Fear is also a border: Mental health for refugees stuck outside the US

“When fear is prolonged,” Alvarado explains, “it stops being a healthy reaction. It becomes chronic and constant. And that’s when it starts to affect how we function day-to-day. It becomes pathological. Just like prolonged sadness can turn into depression, sustained fear can become disabling. It’s no longer just an emotion—it starts to affect our ability to live or survive in our environment.”

MSF teams operate throughout the migration route in the Americas, witnessing how physical and psychological suffering can turn into a paralyzing fear that can be used by political actors, criminal groups, and societies lacking empathy.

Between October 2024 and April 2025, MSF provided over 2,200 individual mental health consultations in cities in Mexico and Guatemala, and treated 251 people with severe conditions requiring mental health medications. This time period covers the transition following the election of US president Donald Trump in November, further restrictions on migration and access to asylum in the US starting in January, and a decrease in migration flows across the Americas.

Fear as a cost

During migration, fear can quickly become more than an emotion. Fear is the first true cost of a journey that hasn’t yet begun—and one that keeps accruing long after a person has crossed any border.

In Tapachula, at Mexico’s southern border, Viridiana says the terror began at home. “My children witnessed everything,” she told MSF social workers at a local shelter. “I never thought I’d end up here. I didn’t even know where I was going. I just knew I had to leave, because my son’s father was threatening to kill me if he ever saw me with someone else.”

“I have a cut on my face,” Viridiana says. “Two stab wounds on my legs, a blow to the head with a revolver, another to the nose with a glass plate. There are so many things that I just can’t erase … and the ones in my heart, only God can heal.”

Across the migration route, MSF’s mental health teams work with people who have suffered physical or sexual violence—whether in their home countries or during their journey. In cities like Esquipulas in Guatemala, and Tapachula, Mexico City, Reynosa, and Matamoros in Mexico, painful stories like Viridiana’s are common, and are part of a systemic crisis, not an accident.

“From a mental health perspective, we see fear reflected in clinical histories,” says Alvarado, “but it goes far beyond anything that can be recorded as a symptom.”

Fear creates a barrier 

In Esquipulas, a town near the Guatemalan-Honduran border, Paula says she chose not to continue her journey out of fear of facing more violence. “We already made it to Mexico. We were in Tapachula, but we didn’t go any further because we were too afraid. They said if migration police didn’t catch you, the cartel would.”

Paula is a survivor of sexual violence in the Darién Gap, where armed men also threatened her 4-year-old son. “In the jungle, they put a gun to his head. Thank God he’s still too innocent to understand most things, but yes, they put a gun to his head—to threaten his father.”

While in Mexico, Paula’s family attempted to apply for asylum legally through CBP One, a mobile app migrants were required to use to request appointments at the US border to apply for asylum. But when the current US administration canceled the program in January, her plans collapsed. “I’ve kind of come to terms with it now,” she says, “but it hurt a lot knowing I was going to have to make the same journey again … only this time, with nothing. I’m okay now, but there are moments when I feel like someone is following me. Like there’s an enemy behind me.”

“Fear doesn’t necessarily respond to a visible threat,” Alvarado adds, “but rather to past traumatic experiences or the context in which people are living. It’s a constant, anticipatory fear—not because of what already happened, but because of what could happen at any moment.”

Holistic support for invisible wounds

In cases like these, fear stops being a temporary emotion and becomes a disabling condition. While it is not the only factor, it is a recurring feature in the majority of mental health cases MSF  supports, and it causes not only deep suffering but also numerous complications throughout the therapeutic process as patients and therapists work to regain mental stability. 

Part of MSF’s comprehensive care package is the mhGAP program, an initiative from the World Health Organization that trains medical and mental health staff to deliver psychiatric-level support in contexts where there are no psychiatrists, specialized services, or access to medication. This protocol is activated when therapeutic interventions alone are not sufficient and allows for the integration of medical evaluation, psychological care, and, when needed, pharmacological treatment.

“What we aim to do is expand treatment options for people, offering a comprehensive approach, with the person’s consent and adapted to their reality,” says Alvarado. The biggest challenge is continuity: Many of the people we treat are still on the move or living in unstable conditions, which makes it hard to follow through on therapeutic processes that require time.

Not all wounds are visible. But when fear threatens to become permanent, humanitarian care must find pathways to recovery where borders have been closed by prejudice and xenophobia.

Mental health care for migrants in the Americas  

MSF teams provide support to people in transit along the Latin American migration corridor, offering mental health care, health promotion, and primary medical attention. We call on authorities, humanitarian organizations, and civil society actors to stop deepening the mental health crisis among people on the move, and to take an active role in building safe environments that foster their physical, psychological, and emotional well-being.