Plagued by insomnia and nightmares, and increasingly isolated from friends and family, Juan Carlos signed up to participate in a pilot mental health treatment program in Ciudad Juárez last year that uses virtual reality-based psychotherapy.
“At first I thought going to a psychologist was for crazy people,” says Juan Carlos who requested his last name be withheld for safety. “But … later you realize that you don’t need to be crazy. I really believe that for what has happened in the city, the majority of us need therapy.”
After nearly six years of violence ignited by the federal government’s assault on organized crime and fighting between rival gangs – in which more than 55,000 people have been killed – Mexico is waking up to the needs of survivors. A handful of promising mental health treatment and crisis intervention initiatives have been launched, notably in Ciudad Juárez and Monterrey, two cities most besieged by cartel violence.
One in four Mexicans over the age of 18 report having experienced theft, threats, extortion, or assault, according to Mexico’s statistics agency, INEGI. The percentage increases to 35 percent in Chihuahua state and 27 percent in Nuevo Leon, which contain Ciudad Juárez and Monterrey, respectively.
Dr. Cárdenas led the pilot program in Juárez, which doubled as a controlled study for the use of “virtual reality exposure” to treat Post-Traumatic Stress Disorder (PTSD) in survivors of drug war violence.
During treatment, a patient navigates a virtual world that resembles the place where the violence occurred – for example, Juan Carlos confronted the scene of a homicide on a dusty street that mimicked Ciudad Juárez – while a psychologist sits alongside, guiding the experience. Afterward, the psychologist discusses techniques for relaxation and reducing anxiety.
“It’s not about forgetting,” Cárdenas says. “It’s about reducing the pain.”
Psychologists first employed virtual reality to treat veterans of the Vietnam War, 25 years after the fact. The technique has been used most recently to treat survivors of the Sept. 11 terrorist attacks as well as US soldiers returning from Iraq and Afghanistan. But virtual reality treatment is not well known in Mexico, and, according to Cárdenas, this is the first study testing its ability to help victims of drug war-related violence.
The pilot program involved 51 participants in the study, and 25 completed the entire program. Those who finished all reported a reduction or elimination of the symptoms they initially reported (measured at one, three, and 12 months after the study's completion). Those who did not complete the program cited a variety of reasons, often relating to security or their inability to get to the clinic.
“In Juárez, the people showed symptoms similar to those seen in ex-war combatants and women who have been raped – violent events that are considered to generate the greatest psychological impact,” says Anabel De la Rosa, a psychologist and doctoral student who worked with Cárdenas on the study.
Juan Carlos counts himself among the successes.
“Right now I have a photo of him by my side,” he says of his brother, noting a photograph he keeps in his home office in Juárez. “The loss is still painful – but not at the level of before.”
At least nine students have been killed in the past two years in Monterrey, a prosperous city in Mexico’s north known for its prestigious universities. This has made the need to treat survivors something of a personal matter for psychologists at the Autonomous University of Nuevo Leon.
In conjunction with state health authorities, the university has increased the operating hours of its in-house clinic, which treats students and the greater community. Some 55 therapists work in the clinic’s department focused exclusively on victims of violence. The clinic has beefed up its emergency program and runs an online portal to answer the public’s questions about mental health services.
“Post-traumatic stress wasn’t common here,” says María Elena Urdiales Ibarra, who directs the university’s clinic. “Unfortunately, now it is. By now, many families have lived something [violent] like this.”
The state health department launched a pilot program two years ago to treat people who have experienced “social violence.” Meanwhile, the university and local health authorities have also teamed up two years in a row on a crisis intervention diploma, in which 315 students and specialists have participated. The university estimates that, as part of the fieldwork involved, graduates have attended to more than 4,000 people affected by violence in the state.
Yet Dr. Urdiales Ibarra says she worries that while authorities in some states like Nuevo Leon have become increasingly aware of the need to treat mental health, many victims are not. It’s not until they become overwhelmed by symptoms – they lose sleep, lose weight, lose their job – that they seek therapy.
“The reality is that they come to us after they’ve been to a doctor, after they’ve been to a lawyer,” Urdiales Ibarra says. “There is not enough awareness in the population.”
A question of access
The lack of awareness may be a function of the lack of public mental health infrastructure in many regions. People in Monterrey, not far from the border with Texas, have more awareness and more options than most.
Obstacles to broad-based treatment remain, says Cárdenas, including a lack of infrastructure, affordable access, and highly trained therapists, as well as public acceptance of therapy as part of the healing process. On a national level, for every 10 people who need attention, Mexico has the mental health infrastructure to attend to one, she says.
“In Mexico and Latin America, there hasn’t been greater acceptance [of therapy] for lack of infrastructure,” she says, adding that most people can’t afford to pay the 600 to 1,500 pesos ($46 to $114) hourly rate for private therapy.
Other countries in Latin America are watching Mexico’s approach. Next month, Cárdenas will present the results of the virtual reality study in Colombia and Peru, two countries that have faced their own internal conflicts and high rates of violence.
In Mexico, Cárdenas and a team of 12 psychologists are working to overcome barriers to access with a Mexico City-based clinic that serves patients long-distance through a secure, proprietary platform for online therapy sessions – a potential bridge to close the access gap.
Because, ultimately, Cárdenas says, “When threats of violence are constant, there are problems with anxiety, substance abuse, post-traumatic stress. It has to be treated.”
The Juárez study revealed the troubling risks of letting such symptoms go untreated, Ms. De la Rosa says.
“In daily life, these [violent] acts become normal,” she says. “There are three homicides around you, and you see it as something normal. The violence becomes something that isn’t inhuman, terrifying, and horrific but something habitual.”
Juan Carlos puts it another way: “The value of life has been lost.”