Latinx Mental Health in the Mexican Consulate: Addressing Barriers Through Social Good

Abstract

Objectives:

This article examines an innovative mental health program in the largest Mexican consulate in the United States guided by a social good organizing framework and an intersectionality lens. The mental health program, Modulo de Salud Mental, was designed to address barriers to help seeking.

Methods:

The Modulo used the central characteristics of the social good model, such as innovative collaborations between systems that otherwise do not typically collaborate and burgeoning technologies to overcome barriers for service utilization among this population. We conducted a qualitative study to examine how the Modulo addressed structural and cultural barriers to care.

Results:

The salient themes from interviews were classified into four categories: current political situation, reasons for seeking services, prior barriers to care addressed by program, and perceived benefits of the program.

Conclusions:

Findings suggest that the Modulo's services and convenient location in an unconventional setting can serve as a model for promoting social good by facilitating help seeking and alleviating illness burden for this immigrant community.

Keywords

latinx immigrants mental health consulate social good health disparities intersectionality collaboration social justice

Mental health and access to mental health services are important elements of social good, according to the definition of social good (Mor Barak, 2018), and also a human rights issue, according to the World Health Organization (2018). Immigrants in general and those from Mexico to the United States in particular, especially under the current United States presidential administration’s policies, are a vulnerable population that has difficulties accessing mental health services because of several barriers, such as mistrust of authorities and vulnerability related to undocumented status, among other structural and cultural factors (Elejalde-Ruiz, 2018; Engelbrecht, 2018; Hatzenbuehler et al., 2017; Hicks, 2018; Morey, 2018; Philbin, Flake, Hatzenbuehler, & Hirsch, 2018; Viruell-Fuentes, Miranda, & Abdulrahim, 2012; Watson, 2017). The social good framework helps underscore the importance of overcoming barriers to accessing mental health services by vulnerable populations (Mor Barak, 2018). It also emphasized the importance of using innovations in crossing systems and technology to increase social good in the world (Mor Barak, 2018).

Intersectionality theory as a framework (Hancock, 2016) helps us understand the vulnerability of this population because of its multiple intersecting identities and characteristics (e.g., immigrants, undocumented status, mixed family documentation status, ethnic minority background, and poverty; Viruell-Fuentes et al., 2012). These factors all contribute to Latinx (a gender neutral term for people of Latin American descent) immigrants’ sense of powerlessness and mistrust of authorities, thereby creating barriers to utilizing mental health services in traditional agencies in the community (Rastogi, Massey-Hastings, & Wieling, 2012). As such, an innovative approach is needed, based on social good, to find solutions to address structural and cultural barriers by providing services where members of this vulnerable population feel safe accessing needed mental health services.

The objective of this article is to examine a unique mental health program in the largest Mexican consulate in the United States, the Consulate of Mexico in Los Angeles. The development and implementation process of this program was guided by social good as an organizing framework and an intersectionality theoretical lens. The program used some of the central characteristics of the social good model such as innovative collaborations between systems that otherwise do not typically collaborate (consulate, university, and community agencies) and burgeoning technologies (e.g., website with videos, telemedicine) to overcome barriers to service utilization in this population.

The program was launched as the Modulo de Salud Mental (Mental Health Module), referred here as Modulo (Module), in 2017. We provide an overview of the existing structure, components, goals, and content that were implemented and in operation during an 18-month period. To elucidate the specific barriers experienced by Latinx immigrants and examine the preliminary impact of Modulo services in addressing those barriers, we present the findings from a qualitative study that explored the perspectives of clients who received on-site mental health services. We underscore the innovation of the Modulo for prospectively addressing social and cultural barriers to alleviate the heavy toll on the mental health of a large immigrant community; meeting the unmet mental health needs of vulnerable individuals has wide-reaching benefits to the well-being of the community at large and the promotion of social good.

Background

The United States is home to a fifth of the total immigrant population around the world (Zong, Batalova, & Hallock, 2018); 26% of immigrants in the United States are Latinx individuals of Mexican origin (Migration Policy Institute, 2016). Although immigration of undocumented Latinxs to the United States has decreased in the last 10 years (Passel & Cohn, 2018), the number of asylum-seeking immigrants from Central America has increased dramatically, accounting for 61% of total asylum applications (Zong et al., 2018). Asylum seekers report fleeing their country of origin due to armed conflict; domestic, gang, and political violence; war; and discrimination against gender and sexual minorities compounded by economic hardship and unemployment (Zong et al., 2018).

In the current sociopolitical environment, especially since the 2016 election of President Trump, Latinx immigration has become a hot topic in media reports and cause for public health concern among community service sectors and academic and research institutions. The plight of immigrant communities has been characterized by serious health concerns, including but not limited to increases in anxiety- and trauma-related disorders, depressive disorders, domestic violence, and violence and hostility toward immigrants; delays in seeking health and mental health treatment due to fear of arrest, detention, and deportation; and separation of families, stigma, and discrimination (Chavez-Dueñas, Adames, Perez-Chavez, & Salas, 2019; Elejalde-Ruiz, 2018; Engelbrecht, 2018; Hatzenbuehler et al., 2017; Hicks, 2018; Morey, 2018; Watson, 2017). The resulting state of fear and uncertainty is reported by Latinx immigrants irrespective of documented or undocumented status (Hatzenbuehler et al., 2017; Morey, 2018; Watson, 2017), which negatively affects quality of life and further deepens Latinx health and mental health disparities (Morey, 2018; Philbin et al., 2018; Viruell-Fuentes et al., 2012).

Health and mental health disparities for racial and ethnic minorities have been widely documented and are even more pronounced for Spanish-speaking Latinx immigrants (Barrio et al., 2008; López, Barrio, Kopelowicz, & Vega, 2012). Disparities consist of less access to services, less likelihood of seeking help, and lower quality of services when help is sought (López et al., 2012). The barriers underlying access and quality of services have been identified as language, stigma, and lack of cultural fit between Latinx family culture and existing traditional mental health services (Barrio & Yamada, 2010; Bledsoe, 2008; Kim et al., 2011; Rastogi et al., 2012). Recent research has shown an increase in mental disorders, such as anxiety and depression, among Latinx immigrants that is associated with an increase in perceived discrimination (Cook, Alegría, Lin, & Guo, 2009). This situation underscores the critical need to develop innovative ways to confront these intersecting challenges and engage nontraditional systems, such as a consulate in providing direct mental health services.

The Consulate of Mexico in Los Angeles provides services to approximately 500 people per day. Services offered include emergency assistance, passport and citizenship documents, and administrative and legal services. For the past 20 years, Mexican consulates have been unique in also providing preventive medical services such as health screenings and education on common health conditions. However, mental health services, including ongoing therapy, information and referrals, had not been offered by the consulates. A mental health program embedded in the Consulate of Mexico in Los Angeles is the first of its kind. The development process for the Modulo described here began in February 2017, and it launched in May 2017, 3 months ahead of the official inauguration in September 2017. The inauguration event received media coverage in local, national, and international outlets. All key stakeholder groups were represented, including top officials at the consulate, and the event featured Mexico’s secretary of state as the keynote speaker.

Development of the Modulo de Salud Mental

The inspiration for the Modulo is credited to the consul general of Angeles, Carlos García de Alba, who took office in June 2016. In his prior position, Consul García de Alba had served as ambassador of Mexico in Ireland, where he developed a small-scale mental health service offered online through the Mexican embassy’s website. He recognized the benefits of the mental health service to the well-being of constituents and sought to replicate the model in Los Angeles, which boasts the largest Mexican-origin population outside of Mexico. His office applied for and received a small seed grant from a nonprofit organization to develop and launch a mental health program that would provide person-to-person services in addition to web-based assistance. At this juncture, the consul’s office forged a collaboration with the Suzanne Dworak-Peck School of Social Work at the University of Southern California to identify Latinx mental health research faculty members with expertise in designing and developing this type of program. Two faculty researchers (the authors) were identified as having extensive experience in Latinx mental health services and as bilingual–bicultural licensed professionals of Mexican origin. Based on findings from the literature on Latinx mental health disparities, the combined clinical experience of the researchers, and the knowledge of the consulate staff in serving Latinx immigrants, a working list of barriers to seeking and accessing services was identified. In addition, we followed the World Health Organization’s priorities for dealing with mental health crises on a global scale. We conducted process meetings with community providers, client advocates, and consulate staff to develop the working list of barriers to inform the design of a hybrid model of in-person and web-based services to best fit the needs of the population served at the consulate. At every step in this process, we consulted with and involved stakeholders in reaching a consensus on the structure and goals of Modulo services.

Throughout the 3-month intense period of development, we were informed by an intersectionality framework that helped us keep in the forefront the marginalized social identities of potential clients of the Modulo. An intersectional framework helped us examine the problems faced by Latinx immigrants, whereas the concept of social good guided our innovative approach to addressing the problems, particularly implementing the Modulo in an unconventional setting.

Social Good as an Organizing Framework

As defined by Mor Barak (2018), social good refers to:
individual, community and society well-being related to (a) domains such as environmental justice and sustainability, diversity and inclusion, and peace, harmony and collaboration; (b) engaging unconventional systems of change such as grass roots and business collaborations, national and international NGOs, and social entrepreneurs; and (c) utilizing innovative technologies and approaches, such as design thinking, big data driven models, and harnessing social media for social change, all aiming to promote social justice. (p. 2)

Domain A

In the process of development of the Modulo, we referred to the World Health Organization (2018) guidelines that access to mental health services is a human right and promoting it is a responsibility of not only governmental institutions but also society as a whole. As such, the Modulo at the consulate involved nontraditional collaborations among the consulate, the university, and the public mental health sector (Los Angeles County Department of Mental Health) in providing outreach, education, and direct mental health services to individuals who face institutional and cultural barriers to mental health treatment. The objective was improving the quality of life of immigrants; in turn, this is said to create more peaceful, harmonious, and thriving communities for everyone (Denhart, 2015).

Domain B

The Consulate of Mexico, with the initiative and support of the consul general and his team, provided a unique opportunity to create nontraditional collaborations focused on meeting the mental health needs of a marginalized population in an unconventional setting. The consulate is a sovereign territory, meaning that immigrants are in a safe and protected environment, where Immigration and Customs Enforcement and other law enforcement agencies do not have jurisdiction. In this respect, the immigration status of individuals is not a barrier to seeking mental health services.

Domain C

The most prominent barriers to accessing mental health services for Latinx immigrants include lack of transportation, language-appropriate services, affordability, and stigma (Rastogi et al., 2012). Meeting the needs of this community requires innovative technologies and approaches. As such, the Modulo design included telemedicine services through an established program of the university. For individuals who cannot access in-person services, the university’s telemedicine program, via an encrypted platform, offers mental health treatment in Spanish or English. The only requirement is a device with an Internet connection.

Intersectionality as a Theoretical Framework

Intersectionality theory emerged out of Black feminist thought and activism and highlighted their exclusion in society and domains of power (Hancock, 2016). It describes how individuals who belong to a social group often share similar identities, and because of the position of these identities in a broader social context, they can experience certain advantages, such as protective factors, or disadvantages, such as institutional oppression and structural racism (Rogers & Kelly, 2011). The social location of Latinx immigrants in the context of the United States leads to multiple intersecting relationships among race, ethnicity, colorism, gender, education, class, immigration status, and the complex experience of a mental health problem.

The tenets of intersectionality have relevance for Latinx immigrants facing a climate of antagonism, discrimination, and scarcity of services. The stressors of daily living characterized by racism, discrimination, and violence can erode the health and mental health of immigrant communities (Chavez-Dueñas et al., 2019; Morey, 2018; Viruell-Fuentes et al., 2012). The use of an intersectionality lens in examining the experiences of Latinx immigrants dealing with a mental illness helped us assess the barriers that negatively affect Latinx immigrants’ likelihood of seeking and accessing mental health services, and along with the concept of social good, it provided a map to develop specific strategies to address those intersecting factors.

Addressing the problems faced by this marginalized community requires an innovative approach outside of traditional service systems that may perpetuate interlocking mechanisms of oppression. In this regard, our innovative approach accounted for the interlocking social identities of Latinx immigrants in addressing barriers to services and thereby facilitated an essential path to social justice for this community.

Research has shown that the time lapse between the experience of a mental health problem and initiation of treatment can prolong the course and severity of serious mental illness (Birchwood et al., 2013; Dell’Osso, Glick, Baldwin, & Altamura, 2013; McGorry, Purcell, Goldstone, & Amminger, 2011; Penttilä, Jääskeläinen, Hirvonen, Isohanni, & Miettunen, 2014). Further, most people lose motivation to access services during the period after outreach (Bandura, 2004). An innovation of the Modulo is immediate access to services following the first contact with staff members conducting outreach and education services.

Based on an intersectional lens and tenets of social good, we developed the Modulo goals at the individual and community levels in alignment with World Health Organization (2018) priorities. The goals were to (a) decrease psychological distress, (b) improve quality of life for individuals and immigrant communities, (c) decrease mental illness stigma, (d) increase help-seeking behavior among clients and their loved ones with identified needs, and (e) increase social connections with other members of the immigrant community and mental health service providers.

Method

Modulo Program

Staffing and components of the Modulo, including the content of outreach and psychoeducation services, were developed and designed following an iterative and recursive process in collaborative meetings with stakeholders. All components and corresponding content areas were informed by an intersectionality and social work lens and drawn from the research and practice literature on evidence-based models and culturally relevant approaches for Latinx individuals (Barrio & Yamada, 2010; Viruell-Fuentes et al., 2012).

Modulo staff

A program orientation and clinical training curriculum were designed specifically for personnel serving Latinx immigrants at the consulate. The collaborative relationships established with the county mental health department produced an arrangement, wherein bilingual–bicultural lay community health workers (promotoras) were assigned to provide psychoeducation and outreach in the consulate waiting room. Health and mental health education strategies led by promotoras (community health workers) have been deemed effective in Latinx communities (Elder, Ayala, Parra-Medina, & Talavera, 2009; Pérez & Martinez, 2008; Tran et al., 2014). The promotoras’ (community health workers) outreach efforts promote services offered by the Modulo, including individual and group therapy and wellness workshops. The bilingual–bicultural clinicians assigned to provide individual and group therapy are primarily master’s-level social work interns supervised closely by a licensed social worker with a master’s degree in social work. The Modulo program coordinator, a PhD-level licensed clinician, provides oversight of the Modulo and conducts the wellness workshops. The consulate assigned an administrative coordinator who serves as a liaison for the Modulo and other service sectors in the consulate.

Psychoeducation

The waiting room provides an opportunity for outreach and psychoeducation. The average wait time is 15–20 min. At such time, the promotora (community health worker) conducts a brief 10-min presentation on mental health topics designed by the Modulo program coordinator. Topics include depression and stigma and the benefits of seeking mental health treatment; the objective is to deconstruct negative notions of mental health treatment, increase understanding of the prevalence of mental health problems, and encourage help-seeking behavior (Thornicroft et al., 2016). When the promotora (community health worker) completes the brief presentation, a clinician on duty is available to respond to questions and meet with individuals in need of immediate services or referrals. This process helps address the barriers of stigma, cost, and engagement of services while reducing the time between outreach and receipt of services. The psychoeducation component relates to Goals C and D of the Modulo.

Website

Another psychoeducation and outreach effort takes place through the Modulo website. This website is shared by the promotoras (community health workers) and includes a video with information about accessing mental health services. This page includes a description of the services provided by the Modulo and its partner organizations. The website offers people an opportunity to schedule appointments online to be seen by a clinician at the consulate. The website services relate to Goals C and D of the Modulo.

Mental health screening and assessment

The clinician on duty conducts a mental health assessment using the Patient Stress Questionnaire, a 26-item tool adapted from validated measures and used in integrated mental health and primary care settings (Blount & Connell, 2011). The questionnaire screens for symptoms of depression, anxiety, post-traumatic stress disorder, and alcohol and drug abuse. The mental health screening and assessment relate to Goals A and B of the Modulo.

Information and referral services

Depending on the results of the screening, clients are referred to either individual or group services. If symptoms of serious mental illness that may require medication are detected, clients are referred to a community mental health provider with specialized services for adults, families, and children, regardless of their immigration status and ability to pay. The information and referral services relate more closely to Goals D and E of the Modulo.

Individual and group therapy services

Based on the initial mental health screening of a potential client, the clinician on duty will initiate individual treatment the same day or as soon as a clinician is available. Individual therapy consists of evidence-based, time-limited (8–12 weekly sessions) cognitive behavioral treatment. At the end of treatment, the client can be referred to one of the partnership agencies for further support if needed. At the baseline assessment, the clinician on duty may determine together with the client that referral to group therapy is appropriate. Groups incorporate psychoeducation and support to address stigma and increase mental health awareness. Groups meet for 2 hr once per week for 8 weeks. Individual and group therapy services relate to Goals A–E of the Modulo.

As of November 2018, the Modulo had provided mental health services to 283 clients via individual or group therapy services, and the Modulo website received 2,939 visits. To determine the preliminary impact of the Modulo, we conducted a small qualitative study to examine the insider perspectives of clients receiving mental health services during the first 18 months of operation.

Qualitative Interviews

Demographic data were collected from clients receiving services through the Modulo. Most of the clients served were female (62%). The average age was 44 years (range = 8–89), and 92% of all clients identified as Latinx individuals of Mexican origin. The most frequent presenting complaint was depression (42%), followed by anxiety (38%). Of the clients served, 64% reported they had never received any mental health services prior to the Modulo (see Table 1).

Table 1.
Client Characteristics.

Characteristics % or M (Range)

Age 44 (8–89)

Gender

Female 62

Male 38

Place of birth

Mexico 92

United States 5

Guatemala 5

Honduras 0.5

Nicaragua 0.5

Presenting problem

Depression 42

Anxiety 38

Substance abuse 3

Psychosis 3

Other 14

Visits to therapist before current visit

Never 64

Once 22

2–4 times 14

Note. N = 283. Percentage values may not total 100% due to rounding error.

Procedures for the qualitative study

Purposive sampling was used to select 10 clients who had received individual or group therapy services. Of the 10 selected clients, nine agreed to participate in a semistructured individual interview. One client declined the invitation due to fear of being recorded. Four clients who initially agreed to participate were not enrolled due to time constraints and scheduling conflicts. Data were collected from five client participants using a five-question semistructured interview. Interview questions were developed using an intersectional lens to examine their views on the current political climate regarding Latinx immigrants, impact on their mental health, perceived impact of the Modulo services they received, and other help-seeking-related experiences (see Table 2). Overall, the topic areas were designed to explore pathways to care and gain insight into the lived experiences of immigrant clients of the Modulo (López et al., 2012). The interviews were conducted in Spanish by a trained qualitative researcher. Interviews were recorded and transcribed. The consulate administration and the institutional review board of the affiliated university approved all study procedures.

Table 2.
Semistructured Interview Questions.

How have you perceived the current political environment regarding Latinx immigrants?

What brought you to seek services at the consulate mental health program?

What do you think about the mental health services being offered at the consulate?

Do you think you would have received services somewhere else if these services were not provided at the consulate?

Have these services had any impact on your life?

Analysis

Qualitative analysis was conducted in two stages by the two authors. First, an initial independent content analysis was conducted. The results of the content analysis produced by each reviewer were discussed; high convergence of categories and themes was achieved. Provisional categories of emergent themes were developed to facilitate further coding. Data were coded and organized using NVivo10 (AlYahmady & Alabri, 2013; Smyth, 2008). The second stage involved an intersectionality analysis of the resulting categories and themes. Themes emerging from the first stage were examined for intersectionality implications, and an intersectionality template was developed (Bilge, 2009; Cho, Crenshaw, & McCall, 2013; see Table 3).

Table 3.
Intersectionality Template.

Category and Theme Social Category Discrete Consideration Intersectional Consideration

Current political environment: Mental health impact Race
Immigration status There has always been a preference or favoritism. I am afraid to call it racism because I don’t want to get in trouble, but it is. And now we have felt fear to even go out with everything that is going on now. This intersectional consideration reflects a disadvantage that undocumented Latinxs have experienced, which seems to have been exacerbated by the current political environment. Being undocumented and Latinx has resulted in perceived racism and fear that affects their mental health. Then that same fear prevents them from seeking mental health services.

Current political environment: Empathy, compassion, and altruism Culture
Immigration status I felt worry for my friends, family, especially many of my friends who are Deferred Action for Childhood Arrivals (DACA).…I spent long periods of reflection and thought thinking “Hey, how can I help him? What can I do? What can I do to help them?” Culture seemed to offer protections with regard to facing the current political situation as well. Even though immigrant status seemed to have a negative mental health impact, all participants expressed feeling empathy and compassion toward those experiencing more severe hardships. Participants shared a strong desire to become involved in altruism to help alleviate the suffering of their fellow migrants.

Reason for seeking services: Migratory grief and loss Immigration status
Culture I then started to feel very alone here in the United States I don’t have family here, I don’t have anybody direct. Friends a lot of them, very distant family, too, but I didn’t feel the empathy, or I didn’t feel the closeness with someone who would take me out of that fear. Participants seemed to experience a sense of loss when migrating to the United States. Latinxs are known to be a collectivist culture; when people remove themselves from their families and friends and enter a new culture, as immigrants that can bring about a sense of deep loneliness that can result in isolation, depression, and anxiety.

Barriers to mental health services: Stigma Gender
Mental illness
Culture I as a man had to break certain beliefs that I had been dragging as a Latinx. Which is machismo, saying “I’m a man, I’m not going to cry. I’m not going to feel, I am not going to feel less.”…It [the program] helped to lower my guard and humble myself and accept that I have a lot of problems and I can’t deal with them alone. Several participants shared that machismo and shame had prevented them from accessing services and expressing emotions openly with loved ones. This intersectional consideration illustrates how traditional cultural gender norms could become barriers for people experiencing mental illness to seek the care they need.

Barriers to mental health services: Cost or lack of insurance
Fear Immigration status
Culture
Race It was very stressful, there was fear of asking for help. Fear of not knowing where to ask for help. I got to these offices by coincidence and saw that they give free services to people who need therapy. That is why I asked for help. This intersectional consideration reflects the compounding of barriers that Latinxs with mental health concerns encounter when trying to access services. Several participants shared that due to their or their family member’s immigration status they were unable to afford to pay for private care; however, the fear and discrimination they had experienced because of their raced and that immigration status prevented them from asking for help.

Perceived benefits of the program: Confianza (trust) Culture
Mental illness This is where I found myself. I practically feel identified.…An American won’t really know our Latinx customs. They don’t know our way of talking. I’m not saying they are not efficient.…But us Latinxs have a particular way of talking, a particular way of acting, we have a double meaning with words. And all of that affects us in some way.…And that is why I feel more identified here at the Consulate of Mexico. Because I have heard the way the therapists speak, and they speak exactly like they do in Mexico. That really helps mentally, because it feels like a more direct help, that is why I feel comfortable here, and there is confianza (trust). Participants described the term confianza (trust) repeatedly when describing the benefits and strengths of the program. It seemed to encompass both comfort and trust and was key in getting participants to seek and accept services at the consulate and to open up and feel comfortable about sharing their mental health concerns with their therapists. Confianza (trust), from a cultural standpoint, seemed to have a protective quality that allowed for Latinxs to open up about their mental illness. It was also clear that it went beyond just someone speaking their language; it was related to a deeper understanding of their native culture.

Results

The qualitative study sample featured five participants who had received individual, group therapy, or both at the Modulo during the past year. Three participants were female and two were male; their age ranged from 26 to 50 years. All participants were immigrants from Mexico. Although we did not inquire about immigration status, all participants volunteered that information during the interview. One participant reported being undocumented, two reported having temporary work visas, one described having a visa granted to victims of crime, and one reported being a naturalized U.S. citizen.

The data revealed salient themes, presented here in separate categories. However, it should be noted that overlap of themes and issues occurred across categories and program goals.

Current Political Situation

Participants shared their experiences regarding the current political climate as it relates to Latinx immigrants and how it affects them and their families. Several themes emerged; however, we only highlight those related to mental health. These results relate to Modulo Goals A, B, and E.

Impact on mental health

All five participants recognized the negative impact on their mental health of the current political situation as related to Latinx immigrants. This impact contributed to each participant’s need for mental health support. With respect to family detentions at the border, a female participant shared: “It has affected me a lot. I feel sad. I feel impotent. I cry sometimes for the children. The children…without their mothers, or their mothers giving them their blouse as a blanket.” Three of the five participants also reported feelings of fear, stress, and anxiety due to living in mixed-status families, in which some members are citizens and others are undocumented. They shared a sense of constant vigilance and concern about the undocumented members’ risk of being deported. A female participant, who is a U.S. citizen but whose husband is undocumented, noted:
It has affected my mental health because of the stress. The stress of constantly thinking about the situation. The stress of seeing him, that he cannot rest because he is always working, and he is not able to go see his parents back in Mexico.…Always stress, when this started, we were always fighting because of the stress.
Another female participant described having frequent experiences of racism and discrimination, but that the current political situation has made her more fearful:
There has always been a preference or favoritism. I am afraid to call it racism because I don’t want to get in trouble, but it is. And now we feel fear to even go out with everything that is going on now.

Reasons for Seeking Services

Aside from the precipitating factors associated with the current political environment, participants described specific reasons why they sought mental health services. The most salient themes that emerged were migratory grief and loss, stress and anxiety, and experiencing violence. These results relate to Modulo Goals A, B, D, and E.

Migratory grief and loss

Two participants shared specific experiences of grief and loss that arose from their immigration to the United States. A female participant shared that she experienced pain and guilt after leaving her children behind in Mexico while she was in the United States working to send money home: “It was many years that I was sending money, I sent them a lot of money.…. And leaving them, that still hurts a lot.”

Stress and anxiety

Participants expressed feelings of stress and anxiety attributable to both their daily lives and their immigration experiences. One male participant shared that a feeling of loneliness and fear of being alone led to stress and anxiety that resulted in dysfunctional attempts to connect with people, an issue he wanted to address in therapy: “I started to feel stress and anxiety and above all I was conducting myself in a bad way. Let’s say I was not happy with myself because I was trying to establish friendships the wrong way.”

Violence

Several accounts of violence, both in Mexico and in the United States, were reported by participants. A male participant who was the victim of a violent crime that resulted in serious bodily harm reported that violence left him in an unstable mental state that led him to seek mental health services: “I was attacked on the street by four people and they injured me.…Mentally, one is never really stable again.”

Prior Barriers to Care Addressed by Program

All participants reported types of barriers that had prevented them from accessing help prior to finding services at the Modulo. The five main barriers identified by participants were stigma, cost, or lack of insurance, fear, time lag, and language. These results relate to Modulo Goals C and D.

Stigma

Stigma was the most salient theme reported by all five participants. Stigma was prominently identified as a sociocultural barrier to accessing care. A male participant reported culture-specific gender-related stigma as a barrier that had prevented him from seeking services previously. He indicated that the Modulo services helped him:
I, as a man, had to break down certain beliefs that I had been carrying as a Latinx. This is machismo, saying, “I’m a man; I’m not going to cry. I’m not going to feel, I am not going to feel less.”…It [the Modulo] helped to lower my guard and humble myself and accept that I have a lot of problems and I can’t deal with them alone.
Another male participant shared a lack of confianza (trust), which can be translated best as a concept capturing a combination of comfort and trust. This lack of confianza (trust) had kept him from seeking services elsewhere:
There are certain things that one, because of a lack of confianza (trust) or fear or insecurity, wouldn’t dare to tell others, and I found refuge in this program, because I found this liberating talk, this counsel and guidance without feeling judged, without feeling criticized.
A female participant shared that she finally felt she could receive services without feeling shame or embarrassment: “This program took the blindfold off my eyes. It took away the shame to be able to talk honestly, openly, and without others making fun of me. Or without people being shocked or without bullying of any kind.” Another female participant shared that she would have never thought of utilizing services until she heard the outreach talk by the promotora (community health worker) at the consulate:
I would have never taken it seriously. I think I thought about what everybody else thinks, and it’s very cliché to say it but, “I am not crazy.”…That’s what I used to think, but I am glad I came because now I want to share it with all my friends and tell them about it.

Cost or lack of insurance

Another salient theme for most participants was cost and lack of insurance as barriers for accessing mental health services. As a female participant described: “I have no papers or money, couldn’t afford a private therapist. I don’t think I would have been able to go anywhere else for a consultation.” Another female participant shared that she was motivated to access services in the consulate because their accessibility. She also shared the following about services for her husband: “I want to see if there is something that could benefit my husband. Because he has no papers, we don’t have insurance, so he can’t go see a therapist. Unless we paid for it, and we obviously can’t pay.”

Fear

Participants reported fear as a reason they had not accessed services. As a female participant disclosed:
It was very stressful, there was fear of asking for help. Fear of not knowing where to ask for help. I got to these offices by coincidence and saw that they give free services to people who need therapy. That is why I asked for help.

Time lag

Despite having some type of insurance, participants reported a long wait to receive services, which discouraged them from seeking services and made it difficult to address immediate needs. A female participant noted: “For my children, it takes a very long time. Even if they are citizens. They might get services, but it takes too long.”

Language

Language as a barrier emerged repeatedly in the interviews. Participants shared that even when services were available, they were often not available in Spanish. A male participant shared his experience trying to find services through other agencies:
I immediately tried to look for help as quickly as possible. I struggled, I struggled a while, it was about 2 months. And then I called, and the problem was that they didn’t have therapy in Spanish.…There were some support groups and things like that, but most of them were in English.

Perceived Benefits of the Program

Five main perceived benefits were identified by participants: an increase in self-awareness, positive gains, improved management of stress and quality of life, gratitude, and confianza (trust).

Increase of self-awareness

Many of the participants reported an increase in self-awareness, as illustrated by one female participant: “I thought this group topic doesn’t really pertain to me. And then I realized that all topics pertained to me in one way or another. I think everything I have learned has had a positive impact in my life.”

Positive gains

Participants expressed that the improvement they had experienced from the services received through the Modulo were beneficial not only for them but also for those around them in both family and work settings. Some participants also shared that witnessing their own gains had led others around them to want to seek services through this program. A female participant shared that her relationships at work had improved since receiving services at the Modulo: “It has helped me so much at work, too. My coworkers are impressed because I have changed so much.”

Improved stress management and quality of life

Participants shared about improvements in several areas of their life. The main one was improved stress management, which for many had led to an improvement in their quality of life, as this male participant shared:
I started going to the gym. I started exercising. I started to do the things I like, such as taking photos, I bought a new camera, and I started to look at the future with personal goals that could give me more life satisfaction. That could maybe improve my knowledge; improve my employment situation, more friends and a bigger social circle.

Gratitude

Gratitude about the services received and toward their therapists was expressed by all five participants. A female participant described feeling grateful for the program and her therapist for providing a comfortable and trusting environment: “I am very grateful with the Mexican Consulate.…I feel like at home here. I feel like I am talking to my older sister.…I don’t know, I feel very at peace.”

Confianza (trust)

An evident overlap existed between gratitude and the sense of trust and comfort participants found in the Modulo. Participants shared having a sense of familiarity, of feeling at home, and being afforded confianza (trust) that strengthened their connection to the Modulo services. A male participant shared the following about his experience receiving services:
This is where I found myself. I practically feel identified.…An American won’t really know our Latinx customs. They don’t know our way of talking. As Latinos, we have a particular way of talking, a particular way of acting, we have a double meaning with words. And all of that affects us in some way.…And that is why I feel more identified here at the Consulate of Mexico. Because I have heard the way the therapists speak, and they speak exactly like they do in Mexico. That really helps mentally, because it feels like more direct help; that is why I feel comfortable here and there is confianza (trust).

In sum, the qualitative findings provide preliminary evidence that Modulo services are meeting the goals of this program—goals that benefit clients, their family, and social network members.

Discussion

This study examined the process of development and implementation of a unique mental health program in the largest Mexican consulate in the United States. Informed by a social good framework, the Modulo de Salud Mental was facilitated by nontraditional partnerships among the consulate, university social work research faculty members, public mental health agencies, and community stakeholders to address the vast unmet need for mental health services in Mexican immigrant communities. The use of an intersectionality framework undergirded by social work values was reflected in the design, structure, components, and content of program services. The distinctive features include the location of services in a sovereign territory, their timely accessibility, and the attention to structural and cultural barriers in seeking and benefiting from mental health services.

Taken together, the demographic and qualitative findings illustrate how a prospectively designed program of services can potentially reduce disparities (López et al., 2012). The findings depict a profile of the immigrant experience in the current anti-immigrant climate. The insider perspectives also provide insight into the help-seeking issues encountered along the pathway to care (prior to, during, and after receiving services).

Demographic data indicate that 64% of 283 individuals served at the Modulo had never accessed mental health treatment. This suggests that the Modulo’s location in an unconventional and convenient setting effectively reached and reduced barriers to care for individuals burdened with psychological distress that would have otherwise gone untreated. In addition, the qualitative findings from clients’ insider perspectives elucidated the negative impact of the sociopolitical climate on immigrants (Chavez-Dueñas et al., 2019). Further, findings provided support for the fit of services with the linguistic needs and cultural context of this marginalized community. Interview data overwhelmingly favored the Modulo’s setting, components, content, and types of services, which reflected the positive gains of individual clients, families, and potentially the community as a whole. This indicates that the benefits of the program support the promotion of social good.

The current anti-immigrant political climate is associated with a general sense of malaise in the Latinx immigrant community (Chavez-Dueñas et al., 2019). Individuals’ awareness of their own psychological distress reflects a sense of being outsiders, seen as different, and singled out based on multiple social identities (race and ethnicity, immigration status, colorism, gender, and educational level). Through the psychoeducational components of the Modulo, they readily recognized the negative ramifications of a stressful environment on their mental health, their family members, and the Latinx community in general. With increased knowledge and awareness, they expressed feeling motivated with an openness to receiving help and continuing to improve their mental health. Moreover, clients indicated great concern for fellow Latinx immigrants undergoing great hardships in their neighborhoods and as depicted in the media. These findings underscore the applicability of an intersectional and social work lens in developing services that consider the intersecting systems of oppression that affect individual and community mental health.

Findings revealed structural and cultural barriers to care that have been documented previously in the literature such as stigma of mental illness, cost, and lack of services in Spanish (Barrio et al., 2008; Bledsoe, 2008; Kim et al., 2011; López et al., 2012; Rastogi et al., 2012). Modulo services were designed to address barriers to care, and the qualitative findings confirmed the responsiveness of the innovative approach in eliminating or reducing most of these impediments to help seeking. The Modulo’s location in the consulate was a significant feature in dealing with the stigma of mental illness. Where services are offered matters; Latinx individuals in this study benefited from an expedited process (immediate engagement in treatment), free of cost, but especially because services were available in a convenient setting free of labels perceived as stigmatizing. Stigma is the initial personal and cultural barrier reported by most clients as dissuading their efforts to access help for emotional stressors and problems. Stigma and fear of accessing mental health treatment are potent factors that stall Latinx immigrants along the pathway to care (López et al., 2012). Moreover, the cultural concept of confianza (trust) was a salient theme raised in all the interviews. Confianza (trust) as a sense of trust and familiarity has been documented in the Latinx health and mental health literature (Añez, Silva, Paris, & Bedregal, 2008; Cabassa et al., 2014; Gallardo, 2013). Modulo services promoted a feeling of confianza (trust)—a level of comfort, trust, and safety—that is essential in building rapport with Latinx immigrants, who may present as fearful and guarded. The concept of confianza (trust) is also conveyed by the nature of culturally relevant services. Clients’ perspectives indicated that they felt seen, heard, and understood by promotoras (community health workers) and clinicians who displayed sensitivity and respect in providing services. Engendering confianza (trust) is a relational first step in combating barriers to care for Latinx immigrants.

Clients shared many examples of positive change and improvement as a result of Modulo services. They delineated the benefits of increased knowledge and self-awareness, positive changes in attitude, and new skills to deal with stressors. Strong expressions of gratitude and appreciation characterized their feedback, confirming their positive gains. Clients reported a sense that because they benefited from treatment, others in their family, friends, coworkers, and the community could also benefit. The unique setting in which services were offered was frequently lauded and inspired a desire in clients to share their improvement with others and promote Modulo services. Again, the concept of confianza (trust) was attributed to the cultural congruence of services, particularly how providers showed warmth and respect in their working relationships.

Implications for Research and Practice

Future avenues for research among vulnerable immigrant populations can benefit from using social good as an organizing framework in addressing barriers to treatment that affect mental health disparities. Creative solutions include engaging stakeholders across nonconventional service settings that are safe and nonstigmatizing environments where immigrants can receive timely services targeting psychological distress and other mental health problems. More controlled studies are needed to expand knowledge and determine how to effectively overcome barriers and reach vulnerable groups to improve their mental health outcomes.

In considering practice implications of the Modulo, we first note that the clinical profile of Latinx immigrants at the consulate paints a picture of a community dealing with high levels of stress, sadness, anxiety, family problems, and for some, discrimination with the associated risk of violence. Experiences of grief and loss stemming from their immigrant identity and status appear to be a significant source of their psychological distress. Personal accounts indicated unresolved grief for what was left behind in Mexico and a sense of isolation and disconnection from social networks. These findings suggest that by incorporating an intersectionality perspective, social work practitioners and program designers can tailor services that attend to the cultural and immigrant histories of this vulnerable population.

In designing programs serving Latinx immigrants, administrators and practitioners can draw from our qualitative findings to examine which program components and services can be made more culturally relevant. With this information, they can guide staff training and organization of services to accommodate structural and cultural characteristics and preferences of the ethnic groups served. For example, the participants’ accounts underscored the need for service providers to not only possess Spanish linguistic proficiency but also a cultural sensitivity that helps create a sense of familiarity and trust resulting in confianza (trust), which in this study led to an openness to services and destigmatization of mental illness and was instrumental in addressing several of the barriers that had previously kept participants from seeking services.

In conclusion, this study suggests that the Modulo program, guided by a social good framework and an intersectionality lens, can serve as a model for how to prospectively integrate the impact of the sociopolitical climate and cultural factors in the design of mental health services for marginalized populations. The Modulo’s location in a nonstigmatizing environment can be replicated in other unconventional settings to more efficiently address the mental health burden faced by Latinx and other immigrant and refugee populations. Addressing the well-being of these communities has far-reaching implications for the promotion of social good in our diverse society as a whole.

Characteristics	% or M (Range)
Age	44 (8–89)
Gender
Female	62
Male	38
Place of birth
Mexico	92
United States	5
Guatemala	5
Honduras	0.5
Nicaragua	0.5
Presenting problem
Depression	42
Anxiety	38
Substance abuse	3
Psychosis	3
Other	14
Visits to therapist before current visit
Never	64
Once	22
2–4 times	14

Category and Theme	Social Category	Discrete Consideration	Intersectional Consideration
Current political environment: Mental health impact	Race Immigration status	There has always been a preference or favoritism. I am afraid to call it racism because I don’t want to get in trouble, but it is. And now we have felt fear to even go out with everything that is going on now.	This intersectional consideration reflects a disadvantage that undocumented Latinxs have experienced, which seems to have been exacerbated by the current political environment. Being undocumented and Latinx has resulted in perceived racism and fear that affects their mental health. Then that same fear prevents them from seeking mental health services.
Current political environment: Empathy, compassion, and altruism	Culture Immigration status	I felt worry for my friends, family, especially many of my friends who are Deferred Action for Childhood Arrivals (DACA).…I spent long periods of reflection and thought thinking “Hey, how can I help him? What can I do? What can I do to help them?”	Culture seemed to offer protections with regard to facing the current political situation as well. Even though immigrant status seemed to have a negative mental health impact, all participants expressed feeling empathy and compassion toward those experiencing more severe hardships. Participants shared a strong desire to become involved in altruism to help alleviate the suffering of their fellow migrants.
Reason for seeking services: Migratory grief and loss	Immigration status Culture	I then started to feel very alone here in the United States I don’t have family here, I don’t have anybody direct. Friends a lot of them, very distant family, too, but I didn’t feel the empathy, or I didn’t feel the closeness with someone who would take me out of that fear.	Participants seemed to experience a sense of loss when migrating to the United States. Latinxs are known to be a collectivist culture; when people remove themselves from their families and friends and enter a new culture, as immigrants that can bring about a sense of deep loneliness that can result in isolation, depression, and anxiety.
Barriers to mental health services: Stigma	Gender Mental illness Culture	I as a man had to break certain beliefs that I had been dragging as a Latinx. Which is machismo, saying “I’m a man, I’m not going to cry. I’m not going to feel, I am not going to feel less.”…It [the program] helped to lower my guard and humble myself and accept that I have a lot of problems and I can’t deal with them alone.	Several participants shared that machismo and shame had prevented them from accessing services and expressing emotions openly with loved ones. This intersectional consideration illustrates how traditional cultural gender norms could become barriers for people experiencing mental illness to seek the care they need.
Barriers to mental health services: Cost or lack of insurance Fear	Immigration status Culture Race	It was very stressful, there was fear of asking for help. Fear of not knowing where to ask for help. I got to these offices by coincidence and saw that they give free services to people who need therapy. That is why I asked for help.	This intersectional consideration reflects the compounding of barriers that Latinxs with mental health concerns encounter when trying to access services. Several participants shared that due to their or their family member’s immigration status they were unable to afford to pay for private care; however, the fear and discrimination they had experienced because of their raced and that immigration status prevented them from asking for help.
Perceived benefits of the program: Confianza (trust)	Culture Mental illness	This is where I found myself. I practically feel identified.…An American won’t really know our Latinx customs. They don’t know our way of talking. I’m not saying they are not efficient.…But us Latinxs have a particular way of talking, a particular way of acting, we have a double meaning with words. And all of that affects us in some way.…And that is why I feel more identified here at the Consulate of Mexico. Because I have heard the way the therapists speak, and they speak exactly like they do in Mexico. That really helps mentally, because it feels like a more direct help, that is why I feel comfortable here, and there is confianza (trust).	Participants described the term confianza (trust) repeatedly when describing the benefits and strengths of the program. It seemed to encompass both comfort and trust and was key in getting participants to seek and accept services at the consulate and to open up and feel comfortable about sharing their mental health concerns with their therapists. Confianza (trust), from a cultural standpoint, seemed to have a protective quality that allowed for Latinxs to open up about their mental illness. It was also clear that it went beyond just someone speaking their language; it was related to a deeper understanding of their native culture.

Footnotes

Acknowledgments

The authors thank Consul Carlos Garcia de Alba for his visionary effort in bringing mental health care to a consulate setting. Thanks to Adriana Argaiz, consul for community affairs, and Karla Torres, director of the Ventanilla de Salud, for spearheading the initial grant proposal and inviting us to collaborate. Thanks to Irene Martinez, executive director of Fiesta Educativa, for her grant management and community liaison support and to all our community partners.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Paula Helu-Brown

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