Models, protocols, and pathways, towards a social perspective in the mental health care of migrants in transit through Mexico.

To guarantee the right to mental health for migrants, we analyze the network of services, models, and protocols of attention produced to address the particular needs of this population. Through interviews with governmental and civil society healthcare personnel, part of the network of services and resources available for mental health, we conclude that psychologists operating in civil society organizations and shelters have innovative paths to provide appropriate care adjusted to the context lived by migrants during transit. Unlike the psychiatric dominant model, the psychosocial model of civil organizations provides a social perspective adequate to include in the protocols of the medical official institutions responsible for mental health care in Mexico.

Introduction

Transit migration, generally considered one of many phases of the migratory process (Düvell, 2012), has begun to pose theoretical and methodological challenges due to a growing overall number of migrants, and systematic abuses of their human rights (Collyer and de Hass, 2010). Time spent in transit has begun to increase and began to be characterized by indefinite stays in areas traditionally used only for passing through, increasingly depending on the economic and migratory policy and not on the individual decisions of those who are migrating (Düvell, 2012, Papadopoulou-Kourkoula, 2008).

In the case of international migrants transiting Mexico to reach the United States, a series of migratory policies have been enacted to dissuade South to North mobility:

Weakening the concept of asylum within the legal framework of international protection. This figure was a permanent feature up until the “caravans” of international and Mexican migrants began to gain greater visibility in Tijuana in the year 2018 (Observatorio de Legislación y Política Migratoria de El Colegio de la Frontera Norte 2020).

More control at the southern border of Mexico when the United States threatened tariffs on imported Mexican goods on June 7th, 2019, and the Mexican government was pressured to sign an agreement to deploy the National Guard to its northern and southern borders.

Finally, the Migrant Protection Protocols (MPP), also known as “Remain in Mexico”, in Spanish “Quédate en México”, forced thousands of asylum seekers to stay in Mexican border cities (Wamsley and Burnett, 2020, Pachico and Meyer, 2020).

These migratory policy decisions obstruct transit through Mexico and convert the country into an indefinite waiting room, forcing us to scrutinize the infrastructure of services available to guarantee the right to health for migrants.

As previously documented by civil organizations, during migrant transit through Mexico (Temores-Alcántara et al., 2015), migrants are generally depleted of economic and emotional resources due to the insufficient guarantee of their basic needs, which in the present analysis has led us to consider not only the services and pathways available to access mental health services, but furthermore: a) the network of services and resources for mental health, and b) the models, and protocols of attention produced to address the particular needs of this population. To achieve this, we performed interviews with governmental and civil society healthcare providers forming part of the network of services and resources available for mental health, with a focus on their experiences in providing care to migrants transiting Mexico.

Social and medical science fields in destination countries such as the United States, Spain, and England have demonstrated an interest in the mental health of migrants. For example, in the United States, immigrant health has been considered among the most pressing public health challenges to controlling and preventing illness for over a century (Horwitz and Grob, 2011). Similarly, interest in the relationship between migration and mental health is known to have originated at the end of the 19th century, when psychiatric epidemiology influenced by social science theories wanted to elucidate the link between mental disorders and the influence of environmental and social contexts (Horwitz and Grob, 2011).

Literature reveals trends toward the generation of evidence to support interventions to reduce mental health disparities of minority groups in the United States (Vega and Rumbaut, 1991). Nevertheless, there is a disconnect between the contributions of these works and the mental health care available to migrants. This may be attributed mainly to the predominance of the biomedical care model at the primary level of care and is strongly oriented towards establishing an organic, individual-level causal relationship between the person and the mental health condition. (Martínez-Hernáez, 2000).

In Mexico, the past several years have seen an emerging interest in the availability of services and access to healthcare for the migrant population. Therefore, we consider it critical to revisit and reflect upon the models which are currently applied to comprehend mental health services for the migrant population.

Materials and Methods

To describe the mental health care model and type of response used by the public sector and non-governmental organizations in Mexico, we lay out the following specific objectives: a) identify the network of mental health services available for the migrant population from governmental institutions and the public sector, b) review the mental health care protocols created by international organizations who provide humanitarian assistance, and c) describe the care model used by care providers, particularly by psychologists who form part of the network of shelters along the migrant route in Mexico.

We performed interviews with psychologists and migrant shelter personnel in Tapachula, San Luis Potosí, and Saltillo between December 2020 and February 2021: a brief and particularly complicated period due to the administrative and legal restrictions related to weakened the figure of asylum in the United States during the health emergency for SARS-CoV-2. Also, the coronavirus pandemic significantly affected humanitarian service provision during the year 2020; therefore, observatories, volunteers confined in shelters, and activists, became key actors in monitoring the complexities faced by migrants during the past two years, particularly, during the beginning of the pandemic.

The pandemic emergency measures enacted also modified the conditions in which studies may take place and allowed only virtual in-depth interviews with eight psychologists from shelters and centers providing services to migrants, considered key actors. The study was supported by the project “Design and evaluation of a collaborative protocol for the detection and care for mental health issues in people in the mobility context”, directed by Ietza Bojórquez Chapela, Ph.D. and César Infante Xibillé, Ph.D.1

As secondary actors, we included the directors of three migrant houses: the migrant shelter of Saltillo, San Luis Potosí, and Tapachula. We also included interviews with two members of human rights defense organizations working in Tapachula at the time of the interview: Doctors Without Borders (Medicos Sin Fronteras, MSF) and Médecins du Monde/Medicos del Mundo. Furthermore, we interviewed five service providers within two mental health care programs in public-sector health centers in Tapachula, México.

Interviews aimed to examine the availability of health care for the migrant population, as well as the strategies developed in different locations to meet the demands and needs of migrants. The journey to the United States goes through multiple points of the Mexican Republic. Beginning in the states of Chiapas and Tabasco, through highways or "La Bestia", it continues north until they reach the Bajío. The main migratory routes to the United States cross Mexico's Bajío region. Querétaro, San Luis Potosi, and Irapuato are also thought of as bifurcation cities, where many migrants take or choose the route to follow towards Mexico's northern border. Three main routes have been identified: the Route to the Northeast Border (Cd. Acuña, Saltillo, Piedras Negras, Nuevo Laredo, among others), the Route to Cd. Juarez, and the Pacific Route. In these three main routes, many of the migrant houses are located. To represent different challenges of the route, three geographical locations considered (Tapachula, San Luis Potosí, and Saltillo) represented three distinct points along the migratory route in Mexico, which captured different moments of the migrant journey including in the south at the moment of entry to Mexico, and the center as the decision point regarding which route to follow towards the northern border. We also aimed to explore the personal experiences of different key actors and the available options within their roles when faced with the unique challenges of this population.

Furthermore, we traced two conceptual and care models for mental health as applied to the migrant population. The first, from the United States, contains materials derived from observation and interviews with mental health care workers and psychologists who have worked with undocumented Latina migrants in health centers and public hospitals in New York City.2 The second model was developed based on the experiences of the network of psychologists participating in the humanitarian action network in Mexico.

The inability to perform direct observation in shelters due to the health emergency during 2020, imposed certain limitations and biases. Nevertheless, we decided to move forward with this study to document the difficult conditions brought on by the 2019 and 2020 procedural changes related to asylum law in the United States. The health emergency also had impacts on migratory corridors used and bureaucratic and legal processes in Mexico.

Finally, I declare that I have no significant competing financial, professional or personal interests that might have influenced the performance or presentation of the work described in this manuscript.

Theory and calculations

The theoretical framework to structure this study is critical medical anthropology, due to its basis in social unequal distribution of power as principal determinants for achieving adequate health care and access (Baer, Singer, and Johnsen, 1986, Morgan, 1987, Soheir, 2022). Within this framework, the study of health conditions and their care does not place the methodological focus on the subject, as is the case in biomedicine. Instead, it is in the social, political, economic, and cultural structure in which illnesses and mental health conditions develop (Menéndez, 2005). This approach is reflected in our conceptualization of mental health not only at the individual level but also at the level of place and structure in which social subjects exist. This is even more relevant when a series of political and social determinants heavily affect the dynamic at international borders and the related human experiences, as well as their access to mental health care (Silva and Miranda, 2020).

Another important discussion point is the public health studies and epidemiology regarding the difficulties of undocumented migration and the implications of this status on the mental health of those who suffer the systematic abuse of their fundamental rights (Murphy, 1961, Vega, Kolodoy, and Valle, 1987, Vega and Rumbaut, 1991). The related literature explores phases of the migration process which should be considered to understand the specific difficulties confronting those who migrate (Bhugra, 2004). For example, in transit, the dangers caused by police and criminal violence, risks and accidents along the increasingly dangerous route, and a journey that from its origin takes place in precarious conditions. The transit resuls in a waiting period associated with extensive bureaucratic processes which are increasingly prolonged with hardened migratory policies (Musset, 2015).

Finally, we turn once again to the proposal by Menéndez (Menéndez, 2003) to analyze the models used to shape the public health sector and humanitarian organizations to explain (Kleinman, 1978) and care for health conditions suffered by migrants: the biomedical and psychosocial models. The latter is understood as a series of concurrent actions based on social psychological principles, unlike the individualistic interpretations of the psychiatric or biomedical model, including an analysis of the environment that accompanies migrants and their families during the migration process (Gómez Dupuis et al., 2014).

Results

According to estimates by the National Human Rights Commission (CNDH its acronym in Spanish), the number of Central American migrants in transit through Mexico in 2015 was close to 420 thousand (Comisión Nacional de los Derechos Humanos 2020). This number has been growing steadily since only in terms of requests for refuge and complementary protection in 2021, the country received around 130 thousand requests. According to the Migration Policy Unit of the Ministry of the Interior, in November 2017, from the 88,741 foreign persons presented to the migration authorities,16,694 were children and adolescents, and 6,866 were unaccompanied (Canales and Rojas Wiesner, 2017). Data from the CNDH also highlights that 34% are under 24 years of age, and 43% are between 25 and 34 years of age. Finally, the data indicate that 13% of those who have crossed through Mexico between 2011 and 2012, were subjected to a crime or aggression on their way to the United States, according to the Survey on Aggression and Abuse of Migrants from Colegio de la Frontera Norte (Comisión Nacional de los Derechos Humanos 2022).

As noted in the introduction, the time that international migrants remain in Mexico is defined by multiple direct policy decisions. The establishment of the Migrant Protection Protocols (MPP) known as “Remain in Mexico” (López Reyes, 2020, París Pombo and Díaz Carnero, 2009) has enabled the systematic expulsion of asylum seekers to the Mexican border cities (Cerón, 2020, Griffiths, 2014). In this manner, according to estimates by human rights groups, United States authorities had returned 27,500 asylum seekers to the Tijuana-Mexicali region by January 2020 (Pachico and Meyer, 2020). By August of 2020, over 60,000 people had been returned to Mexico under this program (Observatorio de Legislación y Política Migratoria de El Colegio de la Frontera Norte 2020, Mossaad, 2019, Reichlin-Melnick, 2020).

The difficulties already confronting migrants, including forced abandonment of their homes due to violence, familial separation, and multiple forms of abuse and violence while crossing Mexico (Velasco, 2009), the delay of court audiences has also given rise to other complicating conditions, such as the transition from regular to irregular status as a result of the long wait for claims processing (Observatorio de Legislación y Política Migratoria de El Colegio de la Frontera Norte 2020). A change in migratory status represents greater vulnerability through more limited mobility, and lesser access to employment, housing, health care, and security (Silva and Miranda, 2020).

On the other hand, we must consider 2020 emergency due to SARS-CoV-2 further reduced the capacity of governmental institutions to address the needs of the migrant population. In terms of healthcare services, for example, health centers were forced to turn their focus towards the detection and management of respiratory diseases, neglecting, until 2021, care for other conditions including mental health. Civil society organizations and/or shelters received economic support only in the form of rapid tests for SARS-CoV-2 and critical inputs for the prevention and control of the virus. Furthermore, during March and December of 2020, many shelters decided to temporarily close their doors and keep those confined who were already inside or who were waiting for the resolution of a legal process.

The isolation within the shelters, according to testimonies by the psychologists interviewed, commonly generated anxiety in migrant individuals not only for the confinement but for the delay in migratory or asylum processes and the continuation of their journey. Many were forced to alter their intended migratory plan due to the interruption in the acceptance and processing of claims, or because they were confined to shelters for longer than planned during March and April of 2020. In the words of one psychologist interviewed in the San Luis Potosí migrant shelter, the daily violence experienced by this population continued throughout the pandemic, as he noted: “The cases of violence and kidnapping continue, the people arrive emotionally affected, and now on top of that is the part about, ‘I don't know what to do with my life, and I don't know what will happen in the world because of COVID-19’” (Interview with psychologist working in San Luis Potosí with five years of experience working with migrants in different shelters, interview January 2021).

Public mental health services for the migrant population

Access to health care, particularly for mental health, has long been a challenge for the migrant population. It is for that reason that, in 2011, health care access for foreigners was legally established in Mexico through the Law on Refugees, Complementary Protection, and Political Asylum. The same year, the Migration Law confirmed that: “migrants shall have the right to receive free and unrestricted medical attention of any type necessary to save his or her life […] and no administrative act shall enact restrictions upon foreigners…” (Chávez Galindo and Lemus Ramírez, 2016, Secretaría de Relaciones Exteriores 2020).

Nonetheless, access to public health services continues to be very problematic. On one hand, personal barriers may form an impediment, such as the lack of information regarding service access and transit times from one place to another, the latter of which are often very short given the desire to arrive as quickly as possible in the United States. However, the characteristics of the Mexican health system are also a critical factor, for the following reasons:

Firstly, migrants in transit who successfully access care must register in the Centers for Integral Care of Border Transit. Then, they receive a letter of declaration of rights and obligations and an affiliation card providing access to Seguro Popular for a maximum of 90 days (non-renewable). For those in active transit, this is no easy task. Furthermore, as Rosales et al. (Rosales Martínez et al., 2017) confirm, foreign-born migrants were required to fill out another form to register for the program previously known as Seguro Popular; this form requires a temporary or permanent resident visa as a form of identification to register for three years (renewable), like the general Mexican population. This option is limited only to regular migrants and leaves behind those with a visitor or regional work cards, which are mainly used by Central American workers in the south of Mexico. Furthermore, this option is only for a limited time and no known provisions exist that offer full and equal coverage to immigrants without formal employment. It is important to note that this does not account for the changes made since the enactment of Bienestar3 and the dissolving of the Seguro Popular medical units and affiliation sites.

The Mexican health system is segmented by different care levels which are relevant to understanding migrant access pathways. For example, the primary care level continues to be the most accessible through the health centers located in the locality of any given shelter. These centers are obligated to guarantee care to the migrant population, as they are mandated to carry out the epidemiological monitoring for the corresponding health jurisdiction. At the secondary care level, admittance to a general hospital requires a referral from a health center or shelter. Finally, psychiatric hospitals are situated within the tertiary level and may be an option for severe cases, including attempted suicide or harm to others. These specialty hospitals are of limited access because there is only one per state, and few specialists at hand to attend them.

To gain access to any of these healthcare options, it is also important to mention that in practice, it is necessary to have a referral from or physical accompaniment by shelter personnel, given the administrative processes previously mentioned. This is particularly salient given a series of problems reported in interviews with shelter psychologists as well as with public healthcare workers, who are familiar with the obstacles to receiving care:

Scarcity of material and human resources: according to the regional health center of the state of Coahuila, medications are frequently lacking, and appointments can be delayed (sometimes scheduled for a month away) given the great demand and the lack of healthcare workers. The same was reported in health centers in Tapachula and San Luis Potosí.

The lack of specialized migrant care in health centers: in interviews, representatives of the mental health programs in Tapachula mentioned that no special care is given to migrants, as mentioned in the following January 2021 interview with the responsible mental health and addiction program:

“For us, the development of a special migrant program isn't anything special. We work not only with migrant mental health, but in general well-being for other conditions like addictions, violence, prevention, suicide, violence to elders and children, and palliative care. For mental health care, we do preventative activities like suicide prevention campaigns every month, as well as care […] (sometimes) Then UNHCR (ACNUR, for its Spanish acronym)4 show up at noon (to the health center) to get care (for the migrants that come with them) and that's not right, they have to arrive at 5:00 AM with their appointment and we'd be glad to attend them just the same as we do for someone from this town. We want migrants to adapt a little to us because we're adapting to them, that they multiply our number of appointments, we also want them to adapt”.

Beneath the apathy noted within the previous testimony, limitations are also revealed in terms of available budget and personnel. The healthcare needs of migrants may exceed the capacity of the limited healthcare workers in the centers, as discussed in the following testimony:

“We always say, ‘thank goodness they haven't come’ (more migrants seeking care) because they multiply our workload. Of course, we're happy to attend them, but we don't have any special emergency team for this program (in mental health), even though there's a program it doesn't work that way. So, we end up neglecting our regular activities, neglecting our Mexican population, to go to them using gasoline we have to pay ourselves (when receiving caravans). So, for us, it's better if they don't pass through here (Tapachula), even though we know that institutions like you all are in favor of the mobility of migrants, and we are too, it's just that without resources it's complicated” (Interview with Gender equality and health program, Secretaria de Salud Tapachula, January 2021).

Other service providers and health jurisdiction chiefs stated that detection and care for mental health issues is part of a service packet that also includes detecting violence and addiction. This means that there is not a specialized care program for migrants or other actions following up on the specific situations linked to the conditions in which this population migrates. This results in the health centers taking on the responsibility of referring migrant patients to the secondary and tertiary levels of care.

Institutional psychiatry perspective: psychologists considered that doctors, particularly psychiatrists, did not account for the experiences of migrants in transit, as shown by the following testimony:

“This girl's history was a series of crises derived from negative migration experiences. The psychiatrists diagnosed her with epilepsy and medicalized her with antipsychotic drugs because they thought she had schizophrenia too. Fortunately, her case arrived at the desk of a younger doctor. That greatly influenced the way she was asked about her personal life: why she left her home, how the journey had been, and what she had done during her time in Mexico. The young doctor asks more about her life and less about her signs and symptoms. The treatment then was much more appropriate, and the trust he generated in her was important. The young doctor recommends writing her feelings in a diary while the other psychiatrists just said: “take this, you're going to feel dizzy, and if you feel other physical symptoms report to us”, they had never heard about the experiences of this girl. The perspective of psychiatrists separates the physical and emotional from the context” (Interview with social psychologist, Casa San Luis, January 2021).

Faced with this set of needs, governmental institutions have been questioned by civil society organizations for reportedly “not complying with the obligations put forth by the United Nations” in terms of migration and asylum, especially in health care (Comisión Nacional de los Derechos Humanos 2022, Chapman, 2019). As a result, shelter and civil society networks have had to assume the leading role in not only general aid, food assistance, housing, clothing, medications, information, and program registry, but also in physical and mental health care.

Specialized support for mental health by shelters

As previously discussed, shelters have also been converted to key spaces for the referral of migrants to health centers and other care levels, as well as even judicial institutions. In the case of victim assistance, migrant shelters offer direct support and accompaniment to the department for assistance to crime victims in the corresponding entity. Each of these departments offers psychotherapy to victims of crime, and human rights violations when the need for psychological support has been identified. Among the activities performed are the accompaniment to appointments and referral to appropriate entities, as well as the creation of networks with other dedicated actors, as described in the following:

Accompaniment. Through therapy provided to migrants, accompaniment, as well as referral to other specialized institutions, is offered, such as in the case of legal proceedings, as explained by one interviewee:

“I don't give therapy, what I do is provide companionship and guidance. If the person needs it, I'll give them exercises, I'll follow up with them, and just if they need more intensive therapy I'll try to refer them (to another healthcare service). Referral may be to several different places and it depends on the root (problem). For example, people who have suffered human rights violations can be seen in the victim care unit of the public prosecutors (in Spanish, fiscalía), who are in charge of providing psychological care. When there are people who haven't been the victim of a crime or rights violation, we have a team member here who accompanies their case” (Interview in January 2021 with a psychologist that arrived at the migrant's house in Saltillo at the end of 2010 due to the kidnapping of migrants in transit).

Referral processes also include appointment management, as confirmed by the psychologist of casa Saltillo, who notes that having an appointment alone doesn't ensure that the process will be straightforward. Insistence and persistence are key to successfully carrying out certain tasks:

“It's one thing to refer a patient and another to make institutions fulfill their responsibility. You have to keep pestering them [the medication] and take the patient back to the doctor to continue psychological care. You have to follow the institutions closely. That's what allows those who stay in the shelter to continue getting care. In my case, I must always stay on top of things […] In the case of violence, problems persist in getting proper case follow-up with institutions, and shelter personnel must be persistent to successfully obtain care for migrants. Referral and accompaniment processes require a constant presence within the corresponding institutions and complicated paperwork processes which migrants tend to abandon due to a lack of understanding”.

Network building with certain key actors. Nearly all psychologists agreed that the referral to institutions has not led to positive experiences. For that reason, they have created a directory of people and organizations to refer migrants, built through networks made through previous interactions with colleagues.

We consider accompaniment by psychologists as an important element for patients to overcome barriers to health care. The accompaniment does not only mean great support to foreigners to navigate unknown health or justice system. It emerges as a strategy in the face of the indifference of governmental agencies to resolve the needs of immigrants. As observatories and international organizations have reported, and as Ariadna Estévez López (Estévez López, 2015) argues, in the face of the humanitarian rights crisis in Mexico, the State has implemented public policies aimed at managing the suffering or exhausting the sufferers, before preventing or addressing the motives for injustice. Thus, the accompaniment of psychologists emerges as a mechanism of resistance.

Care models built through experience

International organizations have developed protocols to support the migrant population during emergencies. These are supported by empirical evidence and field experiences by humanitarian organizations such as the International Organization for Migration, the IASC5, UNHCR, UNICEF,6 and Doctors Without Borders [ ( (Organización Internacional para las Migraciones 2018), Comité Permanente entre Organismos (Comité Permanente entre Organismos (IASC) Inter-Agency Standing Committee 2009) Inter-Agency Standing Committee 2009, Comité Permanente entre Organismos (Comité Permanente entre Organismos (IASC) Inter-Agency Standing Committee 2016) Inter-Agency Standing Committee 2016, (Gregorio Gil and Franzé Mundanó, 1999, Médicos sin fronteras 2021))]. These guides illustrate some of the psychological reactions documented during the migratory process, without a focus on seeking pathological explanations for negative experiences. They also seek to familiarize healthcare providers with the psychological, social, cultural, and economic repercussions of the migratory process on individuals and families.

For example, Doctors Without Borders is an organization that directs its psychological care services toward those who have suffered from violence and significant losses due to conflict, war, catastrophe, epidemic, or sexual violence. In Mexico, the civil society association Institute for Women in Migration (Navarrete, 2012) has created a care manual to address situations of violence experienced by women both before and during their journey through Mexico. The guide also seeks to provide tools to victims of violence which strengthen their response capacity and help to recover a sense of security and control over the situations they confront.

In addition to these efforts, permanent and volunteer psychologists have compiled their experiences to generate a work methodology and care model based on the psychosocial model adressing the particularities of distinct points along the migrant corridor. One example is when migrants enter the center of Mexico, such as in San Luis Potosí, at which point they have almost surely suffered some form of violence upon crossing the southern border or transiting Veracruz. In Saltillo, migrants often show signs of exhaustion and/or anxiety over changes to their planned trajectory.

Each point represents a different challenge and impact on mental health, of which each requires unique considerations for care. For this reason, psychologists have developed their guides derived from their experiences and including a regional focus: that is, lived experiences of migrants from the Northern Triangle7 to the border with the United States (Gómez Dupuis et al., 2014).

The manuals created by international organizations and those produced through the experiences of participants in mental health care services within shelters are rooted in the psychosocial approach; that is, they are based on the understanding that psychological and social factors are not mutually exclusive. This has been proposed by Ignacio Martín Baró (Martín-Baró, 2006), for whom mental health constitutes a dimension of intrapersonal relations between individuals and groups more than it does an individual state. In this way, context is recognized as a central determinant of any mental health disorder suffered by an individual.

Certain situations require specific needs for accompaniment, such as families of disappeared people, women in communities of migrant origin, users of migrant shelters, returned people, children (especially girls), and those who have suffered human rights violations or accidents along the migratory route. In addition, human rights of migrants is a major principle, acknowledging the vulnerable conditions and multiple systematic rights violations lived during migratory transit. In this sense, one care provision strategy is to provide not only accompaniment and psychological support but also education to migrants about their rights, whether within or outside their country of birth.

According to the experiences of psychologists, advising and active listening are key methods for trust-building with victims. Advising consists in identifying needs and direct individuals to the corresponding institution in the case of human rights violations, sexual violence, or kidnapping. In this way, during therapy sessions the psychologist tries to help the patient set a life trajectory with clear goals and objectives, and above all, to ensure that they are aware of the available paths for assistance when needed.

Finally, practical experiences are the basis of these methods of care and follow-up to address mental health needs in the migrant population. One interviewee explained that their professional training was in clinical psychology, but that years of working in shelters had changed their perspective to a more psychosocial approach, as described in the following testimony:

“My viewpoint has changed to something much more psychosocial; you can't separate psychological impacts from the social and political context. In cases linked to human rights violations, I use clinical tools for particular people. For people that arrive in mourning due to multiple losses, the very mourning implicit in migration has to do with who gets to leave, and what it means to be here or there. After traumatic experiences, you also have to use clinical tools, which are a great help. We work to ensure that they understand their context. When migrants start to understand their surroundings and their rights, that allows them to defend their rights, a similar effect to clinical treatment. If we measure things in clinical terms, a person arrives with anxiety and depression; in cases of disappearances, if we look at it clinically the families have anxiety and depression. One thing we see is that health and justice systems with departments for victim care work using clinical programs. And that's what we've been advocating for, when a person is migrating and the department doesn't know that, it's not a mental illness. Of course, there are impacts, but what will effectively reduce anxiety or depression will be getting some news about their family member. There are things related to the context and not the person. When we work with families - how to file a claim and where to do it, who has to do what - it's so important to work with the average education level and language. The justice system works in another language, even more so if you come from another country. To begin with, they come from a situation where they've had little access to formal education, so from the start, there are terms they don't understand beyond the regionalisms they have in their country. It's like a triple impact when they're faced with having to seek justice. So, our work is from a perspective of educating about rights, and everything implicit in the search for missing people”. (Interview with Volunteer psychologist at casa Saltillo, a psychologist by training, with training in theology, she performs spiritual accompaniment with vulnerable communities as well as psychotherapy with a social perspective, January 2021).

We can infer from this testimony that the role of the civil organizations, as well as those in public sector positions, is of vital importance to the protection and reinstation of rights for this population.

Discussion

The care model used in public sector mental health services is based on the principles of psychiatry and biomedicine (Martínez Pincay and Guarnaccia, 2007). For example, when making a diagnosis, The Diagnostic Manual and Statistics on Mental Disorders (DSM V) created by the American Psychiatric Association in 1952 is often used as a baseline, offering a standard for the classification of mental disorders (The Diagnostic & Statistical Manual of Mental Disorders (The Diagnostic and Statistical Manual of Mental Disorders (DSM 5) 1994). This procedure implies differences both in nosology and therapeutic options, as compared to the psychosocial approach. For this reason, we consider it highly relevant to present a comparison between the multiple public mental health care models accessible to migrants in irregular conditions, both in Mexico and in the United States. This helps to better understand the particularities of the psychosocial model which has emerged from civil society organizations in Mexico and Central America.

First, and critically, only 25% of countries worldwide have integrated mental health services into the primary care level. Therefore, healthcare workers, supply of medications, and mental health from the psychosocial approach for migrants and non-migrants continue to be limited in Mexico and beyond (Naciones Unidas México 2021). This is also the case for much of the population of the United States, who depend highly on private medical insurance contingent on employment, and whose coverage of quality mental health care is limited.

Within this stratified system of services for mental health, minority groups and undocumented individuals confront even greater barriers to accessing care. As documented by a previous study (Santillanes, 2017), the emergency room, and to some extent, community health centers, are the only spaces where irregular migrants can access free care.

For the most part, the emergency room of public hospitals is the most common option for use. This space includes triage, referral to a specialist (depending on health insurance), and the prescription of necessary medications. Furthermore, patients suspected to be victims of domestic, family, or sexual violence are generally reported and referred to social workers who work within a network of agencies offering specialized care and protection.

From these characteristics, we can infer that mental health care within the primary care level, in addition to being characterized by the psychiatric model, operates under a welfare approach. This is in comparison to the psychosocial model, for which we will now outline several key concepts including the handling and treatment of mental disorders for people in the migration process.

As compared to the biological, somatic, and individual approach of the psychiatric model, the psychosocial perspective considers other levels such as the family and community, to understand the extent of the condition and the subjects involved. At the same time, it includes an analysis of the environment, which in the case of migrants and their families is frequently accompanied by multiple manifestations of violence throughout different phases of the migration process. Therefore, the main techniques used for patient treatment are active listening and interview, placing significant importance on words, testimony, and verbal expression. Care practices are also accompanied by the promotion of and education about human rights, as well as an accompaniment with solidarity throughout processes like mourning, loss, and sadness which are part of the transit. Finally, therapy consists of interviews that seek to establish a sense of meaning within lived experiences and identify how psychosocial impacts or frustrations rooted in these events are manifested, all to build coping mechanisms and give meaning to experiences.

Conclusions

Epidemiological and public health studies have provided evidence of the challenges around mental health care for migrants; however, it is critical to further examine the structure of care models. For this reason, in this initial comparative exploration, we aim to highlight the development of a care model by the civil society organizations working to fill the migrant care gap left by public institutions.

Psychologists operating in civil society organizations and shelters - in addition to performing accompaniment, case management, and support for bureaucratic tasks with justice or human rights institutions - have also made efforts to forge innovative paths for providing appropriate care adjusted to the context lived by migrants in transit. At the same time, they have developed their instruments and protocols specific to the problem areas identified within the experiences reported by this population. For example, they include the relevance of accompaniment during the processes of seeking justice and a focus on human rights. The latter consists in informing and educating the individual that their irregular status does not deprive them of their rights in Mexico.

We consider the work of these actors as crucial, as it provides a social perspective towards improving the understanding of mental health as a series of social determinants and factors linked to mental health conditions of migrants (Virchov cited (Waitzkin, 1979)). Furthermore, if the orientation of mental health and migration research continues to apply only instruments from the psychiatric epidemiology field, particularly in the case of the United States which has produced most of the related research, the influence of the psychiatric culture will continue to dominate the creation of instruments and the conceptualization of mental health problems, as confirmed by Allan Young (Young, 2016)). This mentality risks limiting our understanding of as broad a field like mental health, neglecting the inclusion of social and historical contexts of individuals (Ruiz, 2022); these factors are key to understanding lived conditions before migration, as well as the particularities of transit under the new conditions imposed by the hardening of borders and the precarity of the majority.

In conclusion, we recommend the integration of aspects of the psychosocial model into the protocols of the official institutions responsible for mental health care.

Finally, I would like to thank the Postdoctoral Scholarships Program of the Universidad Nacional Autónoma de México (UNAM) for the support provided as a scholarship recipient of the Institute of Social Research. I would also like to acknowledge the project “Design and evaluation of a collaborative protocol for the detection and care for mental health issues in people in the mobility context”, directed by Ietza Bojórquez Chapela and César Infante Xibillé, for the facilities and support.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.