How Trauma and Migration Affect the Treatment Process

0:00:13 William Moyers
Hello and welcome to another podcast in our Let's Talk series produced and brought to you by Hazelden Betty Ford. As always, I'm your host, William C. Moyers. And today, our focus is on refugees, immigration, trauma, and substance use disorders. My colleagues Dr. Damir Utrzan and Manual Garcia. Manuel is the Outpatient Program Manager at Hazelden Betty Ford site in St. Paul, Minnesota. Damir is the Manager of Mental Health Services at our main site in Center City, Minnesota. Welcome to both of you.

0:00:44 Manuel Garcia
Thanks for having us.

0:00:45 Dr. Damir Utrzan
Thank you.

0:00:45 William Moyers
So we're gonna talk about a big topic today. Some people would say well Hazelden Betty Ford doesn't know a lot about that. Refugees, immigration, trauma and substance use disorders. But we're actually learning a lot and you all know it personally. Manuel, would you share?

0:00:59 Manuel Garcia
Oh I would actually say that Hazelden Betty Ford supported me in my immigration process. So, thanks for having me again, William.

0:01:05 William Moyers
Excellent. [nods]

0:01:06 Manuel Garcia
My name is Manuel Garcia. And I'm originally from Mexico City. And I immigrated to the United States in 2013. Because I wanted to go through our Hazelden Betty Ford Graduate School. And I graduated in 2014. And I've been with the organization since. And the reason why I mentioned that Hazelden Betty Ford was supportive of me is because in order for me to stay in the United States after going through the Graduate School, I needed to be sponsored. And Hazelden Betty Ford did that for me. And that's the reason why I'm able to be here today.

0:01:44 William Moyers
And we're glad you're here!

0:01:45 Manuel Garcia
Thanks. [smiles]

0:01:45 William Moyers
Damir?

0:01:46 Dr. Damir Utrzan
Thank you, William, for having me on again. Very similar to Manuel's story, I'm a refugee from Bosnia, the former Yugoslavia. And throughout my career, and personal life, I've really been drawn towards the intersection of trauma, substance use, and immigration. And so throughout my training in graduate school, I specialized in working with survivors of politically sanctioned torture—

0:02:10 William Moyers
Mmm.

0:02:10 Dr. Damir Utrzan
—And I served in capacities of a Forensic Evaluator and then even did some work on public policy and advocacy. For instance, working with the American Bar Association Children's Immigration Law Academy. On helping attorneys across the country set precedent and implement precedents. For applications for deferred status of unaccompanied minors.

0:02:34 William Moyers
Let me stick with you for just a second, Damir. We know that the war in Ukraine is a refugee crisis. What is it—when you see the images, when you see the videos from Ukraine, what does it mean to you?

0:02:48 Dr. Damir Utrzan
You know, over time, when you experience any traumatic event or anything that is out of the ordinary, I think in order to survive, you compartmentalize. Because otherwise, sometimes it becomes difficult. And that is not to say that it's maladaptive or inappropriate, there is a healthy degree of separation. And given my career and everything that I've done, I to some degree was insulated from it. And at the same time, a few weeks ago when the conflict was kind of escalating, I was sitting in the morning watching the news and I was exhausted. As a result of working several hours over that past week. And out of nowhere, tears began to stream down my face.

0:03:31 William Moyers
Mmm. Hmm.

0:03:32 Dr. Damir Utrzan
And that caught me off guard. Because I thought, well, okay, I've been through this, I've worked with it, why now? And part of me was also ashamed which is interesting, right? Because I'm a trained therapist, I've worked with the community, and there's nothing to be ashamed of. But, to me that speaks that trauma is intergenerational, it becomes integrated, becomes part of our narrative, our story—

0:03:57 William Moyers
Mmm.

0:03:57 Dr. Damir Utrzan
—And it doesn't truly ever leave us.

0:03:59 William Moyers
So trauma in the Latinx community, is it recognized, Manuel?

0:04:05 Manuel Garcia
I think so. I certainly recognize it. You know, similar to Damir, there's been a couple of times where I hear new stories that just bring tears down my face like for example, the shooting in Texas that happened recently. You know, one of the hardest things for me in that situation was finding out that the shooter was a Latinx community member.

0:04:29 William Moyers
Mmm.

0:04:30 Manuel Garcia
And I too myself was driving into work the day after and just tears started coming. And I think it's because when one of us suffers—

0:04:42 Dr. Damir Utrzan
Right.

0:04:43 Manuel Garcia
—All of us suffer. And I don't think that's something that ever goes away. Another event was the whistleblower talking about the calamities that happened with women trying to get help from physicians and being abused, you know? When I heard about that story I also—it's like at first you're in shock, you can't believe that it's happening, and then it's just a deep pain that this is happening to your people. So, for me it's as much empathy as it is personal experience.

0:05:14 William Moyers
Mmm.

0:05:15 Manuel Garcia
'Cause even though I haven't gone through anything like that, it's people from my community that are suffering and that's always difficult.

0:05:23 William Moyers
Is there stigma around trauma in populations that live around the world? And is there stigma around asking for help, Damir?

0:05:35 Dr. Damir Utrzan
Well, I would preface that with saying that one, I don't think that most people have a unified understanding of what trauma is. It's certainly Western.

0:05:47 William Moyers
Ah.

0:05:46 Dr. Damir Utrzan
The definitions of traumatic stress in the Diagnostic and Statistical Manual of Mental Disorders is a product of the American Psychiatric Association. That's not to say that it's right or wrong—

0:05:56 William Moyers
Mmm-hmm.

0:05:56 Dr. Damir Utrzan
—It's just an important contextualizing factor. That being said, when you're experiencing trauma whether that be momentary or continuous, it becomes part of your life, so you don't necessarily have an opportunity to think about whether or not it's stigmatized. To some degree, it's a position of privilege.

0:06:15 William Moyers
Hmm.

0:06:15 Dr. Damir Utrzan
Because to me, that is life. To me, that is what I've gone through. And I may or may not know anything different. And being able to categorically assign it any sort of value, does to some degree require being in a position of privilege.

0:06:31 William Moyers
Great point. So what about substance use disorders in that context, Manuel? How do they manifest themselves?

0:06:37 Manuel Garcia
I think it's the same. For any underrepresented population it's hard to trust Western medicine.

0:06:43 William Moyers
Hmm.

0:06:44 Manuel Garcia
And so, when you think about how families address substance use disorders, you think about a lot of stigma being attached to showing weakness. In having a mental illness. So unfortunately there's a lot of shame and a lot of resistance to wanna get help because of how it's gonna be perceived by members of the community and members in our own families. So unfortunately, stigma is real and it's real for substance use disorders and any mental illness. So we've got to break through that barrier.

0:07:23 William Moyers
And so how do we do that? I mean, whether it's Ukraine, whether it's the Southern border of the United States, whether it's Ethiopia or Sudan, there are people trying to flee to a better life. But you can't run away from your shadow and your shadow does include—

0:07:40 Dr. Damir Utrzan
Yep.

0:07:40 William Moyers
—That, the reality of trauma and substance use issues. How does society help these people?

0:07:47 Dr. Damir Utrzan
So another clarification that I'd like to make if you don't mind—

0:07:50 William Moyers
Please.

0:07:50 Dr. Damir Utrzan
—Is the difference between voluntary and forced migration.

0:07:53 William Moyers
Yes.

0:07:54 Dr. Damir Utrzan
Voluntary migration is typically motivated by economic factors such as—

0:07:59 Manuel Garcia
Graduate School. [chuckles along with Moyers]

0:07:59 Dr. Damir Utrzan
Right, Graduate School. [smiles] And the United States has a different mechanism for immigration based on economic factors than those that are based on involuntary factors. Whether that be human-made disasters, natural disasters—

0:08:11 William Moyers
Mmm-hmm.

0:08:12 Dr. Damir Utrzan
—And that sort. The latter being really delineated and defined in international doctrine and law. And so, because the United States and its law is grounded, excuse me, are grounded in the United States Constitution, and not so much international policy, there comes a conflict where our domestic implementation of those acts is inconsistent. With how it's meant to be implemented in other parts of the world. And so, the path to coming to the United States for someone who is voluntary is significantly easier, especially if they meet a classification criteria of a certain status like they are a highly ranked cardiac surgeon. Whereas, if you are involuntarily seeking asylum, not only are there multiple steps for you in order to arrive, for example you first and foremost have to be outside of your country of origin. But you then have to meet a burden of proof that displays you are eligible. And then that ceiling or the limits, the numbers of each country, are available and met. Which sometime take years after the fact.

0:09:20 William Moyers
So is it hard for refugees or immigrants to ask for help when it comes to substance use disorders or mental health conditions, Manuel?

0:09:32 Manuel Garcia
I think so. More than anything, lack of availability in one's own language to access services. I think that's the number one block.

0:09:39 William Moyers
Mmm.

0:09:40 Manuel Garcia
There's that and then just the fact that trust is not easily earned. And it's gonna take time. And organizations have to do a better job of making sure that they understand the communities that they're hoping to serve. And once that starts to happen and people will start picking up the phone, reaching out. And if services are available in your language and people actually care about who you are. I'll give you an example. A quick story. And this actually happened to a personal friend of mine. Grew up in Oaxaca, Mexico and moved to the United States, forced migration—

0:10:20 Dr. Damir Utrzan
Mmm-hmm.

0:10:21 Manuel Garcia
—Because I think that even though there's an economic desire to come to the United States to better your life, sometimes that's not what people want. People wanna stay with their culture—

0:10:32 Dr. Damir Utrzan
Mmm-hmm.

0:10:32 William Moyers
Yes.

0:10:30 Manuel Garcia
—And with what they grew up loving. But she was forced to move to the United States, seeking a better life, and some of her fondest memories as she sought therapy for the first time, were of her working the fields picking onions with her father. And as she was telling this story to the therapist, the therapist's response was, 'Was this reported?'

0:10:53 William Moyers
Mmm.

0:10:55 Manuel Garcia
'You know child labor is a thing here in the United States, right?' What do you think happened? She never came back to therapy. She was never open to therapy ever again. So if instead of having that approach of pre-judgment with people who come from different cultures, if we just ask questions and try to understand where people come from, she would have understood that this is something that her and her father chose to do together.

0:11:21 William Moyers
Yes. Yeah.

0:11:21 Manuel Garcia
And it was a bonding experience.

0:11:23 Dr. Damir Utrzan
Just to add to that, so one of the immigration nationality laws in the United States are actually more complex than the tax code. [Manuel chuckles] And one of the defining characters of those policies and laws is moral turpitude. The U.S. Constitution doesn't really reference immigration. Just really anywhere. It's in one place but it's unclear. And the broad definition of moral turpitude is what it is—it's broad. And going back to stigma, if someone self-identifies as you know struggling with substances or mental health, it could be implied that they are—

0:12:01 Manuel Garcia
Unfit.

0:12:02 Dr. Damir Utrzan
Right. That they're not fit—

0:12:03 Manuel Garcia
Mmm-hmm. [nods]

0:12:03 Dr. Damir Utrzan
—Based on moral turpitude. That they don't have outstanding character—

0:12:06 William Moyers
Mmm.

0:12:07 Dr. Damir Utrzan
—Or good character. So there's really no incentive and based on the historical precedent in this country, right, where you know on one hand, the Statue of Liberty reflects and represents a hope for a better future, on the other hand, there have been acts committed and perpetuated by the government that contradict that ethos.

0:12:26 Manuel Garcia
I just wanna add real quick that, you know, if there's a person going through an immigration process, even like myself seeking citizenship now, not just permanent residency. If I were to be honest for example, if I'm suffering from a substance use disorder, and I'm honest in my interviews about it, forget about it.

0:12:45 William Moyers
Right.

0:12:45 Manuel Garcia
I'm not gonna be able to stay in the U.S.

0:12:47 William Moyers
Right.

0:12:48 Manuel Garcia
So, that's where we go back to trust. [looks over at Damir]

0:12:49 Dr. Damir Utrzan
Right.

0:12:50 William Moyers
Yes. Trust. Before we go, we've only got a couple minutes. Why is—we're a nation of immigrants—

0:12:59 Dr. Damir Utrzan
Mmm-hmm.

0:12:59 William Moyers
—We are!

0:13:01 Dr. Damir Utrzan
Mmm-hmm.

0:13:01 William Moyers
It's our history. Why academically and clinically, why are we not a nation that's set up to train more clinicians, more administrators, more down-in-the-trenches Peer Support Specialists, to work with diverse populations. Why are we not doing that?

0:13:20 Dr. Damir Utrzan
You know, life I think. Most of us are trying to make it through life day by day. And as those who are in recovery it may be moment to moment. And we get caught up in the turbulence of a pandemic. Financial setbacks. And so getting back on track is more often than not difficult and challenging. That's not to negate the fact that there is a need. But it doesn't have to be as extensive as setting up a framework. It can start with a conversation.

0:13:51 William Moyers
Mmm-hmm.

0:13:51 Dr. Damir Utrzan
Because really that's how recovery starts. It's a conversation.

0:13:55 William Moyers
Mmm-hmm. Mmm-hmm. Last question before we go. And even at Hazelden Betty Ford, I mean, we're not far off from our 75^th anniversary, we've been doing really good work for a long, long time. But we've been slow. Right, Manuel? And Damir? We've been slow to recognize not just the need but our responsibility to help people who come from other places.

0:14:23 Manuel Garcia
I think it's just a reflection of how society has been in the United States. You know, I don't think that it's something that's unique to Hazelden Betty Ford, on the contrary. Being in the DEI Committee for the NAACP, I can tell you that other providers across the U.S. look up to us and see us at a leading example in Diversity, Equity, and Inclusion efforts.

0:14:41 William Moyers
Mmm-hmm.

0:14:44 Manuel Garcia
So I don't think it's unique to our organization, but what I will say is I'm glad that it is now made a priority. And that resources are being allocated to make sure that we are providing culturally responsive care. And that I really like hearing our leaders say that diversity, equity, and inclusion is a priority and that we're hoping to serve as many people as we can.

0:15:07 William Moyers
Yes.

0:15:08 Manuel Garcia
So, as much as I wanna understand why it hasn't happened, I think that just it hadn't been made a priority. And now, something interesting for our organization is that we wanted to make DEI a priority before the murder of George Floyd. Now that kicked it into high gear—

0:15:26 William Moyers
Yes.

0:15:26 Manuel Garcia
—Absolutely, but we were already thinking about doing it. And being completely honest, that's where my focus is now. If I stop and think about why is Hazelden Betty Ford—why haven't we done it yet—it would be a setback. Right now we're looking forward and we're doing everything that we can so that moving forward, we're seen as that leader and that provider—

0:15:46 William Moyers
Mmm-hmm. Mmm-hmm.

0:15:47 Manuel Garcia
—For communities that are underserved.

0:15:50 Dr. Damir Utrzan
And so, progress over perfection?

0:15:52 Manuel Garcia
Yep. [grins]

0:15:51 William Moyers
Right. Day at a time.

0:15:53 Dr. Damir Utrzan
Right.

0:15:54 Manuel Garcia
One, yeah.

0:15:54 William Moyers
Do you think it's realistic that we can as an organization be more inclusive and meet those unique clinical needs of diverse populations?

0:16:06 Dr. Damir Utrzan
I think we already are.

0:16:08 Manuel Garcia
Mmm-hmm. [nods, smiles]

0:16:08 Dr. Damir Utrzan
And to say definitively in either direction, to some degree would be naïve because the landscape changes, and we have to be flexible and adaptive. [Manuel nods] And I do think that we are certainly on our way to that.

0:16:21 William Moyers
And you all are leading that effort, you are shining examples of change. And the change that's necessary to meet the needs of more people. Because we know that addiction doesn't discriminate and neither should recovery. So, Dr. Damir Utrzan, Manuel Garcia, thank you so much for being here today. [turns to camera] And thanks to all of you for being with us again. On behalf of our Executive Producer, Lisa Stangl, and the A Team at Blue Moon Productions, thanks for joining us. We hope you'll come back and tune in to another edition of Let's Talk. We'll see ya again.