0:00

You're listening to Road to Resilience. I'm Jon

0:02

Earle. Last May, just as

0:04

news was breaking that the government was separating

0:07

migrant children from their parents, researchers

0:09

from the Icahn School of Medicine

0:12

at Mount Sinai arrived at an immigration detention

0:14

center near the border. Over the next

0:16

two months, they interviewed more than

0:18

400 migrant mothers about

0:20

their children’s mental health. Did their

0:22

kids seem happy? Were they having behavioral

0:24

problems? And so forth. The

0:26

researchers’ findings were published last month

0:29

in the journal Social Science and Medicine.

0:31

It's the first large, empirical

0:33

study to look at the mental health of children in U.S.

0:36

immigration detention, and it raises important

0:39

questions, including about the mental toll of

0:41

the child separation policy.

0:43

Today on the podcast, I'm joined by two

0:45

co-authors of the study, Dr. Craig

0:47

Katz and Priscilla Agyeman.

0:50

Dr. Katz is a psychiatrist at

0:52

Mount Sinai, and a Co-director of the

0:55

Mount Sinai Human Rights Program. Priscilla is a clinical research

0:57

coordinator and a recent graduate of the

0:59

Icahn School of Medicine, where she studied public

1:01

health. Now, this is a podcast

1:03

about resilience. So why are we doing an episode

1:05

about this study? Two reasons:

1:08

first, no matter where you stand on immigration,

1:11

I think we can agree that the current crisis contains

1:13

within it a massive resilience challenge.

1:15

We're talking about millions

1:18

of people fleeing their homes. Thousands of

1:20

children moving through federal custody, often alone.

1:22

The sheer scale of it is hard

1:24

to wrap your mind around. Which leads me

1:26

to reason No. 2: If you're looking

1:28

for resilience stories, examples of

1:31

survival and sheer toughness, look no further.

1:33

Migrants are some of

1:35

the most resilient people you will ever meet.

1:37

In the conversation that follows,

1:40

Priscilla and Dr. Katz talk about

1:42

what it was like to visit this particular detention center,

1:45

what they found, and what it

1:47

means for all of us. Thank you both

1:49

for being here.

1:50

Thank you.

1:51

Thank you for having us.

1:52

Okay. So, Dr. Katz, can you start off by talking a little

1:55

bit about the human rights program

1:57

and what it does here at Mount Sinai?

1:58

Yeah Mount Sinai has had a long-standing involvement

2:00

doing human rights work and the

2:02

clinic goes back in different incarnations a

2:05

number of years now and our main

2:07

focus is on providing asylum evaluations

2:10

for asylum seekers, and

2:13

that mission is

2:15

really driven by the understanding the

2:18

evidence that if

2:20

you have a medical professional who has written

2:22

in an affidavit, that's

2:24

that in support of the trauma

2:27

that you describe having on

2:29

undergone in your home country that having an

2:31

affidavit like that greatly increases your chances

2:34

of being granted asylum quite a bit

2:36

actually like 90 percent Grant rates composed

2:40

as opposed to maybe like 30

2:42

percent. So it makes a huge difference.

2:45

So is this the first type of study that

2:47

the human rights program has worked on?

2:50

This is I believe our first

2:52

detention-based study. Yeah, we've

2:54

definitely done some other studies over

2:57

the years and have a lot of other ones cooking

2:59

right now. But this is definitely the first in detention.

3:03

So where does the story begin? How

3:05

did the study come about?

3:07

So a resident

3:09

and I—as part of our global health track, one of the

3:11

residents opted to go to a family detention

3:13

center with me and do some

3:15

work and this was in January 2018.

3:18

So

3:20

we went to the family detention center in Texas

3:22

and did quite a few

3:25

on-site evaluations, the kinds we would do

3:27

here. We just did a bunch, just banging them out one after

3:30

the other. And one thing that struck us,

3:33

of course, was that this was a family

3:35

detention center. So this was mothers and kids. And it just

3:37

struck us that that

3:39

was something that we wanted to draw some

3:41

attention to--the fact that, of course, the sheer fact

3:44

that there are kids being detained, right, and what you know

3:46

many would call being basically imprisoned, but also

3:48

to explore what's going on with

3:51

them mentally, because most of

3:53

the evaluations we did were in their mothers.

3:55

And so we also knew the literature, the

3:58

scientific literature, there wasn't anything on this, and

4:00

so we thought this would be an

4:02

enormous contribution to medical literature and especially for advocacy purposes

4:04

depending upon what we found.

4:12

Priscilla, what was the facility

4:14

like?

4:15

So the facility is, for lack

4:18

of a better word set up like kind of

4:20

like a concentration camp. Like there are a

4:22

lot of, it’s—there's a visitation

4:25

trailer that we were you

4:28

know able to go through every day and that

4:30

was the only location that we were able to visit.

4:33

We were prohibited from going anywhere

4:35

else on the "campus" I guess you

4:38

can say. But the way that it was set

4:40

up was the women would come in to the

4:42

visitation trailer to see their lawyers or, you

4:44

know, the other volunteers that were

4:47

working on their asylum cases, and so that's

4:50

where we were on a daily basis, um—

4:53

So, so you're in this visitors trailer, right,

4:55

you're working with the lawyers, you

4:58

approach one of these women and you say, "Hi, I'm so-and-so

5:00

and we're doing this study, would you like to participate?" And

5:03

what were--I understand you had one of several questionnaires

5:05

that you would use—

5:06

Right, so we use two different

5:08

surveys. The first one was the Strengths and

5:10

Difficulties Questionnaire, which is a widely

5:12

used tool to assess behavioral—

5:16

General mental health symptoms

5:18

and behaviors and conduct in

5:20

kids.

5:21

Right, so we used that. And both of

5:23

the surveys were in Spanish. And then

5:26

the other survey that we used was the PTSD, Post-traumatic

5:29

Stress Disorder Reaction Index

5:31

for children, the UCLA version. So this

5:33

was a specific survey that

5:36

measured, you know, the levels of

5:38

PTSD presentation, I guess

5:40

you could say, that they

5:43

had by

5:45

way of if they had reoccurring nightmares

5:47

or dissociation, certain psychiatric, I guess, symptoms that

5:49

you would

5:52

look for in

5:54

children to

5:57

assess PTSD. The woman were overwhelmingly open to

5:59

talking about their children and

6:02

their mental health. I think

6:04

it was, you know, probably a

6:07

moment of reflection for them because

6:09

if you're going through that much trauma and

6:11

distress, it can be really easy to forget that

6:14

or not notice that

6:16

your child is

6:18

quieter than usual or they're having

6:21

nightmares, or maybe they're peeing in the bed a

6:23

lot and they're not at the age where

6:25

they should be doing that. So I think that

6:27

them talking to us, or what they expressed, was that them

6:30

talking to this to us was actually in

6:32

some way therapeutic for um. So that was

6:34

basically how we approached

6:37

the study. And we did a

6:40

total of 425 of these in eight

6:42

weeks.

6:42

Wow. What was that like?

6:49

Hard. Difficult.

6:54

Challenging. Stressful. It

6:57

felt like such

6:59

an enormous responsibility as—I'm a

7:01

child of immigrants myself. My

7:04

parents didn't go through what

7:06

these women and children were going

7:08

through, but I felt very responsible to try my

7:10

best to

7:13

show up. Even if I didn't feel

7:15

like it, even if I was tired or burnt out or dealing

7:17

with compassion fatigue, which I

7:20

think both Sarah and I definitely

7:22

felt. However, it felt like we were

7:25

doing something important

7:28

and we're doing something necessary.

7:34

Hmm. I'm wondering if you, any of the people that

7:36

you met kind of stand

7:38

out in your mind, and you could share a little

7:41

bit about one person or

7:43

one family that you encountered.

7:44

Right. There's actually several

7:47

women that really stick out, and

7:49

I will always remember their

7:51

stories. The first woman that

7:55

I spoke with

7:57

was younger than me,

8:00

actually, and she had a son.

8:02

She was from Honduras, and she fled

8:04

because of gang retaliation.

8:07

Her brother did not want

8:09

to join a gang—and this is a very common narrative—a lot

8:11

of the women were fleeing because

8:14

of gang violence or retaliation for not joining

8:16

a gang. So her brother

8:20

refused to join the gang. Her

8:22

brother actually ran away,

8:25

left the country, because the

8:27

gang was trying to recruit him

8:29

so much that they

8:31

were threatening him, threatening members

8:34

of his family. So he left the country,

8:36

and she stayed. She had a husband and

8:38

her child, and she

8:41

stayed. But the gang members

8:43

knew that that was her brother.

8:45

And because they knew that they ended up

8:47

actually gang raping

8:50

her. And

8:59

that was a very, very difficult--that was

9:02

one of my first conversations with one

9:05

of the woman, and she completely broke

9:07

down because, you know,

9:09

she felt like it was her fault and,

9:11

you know, she didn't do

9:13

anything to stop it. And you

9:15

know, we had to let her know that that is

9:17

not her fault. That was she didn't do anything

9:20

to ask for that type of behavior or

9:23

treatment. So she left the

9:25

country with her son in

9:28

order to seek asylum. So stories like that

9:30

hearing stories like

9:32

that on a daily basis definitely--it drills into your

9:34

mind how much

9:37

these women are, they're not they're not criminals.

9:39

They're not running out of fear

9:42

of the police trying

9:44

to arrest them or something like that.

9:47

They're running for their lives, literally.

9:52

I mean it takes remarkable courage

9:57

to pick up your life and, and take

9:59

an often uncertain migration

10:02

path, right, it wasn't like they were you know going

10:04

onto Travelocity and booking a flight to the

10:06

United States, right? They were hauling

10:09

through often unsafe or

10:11

unpredictable circumstances to get here--

10:13

With their children.

10:13

With their children, right. And so I mean, these

10:16

are people you have to

10:18

have a lot of respect for that now, that they

10:20

made a really hard decision often, leaving family behind, sometimes

10:22

leaving kids behind.

10:25

Decisions about as to who to

10:27

take or who not to take. You

10:29

know, I think it's you know, I admire

10:33

the people that I met in a

10:35

very deep, in

10:37

a deep way, actually, almost a

10:39

spiritual way what they've been through. It's

10:41

quite striking.

10:49

Let's talk a little bit about the results. What

10:52

were some of your findings?

10:55

We found high rates of

10:57

behavioral and emotional problems in the

10:59

kids. That's how the Strengths and Difficulties

11:01

Questionnaire kind of breaks out into broad

11:03

clusters. And we also found

11:06

high rates of posttraumatic stress disorder

11:09

as well. Now, these are all according

11:11

to surveys, right, so they're not

11:13

definitive diagnosis, but these are very, very

11:15

suggestive numbers. And our unanticipated finding

11:18

is that when

11:21

we were there was in

11:23

the heart of the period of child separation, and Priscilla and

11:25

Sarah and Josh were able

11:28

to interview some mothers who had

11:31

been separated from their kids and

11:33

now were reunited with them to ask them, interview them, the

11:35

same exact questionnaires, but now we have

11:37

detained, previously separated, now reunited kids. And perhaps

11:39

the most striking of our

11:41

findings, again, not a

11:44

surprise that kind of

11:46

know it told us in science what

11:48

you know in your heart, right, was that the separated, detained

11:51

kids actually had higher rates

11:53

of emotional problems and PTSD compared

11:55

to the detained kids who, themselves,

11:58

on the whole had higher

12:00

rates compared to the general population in

12:02

the US.

12:06

How much higher?

12:07

Actually, I confess l don't remember the exact

12:09

numbers so I'd have to look up the

12:11

numbers for you, if you like, I can do that,

12:13

but—

12:14

Actually, I have them.

12:16

Yeah, OK. I

12:18

can never—the numbers never stick in my mind.

12:21

You'll have to correct me if I'm interpreting them

12:24

wrong. So I found compared

12:26

to--this is the findings

12:28

compared to the general U.S. population. I

12:31

have five percent for

12:34

the general population for emotional behavioral difficulties

12:36

and 10 percent, so double.

12:38

And then—this was really startling for me—PTSD

12:41

for teens—

12:41

Right, was four times as much.

12:41

Four times as much. When you got

12:43

those results, what was your reaction?

12:47

In some sense, my reaction was like, why

12:49

did we need to do this study? Right?

12:52

Didn't we all kind of know this already. Right,

12:54

but now here the hard numbers, right? So,

12:57

you know, someone's got

13:01

to act on this.

13:03

What's been the response either from colleagues, media, government?

13:05

Well, it's complicated. Colleagues are quite interested,

13:07

but colleagues-- we're preaching to the

13:09

choir, right? So, you know,

13:11

the psychiatric community has been quite up-in-arms about

13:13

this and being, you know, putting all sorts of policy

13:16

statements about how, how damaging child separation is in

13:19

particular. We feel fortunate

13:21

to have the data

13:23

to back it up. The complicated reaction is

13:25

actually been from our

13:27

legal colleagues who were concerned, actually, about releasing

13:30

this data. They thought the data would

13:33

be misused, that, in

13:35

other words, that people would say other countries

13:37

are sending us their crazies.

13:38

That’s startling.

13:49

It is startling and it speaks to the nature

13:52

of the political climate right now, I guess,

13:54

that we would have to kind of feel guilty

13:56

about publishing our findings. But we do. And I

13:59

have to say I

14:01

fear that one day soon

14:04

I'm gonna hear from them that there

14:07

were repercussions in some way. Right. Even for if

14:09

the fact of our being there or that someone

14:12

is holding up our our paper and

14:14

using it as justification for current hard-line

14:16

immigration policy.

14:25

Yeah. There was one other piece of the

14:27

findings that I think is important to highlight and that's

14:29

that even though you found these higher levels

14:31

of mental distress and children in these facilities,

14:33

you say very explicitly that you couldn't, you

14:36

couldn't pinpoint the source of that. You

14:38

couldn't say, for example, that because the

14:40

that being in detention

14:42

caused this distress. And you say that for all you know,

14:44

it could have preceded it. It could have come from some things that

14:47

happened in their home countries, and I just think that's important to

14:49

say as well. Like what we know and what we don't know based on the study.

14:51

That's correct, I think part of maybe some of

14:54

the disappointment on the part of our legal colleagues

14:56

is that we couldn't show that the detention

14:58

caused this. And it wasn't really

15:00

necessarily designed to do

15:02

that. We did actually ask about

15:04

the conditions of detention.

15:06

We did do a survey on that,

15:09

and that was going to be

15:11

our one attempt to, if we could at least correlate the

15:13

assessment of the quality and

15:15

conditions of the detention center and the

15:17

mental health system symptoms in the kid, then we

15:19

could show some connection between the two. But in

15:22

fact our data didn't show that. In fact

15:24

to be, you know

15:26

open about this, the ratings of the quality

15:29

of detention were actually, were pretty good.

15:32

For this particular facility.

15:35

For this particular facility, which

15:37

is, I think, unique to

15:39

this facility. It's hardly, I think, representative from what

15:41

I've seen and certainly from what we know

15:44

from other colleagues. So we couldn't show

15:46

that. But what we do know

15:48

is that we're looking at a population of

15:51

kids who have, you know, are carrying with them a

15:53

large mental health burden

15:57

and who—if there are any concerns about what they are going

15:59

to contribute or if they're going to stay in the

16:01

United States and what they're going to contribute to society,

16:05

that we have, I

16:07

think, if not a moral obligation then

16:09

maybe selfish obligation. If we want them

16:11

to be good contributors to our society, to correct

16:13

their trajectory now and not

16:16

leave these problems untended. Because

16:18

you leave them unattended, unaddressed, undiagnosed, they're going

16:21

to get

16:25

worse. Right, as a general rule in the

16:27

world of mental health, the longer you've got something, the longer

16:30

you're going to have it, even when you get help, and

16:32

the more problems it's going to

16:34

cause. So this

16:36

is a chance to actually intervene

16:39

and help them on a humane

16:41

basis and really help our society.

16:45

What sorts of care

16:47

are they receiving?

16:50

So they have a medical

16:54

facility on site. They

16:56

have physicians, I

16:59

believe even a dentist, if

17:02

I'm not mistaken. And there is

17:04

a behavioral specialist or

17:07

psychiatrist on site as well.

17:09

However, we don't know anything about their

17:12

their range of training, their

17:15

specialty, if they are, you know,

17:18

trauma-informed, which, I think,

17:21

is really important in this population. So that was

17:25

something that still has a

17:27

huge level of mystery. Because there really was no

17:30

way to tell.

17:33

And it's I think it's maybe you found

17:35

it otherwise, but it was not clear to me that

17:38

there was a even a psychiatrist back

17:40

there.

17:41

Right.

17:41

There might be a psychologist which would be fine. But,

17:43

you know, there's this sort

17:45

of whole mysterious thing like who was behind this door. So

17:48

what the services are. There's

17:50

something back there, but we don't know

17:53

what it is. And there's I mean there's such a

17:55

shortage in this country of child

17:57

mental health professionals. I would be really surprised if there's

18:00

any child mental health professional back there.

18:04

When we talk about mental health

18:06

services for a population like this? What

18:10

are the sorts of things that you know

18:12

in a perfect world you would begin to introduce is

18:14

it is it sending psychologists in to do one-on-one

18:17

therapy? Is it—

18:19

Well, you know, child and

18:21

adolescent psychiatry is a different field than

18:23

adult psychiatry. I'm an adult psychiatrist. So really

18:26

what you would have

18:29

is a child mental health professional who is trauma-trained or

18:31

as Priscilla use this term

18:33

“trauma-informed.” That would be the ideal to

18:35

work with this population. And

18:37

whether it would

18:39

come down to individual therapy or group or play

18:41

or medications is kind of hard to

18:43

say depending upon the nature

18:46

of the problem. And I'm sorry and I

18:48

should add, one of the best predictors

18:51

of how a child going to do under traumatic circumstances

18:53

is how their parent is going to do. As

18:55

the parent goes so goes the child, unless the

18:57

child has other pre-existing mental health vulnerabilities. So, ideally you

19:00

don't just treat the child, but you treat the

19:03

parent as well.

19:11

So the picture I'm getting in my head is of

19:14

a population that is

19:17

distressed, and that

19:19

would require, as you

19:22

just said, significant intervention. Is that correct?

19:23

That is correct. And we and we've seen the

19:25

other end of this. Like I just

19:27

interviewed a woman from Central America

19:30

did an asylum evaluation a few weeks

19:32

ago here. She's in the community. I forget what

19:34

state she's in but I did this remotely. She had been

19:36

separated from her kids, now reunited,

19:39

and she—I was interviewing her, not

19:42

the kids, but the kids are just, for lack

19:45

of a better word, just an awful

19:47

mess psychologically, psychiatrically. They need care and they just

19:49

can't find it. I mean they're just trying

19:51

to get their life

19:53

together, like where they're going to live, how they're going to

19:56

make ends meet. And the kids, thankfully, are able

19:58

to go to their local school. But they're not getting the mental

20:00

health care because they can't afford it and they

20:03

don't how to find,

20:05

if they even exist, pro bono or discounted mental health

20:07

services for the kids. So the problem extends out across their

20:09

trajectory well beyond

20:11

detention, but it starts at

20:13

detention.

20:21

So what does the future

20:23

look like for these women and children—that's question one—and

20:26

two, what's next for you and your

20:28

research in this area?

20:31

What's next for them? You know,

20:33

I think there's so many different paths. I think so many

20:35

of them if they are—I mean if they go, if they

20:38

are deported, for many

20:40

of them we believe it’s a virtual death sentence

20:42

because they were already being threatened

20:44

in their home country. And then the

20:46

fact that they tried to flee, right, is even more

20:48

problematic. So they are

20:50

terrified literally for their lives even more than

20:53

when they fled. For those who stay in our country.

20:56

You know, it just seems to me there

20:58

are so many obstacles working against them in terms of the environment

21:01

that they find themselves in. So, but again, I

21:03

think of these as really resilient

21:06

people who know how to make

21:08

things work eventually, so I'm hopeful for

21:10

them. I'm actually very hopeful be in another

21:13

respect—even if they don't get access to specialized mental

21:16

health services, one of the best ways for

21:18

people to recover from trauma is social

21:20

support. And in communities that we've worked in—I've been down

21:22

in San Antonio—there just so

21:25

many wonderful people religious groups

21:27

and otherwise who are banding together and providing volunteer services just

21:29

to help make sure people

21:32

have clothes and a backpack and a

21:34

phone to call and know how to get

21:36

a bus ticket to go to meet

21:38

their family. And I'd like to think that that social support—that they're

21:40

hopefully also finding in their destination communities around

21:43

the United States—that that that support is going

21:46

to make an enormous difference in their recovery

21:49

trajectory, even if they don't get

21:51

the high-powered mental health

21:53

services that I'm referring to. As for our next

21:55

steps—and you asked the question about what are

21:57

our next steps—I'm not sure. To be

22:00

honest, I think right now

22:03

rather than doing research, we're just trying to

22:05

keep up with the flow of requests

22:08

for asylum evaluations. We can't keep

22:10

up. And in terms of those are

22:14

referred to us or going out to

22:16

the detention centers, there are just

22:18

not enough of us. And

22:20

so I think we're probably at

22:22

the moment less focused

22:25

on the academics and more on getting, like, with some trepidation, getting

22:27

information out this out there like this, letting people

22:30

know, on just keeping

22:32

up with the with the steady flow

22:34

of this asylum-seekers.

22:51

Well, I just want to wrap by thanking you both for doing

22:54

the study and for your ongoing work. It's

22:56

been really, really nice speaking with you. Thank you

22:58

for being here.

22:59

Thank you.

23:01

Thank you.

23:01

If you're interested, I highly recommend reading

23:03

the whole study. It's compact and readabe,

23:05

and it includes links to related studies that

23:07

will give you a more complete sense of how immigration

23:10

policy impacts migrants' health. We’ll

23:13

include a link to the study in the shownotes. Thank you

23:16

again to Dr. Katz and Priscilla for making

23:18

time to talk to us. Thank you also

23:20

to the other co-authors of the study: Sarah

23:22

MacLean, Joshua Walther, Dr. Kim Baranowski,

23:25

and Dr. Elizabeth Singer. On

23:27

the next episode, we're going to hear from a man

23:29

who fled anti-gay violence in his native

23:32

Ghana, and sought asylum in the U.S. But when

23:34

he got here, he quickly realized that

23:36

some of his greatest challenges may still lay

23:39

ahead. It's a resilience story you

23:41

won't forget. Road to Resilience is a

23:43

production of the Icahn School of Medicine at Mount

23:46

Sinai. It's produced by Katie Ullman, Nicci Hudson, and

23:49

me, Jon Earle. Our executive producers are Dorie

23:52

Klissas and Lucia Lee. From all

23:54

of us, thanks for listening. See you next

23:56

time.