos uno del otro. Muchas veces nuestros hijos tratan de negociar nuestra partida y nos ofrecen Razones por las que dejamos a nuestros hijos atrás que ellos van a trabajar o van a asumir otras responsabilidades de adultos a cambio de que no nos vayamos. Los niños pueden A algunas nos llevó algo de tiempo el tomar la decisión de también pedirnos que los traigamos con nosotras para que así emigrar hacia el Norte. A otras no tanto; emprendimos la ellos nos puedan ayudar en el nuevo lugar a donde vamos a ir marcha en cuanto nos fue posible. Sin embargo, el despedirnos a vivir. La insistencia de nuestros hijos de no querer separarse de nuestros seres queridos fue igualmente difícil para todas. de nosotras nos hace experimentar profunda tristeza y nos Para aquellas que tenemos hijos, la despedida fue hace reevaluar nuestra capacidad maternal. Sin embargo, si particularmente dolorosa. Primero tuvimos que pensar en que 173 queremos forjarnos un futuro un poco más seguro, tenemos El viaje migratorio y sus dificultades que continuar con la meta. El día que estamos listas para salir, puede que escojamos no despedirnos de nuestros niños Cuando finalmente emprendemos nuestro viaje hacia un futuro solamente para no presenciar sus dolorosos cuestionamientos mejor muchas estamos dejando a nuestros hijos y otros seres y su dolor. queridos, también nuestras costumbres y tradiciones. No obstante, muchas estamos llevando con nosotras dolor y Manteniendo el contacto con nuestros hijos recuerdos contradictorios que provienen de una o varias experiencias negativas que pudiéramos haber vivido. A pesar de las distancias que nos separan de nuestros hijos de todas maneras sabemos que necesitamos mantener una Eventos que pueden ocurrir antes del viaje migratorio conexión emocional con ellos. Así que nos esforzamos por trabajar para su bienestar y de estar de alguna manera presente Antes de venir a este país, varias soportamos situaciones de para ellos. La mejor manera que tenemos para mantener pobreza intensas, experimentamos años de guerra y violencia comunicación con los niños es a través de llamadas política y social y a travesamos mucho tiempo de estrés telefónicas, cartas, correos electrónicos, textos, regalos, y las continuo. También es muy posible que cuando niñas algunas remesas que con tanto orgullo podemos enviar a nuestro país hayamos pasado por abuse físico, emocional y sexual. Hay de origen. muchas probabilidades de que también hayamos visto violencia doméstica, de que hayamos estado en una relación sentimental abusiva, o de que hayamos perdido a algún ser querido por la violencia en nuestras comunidades. A pesar de todo esto, muchas de nosotras escogemos no hablar de estas vivencias. Muchas preferimos callar y sufrir nuestro dolor a solas.

Eventos que pueden ocurrir durante el viaje migratorio

Infortunadamente, si no tenemos la documentación adecuada Estamos convencidas de que trabajar en los Estados Unidos para entrar a los Estados Unidos nos vemos forzadas a puede hacer una diferencia en el presente y el futuro de emprender un viaje migratorio por varios puntos de Centro nuestros hijos, sin embargo esto implica que en muchas América y México. La travesía puede rápidamente tornarse en ocasiones tengamos que separarnos de ellos y a menudo por dramática, especialmente porque las mujeres usualmente largos periodos de tiempo. Hacemos lo mejor para mantener tomados rutas un poco más encubiertas que nos dejan nuestras responsabilidades de madre por medio de nuestras desprotegidas de instituciones religiosas y sociales que remesas, la comunicación y la guía que podamos ofrecer a usualmente operan a través de la ruta del migrante. través de las fronteras que nos alejan. Quisiéramos pensar que el cruzar la frontera solo nos enfrenta

174 a dificultades comunes con agentes de inmigración, pero la limitadas, y en donde podríamos pasar varias semanas, meses realidad es que esto no es así. y aún años sin que nuestros casos sean procesados. Infortunadamente, mientras estamos en estos centros de El emprender la ruta migratoria puede ser para muchas de detención también existe la posibilidad de exponernos a nosotras un verdadero reto para nuestra integridad e identidad situaciones abusivas que podrían añadirse a las memorias como mujer. Al tratar de llegar a nuestro destino final difíciles que ya tenemos con nosotras. podemos enfrentarnos con condiciones climáticas extremas, falta de comida y bebida y grupos vigilantes anti-inmigrantes. La vida en América También nos podemos exponer a los atropellos de criminales comunes y oficiales corruptos, o miembros de la delincuencia Una vez estamos en Estados Unidos tenemos que empezar a organizada. No es fácil hablar de este tema, pero acostumbrarnos a las diferencias culturales, a la manera de lastimosamente la violencia prevalente en contra de la mujer vida de esta nación, y a los retos socioeconómicos que llegan migrante puede envolver asaltos y ultrajes sexuales, secuestro, con la estancia en un nuevo país. La adaptación a estos extorsión, tráfico laboral, prostitución, venta dentro del mundo cambios podría tomarnos varios años. Además, si hemos de la esclavitud sexual, tráfico de órganos y otros horrendos entrado sin la documentación adecuada, puede ser que también crímenes. Sí, cualquiera de nosotras o alguien a quien nosotras tengamos que lidiar con la ansiedad y el miedo a ser conocemos, pudo haber experimentado alguna de estas deportadas. Diferentes estudios han mostrado que la vejaciones. inhabilidad de encontrar un trabajo, el vivir en condiciones poco favorables, la necesidad de tener que reconstruir nuestro Lo que puede suceder una vez cruzamos la frontera grupo social, y la discriminación, podrían contribuir a un intenso sufrimiento psicológico. Como si esto no fuera Con gran esfuerzo y determinación superamos los obstáculos suficiente, muchas de nosotras podemos volver a caer presas y dolores vividos durante la marcha hacia los Estados Unidos. de relaciones abusivas y violentas aquí mismo en los Estados Damos gracias a la vida si es que no experimentamos ninguna Unidos. Como nuevas inmigrantes, usualmente estamos situación denigrante, pero nos aferramos a nuestra fortaleza obligadas a depender de otras personas debido a nuestras interna si es que nuevas heridas se añadieron a algunas ya limitaciones económicas, porque no hablamos todavía el existentes. A pesar de todo lo ya vivido, muy probablemente inglés, y porque no conocemos cómo se hacen las cosas en nuestra lucha no termina al cruzar la línea fronteriza. este país. Estas circunstancias podrían hacernos victimas de personas inescrupulosas que no dudaran de tomar ventaja de Los países que reciben inmigrantes no siempre ofrecen un nuestra situación. ambiente amigable a los recién llegados, especialmente si el país está experimentando retos económicos o si la cantidad de Ante tantos retos, la motivación de conseguir nuestros sueños migrantes que llegan es muy alta. Si somos aprendidas en viene solamente de aferrarnos a nuestra fe y de decidir creer México o en territorio Estadounidense, podemos ser enviadas que ya se nos ha dado la capacidad para cambiar las cosas. a centros de detención en donde muy probablemente nos Frecuentemente nos recordamos a nosotras mismas que esta enfrentaremos a condiciones de hacinamiento y provisiones habilidad ya está dentro de nosotras.

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Impacto del Viaje Migratorio riesgo alto de desarrollar problemas como la ansiedad, depresión, estrés postraumático, desordenes sicosomáticos, Cómo las dificultades vividas nos pueden afectar adicciones, u otras complicaciones que podrían afectar nuestro buen funcionamiento. Es cierto que al emigrar incrementamos las posibilidades de poder trabajar y tener nuestro propio dinero. Podemos mejorar Por increíble que parezca, estos problemas que tienen un nuestra educación o la capacidad de ayudar más efectivamente origen mental, si no se les pone atención adecuada, pueden ser a nuestras familias. Muchas de nosotras logramos los causantes de enfermedades físicas y crónicas como experimentar mayor autonomía e independencia financiera; enfermedades cardiovasculares, obesidad, diabetes o asma, sin embargo, esta autonomía nos puede traer nuevas entre otras. En algunas culturas, incluyendo la Latina/Hispana, responsabilidades y consigo nuevos retos emocionales y no creemos mucho o nos rehusamos a hablar de problemas de físicos. Muy probablemente, como inmigrantes vamos a tener salud mental. Sin embargo, las condiciones mentales son muy que aprender a lidiar con el hecho de estar lejos de nuestros comunes y existen maneras efectivas de lidiar con estas. seres queridos, de tener un soporte social limitado y de adquirir un nuevo lenguaje. También tendremos que lidiar con Las condiciones mentales y la familia la circunstancia de movernos en una cultura y sistema nuevo, de trabajar y enviar remesas y de tener que ser madres para La condición mental de una persona también puede afectar a nuestros hijos desde lejos. Si tenemos heridas y cicatrices su familia. Casi todos los seres humanos vivimos la vida en causadas por situaciones pasadas, entonces también tendremos relación con grupos familiares y sociales. En asociación con que lidiar con esto en nuestro nuevo país de acogida. esta experiencia, se ha comprobado que los dolores causados por nuestras heridas emocionales también pueden alcanzar a todos aquellos que nos rodean. Por ejemplo, estudios han encontrado que las parejas de personas que han sobrevivido a torturas frecuentemente sufren de depresión, estrés postraumático, y de desórdenes físicos.

Si nosotras hemos vivido alguna experiencia de trauma y ahora enfrentamos consecuencias mentales y emocionales, es muy probable que esto altere nuestra relación con nuestros hijos, ya que podríamos estar emocionalmente y mentalmente inhibidas de ser madres efectivas para ellos. También existe una gran posibilidad de que les pasemos nuestros síntomas a nuestros hijos! Investigaciones científicas muestran que Debemos entender que debido a estos cambios drásticos que debido a la estrecha relación de apego entre madres e hijos, los vivimos en un periodo de tiempo relativamente corto síntomas que una madre está sintiendo debido a experiencias combinados con heridas emocionales pasadas, estamos en un traumáticas, también pueden ser sentidos por sus hijos. Esto

176 quiere decir que si por ejemplo una mamá se está sintiendo de nuestros niños todavía puede que no reciban comida triste, ansiosa, o desesperanzada, hay una gran posibilidad de nutritiva, que no se les atienda sus necesidades emocionales o que los hijos de esta madre también se sientan de esta manera. de salud, de cuidado dental, o cuidado de la salud mental.

Los niños que dejamos en nuestros países de origen Infortunadamente, las consecuencias de estas carencias pueden ser expresadas por los niños en formas como bajo rendimiento Una de las mayores motivaciones que nos lleva a dejar en la escuela, falta de motivación para estudiar, ansiedad, nuestros países es el de poder ofrecerle a nuestros hijos un agresividad, tendencia a la depresión, estima propia negativa, mejor futuro. Aunque parezca contradictor, para poder hacer no darle importancia a las cosas que están pasando, esto muchas veces tenemos que separarnos de ellos y dejarlos comportamientos antisociales, pensamientos de que estar en manos de familiares en tanto que podemos empezar a muerto sería mejor, y deseos de querer morir. lograr nuestras metas. Cuando empezamos a mandar remesas nuestros niños ciertamente se benefician porque pueda que Los retos que enfrentamos con nuestros niños después empiecen a tener una alimentación más balanceada, mejor de la reunificación familiar acceso a educación y a cuidado de salud. También tenemos que admitir que hay una parte de dejar nuestros niños atrás de La separación que la inmigración trae no es fácil ni para la que pocas veces se habla. Esto es, las dificultades que nosotras ni para nuestros niños. Muchos cambios ocurren muchos niños pueden pasar al estar separados de sus madres. durante el tiempo que permanecemos separados. Cuando finalmente nos volvemos a ver, la mayoría de nosotras Los niños que se separan de uno o sus dos padres porque los tenemos un tiempo muy bonito con nuestros hijos, y el padres emigran, responden de diferentes formas a la tensión reencuentro no trae muchas inconveniencias ya que nuestros que esto les puede traer. Muchos niños pueden desarrollar hijos se pueden acoplar rápidamente a nosotras y nosotras a procesos mentales poco saludables, adoptar comportamientos ellos. Sin embargo, es muy común que algunas nos veamos inapropiados, o pueden interpretarlo como una experiencia sorprendidas por lo difícil que puede ser el volver a vivir y traumática. Estas reacciones pueden depender de diferentes compartir con nuestros hijos. factores como por ejemplo, las características de la unidad familiar antes de la separación, el tipo de relación que Información recolectada muestra que aquí en los Estados mantienen los miembros de la familia, la personalidad del Unidos la reunificación familiar en ocasiones está marcada por niño, y el suporte que los niños reciben de las personas que se decepciones y desilusiones. Pero, por qué se presentan tales van a quedar a su cargo. complicaciones, si después de todo hemos estado trabajando duro para que este momento de reencontrarnos se diera? Las dificultades emocionales que estos niños experimentan Puede ser que la larga e impredecible separación que las pueden estar conectadas con la falta de contacto físico sano, mujeres Latinas experimentamos con nuestros hijos, logra besos y abrazos fraternales, u otras expresiones claras de amor crear una profunda brecha que se deja sentir una vez estamos y cuidado. A pesar de que nosotras estemos enviándoles juntos nuevamente. Tanto los niños como nosotras debemos dinero y ayudando a nuestros hijos, infortunadamente algunos habituarnos a vivir juntos en un ambiente en el que muy

177 seguramente tenemos expectativas poco realistas uno del otro. estuvieron cuidando en nuestro país de origen. Los niños La relación idealizada que hemos construido y con la que pueden extrañar a otros familiares o a amigos, y puede que hemos soñado, puede estar en conflicto con las dificultades no sea tan fácil para ellos establecer una relación con los personales y los traumas que podamos haber atravesado. nuevos miembros de la familia aquí en los Estados Unidos. Todo esto se complica con la falta de apego emocional, físico, y psicológico entre nosotros que se pudo haber resquebrajado Cuando la separación ha sido muy larga, es usual que tanto por la distancia física que hemos vivido por años. los niños como nosotras nos sintamos como si fuéramos extraños. Nosotras nos frustramos fácilmente, si es que nuestros niños no quieren compartir con nosotras, o se demuestran resentidos y tristes en lugar de contentos por nuestra reunificación. En ocasiones toma un poco de esfuerzo, entendimiento, y algo de ayuda profesional para lograr crear una relación sólida y respetuosa con los niños.

Dificultades para disciplinar

Disciplinar y reestablecer la autoridad de padres con nuestros niños, puede ser difícil después de que nos En muchos casos, nuestros niños quienes muy seguramente volvemos a encontrar. Después de estar separados por tanto ya están en la edad de la adolescencia, deben enfrentar los tiempo, pueda que nos sintamos culpables al tener que diferentes retos de empezar una nueva etapa en su desarrollo corregir y enseñar a nuestros hijos. La culpabilidad que en un país diferente con lenguaje y cultura desconocida, sin sentimos puede muy bien llevarnos a ser más complacientes ningún apoyo social de amigos cercanos, y en una familia con ellos de lo que es saludable, y a aplicar técnicas de muy diferente a la que ellos conocían antes de que nosotras disciplina inconsistentemente. partiéramos. Puede ser que esta familia ahora este conformada por nuevos hermanos nacidos en Estados Debemos recordar que en los Estados Unidos perdemos el Unidos y una nueva pareja sentimental de mamá. Para apoyo social que nuestras familias y amigos nos brindan al nuestros niños el asimilar todos estos cambios en un breve ayudarnos con la crianza de nuestros hijos, como es periodo de tiempo, puede tornarse en una tarea muy difícil costumbre entre los Latinos. Es importante entender que en de lograr. la cultura de este país, la disciplina que utiliza el castigo físico no es aceptada, así como lo es todavía en muchos Dificultades de apego emocional países, y como muy seguramente nosotras mismas fuimos enseñadas. A pesar de que nuestros hijos ya estén reunidos nuevamente con nosotras y nuestra nueva familia, todavía existe la Las diferencias que encontramos en la manera de disciplinar probabilidad de que ellos extrañen a las personas que los en este país, nos pueden confundir, nos pueden hacer sentir

178 impotentes en frente del comportamiento de nuestros hijos, y mucho’, ‘Siempre estoy planeando enviarles lo que nos puede dejar con miedo de ser acusadas con los servicios necesitan para vivir una vida digna y con un futuro de protección al menor. mejor’, ‘Voy a mandar a buscarlos apenas pueda’.

Que podemos hacer si estamos separadas de  Mantén un contacto permanente con tus hijos nuestros niños o si ya hemos logrado la reunificación? Llámalos, mándales mensajes electrónicos y, si te es posible, compra una cámara para la computadora para En la revista Ser Padres la experta Carola Suárez-Orozco nos que se puedan ver. Envíales regalos simbólicos que dice que nosotras podemos hacer mucho por mantener una demuestren que estás pensando en ellos, mantente al buena relación a larga distancia con nuestros hijos. Estas son tanto de sus actividades, y comparte detalles de su algunas de sus recomendaciones: vida diaria y de sus planes futuros.

 Explícales nuevamente por qué te fuiste  Prepárate para la reunificación

Usualmente resulta menos doloroso si preparamos a Entabla amistades con personas que tengan hijos de la nuestros hijos para nuestra partida y les explicamos misma edad de la de tus niños, averigua sobre porqué vamos a partir. Si tú te marchaste sin una programas comunitarios disponibles y fomenta mayor explicación, ofrece una ahora, y reitera tu cariño. estabilidad en tu vida personal y familiar.

 Asegúrate de que tu hijo no se culpe por tu Que podemos hacer si ya tenemos otra vez a nuestros hijos ausencia con nosotras?

A veces los niños se sienten responsables de lo que le Carola Suárez-Orozco continúa diciendo: pasa a la familia. Ellos se pudieran estar diciendo a sí mismos: ‘Si hubiera sido más amoroso mamá no se  Hablemos acerca de lo que sentimos hubiera ido’. Dile a tus hijos cuanto los quieres y que a pesar de tu larga partida, la familia se beneficiará a Una vez estemos juntos otra vez muy seguramente largo plazo. ambos, nosotras y nuestros hijos, vamos a experimentar sentimientos encontrados. Es posible  Mantén una buena relación con la persona a cargo que, aunque el niño esté contento de estar contigo, de los niños extrañe a las personas que lo cuidaron, a sus amigos, y la libertad que tenía antes. Quizá el niño se sienta Asegúrate de apoyarla y de no minimizar o quitar su desilusionado de su nueva vida si es que está pasando autoridad. Siempre recuérdales a tus hijos cuánto los mucho tiempo en casa, si tiene dificultades con el quieres. Diles palabras como: ‘Mamá los extraña idioma, si debe acostumbrarse a los nuevos miembros

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de la familia, o si no tiene el estilo de vida con el que  Motivémonos a participar en terapia individual y soñaba. Hablen sobre lo que están experimentando. en terapia de familia Escucha a tu hijo, y explícale que mucho de lo que siente es muy normal. Con la terapia psicológica se aprenderán nuevas formas de pensar y afrontar situaciones cotidianas,  Concédele gustos a tu niño pero establece un límite problemas complejos y todo aquello que causa saludable malestar. Con terapia se puede encontrar solución a la depresión, la ansiedad, fobias, duelo, y en general a Procura agradar a tu niño, pero no trates de cualquier trastorno psicológico. Se aprende a ser compensarlo por los años de ausencia consintiéndolo dueños de nuestros pensamientos y nuestras y otorgándole privilegios sin medida. Restablece tu sensaciones, lo cual crea beneficios en todos los autoridad en los puntos de mayor importancia. aspectos de la vida, incluso en la salud del cuerpo. La terapia puede ayudar a nuestra familia a superar los  Entiende las reacciones de tu niño problemas que están afectando su funcionamiento. La mayoría de las personas pueden beneficiarse de la Debes comprender que es normal que en ocasiones tu terapia psicológica. No hay edad, genero, oficio, hijo sienta mucho enojo y se sienta abandonado. Si te profesión, nivel económico, ni nada, que limite la es difícil lidiar sola con esta situación, no dudes en posibilidad de recurrir a este beneficio. buscar el apoyo de un experto en temas de familia.  Obtengamos información en las escuelas, centros Otras opciones que tenemos a nuestro alcance: de salud, agencias comunitarias, o líneas de ayuda acerca de programas disponibles para nosotras y  Tomemos clases de padres nuestros hijos

Durante estas clases podemos aprender acerca de Programas de organizaciones no lucrativas, como diferentes temas concernientes a la crianza de nuestros Avance, que ayuda a los padres a establecer vínculos hijos. Podemos educarnos acerca de las diferentes con sus hijos, y Abriendo Puertas, que ayuda a los etapas del desarrollo, y como cambia el padres a comunicar expectativas académicas a sus comportamiento de los niños de acuerdo a la etapa en niños, son un buen comienzo para adquirir guía y la que estén. También podemos instruirnos acerca de suporte social. Investiga si la escuela de tus hijos técnicas de disciplina efectivas y cómo manejar las trabaja en conjunto con alguna de estas agencias. dificultades de conducta de los niños. Durante las clases de padres afianzamos nuestro conocimiento acerca de cómo criar niños saludables y felices, y como balancear el respeto y la responsabilidad dentro de nuestra familia.

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Si tú sientes que las memorias de situaciones dolorosas presentes o pasadas de están molestando, hay personas que te quieren escuchar, pero debes de tomar la decisión de compartir tu historia. Sabemos que no es fácil, pero puede tornarse en una experiencia liberadora. Primero debemos vencer el miedo, la incomodidad, o la vergüenza que nos pueda causar el entender que podemos estar lidiando con una condición mental.

Salud Mental

No cabe duda que nosotras como inmigrantes afrontamos un Hablando de condiciones mentales sinfín de retos, individuales y familiares, antes y después de la salida de nuestros países de origen. Nuestra fortaleza y A muchos Latinos no nos agrada mucho hablar de problemas capacidad para confrontar con valentía los dolores y de salud mental. En efecto, uno de los mayores traumas, nos impulsa a ir adelante. Sin embargo, hay una impedimentos que nos detienen a nosotras las Latinas a realidad que no podemos ignorar. Está comprobado que una buscar ayuda cuando tenemos mucha tristeza, desesperación, acumulación de dificultades puede ultimadamente o desolación, es nuestra creencia de que los problemas sobrecargar nuestra salud física, mental, emocional y relacionados con la salud mental son algo vergonzoso, espiritual. negativo y que solo le suceden a las personas débiles. A ésta creencia se le llama ‘estigma’ y está presente en varios Si es que hemos atravesado situaciones frustrantes y dolorosas grupos culturales. Muchos en la comunidad Latina llamamos puede ser que nos sintamos derrotadas y sin valor. Puede ser a todos los retos de salud mental como ‘locura’ y los que nos involucremos con personas que nos hacen daño, que relacionamos con pérdida de control e incurabilidad. estemos enojadas todo el tiempo, que no podamos disfrutar de Muchas personas que presentan síntomas psicológicos nuestros logros. Puede que estemos discutiendo pueden tener miedo de ser rechazadas por su familia o su constantemente con nuestros hijos, y que no podamos estar grupo social. En la comunidad Latina es muy común el tratar disponibles emocionalmente para nadie y en particular para de esconder o negar las enfermedades de carácter mental; de nuestros niños. esta manera intentamos proteger nuestra reputación o la de la familia. Debido a este fuerte estigma, estudios demuestran Tenemos el derecho a sentir dolor si creemos que la vida nos que Latinos que necesitan servicios de salud mental ha maltratado; sin embargo, no podemos permitir que ese simplemente no utilizan los tratamientos que pudieran estar dolor toque negativamente a las personas que nos rodean a su alcance. especialmente a nuestros hijos.

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Qué es un trastorno de salud mental? realidad satisfactoria.

Un trastorno mental es un cambio significativo del estado Otros factores igualmente importantes incluyen posibles del pensamiento, la regulación emocional o del presiones sociales y culturales, y problemas en el comportamiento de una persona, que se manifiesta como una funcionamiento del sistema familiar. Algunos ejemplos alteración del funcionamiento de los procesos psicológicos, específicos de estos diversos factores podría ser: los genes biológicos, o de desarrollo que son los que hacen que la y los antecedentes médicos en la familia, sufrir una lesión en mente realice su trabajo. Usualmente, los trastornos mentales el cerebro, o tener experiencias de vida como estrés o un están asociados con la presencia de un estrés notable o una historial de abuso. La exposición de la madre durante el discapacidad en el área social, profesional, u otras embarazo a virus o químicos tóxicos puede igualmente tener actividades importantes para la persona. un rol. Condiciones que aumentan el riesgo de desarrollar un trastorno mental incluyen el uso de drogas ilegales o el padecer una condición médica severa como cáncer.

No debemos sentirnos solas si es que estamos atravesando un trastorno de salud mental. La Asociación Americana de Psicología escribe que según estudios publicados, alrededor de 25% de todos los adultos en los Estados Unidos padecen de una enfermedad mental, y que casi el 50% de los adultos en Estados Unidos desarrollaremos al menos un trastorno mental durante nuestra vida!

Algunas condiciones que pueden alterar nuestra Cuál es la causa de los trastornos mentales? salud mental

En la actualidad, muchos expertos dicen que los trastornos Valdría la pena que conozcamos alguna información básica de mentales no se derivan de una sola causa, sino que pueden las condiciones que podrían afectar nuestra salud mental. ser inducidos por una combinación de diferentes factores Estas condiciones incluyen: trastornos de ansiedad, desordenes que se suceden en un individuo al mismo tiempo. Estos depresivos, desordenes relacionados con trauma y estrés, factores usualmente incluyen: malfuncionamiento de las trastorno bipolar, trastorno obsesivo-compulsivo, trastornos de estructuras cerebrales o de la química del cerebro, o de otros la personalidad, o esquizofrenia y otros trastornos psicóticos. órganos del cuerpo; comportamientos negativos que han sido aprendidos; presencia de procesos de pensamiento ilógicos y En la siguiente sección algunas de estas condiciones son suposiciones des-adaptativas; presencia de memorias examinadas. traumáticas y conflictos relacionales que se sucedieron durante la niñez; o interferencias para alcanzar una auto-

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Trastornos de Ansiedad  Inquietud o sensación de estar atrapado o con los nervios de punta El miedo y la ansiedad forman parte de la vida y hasta cierto  Temblor punto nos pueden ser útiles, ya que nos permiten estar alerta  Dificultad para respirar o ser cuidadosos. Usualmente estas sensaciones terminan  Palpitaciones poco después de que la situación que las provocó se disipe o  Boca seca desaparezca. Sin embargo, para millones de personas en los  Vértigo y mareos Estados Unidos, la ansiedad no desaparece, al contrario,  Náuseas y diarrea empeora con el tiempo. Muy probablemente estas personas tienen trastornos de ansiedad. Los expertos han identificado Trastorno de Pánico: (Ataques de pánico) diferentes tipos de ansiedad como: trastorno de ansiedad generalizada, trastorno de pánico, fobia social, agorafobia, y De acuerdo a Medline Plus, el trastorno de pánico es una otras fobias específicas. sensación repentina de terror sin que haya un peligro aparente. Los ataques de pánico pueden ocurrir en cualquier momento, Trastorno de Ansiedad Generalizada en cualquier lugar y sin previo aviso. La persona puede tener miedo de otra crisis y evitar los lugares en los que sufrió una El trastorno de ansiedad generalizada es una condición en la crisis anteriormente. Esta condición algunas veces comienza que se experimenta una ansiedad persistente que no está cuando una persona se encuentra sometida a mucho estrés. El causada por algo en particular, o que está fuera de trastorno de pánico es más común entre las mujeres que entre proporción con la expectativa de la persona. Por ejemplo, los hombres y suele comenzar entre los adultos jóvenes. una persona con esta condición puede sentirse Durante un ataque de pánico la persona puede sentir como si constantemente ansiosa por un niño perfectamente saludable. estuviera perdiendo el control. También pueden presentarse Esta condición usualmente comienza a afectar a las personas síntomas físicos tales como: al final de la adolescencia.  Latidos rápidos del corazón(taquicardia) Una persona con ansiedad generalizada se encuentra tensa y  Dolor en el pecho o en el estómago preocupada más días de los que está tranquila y sosegada.  Dificultad para respirar Esta persona puede sentir una ansiedad tal, que su  Debilidad o mareos funcionamiento diario es impactado negativamente. Otras  Transpiración señales incluyen lo siguiente:  Calor o escalofríos  Hormigueo o entumecimiento de las manos  Problemas del sueño  Miedo a morir  Tensión muscular  Irritabilidad Trastorno de Estrés- Postraumático (TEPT)  Dificultad para concentrarse  Fatigarse fácilmente Una persona puede sufrir de TEPT (el cual está bajo la

183 categoría de desórdenes relacionados con trauma y estrés) semanas o más. La depresión nos puede afectar a cualquier después de haber vivido o haber visto eventos traumáticos. edad, pero suele empezar en la adolescencia o en adultos Este trastorno hace que la persona se sienta estresada y con jóvenes y es mucho más común en las mujeres. Los tipos mucho temor después de que el peligro haya pasado, y principales de depresión abarcan: la depresión mayor, el usualmente no solo afecta su vida sino también la de los que trastorno depresivo persistente, el trastorno disfórico le rodean. Los síntomas del TEPT pueden empezar tan premenstrual, y el trastorno de desregulación disruptiva del pronto como se vive el evento traumático; sin embargo, estado de ánimo. síntomas nuevos y más serios pueden desarrollarse meses o hasta años más tarde, todo depende de la persona. El TEPT Los síntomas de la depresión pueden incluir: puede afectar a cualquier persona, incluso a niños.  Sentirse triste o "vacío" El trastorno de estrés postraumático puede causar problemas  Pérdida de interés en las actividades favoritas como:  Aumento o pérdida del apetito  No poder dormir o dormir demasiado  Escenas retrospectivas, o el sentimiento de que el  Sentirse muy cansado evento está sucediendo nuevamente  Sentirse sin esperanzas, irritable, ansioso o culpable  Dificultad para dormir o pesadillas  Dolores de cabeza, calambres o problemas digestivos  Sentimiento de soledad  Ideas de muerte o de suicidio  Explosiones de ira  Sentimientos de preocupación, culpa o tristeza Trastornos Psicóticos

Si deseas saber más acerca de los otros trastornos de Estos son trastornos mentales que causan ideas y ansiedad visita la página en la red de Medline Plus en percepciones no comunes, y que generalmente hacen que las español. personas pierdan el contacto con la realidad. Dos de los síntomas más sobresalientes son los delirios y las Depresión alucinaciones. Los delirios son falsas creencias, como por ejemplo la idea de que alguien está en contra de la persona, o La depresión (la característica central de los diferentes que la televisión le envía mensajes secretos. Las desordenes depresivos) usualmente describe la condición en alucinaciones son percepciones falsas, como ver, escuchar, o la que una persona se siente triste, melancólica, infeliz, sentir algo que en realidad no existe. Algunos de los tipos abatida o derrumbada. La mayoría de nosotras nos hemos de trastornos psicóticos incluyen: la esquizofrenia, la sentido de esta manera en algunas ocasiones, muy psicosis reactiva breve, y el trastorno esquizo-afectivo. seguramente durante periodos cortos. No obstante, la depresión clínica es un trastorno del estado anímico en el Señales de alerta tempranas de los trastornos psicóticos: cual los sentimientos de tristeza, pérdida, ira o frustración interfieren con la vida diaria durante un periodo de varias

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 Disminución preocupante en las calificaciones o el y suporte que les ayude a establecer una vida confortable y rendimiento en el trabajo segura. El aislamiento es la experiencia de estar o de sentirse  Dificultad reciente para pensar con claridad o separado de otros y de no tener contacto social con otros. El concentrarse aislamiento social es diferente a la soledad, la cual puede ser  Desconfianza, ideas obsesivas o inquietud alrededor simplemente el estado de encontrarse sola, usualmente porque de los demás así lo desea la persona. Tomar tiempo para estar solas puede  Aislamiento social, pasar mucho más tiempo a solas ser una experiencia saludable que nos permite reconectarnos de lo habitual con nuestras necesidades, metas, creencias, valores y  Ideas inusuales y excesivamente intensas, sentimientos. No obstante, cuando una persona experimenta sentimientos extraños o ausencia de todo tipo de demasiada soledad o se siente socialmente aislada, ésta sentimiento persona puede desarrollar sentimientos de desolación,  Descuido en los cuidados personales o la higiene ansiedad social, desamparo, impotencia, depresión y otros. personal  Dificultad para distinguir la realidad de la fantasía  Habla confusa o problemas de comunicación

Es posible que cualquiera de estas señales por sí sola no sea significativa, pero si alguien muestra varias de las señales indicadas en esta lista, sería recomendable consultar con un profesional de la salud mental. Es importante buscar ayuda si notamos que se presentan estos cambios de comportamiento y que comienzan a intensificarse o no desaparecen. El tratamiento temprano de la psicosis aumenta la probabilidad de lograr vivir un estilo de vida satisfactorio. El aislarse socialmente a uno mismo a propósito se muestra Si deseas saber más acerca de otros trastornos mentales visita cuando la persona prefiere estar en casa por días, sin hablar la página en la red de Medline Plus en español. con sus conocidos. Si la persona tiene algún contacto con alguien, este contacto es muy breve y superficial, y cualquier Otras condiciones que pueden comprometer nuestra relación social significativa y duradera es prácticamente estabilidad emocional y mental son el aislamiento social y el inexistente. choque cultural. El aislamiento social es típicamente considerado como Aislamiento Social perjudicial. Si una persona ya se está sintiendo despreciada, avergonzada, sin valor, o con tristeza, el aislamiento puede Personas recién llegadas a este país pueden confrontar empeorar esta auto-evaluación. El aislamiento no es en sí un aislamiento social y retos para encontrar información relevante

185 diagnóstico, pero puede ser la causa o el síntoma de otra  Miedo irracional hacia este país condición mental existente.  Sensación de pérdida de la identidad  Pérdida del sentido del humor Choque Cultural  Sentirse inadecuado e inseguro  Sentimientos de soledad La migración envuelve una pérdida de todo lo que nos es  Evitar encuentros sociales familiar, incluyendo el idioma, actitudes, valores, estructuras  Dificultades para dormir sociales y soporte social. Además de esto, hay estresores post-  Enojarse por cuestiones menores migratorios, incluyendo el choque cultural, que nos pueden  Nerviosismo y cansancio significativos conducir a padecer un problema mental. El choque cultural es  Conflicto familiar la molesta sensación de incertidumbre que muchas personas  Insatisfacción general con la vida experimentan cuando llegan a un ambiente que no les es familiar, y del cual no saben las normas de comportamiento A pesar de todo esto, hay buenas noticias. Según varios aceptable o qué esperar de otros. Otras situaciones que pueden estudios, a medida que un nuevo inmigrante se vaya agudizar el impacto del choque cultural en una persona acostumbrando y adaptando a su nuevo país, los cambios incluyen: las actitudes negativas de la sociedad a dónde empiezan a aparecer menos amenazantes. Adaptarse a la venimos a vivir, el racismo, la discriminación, falta de empleo, nueva cultura puede ayudar a reducir los sentimientos de la discrepancia entre las expectativas que teníamos y lo que desconsuelo y pérdida experimentados inicialmente. hemos logrado, dificultades financieras, preocupaciones legales, condiciones de vivienda inadecuadas, y en general la Algunas estrategias para lidiar con el choque cultural y sensación de que no encontramos oportunidades para avanzar. fomentar nuestro proceso de adaptación:

Sentir aflicción y una sensación de pérdida es comúnmente  Sé paciente. No trates de entender todo una reacción normal y una consecuencia natural del proceso inmediatamente de migración. Sin embargo, si hay síntomas que causan un  Evalúa tu situación y tus reacciones. Se flexible; malestar significativo y nos inhabilitan por un periodo de tolera la ambigüedad. Acepta que las cosas son tiempo considerable, siempre es recomendable buscar ayuda. diferentes  Identifica maneras de pensar positivamente. Usa tu Las siguientes señales nos pueden mostrar si estamos sentido del humor. Date permiso de fallar experimentando choque cultural:  Recolecta información que ayude a tu situación  No desacredites a este país  Tristeza profunda  Hazte amiga de personas que ya viven en este país  Sentimientos de culpabilidad por haber dejado el país  No te auto-compadezcas. Cree en ti misma y en la de origen nueva cultura a la que llegaste  Extrañar intensamente el país de origen  Cuida tu salud. Se activa mental, física, y  Hacer estereotipos de los habitantes de este país socialmente

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 Usa a amigos y a familiares como un apoyo social compartir nuestras preocupaciones y dilemas. Estos  Aprende todo lo que más puedas acerca de cómo profesionales nos ayudan a entender la situación que funcionan las cosas en este país (trata de enfrentamos y a clarificar la condición mental que familiarizarte con el idioma y las costumbres) pudiéramos haber desarrollado. Ellos nos muestran como  Pide ayuda cuando sea necesario. No te sientas mal los diferentes avances y estudios han encontrado normas por hacerlo. Todas necesitamos de suporte y guía. para manejar los trastornos mentales, para controlar el estrés, y para solucionar adecuadamente diferentes dificultades. En Cómo se tratan los trastornos de salud mental? la actualidad existen varias modalidades de psicoterapias. Estudios han demostrado que el tratamiento psicoterapéutico Primero que todo, debemos entender que los trastornos puede ser extremadamente beneficioso para nosotros los mentales pueden ser tratados exitosamente y que en la Latinos. mayoría de los casos podemos recuperarnos y vivir un estilo de vida muy satisfactorio. La Alianza Nacional en Medicación: Problemas Mentales (NAMI, por sus siglas en ingles), ofrece las siguientes pautas de tratamientos: Existen diferentes clases de medicamentos para tratar los trastornos mentales. Nuestro psiquiatra (doctor en medicina Educación y apoyo social: que se especializa en el funcionamiento del cerebro y la mente) puede ayudarnos a encontrar el o los medicamentos Un paso importante hacia la recuperación es saber y más adecuados para nuestro problema en particular. Es muy entender acerca del mal que nos aqueja y aprender a cómo común que las personas traten varios medicamentos antes de lidiar con el mismo. En la medida en que nos sea posible, que encuentren el más efectivo para su situación. también es importante que formemos un sistema de apoyo que incluya a familiares, amigos, personas que tengan una experiencia parecida a la nuestra, y a profesionales de la salud mental. Instituciones como NAMI ofrecen clases de educación y grupos de apoyo gratuitos para personas que vivimos con algún trastorno de salud mental y para nuestros familiares. Para encontrar una agencia de NAMI, podemos visitar www.nami.org o llamar al 1 (800) 950-NAMI (1 800 950- 6264).

Psicoterapia:

Otras opciones de recuperación: Esta intervención nos permite dialogar con un profesional de la salud mental (terapistas, psicólogos, consejeros) y Otras prácticas que pueden contribuir de una manera

187 importante en nuestra sanación incluyen la fe y la oración, el Visitemos a un profesional de la salud mental arte (música, danza, artes plásticas, etc.) y la meditación. Un estilo de vida sana y activa que incluya una dieta balanceada Entre más pronto obtengamos ayuda y respuestas a las dudas y un régimen de ejercicio, permitirá que nuestro cuerpo y que tengamos con respecto a lo que estamos experimentando, mente respondan de una manera óptima. mejor. NAMI recomienda que hagamos una lista de todos los cambios y comportamientos que hemos sentido y que nos Hospitalización: preocupan, y que no sintamos miedo de hablar sinceramente con el profesional de la salud mental. Una descripción En algunas ocasiones es muy necesario que seamos completa y sincera de la situación, ayudará a determinar qué hospitalizadas si es que entramos en una crisis causada por está sucediendo. Profesionales de la salud mental incluye a nuestro trastorno mental. Al estar hospitalizadas se nos psiquiatras, psicólogos, terapistas de matrimonios y parejas, y mantendrá seguras y estables y se nos ayudará a superar el trabajadores sociales. impase. Perseveremos hasta que obtengamos tratamiento adecuado Qué podemos hacer si necesitamos asistencia para manejar nuestro problema de salud mental? Encontrar servicios efectivos puede ser un tanto difícil. Es muy importante que aprendamos lo más posible acerca del La Alianza Nacional en Salud Mental (NAMI, por sus siglas trastorno mental, los tratamientos disponibles, nuestros en ingles), recomienda que: derechos, entre otras cosas. Esta información puede ayudarnos a entender el sistema de la salud mental de este país y a perseverar hasta recibir tratamientos apropiados. Nuestro Hablemos abiertamente sobre el tema doctor primario puede ser un primer punto de contacto para adquirir información, y organizaciones como NAMI nos Si nosotras hemos notado alguna señal que indique que pueden guiar también. nuestra salud mental ha sido comprometida, digámoselo a nuestra familia o a alguien cercano a nosotras y pidamos Contactemos a NAMI apoyo para buscar ayuda adecuada. Si pensamos que un ser querido puede estar confrontando alguna dificultad de salud Debemos confiar en que no estamos solas. Entidades como mental, hablemos con esta persona acerca de los cambios NAMI, que es una agencia para personas y familias que viven que hemos notado y con paciencia y respeto toquemos el con problemas de salud mental, ofrecen información, tema con él o ella. Cuando hablemos con esta persona educación, ayuda, y apoyo. Para encontrar una agencia de debemos recordar que muchos se sentirán confundidos o NAMI, podemos visitar www.nami.org o llamar al 1 (800) avergonzados por lo que están atravesando, así que 950-NAMI (1 800 950-6264). debemos usar palabras adecuadas.

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Qué pasa durante una sesión de terapia psicológica? La información que compartes es confidencial

La psicoterapia es un proceso de aprendizaje que tiene como La información que se obtiene durante las sesiones de terapia finalidad el ser capaz de manejar y/o reducir malestares ayuda a la profesional de la salud mental a tener una mejor físicos y emocionales. comprensión de la situación y el problema. La mayoría de la información que compartes en la sesión es confidencial. Durante la primera sesión de terapia, usualmente la Algunas situaciones específicas como la amenaza de suicidio, profesional de la salud mental recopila información sobre la amenazar con lastimar a otra persona, o admitir haber abusado cliente y le permite que exprese cómo quiere ser ayudada. La de un niño, un adulto dependiente, o a una persona de edad evaluación y valoración de las dificultades que la cliente avanzada están excluidas legalmente de esta confidencialidad. presenta suele completarse en dos o tres sesiones. Si tienes dudas sobre la confidencialidad habla con tu Posteriormente se determina la mejor estrategia de terapista. intervención psicoterapéutica, y se definen las metas de la cliente. En este punto la cliente puede darse cuenta si esta es Duración de la sesión de terapia la intervención que busca para resolver su problema. Una sesión de terapia usualmente dura unos 50 minutos. El Después de la evaluación inicial y durante las sesiones tiempo que toma todo el proceso varía de persona a persona, siguientes, la cliente y la terapista trabajarán juntas para ya que la experiencia de cada persona en la vida es única. El identificar y cambiar los patrones de pensamiento y tratamiento puede tomar unas semanas, meses o más. Sin comportamiento que le impiden a la cliente sentirse bien. Se embargo, la mayoría de las clientes obtienen algunos propondrán formas alternativas de percibir las circunstancias, beneficios después de algunas sesiones. y la cliente se verá motivada a asumir y utilizar como propios las destrezas y el conocimiento que ha redescubierto acerca de Qué no hay que esperar de una psicoterapia? sí misma y de su entorno, para confrontar sus dilemas.  No hay que esperar una cura milagrosa. Las En la mayoría de los estilos de psicoterapia, normalmente la soluciones van a llegar, pero hay que buscarlas con terapista y la cliente se sientan una en frente de la otra, y la entereza. terapista hace preguntas sobre pensamientos y sentimientos. Si tú estás participando en terapia, no te preocupes si te cuesta  No permitas que la psicoterapista haga o pida algo que hablar abiertamente. Tu terapeuta te ayudará a tener más esté en contra de tus principios morales. Frases como: confianza y comodidad. Si no te sientes a gusto con la ‘Yo sé lo que es mejor para ti’, no deben ser usadas terapista, no te conformes, busca el servicio de otra por parte de la profesional. Como en otras profesional. Es importante que sientas que estas en un lugar profesiones, hay un pequeño porcentaje de terapistas seguro para que se fomente confianza y estés motivada a que puede usar mal su influencia. Tú no debes hacer cumplir con el proceso de terapia. nada que vaya en contra de tus valores.

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 Una terapeuta no debe tocarte sin tu permiso. que te llevó a buscar ayuda profesional, y recibirás Ocasionalmente, un profesional puede posar su mano comentarios positivos de otras personas acerca de tu actitud. sobre el hombro o el brazo como muestra de apoyo o Tú y la terapista evaluarán si has logrado las metas cercanía; ningún otro tipo de contacto suele ser establecidas al inicio del proceso. necesario. Si constantemente tu terapeuta busca el contacto físico, este puede ser un comportamiento Por qué debería acudir a terapia psicológica? inadecuado y poco ético. Posiblemente te estés preguntando por qué deberías tu  Experimentar una dificultad o desacuerdo con la participar en un proceso de terapia psicológica. Quizá algunas psicoterapeuta no es común, pero si sucede es crucial de las ideas siguientes te convenzan: aclararlo cuanto antes. No hacerlo impactará negativamente la terapia. No dudes en descartar a una  Porque tu mereces ser escuchada y apoyada. terapista que no escuche tus inquietudes y malestares.  Porque la vida te fue dada para vivirla con paz mental y estabilidad emocional.  Porque tus niños y toda tu familia merecen tener a una madre, esposa, hija, hermana, tía que pueda compartir con ellos pensamientos sanos y sentimientos positivos.  Porque podrás reforzar tu sistema de apoyo social. El apoyo social no sólo nos protege de los estresores, sino que también fomenta la autoeficacia y la autoestima, lo cual a su vez facilita el comportamiento saludable.  Porque ya estás aquí, en el país en donde siempre has creído que vas a salir adelante. Por lo tanto mereces estar ‘libre de síntomas’. Si tu salud mental es óptima, aumentaras tus posibilidades de Cómo sé que ya estoy lista para terminar la desarrollar al máximo tu potencial y de funcionar intervención terapéutica? adecuadamente en tu nuevo país de acogida.

Al finalizar el tratamiento notarás que lograste confrontar el Encuentra a continuación diferentes recursos que podrían problema que te motivo a buscar la consulta, y que descubriste ponerte en contacto con servicios de salud mental. nuevas destrezas para lidiar con los desafíos más efectivamente. Tú y la terapista decidirán juntas cuándo estarás lista para terminar tus sesiones de psicoterapia. Un día observarás que ya no te despiertas preocupada por la dificultad

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Recursos Southern California Counseling Center 5615 W. Pico Blvd Agencias que Ofrecen Servicios de Salud Mental Los Angeles, CA 90019 (323) 937-1344 Amanecer Community Counseling Services 1200 Wilshire Blvd #500 Sunrise Community Counseling Center Los Angeles, CA 90017 537 S. Alvarado St (213) 481-1792 Los Angeles, CA 90057 (213) 207-2770 Casa de la Familia 3550 Wilshire Blvd #670 NAMI Los Angeles, CA 90010 4305 Degnan Blvd # 104 (213) 384-8494 Los Angeles, CA 90008 (800) 950-6264 / (323) 294-7814 East Los Angeles Women’s Center 1431 S. Atlantic Blvd Agencias que Ofrecen Servicios de Salud Mental para Los Angeles, CA 90022 Niños (323) 526-5819 Children’s Institute Inc. Eisner Pediatric & Family Medical Center 711 S. New Hampshire Ave 1530 S. Olive St. Los Angeles, CA 90005 Los Angeles, CA 90015 (213) 385-5100 (213) 747-5542 Los Angeles Child Guidance Clinic Institute for Multi-Cultural Counseling & Educational 4401 Crenshaw Blvd #300 Services Los Angeles, CA 90043 3580 Wilshire Blvd #2000 (323) 290-8360 Los Angeles, CA 90010 (213) 381-1250 Children’s Hospital LA 3250 Wilshire Blvd # 3,5,6 Pacific Clinics Los Angeles, CA 90010 520 S. Lafayette Park Pl. #300 (323) 361-7827 Los Angeles, CA 90057 (323) 361-3189 (213) 252-2100

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Violencia Domestica/Abuso Martin Luther King Jr-Macc 2021 Wilmington Ave Peace Over Violence Los Angeles, CA 90059 1015 Wilshire Blvd #200 (310) 668-4321 Los Angeles, CA 90017 (213) 955-9090 St. Johns Well Child & Family Center Clinic th 808 W. 58 St Strength United Los Angeles, CA 90037 14651 Oxnard St (323) 541-1411 Van Nuys, CA 91411 (818) 787-9700 USC-Eisner Family Medicine Center at California Line de 24-Horas de Apoyo, Recursos & Ayuda durante una Hospital crisis: (818) 886-0453/ (661) 253-0258 1400 S. Grand Ave, # 101 Los Angeles, CA 90015 (213) 741-1106 Líneas Directas de Apoyo (Hotlines) (Espera por la indicación en Español) Hollywood-Wilshire Health Center 5205 Melrose Ave Violencia Domestica: 1(800) 978-3600 Los Angeles, CA 90038 Salud Mental: 1(800) 854-7771 (323) 769-7800 Abuso de Substancias: 1(800) 564-6600 Salud de la Mujer: 1(800) 793-8090 Prevención del Suicidio: 1(888) 628-9454 o 1(877) Ayuda Legal 727-4747 Línea para los Jóvenes: 1 (800) 852-8336 Coalition For Humane Immigrant Rights of Los Angeles Línea para Jóvenes en Crisis: 1 (800) 843-5200 (CHIRLA) Condado de Los Angeles Línea de Servicios Humanos: 211 Organización sin ánimo de lucro que trabaja para defender los (24horas en servicio) derechos humanos y civiles de los inmigrantes y refugiados en Los Angeles Recursos de Salud para Personas sin Documentos de este País 2533 W. Third Street, Suite 101 Los Angeles, CA 90057

Tel: (213) 353-1333 Ventanilla de Salud Los Angeles http://www.chirla.org/ 2401 W. 6th St

Los Angeles, CA 90057

(213) 351-6826

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El Rescate (213) 385-2977, ext. 600 Provee representación legal gratuita e información para la www.publiccounsel.org comunidad Centroamericana en Los Angeles Otras Organizaciones th 1501 W. 8 St #100 Los Angeles, CA 90017 Asociación Americana de Psicología (213) 387-3284 www.apa.org/centrodeapoyo/ www.elrescate.org El Centro de Apoyo de la Asociación Americana de Psicología es un recurso en línea donde se puede encontrar artículos e L.A. County Bar Immigration Project información relacionada con los aspectos psicológicos que Provee información en todas las áreas de la ley de afectan el bienestar físico y emocional de cada día. inmigración, y ofrece asistencia con diferentes procesos de aplicación NAMI (Alianza Nacional en Problemas Mentales) www.nami.org (sección en Español) 300 N. Los Angeles St., Room 3197 Aquí se encontrara diversa información acerca de la salud Los Angeles, CA 90012 mental al igual que apoyo y guía. (213) 485-1872 www.lacba.org Alianza Nacional para la Salud de los Hispanos www.hispanichealth.org Legal Aid Foundation of Los Angeles La salud mental y la salud física son fundamentales para el Asesora en cuestiones de reunificación familiar, y asiste a bienestar. Entre muchas otras cosas, aquí existen herramientas mujeres inmigrantes que han sido víctimas de abuso a librarse y recursos para tomar control de nuestra salud. de la violencia domestica Medline Plus 5228 Whittier Blvd. https://medlineplus.gov/spanish/mentaldisorders.html Los Angeles, CA 90022 Este sitio ofrece muy variada información de salud mental (323) 801-7991 http://www.lafla.org/

Public Counsel Asiste a inmigrantes quienes hayan sido abusados por un ciudadano de este país o por un residente permanente, y a víctimas de tráfico humano u otros crímenes

610 S. Ardmore Ave Los Angeles, CA 90005

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Referencias Practice. www.unicef.org/socialpolicy/files/Postscript _Formatted__Migration_Development_and_Children_Left_Behind. American Psychological Association. (2017). Data on Behavioral pdf Health in the United States. www.apa.org/helpcenter/data- Desjarlais, R., Eisenberg, L., Good, B., & Kleinman, A. (1995). behavioral-health.aspx. world mental health. New York, NY: Oxford University Press. Azor, F. (2017). Cómo es una psicoterapia. Gabinete de Psicología. Dimmitt, A. L. G. (2013). Mexico’s missed opportunities to protect www.gabinetedepsicologia.com/sesion-de-terapia-psicologos- irregular women transmigrants: Applying a gender lens to migration madrid-tres-cantos. law reform. Pacific Rim Law & Policy Journal, 22(3), 713-749. Beneria, L., Deere, C. D., & Kabeer, N. (2012). Gender and Engstrom, D. W., & Piedra, L. M. (2005). Central American international migration: Globalization, development, and survivors of political violence: An examination of contextual factors governance. Feminist Economics, 18(2), 1-33. and practice issues. In M. J. Gonzalez and G. Gonzalez-Ramos Bhugra, D., & Becker, M. A. (2005). Migration, cultural (Eds.), Mental health care for New Hispanic immigrants (pp. 171- bereavement and cultural identity. World Psychiatry, 4(1), 18–24. 190). NY: The Haworth Press. US National Library of Medicine. www.ncbi.nlm.nih.gov Foner, N., & Dreby, J., (2011). Relations between the generations in Brigden, N. K. (2012). ‘Like a war’: The new Central American immigrant families. Annual Review of Sociology, 37, 545-564. refugee crisis. NACLA Report on the Americas, 45(4), 7 García, J.R. (2012). Mental Health Care for Latino Immigrants in the Castaneda, E., & Buck, L. (2011). Remittances, transnational U.S.A. and the Quest for Global Health Equities. Psychosocial parenting, and the children left behind: Economic and psychological Intervention, 21, 305-318. http://dx.doi.org/10.5093/in2012a27 implications. The Latin Americanist, 55(4), 85-110. doi: Good Therapy. (2015). Isolation. www.goodtherapy.org/learn- 10.1111/j.1557-203X.2011.01136.x about-therapy/issues/isolation. Cernadas, P. C. (2015). Childhood and migration in Central and Hondagneu-Sotelo, P. (1992). Overcoming patriarchal constraints: North America: Causes, policies, practices and challenges. Center The reconstruction of gender relations among Mexican immigrant for Gender and Refugee Studies, Introduction. women and men. Gender and Society, 6, 393-415. www.refworld.org/docid/54e5c3574.html Horton, S. (2009). A mother’s heart is weighed down with stones: A Ching, J., Londoño-McConnell, A., Molitor, N., & Ritz, M. (2017). phenomenological approach to the experienced of transnational Entendiendo la Psicoterapia. Asociación Americana de Psicología. motherhood. Culture, Medicine and Psychiatry, 33, 21-40. doi www.apa.org/centrodeapoyo/entendiendo-la-psicoterapia.aspx. 10.1007/s11013-008-9117-z Cummings, S. B. (2008). Cuando los Padres se van y los Hijos se Medline Plus. (2017). Información de salud para usted. Quedan. Ser Padres Magazine. www.parents.com/parents- Enfermedades Mentales. Biblioteca Nacional de Medicina de los magazine/cuando-los-padres-se-van-y-los-hijos-se-quedan/. Estados Unidos. www.medlineplus.gov/spanish/mentaldisorders Danish, E. (2017). Parenting Classes: Pros and Cons. Health .html Guidence. www.healthguidance.org/entry/16109/1/Parenting- Menjivar, C. (2012). Transnational parenting and immigration law: Classes-Pros-and-Cons.html. Central Americans in the United States. Journal of Ethnic and D’emilio, A. L., et al. (2007). The impact of international migration: Migration Studies, 38(2), 301-322. children left behind in selected countries of Latin America and the NAMI. (2013). Compartiendo Esperanza: No hay salud sin salud Caribbean. www.unicef.org/socialpolicy/files/The_Impact_of_ emocional. www.nami.org/getattachment/Get-Involved/What-Can-I International_Migration_LAC.pdf -Do/Engage-Your-Community/Speaking-with-Latinos-about- De la Garza, R. (2010). Migration, development and children left Mental-Health/Esperanza_There-Is-No-Health.pdf behind: A multidimensional perspective. UNICEF Policy and

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Appendix C

Project Evaluation Form

For a Woman of Courage Like You: Your Physical, Sexual, Emotional, Spiritual, and Mental Health is Important; Take care of it

A Guide for the Migrant Woman

Client’s Evaluation

Name:______Date:______

Please rate the following questions in regards to the guidebook ‘For a Woman of Courage like You’, using a scale of 1 to 5:

(1) Poor (2) Fair (3) Good (4) Very good (5) Excellent

1. Information provided to understand the experiences of a migrant woman 1 2 3 4 5

2. Information provided to understand the experiences between a migrant mother and her children 1 2 3 4 5

3. Information provided about what a mental health condition is and the description of some of the mental health diagnoses 1 2 3 4 5

4. Information provided about what psychotherapy is and what can and can’t be expected during a session 1 2 3 4 5

5. Information provided to motivate a person to look for mental health services 1 2 3 4 5

6. Is there any information that has not been included in the guidebook?

______

7. What was the most helpful for you in the guidebook?

______

8. What was the least helpful for you in the guidebook?

______

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Please indicate your opinion about the following statements using a scale of 1 to 5:

(1) Strongly disagree (2) Disagree (3) No opinion (4) Agree (5) Strongly Agree

9. By reading the guidebook I learned that a mental health condition is a common occurrence, and that 1 2 3 4 5 in reality anybody can be affected by one during his/her life time

10. By reading the guidebook I learned that psychotherapy is a good option to treat a mental health condition 1 2 3 4 5

11. I would recommend the guidebook to family or friends who are in this country and who are separated from their children or are planning to reunify with them 1 2 3 4 5

12. What can be done to improve the guidebook?

______

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Appendix D

Forma de Evaluación del Proyecto

Para una Mujer de Valor como Tú: Tu Salud Física, Sexual, Emocional, Espiritual y Mental es Importante; Cuídala

Una Guía para la Mujer Migrante

Nombre:______Fecha:______

Por favor califique las siguiente preguntas relacionadas con la guía ‘Para una Mujer de Valor como Tú’, usando la escala del 1 al 5:

(1) Pobre (2) Regular (3) Bueno (4) Muy Bueno (5) Excelente

1. Información proveída con respecto a las experiencias de una mujer migrante 1 2 3 4 5

2. Información proveída con respecto a las experiencias entre una madre migrante y sus hijos 1 2 3 4 5

3. Información proveída acerca de lo que es una condición de salud mental y la descripción de algunos diagnósticos relacionados con la salud mental 1 2 3 4 5

4. Información proveída acerca de lo que es la terapia psicológica y de lo que se puede o no esperar durante una sesión 1 2 3 4 5

5. Información proveída para motivar a una persona a buscar servicios de salud mental 1 2 3 4 5

6. Hay alguna información que no haya sido incluida en la guía?

______

7. Que fue lo más beneficioso para usted de la guía?

______

8. Que fue lo menos beneficioso para usted de la guía?

______

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Por favor indique su opinión acerca de las siguientes afirmaciones usando la escala del 1 al 5:

(1) Muy en Desacuerdo (2) En Desacuerdo (3) No hay Opinión (4) De Acuerdo

(5) Totalmente de Acuerdo

9. Al leer la guía aprendí que una condición de salud mental es algo que muchas personas desarrollan, y que en realidad cualquiera puede padecer de una en cualquier momento de su vida 1 2 3 4 5

10. Al leer la guía aprendí que la terapia psicológica es una buena opción para tratar una condición de salud mental 1 2 3 4 5

11. Yo recomendaría esta guía a familiares y amigas que están en este país y quienes están separadas de sus hijos, o a quienes estén planeado reunirse con ellos 1 2 3 4 5

12. Cómo se podría mejorar la guía?

______

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