key: cord-0819913-9sqt47tz
authors: MacLean, Sarah A.; Agyeman, Priscilla O.; Singer, Elizabeth K.; Baranowski, Kim A.; Katz, Craig L.
title: Perspectives on Working with Immigrants Held in Detention Using Photovoice
date: 2020-10-19
journal: Psychiatr Q
DOI: 10.1007/s11126-020-09853-z
sha: 120bfd6478ebc8498d46b91ba8107fcd91c9561a
doc_id: 819913
cord_uid: 9sqt47tz

Those who work with immigrants in detention centers may be at increased risk of secondary trauma. This study used Photovoice to capture reflections on how the lives of volunteers are affected by their work on behalf of immigrant family detainees. Participants were recruited over a two-month period in 2018 from amongst the volunteers of a non-governmental organization that provides legal services to the detainees at one immigration detention center. Participants submitted photos and captions that explored their experiences with their work. Thirteen volunteers consented to participate and submitted 44 photos with captions to the project. Major themes included emotional challenges of the work, frustrations with the U.S. government, comparison of their experiences to those of their clients’, and finding uplifting moments. Our findings regarding the significant emotional challenges of this work are of particular importance given the increasing coverage of immigration detention in the media and the increased interest in volunteer opportunities to support this population.

Across the world, human displacement and migration are at record levels, with 70.8 million people forced to leave their homes due to conflict or persecution in 2018 [1] . In the United States, higher rates of immigration have been driven in large part by increases in the number of individuals and families from Guatemala, El Salvador, and Honduras, many of whom are seeking asylum due to human rights violations in their countries of origin [2] [3] [4] . Studies consistently demonstrate high rates of emotional distress among these migrants due to a variety of factors, including trauma experienced in their home countries and violence during migration [5, 6] . In particular, those held in immigration detention face high rates of deleterious mental health outcomes [7, 8] .

Over the past 5 years, the U.S. has created more detention centers designed to hold women and children and thus has increased its capacity to detain immigrant families seeking asylum [9] . The first step in determining eligibility for asylum is to undergo a screening interview, which entails an asylum officer evaluating whether the asylum seeker has a credible fear of persecution or torture upon returning to their country of origin. While awaiting this interview, asylum seekers are held in an immigration detention center [10] . Lawyers or legal assistants can help asylum seekers navigate this process and effectively narrate their claims for asylum [11] . While immigrants being held in immigration detention have the right to legal counsel, the government does not pay for legal services and immigrants must secure either paid or volunteer legal services. Immigrants that are represented by legal counsel are more likely to be released from detention, but less than 25% of detained immigrants had legal representation between 2007 and 2012 [12] .

Due in part to increased coverage of immigration in the news media, there has been increased public interest in volunteering as visitors or legal assistants in immigration detention [13, 14] . Trained clinical professionals, in particular, can provide pro bono forensic medical and psychological evaluations that document the physical and psychological evidence associated with their reports of persecution [15] . While engaging in this work, however, there is an increased risk of secondary trauma: among clinicians who provide evaluations for immigrants seeking asylum in the U.S., 26.2% report experiencing vicarious trauma from their work [16] . Clinicians report feelings of isolation associated with their work with immigrants, as they may feel as if others are unable or unwilling to learn about the impact this work may have on the clinician [17] . There has been less research, however, on lawyers and legal volunteers working with asylum seekers. Among professionals working with clients exposed to trauma, one study found higher rates of secondary trauma among lawyers than among social service case workers or mental health professionals [18] . While the psychological benefits of volunteering, in general, have been well-documented [19] , there is more limited data specifically on the impact of short-term volunteer commitments. One study found that long-term volunteers demonstrated higher scores for overall psychological well-being when compared to short-term volunteers matched on age, income, and gender [20] .

Photovoice is a methodology that allows participants to use photography to document an aspect of their lives in an effort to promote reflection on individual-and community-level issues, in addition to advocacy efforts [21] . Photovoice has been used as a tool in various social justice initiatives, including those aimed at combatting racial injustice and homelessness [22] . It has also been used amongst various immigrant groups to explore assets and challenges [23, 24] . To our knowledge, however, there have been no studies on the experiences of volunteers working with immigrants in detention center settings. The objectives of this study were to gather a visual narrative of legal volunteers at one immigration detention center, to allow participants to reflect on how their lives are affected by their work on behalf of the legal needs of immigrant family detainees, and to increase our knowledge of the experiences of individuals who engage in volunteer work with detained immigrants.

Participants were recruited over a two-month period in 2018 from amongst the volunteers of a non-governmental organization (NGO) that provides pro bono legal services to the detainees at one immigration detention center. Volunteers tend to be lawyers and/or Spanish-speaking professionals who spend one to two weeks at the detention center. The project was announced at weekly meetings and interested participants were screened and consented. Participants were included in the project if they were at least 18 years of age and were fluent in English. All participants provided written, informed consent. The research protocol, survey, and consent forms were reviewed and approved by the Institutional Review Board (IRB) at the Icahn School of Medicine at Mount Sinai.

Participants were asked to document illustrations of their experiences volunteering at the detention center. Privacy was maintained throughout the process. Consistent with the policies of the detention center, photography was prohibited on the facility property. In addition, participants were instructed not to include identifying information about themselves or others in their images. Lastly, their images were presented without the inclusion of their names or other identifying information, as per the informed consent. All of the volunteers, regardless of participation in this study, engaged in two reflection sessions per week hosted by the NGO. Given the constraints inherent in this intensive and time-limited volunteer work, a modified Photovoice protocol was used for this study where participants submitted their photos digitally and included captions that provided a text-based reflection of their images and experiences.

After reviewing the photos and captions, key themes and topics of interest emerged and a preliminary codebook was developed to analyze the submitted images and text. Codes were added by an iterative process throughout data analysis as new themes emerged to create the final codebook. Exemplary photographs and captions were identified for each theme.

Thirteen volunteers consented to participate and submitted 44 photos with captions to the project. Major themes from the submissions are described below.

Emotional Challenges Many photographs reflected on the emotional impact of this work.

One participant submitted a "word cloud" of words frequently used among their notes, including "threatened" and "scared," and described it as a "chilling snapshot" (Fig. 1) . Another participant wrote, "Today was tough… brought a lot of tears, awful stories, shared one after the other, as family separation stories resonated throughout the [visitation] trailer." The same participant shared another photo with the caption, "Today I broke a lot, in front of everyone… All of it was too much for my heart. There's little time to address our emotions and allow for digestion of all of this." In contrast, 11 photo submissions were depictions of nature as a soothing presence, including sunrises, plants, the sky, or the stars. One participant noted, "In reflected frustration with the actions of the U.S. government as it relates to immigration and detention. One participant described fellow volunteers as "determined, loving, generous people helping those who are hidden by our government" and another described their work as "[figuring] out the mess the government created." Another participant submitted a photo of a drawing given to them by a child detainee and, reflecting on the detention center rule against physical contact with detainees, wrote, "I wanted so badly to comfort [the child] through touch, but you can't hug or tap or hold or do anything besides shake hands." One participant submitted a photo of their bottled water, reflecting on the poor quality of the town's drinking water, which they describe as "a crime against the mother and children detainees" (Fig. 2) . Finally, one participant submitted a photo of the sky and reflected, "When I left the sterile white walls of the detention center that day, I looked back at the ominous fenced-in detention center built sunken in the ground, hidden from the highway. I knew why there were no labels outside the building, and no street name leading to it: the government doesn't want these refugees or the conditions they are in to be found" (Fig. 3) .

Comparison to Clients' Experience Many submissions reflected on the juxtaposition of the experiences of detainees and those outside of the detention center. One participant submitted a photo taken while jogging and wrote, "I was aware of my freedom and ability to move, unlike our clients in the detention center." Another shared a photo of travelers at the airport and reflected that they are "free to move about… to travel and live where they will." Reflecting on a plant that looked similar to one that grew in their garden, another participant wrote, "Here grows something familiar but different. A reminder that we're all still on the same planet, even if things look wrong." Finally, a nursing mother shared a photo of their breast pump in a transparent backpack that would expedite their getting through security. They reflected that several people had praised their sacrifice in leaving their young child to do this work. They wrote, "My small sacrifice felt like nothing compared to what the women and children with whom I met had gone through" (Fig. 4) .

Bringing Work Home Some submissions reflected on how concepts from this work linger even after working hours. One participant reflected on a passage from the Bible they found in their hotel room: "I think the minor child has a strong claim for asylum due to direct government persecution of 'male children under the age of two' and inability to relocate within Judea. The parents likely do not have independent claims but their cases should be linked to minor child so long as Egypt immigration officials did not separate family." Another participant included a photo of their morning coffee and wrote, "In the morning, I drink my coffee and study the words [in Spanish] I'll need to know in the coming day. 'Family petition,' 'unlawful presence,' 'final order of deportation'" (Fig. 5 ).

As photography is not allowed in the detention center, 18 photos showed landmarks of the surrounding community. One participant described the scenes of the small town on their jog: "stray puppies, empty school yards, quiet streets but for birdsong." Another wrote, "This town and its detention center is the most foreign place on earth." A third submitted a photo of a road sign that lists the population of the town, but commented that "the number of detained [people] here would roughly double the town's population. If they counted."

Uplifting Moments Many submissions highlighted positive moments found amongst this challenging work. Two photos shared drawings made by child clients, while another submission included a photo of a flower as a reminder that "good can grow anywhere." One participant, noting how their hotel was overrun by moths, shared the story of a child excitedly calling a moth seen at the detention center "butterfly!" One photo of clouds was accompanied by the anecdote, "I heard news that one of the women I helped had been given a 'positivo' [positive legal decision]. Gratitude swelled up in me as I took in what it must be like to have fought so hard for your and your child's life, and then be released into a new country that can offer safety. I felt so thankful for what we all have here, and thankful that she can have some freedom from violence that she, her child, and we as humans all deserve, regardless of where we are from." One participant declared, "I am reassured that I am using my power, my privilege. I am exactly where I am meant to be, right now" and another said, "We've got Spanish, the law, brains, and passion on our side. Wish us luck."

This study used a modified Photovoice protocol as a form of participatory research to give legal volunteers at an immigration detention center the opportunity to critically reflect on their experiences using visual images. A major theme identified was the expression of the emotional challenges of this work. While our study did not specifically measure secondary trauma in our participants, these challenges give context to previous quantitative studies of professionals in the legal sector. Studies have demonstrated high rates of secondary traumatic stress symptoms among lawyers working with clients who have experienced trauma [25] and among those working with asylum seekers [26] . Among professionals working with clients who have experienced trauma, lawyers have shown higher rates of secondary trauma than social service case workers or mental health professionals [18] . Lawyers may have fewer opportunities to learn techniques to help them cope with hearing detailed accounts of traumatic experiences [27] . Thus, legal professionals, such as our participants, may benefit from a psychoeducational model to identify, prevent, or diminish the effects of secondary trauma, with a particular focus on clarifying personal motivations that led them to engage in work with survivors of trauma. In particular, given the time-limited work of our participants, they may benefit from interventions specifically geared towards a "mentality of prevention" to allow for identification of symptoms of secondary trauma as soon as they arise [28] .

While many submissions emphasized the emotional challenges of this work, participants also highlighted uplifting moments and beautiful scenes that they had witnessed. This underscores their resilience, or positive responses to adversity or significant stress. In studies of resilience among healthcare providers and first responders, social support, self-efficacy, and mindfulness have been identified as factors that sustain the development of this trait [29, 30] . Future studies might specifically explore factors that support the development of resilience in those working with detained immigrant populations.

A key component of Photovoice projects is the dissemination of photographs to the wider community, as this broadens the opportunities for reflections and dialogue around the images, and increases capacity for community action, social mobilization, and policy change [31, 32] . Given that the volunteers at this detention center are generally only present for one week, it was not feasible to have a physical exhibition of the photographs. Instead, an exhibit of exemplary, deidentified photos are being digitally shared with a wider network of current and former volunteers of the NGO. This allows for the photos and stories to be disseminated to a wide audience who might benefit from reflecting on their volunteer experiences. Reflection is particularly important in volunteer settings as it allows volunteers not only to challenge their own assumptions and beliefs, but also to ensure that their work is beneficial to the community being served [33] . Furthermore, as part of the Photovoice methodology, reflection serves to advance advocacy efforts, allowing participants to become better advocates for themselves and their community [21] .

Our results must be interpreted with several limitations. Due to the small sample of 13 participants volunteering with one NGO at only one immigration detention center, our results may not be generalizable to those working with different immigrant populations in other sectors. Furthermore, our ability to utilize a traditional Photovoice protocol was restricted by the daily time commitment of the volunteers, their participation in other reflection sessions, and the fact that most were present at the detention center in a volunteer capacity for merely one week. Future studies could examine a wider population of volunteers and paid legal representatives using a more traditional Photovoice approach. Additionally, as legal representatives continue to visit clients in immigration detention centers during the COVID-19 pandemic [34] , future studies could explore the impact of this additional stressor.

To our knowledge, this is the first study examining the perspectives of volunteers working with immigrants in detention. Our results demonstrate that legal volunteers face significant emotional challenges associated with this work, and that their sense of personal freedom compared to their clients' absence of freedom weighs on them heavily. In spite of this, volunteers also actively highlight uplifting moments. These findings are particularly important in terms of building positive coping mechanisms and resilience among volunteers, especially given the increasing coverage of immigration detention in the media and the growing interest in volunteer opportunities to support asylum seekers to the U.S.

Authors' Contributions Sarah MacLean was involved in developing the methods, collecting the data, analyzing the data, and drafting the manuscript. Priscilla Agyeman was involved in developing the methods and collecting the data. Elizabeth Singer, Kim Baranowski, and Craig Katz were involved in developing the methods and preparing the manuscript.

Funding This study was funded by the Department of Medical Education, Icahn School of Medicine at Mount Sinai.

Disclosure of Potential Conflicts of Interest The authors have no conflicts of interest to disclose.

Research Involving Human Participants and/or Animals The research protocol, survey, and consent forms were reviewed and approved by the Institutional Review Board (IRB) at the Icahn School of Medicine at Mount Sinai.

Informed Consent All participants provided written, informed consent.

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Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations

MacLean is a fourth-year medical student at the Icahn School of Medicine at Mount Sinai

MPH is a clinical research coordinator at the Icahn School of Medicine at Mount Sinai

MD is an Associate Professor of Emergency Medicine and Medical Education at the Icahn School of Medicine at Mount Sinai

PhD is an Adjunct Clinical Instructor of Medical Education at the Icahn School of Medicine at Mount Sinai

MD is a Clinical Professor of Psychiatry, Medical Education, and System Design and Global Health at the Icahn School of Medicine at Mount Sinai