The Psychiatric Hospital as Safe House? Strange Asylum for Undocumented Immigrants with Mental Health Needs – Nora Kenworthy
Over the past few years, stories have trickled into the U.S. national media about hospitals struggling to cope with the burden of caring for undocumented immigrants who lack insurance and are ineligible for benefits. These reports, including a recent series by New York Times reporter Kevin Sack and an even more recent NYT piece by Sam Roberts, feature accounts of chronically-ill patients being removed from dialysis, or ‘repatriated’ to their countries of origin in comas, to be cared for by long-lost and poorly-equipped relatives. As Luis Plascencia wrote on this blog a few years ago, these rare glimpses into hospital decision-making processes indicate that rising costs and non-existent legal protections for immigrants have led to a ‘privatization’ and ‘outsourcing’ of deportation by health care institutions.
To date, this meager public attention has focused exclusively on hospitals treating physical illnesses. Virtually no mention has been made of how psychiatric and mental health institutions handle undocumented immigrants. Several reports—for example, by the ACLU / Human Rights Watch, Texas Appleseed, and the New York Times—have shed light on the fragile mental health of immigrants in detention. Yet we know little about the policies of either psychiatric hospitals or state offices of mental health regarding undocumented immigrants.
This population faces a nexus of vulnerabilities that makes them among the most socially isolated and—given the current political climate—most undesirable groups in the U.S. As poor members of racial or ethnic minorities with significant histories of psychiatric illness, they are not only more likely to become undocumented, either before or during care, but also especially prone to unlawful or unethical deportation, removal, or repatriation.
Since 2008 I have worked, as a graduate student and researcher, with a team of academics, clinicians and administrators to study the unique situation and acute needs of a group of undocumented immigrants residing within a state psychiatric institution in the Northeastern U.S. Unwilling to repatriate its undocumented patients against their wishes or to turn them over to Immigrations and Customs Enforcement (ICE) for deportation, the hospital struggles to find ways to transfer patients to less-restrictive settings like group homes or community-based services and thereby continue supporting their recovery. But there’s a problem: patients’ undocumented status makes them ineligible for medical and disability benefits, without which they are hard-pressed to access supported accommodation and psychiatric care in community settings. As a result, the asylum setting becomes a kind of reservoir—a hospitalized sanctuary-cum-holding cell—for immigrants who are unable to be discharged but unlikely to ever obtain legal status.
Our research indicates that immigrants often lose crucial documentation during periods of mental illness or hospitalization. Hospital staff struggle mightily to help immigrants obtain legal status, although they lack the necessary training in immigration law. Barred from community-based services, and often lacking strong English skills, patients are ill-equipped to navigate the bureaucratic hurdles necessary to obtain documentation. Hospitals like this offer unlikely shelter to a population that has no other recourse to treatment, housing, or support. But confinement is a strange instrument of kindness, one that hospital residents and clinicians alike find confusing as well as morally and legally uncomfortable.
Scarce information is available about how other psychiatric institutions handle undocumented immigrant patients, though few may be as protective of their charges, or as reluctant to opt for repatriation and deportation, as the one with which we have worked. The few reports we have obtained from other facilities indicate they often rely on “voluntary repatriation” for undocumented patients. How can institutions guarantee that these removals are voluntary, or that full and informed consent has been obtained?
According to the scant information we are able to access, hospitals employ a wide variety of strategies in coping with such populations—strategies that include repatriation and removal, and that rarely attract public notice. We need more publicly accessible data about how many patients are voluntarily or forcibly removed from psychiatric institutions on the basis of their immigration status each year. At present, hospitals and state offices of mental health have no incentives to track or share this data. In at least one case, documented in a 2010 Human Rights Watch report, immigrants were sent directly from mental health facilities into detention.
Corporations like Mexcare allow U.S. hospitals to outsource the unlawful “voluntary” removal of ill patients to their countries of origin. For a healthy profit, they absorb responsibility for the dirty work of removing patients from the health system, flying them home in medically-equipped jets, and even tracking down family members on whom responsibility for acutely ill persons is thrust, regardless of whether they, or the local health care systems, are capable of providing adequate care.
For immigrants with mental health conditions, the boundaries of responsibility are even fuzzier. Psychiatric illness further clouds issues of consent and accountability around repatriation, potentially rendering patients less able to: 1) give consent; 2) articulate their wishes; 3) be informed about their rights; 4) access legal services; 5) contest removal; and 6) draw attention to their cases. State policy, de-facto administrative practice, and the ethical obligations of physicians and hospitals may differ considerably regarding issues of care, discharge, and responsibility.
Current policy options are fraught with difficulties. Mental health advocates argue that patients should be entitled to more community-based care options, but these rarely exist for those without benefits. With immigration laws tightening and becoming more punitive by the day, gaining documentation is elusive for many immigrant groups, and it is especially difficult for those struggling with mental illness and hospitalization. This population occupies an interstitial space between immigration laws, which are increasingly stringent, and our country’s troubled psychiatric institutions, which provide ad-hoc shelter for mounting numbers of homeless, indigent, and socially abandoned individuals.
In the short term, hospitalization should never prevent immigrants from seeking documentation. Hospital staff need more assistance in helping patients with their immigration casework, and the mental health system must take steps to ensure patients do not unnecessarily lose documentation, or opportunities to become documented, because they struggle with mental health problems or are isolated in psychiatric hospitals.
These sites of strange refuge, and their marooned charges, will likely become more common unless immigration and mental health policies are dramatically improved. They deserve more attention from academics and policy-makers alike, and we owe it to those untold numbers of immigrants facing confinement or unjust repatriation to raise the veil of secrecy about the institutions involved in their care.
Nora Kenworthy is a PhD student in Sociomedical Sciences at Columbia University, where she is also a fellow with the Columbia Population Research Center. Her work focuses on political determinants of health, and how health systems and health-seeking impact citizenship, political participation, and social belonging. She recently completed a research project on undocumented immigrants in psychiatric institutions in the U.S., with funding from the Center to Study Recovery in Social Contexts.
Kenworthy, Nora. 2012. “The Psychiatric Hospital as Safe House? Strange Asylum for Undocumented Immigrants with Mental Health Needs.” Accessed [date] at https://accessdeniedblog.wordpress.com/2012/01/04/the-psychiatric-hospital-as-safe-house-strange-asylum-for-undocumented-immigrants-with-mental-health-needs-nora-kenworthy/.