Sara trembled, her eyes closed. Her small, 18-year-old figure was there in the passenger seat of my car, but her mind was locked behind a closed door. She grabbed her head. A vein in her forehead was swelling; it was as if her thoughts were exploding.
I was there in response to a desperate call. She said she was alone and afraid. Deeply afraid. She said she needed someone to talk to. It was 10 at night; I drove across town and picked her up.
I didn’t know what to do next.
This girl is from far away, El Salvador, but her story is familiar to many here. Sara (not her real name) is the face of hundreds of thousands of unaccompanied minors who have come to the United States from Central America. She left behind a childhood of abuse, bringing along the wounds of trauma. Once she arrived in this country, the mental-health services she needed were not always readily available.
In many ways, Sara’s is the best-case scenario — but it certainly didn’t feel that way the night she called.
With her immigration status in limbo and no health insurance, I had concerns about what inadvertent doors I would open if I took her to the emergency room. Would they keep her for the night? How would she afford it? Would they refer her to immigration authorities?
I wound up calling a nurse from a clinic that serves undocumented workers. He came over and helped to talk Sara through the immediate crisis. The rest of her journey to mental health has been an ongoing process, and not always an easy one.
And yet, in many ways, Sara has been lucky. At every turn, she met people who stepped out of the boundaries of their jobs to help her: social workers, psychologists, teachers, nurses, attorneys, case managers, and me, a journalist.
I met her by chance in the waiting room of an immigration attorney’s office in Phoenix. I was there working on a story about another kid. The 2014 World Cup was underway, and I made a joke about my country’s soccer team, Uruguay. I remember her dark black hair neatly pulled back and her square glasses that looked just a bit like mine.
Impulsively, she blurted, “What kind of literature do you read?” Her dimples revealed the child behind the eloquence of her question.
I must have said I really like Junot Diaz. She told me she really liked a book called Mandingo. It is the story of an African slave in the southern United States who falls in love with his captor.
At that point, all I knew was that she had come to the U.S. alone. I suggested we keep in touch via Facebook, which seemed less personal than a phone number, since I was intrigued by her love for books and felt she might have a story to tell — but I didn’t want to scare her by asking.
A few days later, her name popped up on my Facebook chat feed. She was curious about me. I explained I was a reporter doing research on unaccompanied youth coming from Central America. I told her I had to get back to my writing.
Another day, she was back in the chat talking about soccer, but quickly changed the subject — big time.
“Can I ask you a question? Do you believe in God?” she asked in Spanish.
“Yes,” I said.
“Is it true that if you feel empty God can fill that emptiness?” she asked.
“It’s a question that could take me hours to answer,” I said. “But I’m going to tell you what I humbly believe…”
“I don’t know if that’s not true or if it’s me that doesn’t feel it.”
Then she went on.
“I don’t have anything or anyone,” she said. “I feel desperate for someone to listen to me.”
In the middle of 2014, the news was exploding about the 52,000 unaccompanied Central American minors who’d reached the U.S. border.
It wasn’t a new phenomenon, but an extreme situation, and it fueled an already polarized debate on illegal immigration.
Even if they reach the border illegally, under current U.S. law such children can claim asylum and enter the country through a legal process. But once here, they don’t receive immediate status or benefits.
They seldom leave their demons behind, and too often, the U.S. system is not equipped to help them in that regard.
“We don’t have a mental-health system, whereby you can come in, regardless of what kind of documents you have, and you’ll be treated,” says Claudette Antuña, a bilingual forensic evaluator and clinical social worker who specializes in providing forensic evaluations for immigration court on children and families in Seattle.
At press time, it’s unclear whether potential new executive actions by the Trump administration could change access to health-care services for asylum seekers like Sara, and, even more important, affect the chances for some to gain protections in the country.
Other refugee populations coming to resettle to the U.S. often face similar struggles to the ones Sara faced.
“You’re fighting against a long legacy of distrust of authority and power in caregivers, because a lot of refugees and unaccompanied minors really have suffered at the hands of people who said they were going to take care of them,” says Dr. Alisa Miller, research associate at the Refugee Trauma and Resilience Center.
But there are differences, too. Unaccompanied minors are like “little adults,” says Miller, a psychologist; unlike most refugee children, they don’t have the protective shield of an adult family member.
The number of children arriving at the border from Central America has dropped, but is still significant. Almost 47,000 minors traveling alone were apprehended in the most recent time period recorded between October 2015 and September 2016.
Most come from Guatemala, El Salvador, and Honduras. All three countries are still suffering the sequels to civil wars in the ’80s during the Reagan administration, which funded a military that perpetuated abuse of civilians.
They’re fleeing community violence at the hands of gangs that trace their roots to the U.S. Some also come to find economic opportunities.
“All of these youths have a history of neglect, poverty, oppression, marginalization, and consequent disempowerment,” says Suzana Adams, a clinical psychologist in Phoenix who specializes in trauma and immigration issues.
“Some are very resilient and able to metabolize their past experiences with more facility than others, but all carry scars or wounds similar to the ones of other refugees running away from war. They suffer from depression, anxiety, and complex post-traumatic stress disorder,” Adams says.
Adams has been working with this population for five years in Arizona; most of the cases she sees are referred from government agencies and federally funded shelters under the watch of the federal Office of Refugee Resettlement (ORR).
Most of the Central American youth that come alone to the U.S. are reunited with family here. If not, they go into foster care or remain in a shelter until they turn 18. After that, they may go to a group home facility run by a nonprofit or be deported.
Between October 2014 and September 2015, close to 28,000 youth were reunited with family members, but only a third received post-release services that may include mental-health care, according to the ORR.
The agency doesn’t keep track of mental-health services granted to either refugees or asylum seekers.
When a child is released to family, a representative of the Office of Refugee Resettlement calls within 30 days to check on their well-being. The agency also created a hotline where youth can call if they have trouble adjusting to their new life. Many kids need more than that.
Among the challenges to receiving meaningful, sustained assistance: trouble accessing insurance, cultural perspectives, and a weak safety gap. Basic communication is a problem as well, due to the lack of bilingual and multicultural psychologists.
“It’s a huge mountain for them to overcome to totally integrate into a new society, without language skills and without the academic background,” says Antuña. “They’re, like, lost.”
Sara and her older half-brother were raised by his godparents in Cabañas, El Salvador. Her story here is pieced together from long interviews with her, and written accounts including a psychological evaluation in the U.S. and a brief one from her home country.
Her mother left for the U.S. when Sara was 3, eventually settling with Sara’s grandmother and an uncle in California. She never met her father, and once she’d left, phone calls from her mother were rare.
As a young child, Sara had lots of tiny curls, as she does now. In El Salvador, they call that type of hair colocho. She spoke fast and a lot, she recalls, because she felt adults didn’t listen. So when she got a chance to speak, she tried to get to say as much as she could.
But Sara says that for a long time, she believed her world was perfect.
In her imagination, the back patio of the house where she grew up felt like a huge farm. She played with Ruben, a rabbit, and nameless chickens and dogs. She dug in the ground and pulled out earthworms. She stole the neighbor’s mangos and climbed every single tree she could.
When she was 8, a psychologist gave a talk at school about child abuse at home.
“When I saw all that, I felt something was falling apart. I got angry, I stood up and cried, and left the classroom,” she says.
She hid among bamboo branches in the school’s patio.
“Everything that was normal to me wasn’t,” she says.
She stopped eating and started thinking about death.
“I thought, ‘Life is trash, everything is wrong,’ and at the same time: ‘I’m bad, because that happened.’”
Sara had experienced sexual abuse since an early age.
“It wasn’t one time or one person, it was several,” she says. “The first person that harmed me in my country was a police officer. ‘I’m a police officer and you’re wrong,’ [he said]. That was the threat.”
He was a family member, and she used to play at his house.
That’s why she climbed trees. So she couldn’t be seen.
Her home wasn’t safe, either. She would crawl out of her window with a pillow, onto the roof of the house to sleep, so the man who raised her like a father wouldn’t find her.
But she would be reprimanded by his wife if she was caught not sleeping in the room.
Her brother started molesting her, too, she recalls, and when she spoke up to a young classmate at school, she was the one admonished.
Sara’s favorite place in the world — school — became the most uncomfortable when rumors started among the other children of what happened with her brother.
So when things got worse and he raped her, she didn’t tell anybody.
Her brother was part of a gang, and this was one way to rise in the ranks. It was the price her brother made her pay; she later rationalized it that way, she says, looking for an explanation.
She had no one to talk to. She spent hours alone, hiding on the patio of the school, where she met a 15-year-old girl who befriended her and taught her how to cut herself to release the emotional pain.
“‘You’ll feel better,’ she told me,” Sara remembers. She did. She’d continue cutting as she got older.
She was 13 when she first met a psychologist. She went because her physics professor saw the cuts. She would see the psychologist secretly, and with time, she dared to tell her something was wrong at home.
El Salvador authorities opened up a criminal investigation against her brother and her adopted father. Sara was scrutinized and questioned and, ultimately, removed from her home.
Sara lived in 16 residential treatment facilities in El Salvador. In some, she was ostracized because her brother was in a gang; in others, she felt like she didn’t fit in. She was 15 when she was first sent to a domestic violence shelter for older women. She stood out because of her skills at the occupational workshops; she was good at embroidery.
Her brother went to jail for other crimes, but Sara refused to testify against either him or the other man.
So she was sent to a state-run shelter for youth that she says “felt like a jail.”
“It’s not humane not even for a child; it had soldiers,” she adds.
The kids there belonged to gangs, and some of them tried to put a tattoo on her. When she was 15, a psychological report from one of the shelters said she had anorexia and described her complaining about not being able to sleep and “always doing things wrong.”
They forced her to eat through a feeding tube in her nose, and forced her to take medication that numbed her. That’s what gave her a chilling fear of psychiatrists.
Since she didn’t make progress, they sent her to Exodo, a non-governmental organization. They gave her good food, an education, and they imposed a strong religious discipline.
“You had to pray for God,” she says. She was still depressed and only wanted to sleep.
When she was 16, she escaped and went to live with an aunt. But Sara and her aunt didn’t get along well, and she returned back to her town, living in friends’ houses for a while, crashing on couches and, one time, at an empty college. She took whatever jobs she could to buy notebooks and pencils for school; when there wasn’t an adult family member around to enroll her, she had to rely on the help of a professor.
On the streets there was another threat; her brother’s gang wanted revenge.
One night, she was walking back from selling homemade coconut candies when a group of girls and a boy came to beat her up.
They threw her to the ground and started kicking her. When they left, she laid in the dirt for an hour; her legs and chest were bruised. Her lips were so swollen that she couldn’t speak. She went home covered in mud but wouldn’t go to the police because the rules of the street are to keep quiet.
A year later, Sara got word that her mother had died; she had AIDS. Sara was called to identify the body, shipped back from the U.S. — and that’s how she came to see her mother for the first time in more than a decade: in a coffin at an airport in El Salvador.
“I don’t know what I felt,” she says about seeing her. “I felt afraid.”
All of that was on Sara’s mind when she got an offer to come to the U.S.
She’d never met her uncle in California, but he offered to send her money as an inheritance or to help her get to the U.S. where she would be safer from her brother’s threats. She took the second option.
She paid $3,500 up front to her smuggler and set out to the U.S. with three other Salvadorans. They traveled in buses to Guatemala and crossed a mountain into Mexico.
Her group was joined by others and packed in a van.
As they made it to Villahermosa in the southern state of Tabasco, near the Gulf of Mexico, each was given a cellphone to follow instructions from a smuggler, along with 500 pesos (about $23 dollars) for the mordida, an extortion fee paid to federal officials during regular inspections of the bus. She hid the bills in her hair and belt. She placed them in the hands of federal and military officers that gave them clear passage.
She says it wasn’t such a bad journey. But when they reached Reynosa, Tamaulipas, near the border of McAllen, Texas, that changed.
After five days locked in a house, Sara and the other members of her group were taken to a warehouse and left alone, only to receive the surreal visit of two men with guns and knives in their hands “out of a scene of Rambo,” she recalls, demanding the location of a missing van her group had never seen.
The men eventually left and the smugglers returned; they decided it was time to leave for the U.S. For more than four nights, they couldn’t hide from the Border Patrol to cross the Rio Grande.
They finally succeeded in crossing — and then got caught. Border Patrol agents took all of Sara’s belongings, including her asthma inhaler. Sara was placed in a small holding facility. She had imagined metal bars and armed soldiers, but instead she compared her surroundings to a scene from the movie Planet of the Apes.
A series of small cells wrapped around the desks of Border Patrol officers with, as she puts it, “their doughnuts and warm jackets.”
One cell held toddlers who played and smiled, filthy and hungry from the journey. Another had men who paced with defeat on their faces.
She spent three days there. The temperature inside was cold and triggered an asthma attack without her inhaler, so they had to take her to the hospital.
Sara was put on a plane for the first time in her life — sent by immigration authorities to the custody of Southwest Key, a shelter for unaccompanied minors in Phoenix.
She was there for only a month, and felt the urge to cut herself again, but didn’t have a way to do it.
At one point she locked herself in a bathroom. She recalls that a staff member knocked on the door saying: “Open the door or ICE will come for you.” (ICE refers to Immigrations and Customs Enforcement.)
“It was the worst thing they could have told me,” she says. Two hours later they tore down the door to the bathroom to find Sara naked in the shower. They tried to bribe her, promising access to music if she would get dressed and exit the room.
She requested Facundo Cabral from Argentina and Pablo Milanes from Cuba, both troubadours with the depth of Bob Dylan, light years from her generation’s music.
After that incident, they put her under “one on one supervision,” concerned that she’d harm herself and sent her to see a psychologist. That’s when she met Suzana Adams.
In her evaluation, Adams, a Brazilian multicultural and multilingual clinical psychologist, described Sara as “resistant and guarded” during their first meeting.
She wrote that Sara met the criteria for post-traumatic stress disorder, noting that her traumatic experiences affected “her ability to trust and connect with others in a healthy manner.”
They stayed in touch over the phone on and off in the years to come. Sara was released from the shelter just a few weeks before turning 18 and sent to her grandmother’s house in the fields in Fresno, California.
Adams set up an appointment for her in a clinic so she could have therapy.
But Sara went only once because she couldn’t afford it.
The psychologist also recommended that she be enrolled in school. Instead, Sara worked in the fields picking almonds, and later broccoli and asparagus. She woke up at 5 a.m. and worked for 12 hours a day. In the morning, it was so cold that her hands would stick to the pole she used to grab the almonds above, her neck tired from looking up. She couldn’t feel her toes. Her feet were heavy, as her shoes always had a thick layer of mud stuck to them. When the sun came out, she felt her face cracking from the change.
She lived with her grandmother in a crowded apartment with seven men.
One day, she says, her uncle demanded she sleep with him to pay him back the money he invested on her smuggler. Sara was furious and refused. He knew about her rough childhood. He gave her three days to leave the house or pay.
In desperation, she called a staff member she had met at the Southwest Key shelter, who sent her the money for a bus ticket and picked her up at the Greyhound station in downtown Phoenix.
“I kept busy and I kept moving,” she says. “That helped me survive.”
I met Sara just a few days later at the Florence Refugee Project in Phoenix. She was there to make sure she had legal representation.
Sara and I went to bookstores together, and the public library. We became friends. I loaned her books in Spanish. We went for Salvadoran food and talked about literature.
She was jobless and lived with the family of a shelter staffer who had helped her.
When we met, she often had flashbacks of her past.
She had strong headaches and would withdraw from conversation. She agreed with me that she needed help from a mental-health specialist, but wouldn’t dare to ask her immigration attorney, so I did it for her.
They looked for help, but it wasn’t easy. Sara didn’t have an immigration status yet; that means no health insurance, which meant she couldn’t have access to affordable mental-health services. Two months went by. Every night, I would receive messages Sara sent from her cellphone telling me about losing hope, or emoticons with tears pouring from their eyes.
I gave her a number for a suicide hotline. There were nights I was on the verge of calling it for her.
Finally, through her attorney’s connections, the International Rescue Committee started offering her services because she was considered a victim of trafficking after the threats she faced from her uncle. The IRC helped pay for six months of her rent; they also got her a job at a hotel as a maid. Still, with no health insurance, she couldn’t get mental-health services.
The IRC also offered regular English classes for refugees, and she joined them.
“It’s great to have your basic needs, but you can’t succeed just with the apartment, the refugee card, and a job,” she says. “You can’t keep that up if you’re not doing well emotionally.”
One day during her English class she had an asthma attack. Her inhaler had run out. Her teacher was worried — sensing there was more to her challenges than that — and he shared the story with a group of his adult students at another school.
“He was wondering if anyone was interested in helping,” says Elvia Ponce, one of the students. “I waited till the end of class to see if anyone would, and since no one did, I volunteered.”
That’s how a few days later, Ponce, a petite 50-year-old working mom from Michoacan, Mexico, came to meet Sara. She remembers how skeptical Sara was.
“¿Y tu por qué me quieres ayudar? (Why do you want to help me)?” Sara asked Ponce in Spanish.
Ponce told her about her own struggles, growing up in a home with domestic violence to later become a married women experiencing it again.
What Ponce saw that day was Sara’s fear. The fear of being wounded again. Shortly after, Ponce got Sara an inhaler from one of her grandsons and gave her a television and new bedding. Sara had never liked going to church, but started to attend with Ponce.
There was other good news. Adams started to give her therapy pro bono.
At the same time, attorneys at the Florence Project were preparing Sara’s asylum case. She had to go over every single detail of her past.
“It made me really anxious,” she says.
What worried her the most was going in front of an immigration official to recount her life experiences and the fear she would have a crisis in the middle of it.
That’s not uncommon for a lot of young immigrants who start to relive their story when they tell it in court — and it feels so real that they can’t tell it apart, says Golden McCarthy, a director of the children’s program at the Florence Project, a nonprofit organization that provides pro bono legal services to immigrants.
Sometimes kids will shut down during a practice interview. Anna Marie Smith, a social worker with the Florence Project, tries to help them by teaching coping skills.
But in general, mental-health issues often take the back burner for youth. In Arizona, employees can face legal sanctions if they provide a service to an undocumented immigrant, giving way to further scrutiny for people that do qualify for services.
“Being in Arizona and without status or being in the middle of obtaining status can be highly anxiety-provoking,” says McCarthy. “Kids would ask: ‘If I’m on my way to school and the police stop me, what do I say?’”
Legal and social services have to be integrated, she adds.
“If they don’t have their basic needs met, which includes mental health, you can’t really fight their legal case. But if they don’t have their legal case, it makes it very hard to meet their basic needs in the United States. I don’t think you can really separate them,” McCarthy adds.
Most Florence Project clients don’t qualify for public benefits while their immigration cases are being sorted out, and it can take years for a case to be resolved.
The Affordable Care Act doesn’t provide health-care coverage to undocumented immigrants. Yet, being an immigrant with documents is not a guarantee of having coverage, either. A green card gives you access to the marketplace if you work, but even then you might not be able to afford it. They need to wait for five years before they qualify for Medicaid (known as AHCCCS in Arizona).
There are other hurdles.
Navigating an application for AHCCCS is not easy for native English speakers, so it’s much more of a challenge for a newly arrived young person that could be illiterate, or speak Spanish or indigenous languages less familiar here, Anna Marie Smith says.
“Our clients fall into [these] very specific categories that not everybody knows about,” she says.
There are a few places that provide mental-health services with a sliding scale of fees, regardless of a person’s immigration status. For the past four years, Valle del Sol has had private donors that allowed the nonprofit to serve youth regardless of their ability to pay or status, says Angela Florez, chief development officer at the agency, which is based in Phoenix.
“There’s a huge need for educating our community in what services there are,” says Stephany Martinez, a community health worker supervisor at Valle del Sol. There are also taboos. Some become guarded when there’s talk about psychiatric medication, she adds.
Coming from low-income families, many have never experienced going to a counselor or meeting a therapist, says Brian Jauregui, the director of the unaccompanied minor program at Catholic Charities in Phoenix.
Catholic Charities offers mental-health counseling to this population as well. At least 10 Central American kids are part of the organization’s refugee program, and others are in long-term foster care.
But not all of them are referred to these services. Some fall through the cracks once they turn 18, and often end up living alone with the pressures of making a living. Mental-health treatment becomes an afterthought.
Sara won her asylum case. Her attorney then filed a petition on the grounds that Sara is part of a protected class of young girls that have been exposed to sexual violence and neglect suffering now from PTSD.
Still, things didn’t get better for her.
Around May 2015, I got a call. I was on my way to the airport for a work trip. She was in the hospital. Her voice sounded small.
“Don’t be mad,” she said in Spanish. “I’m all right now.”
She told me later that she had taken every single painkiller and allergy pill she could find at home to try to shut down what she saw.
“I couldn’t sleep at night because I’ll see my mother,” she told me. “With my history, I already had so many problems with people taking me seriously I didn’t want to say anything.”
Sara had been working in a hotel for several months, cleaning 15 rooms a day; she was doing well, and even won employee of the month. She lived alone in a small apartment with a blue couch and her own set of plates and cups. She still didn’t speak much English. Life felt lonely, and senseless.
Elvia Ponce went to see her at the hospital immediately.
“She was confused and negative,” she remembers.
After many ups and downs, Sara started to take medication to help her deal with anxiety.
“I was stuck in my pain,” Sara says. “Everything has a limit; even if someone loves you very much, they’re not going to want to see how you destroy yourself.”
While she was getting back on her feet, her bosses at the hotel fired her; it was a hard blow. Ponce gave her a place in her home. But she didn’t hesitate to splash water on Sara’s face if she didn’t wake up early for school.
The mantra was: Go to school. Take your medication. Work.
“She knew she couldn’t lie to me,” Ponce says.
Not long ago, Sara and I met at a coffee shop.
She is wearing shorts and I can see the old scars on her legs. She orders a chai reluctantly in English, because she’s often shy to speak it in front of me. She’s been taking English classes in the morning, preparing for her GED, and working in the evenings at a restaurant.
There’s no doubt in her mind that she’ll go to the university — soon.
She keeps up her therapy with Adams diligently.
“I’m very proud of her; she’s a role model,” Adams says.
Sara has friends who are missing, living on the streets somewhere in Phoenix. They came here as unaccompanied children and while they have documents, the past still haunts them.
“They all have the same type of confusion I had, the same reasons why I stopped eating and sleeping, all of those things that caused me not to have a normal life or will to live. They have the same thing in different words,” she tells me.
“They’re trying to tell the world, ‘I need mental health; my mind is driving me crazy.’ It’s not that they’re crazy; simply, imagine that all your life you were taught to destroy, to use drugs, to see that as normal, and all of a sudden you see reality.”
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SHOW ME HOW
She speaks again about emptiness, but this time it isn’t a question, it’s her answer.
“I understand what that emptiness is. It’s not that they lost something. It’s not that they lost their mom or dad — what they lost is themselves,” she says.
“They’ve reached a point, they don’t know who they are.”