The Mental Health of ICE Detainees and Their Families

As the fall season drops its foliage of deep oranges and golden yellows to the ground, it also signals the upcoming flurry of holiday gatherings with loved ones. I pause for a moment to recall the events of the past spring when news of child separations at the U.S.-Mexico border caused an uproar, and I remind myself that although the uproar has quieted down, the repercussions of those actions are still being felt by many in this country. As psychiatry trainees, we are familiar with the process of how acute distress can give way to long-standing detriment to mental health. For people, both U.S. citizens and undocumented immigrants, who remain within our country but separated from their families, this holiday season is sure to be a challenge. The issue of immigration has been hotly contested for decades, and deportation is not new. In fact, under the Obama administration, more than 2.7 million people were deported (1). So if deportation is not new, then why is there such controversy at this time?

Not until recently, under the current president's administration, have we seen a series of policies laced with anti-immigrant rhetoric such as the "zero tolerance" policy, which actively used separation of families as a tactic to deter people from coming to this country. These policies were considered so dangerous to the physical and mental health of those affected that several professional associations, including those within medicine such as the American Psychiatric Association, American Academy of Child and Adolescent Psychiatry, and American Academy of Pediatrics, released position statements calling for an end to family separations. On June 20, 2018, after facing much international criticism and pressure, President Trump reversed this controversial policy. Despite having a deadline for reunification of families mandated by the courts, there are currently several hundred children yet to be reunited with their parents as a result of adults being held in detention facilities indefinitely or who have already been deported (2). There are currently more than 13,000 migrant children in detention centers across the country, and they are now being moved into tent cities in Tornillo, Texas, which is potentially worsening the mental health of these children (3). Child and adolescent psychiatrists have commented on the trauma that is caused by separating children from their parents, which not only profoundly inhibits the ability to form trusting attachment relationships early in life but can lead to adverse health outcomes and poor life chances throughout the life course (4).

The concept of "structural violence" was recently discussed by Grace et al. (5), who posit that recent U.S. immigration policies have not only sought to deter immigration by targeting the safety of the family unit but have created a "violence of uncertainty" that makes life in the United States an unlivable experience through insecurity, which for many is the fear of not knowing whether they will be detained by U.S. Immigration and Customs Enforcement (ICE) from one day to the next or whether deportation will lead to the loss of their children. This uncertainty creates mistrust in places such as doctors' offices and hospitals, which deters people from seeking medical care when it is needed, thus creating multiple health crises in these communities (5).

During my child psychiatry rotation, I met a teenage girl who became distraught after learning that her father might be deported. She subsequently made a suicide attempt by taking her mother's prescription medications. She is a U.S. citizen, but her father is not. For psychiatry trainees, teenage suicide is an important topic as well as an unfortunate but common occurrence. The insecurity felt in many communities is creating new health issues while exacerbating existing ones. Up to a quarter of the adults deported from the United States in the past few years have been parents of children who are U.S. citizens (6).

The health consequences of being detained are poorly understood. To date, no formal research has been conducted on this highly vulnerable population—for obvious ethical considerations. However, enough news reports have surfaced that we can theorize a pattern of mental health implications. According to Human Rights Watch, there have been 74 deaths in U.S. immigration detention centers from March 2010 to May 2018 (7). Immigration advocates have criticized the use of solitary confinement for detainees, which often results in severe mental health consequences; for example, a 40-year-old man with a history of schizophrenia reportedly committed suicide shortly after being held for 21 days in solitary confinement (8). All detainees are supposed to undergo a comprehensive medical evaluation, including mental health screening. However, the details of what exactly is provided are unclear. A disturbing report emerged in July 2018 when a federal judge in California ordered the Trump administration to halt the use of psychotropic medication in migrant children unless parental consent or a court order has been obtained (9). Apparently, a facility in Texas was giving psychotropic medications to children without parental consent. A lawsuit against the facility is currently pending, although the facility denies any wrongdoing. These issues affecting the mental health of detainees are extensive and complicated, and the health effects are widespread and have an impact beyond immigration status.

For psychiatry residents across the country, it is now more likely than ever that each of us may encounter someone who has been affected by these policies or that a medical colleague may refer someone in crisis to our care for mental health evaluation or treatment. We must remember our Hippocratic Oath, calling us to the service of all of humanity, not just for a few that have been designated worthy. It is by working together to end inhumane policies that create negative health consequences that we can help to heal our country.