I’ve had enough! Even though it is difficult to find out the facts about the separation of immigrant children from their parents along our southwest border, there are certain clinical and ethical principles that we must reaffirm to our colleagues, the public and society.
Although there may be several clinical principles to fall back on, perhaps the most basic and time-tested one is the hierarchy of needs put together by the psychologist Abraham Maslow. It consists of a pyramid of five levels of need: physical, security, social, ego, and self-actualization, from bottom to top.
For the children separated from their parents, or even any of the detainees, that means that first of all, adequate air, water, food, rest and health are the basic priorities. Without objective assessment of the holding places, we can’t know for sure if that need is being met.
There are reports—that may or may not be true—of young children being medicated in order to calm them down. But if so, is the medication for their health or is it for social control? We need verification. For those who come from certain cultural backgrounds, such as African Americans and Native Americans, the forcible removal of children from parents may be triggers to historical trauma. But there’s no doubt any child separated from home and family for an extended period will feel some trauma.
For the level of security in the hierarchy model, adequate safety, shelter and stability is needed. It is hard to even imagine that the separated children feel stable after being separated from their parents, let alone on top of leaving their country and other loved ones.
For the social need of being loved, belonging and inclusion, that means “good enough” parenting and feeling a part of a community. When children are in a new community of sorts, such as a holding area, suddenly separate from their parents and familiar surroundings, those needs are compromised.
The level of the ego in Maslow’s model, refers to self-esteem, power, recognition and prestige. How can parents and children feel good about their situation when they have been disempowered and rejected by authorities, all without knowing what their immediate future holds?
The top of the hierarchy is self-actualization. Many immigrant families attempting to get into the United States to escape violence in their home country are ultimately trying to self-actualize in terms of development. This is what our country is known for: opportunity. However, for that to happen, the lower levels need to be adequately fulfilled over time.
If we are not directly involved with these families and children, it may seem that there is nothing therapeutic for us to do. However, we physicians have an American Medical Association Code of Medical Ethics, which many other mental healthcare disciplines also follow. Many aspects of the code seem relevant here, starting with the preamble, which states that we have a secondary ethical responsibility to society. What is that in this situation?
Then there are at least three of the nine principles that are applicable.
Section III: A physician shall respect the law and also recognize a responsibility to seek changes in those requirements which are contrary to the best interests of the patient. This means we have to be involved politically if we think the current laws are psychologically damaging to children and families.
Section VII: A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health. Clearly, there is a public mental health concern regarding these children and families. Yes, an argument could be made that border control of the entry of drugs and criminals is a threat to our public health, but that requires proper and rapid screening of those being held to see if that fits any of them.
Section IX: A physician shall support access to medical care for all people. We need evidence that the medical, including mental health, needs of the detainees are being fulfilled. Not only that, but the mental health needs of the caregivers need to be considered since there is so much pressure and uncertainty on them, and they might be vulnerable to secondary trauma. Though some may say we should not participate in giving care if human rights are being violated, so as not to support the perpetrators. For us, patients have to come first. Therefore, we need adequate numbers of clinicians to assess the needs of those being held.
Of course, some of these concerns may relate to our everyday work regarding children who are—or even need to be—separated from their parents for their presumed well-being. However, we now need to go beyond our everyday workplaces when it is clear that other children and families are at high psychological risk, do we not?