A North Carolina program digitally connects farmworkers with a bilingual therapist, overcoming some of the barriers they face in getting the treatment they need.
Marco Garcia lay on the sheet-covered couch of his mobile home in rural western North Carolina, staring at the ceiling. He longed to be outside picking blueberries, tomatoes, and cucumbers, like he’d done the 27 years since he emigrated from Mexico. But he had a diabetic ulcer on his leg, and he couldn’t work. Meanwhile, his wife had to earn money to support them both, all while taking care of him.
“I would think, ‘What am I doing in this world?’” said the 57-year-old last summer. “I would get to a point where I would rather die. I felt like I was no use.”
When a health worker at North Carolina Farmworker Health Program (NCFHP) offered him the opportunity to speak with a bilingual mental-health therapist via videoconference, he acquiesced, though he had never seen a therapist before and felt nervous.
Garcia pinpoints his second therapy session, conducted via iPad in his living room, as a turning point—and he has since pulled out of his depression. The conversation turned to religion, and that resonated with him. “I started thinking about what I was going through and realized I had faith,” said Garcia, wheelchair bound at the time. “It gave me a lot of strength.”
Many of the two- to three-million farmworkers who plant, pick, and process food in the U.S. experience mental health issues. They’re isolated on farms, often separated from their families, and living and working under difficult conditions, and many of them face discrimination and fear due to their undocumented status. Anxiety, depression, and alcohol abuse are common responses.
At the same time, farmworkers often live and work far from healthcare facilities. In the U.S. more than 90 percent of psychologists and psychiatrists work exclusively in metro areas, and about 60 percent of rural Americans live in areas with a mental health professional shortage, according to numbers from the Center for Rural Mental Health Research. Farmworkers are also often on the move, and they lack the time off work, transportation, and insurance coverage that make pursuing treatment possible.
The new NCFHP farmworker teletherapy program is one of the first of its kind in the U.S.—and its creators are hoping it can become a model for others. Using iPads and hotspots, farmworkers can tele-connect with a bilingual therapist at El Futuro, a Durham-based nonprofit clinic that serves Latinx families. In the first year, 2019, about 82 farmworkers took advantage of the program.
The North Carolina effort is part of a larger trend, as community health organizations across America are increasingly turning to telehealth. According to an analysis of 25 billion privately billed claim records by the nonprofit FAIR Health, the use of telehealth services increased by 643 percent nationally between 2011 and 2016—and 960 percent in rural areas. Mental health services accounted for 31 percent of telehealth claims in 2016.
“Most highly qualified [healthcare] professionals don’t want to live in small towns,” said Karla Siu, the former clinical director of El Futuro, who helped get the therapy program off the ground. With teletherapy, she said, “we can provide the clinical resource without asking the clinician to [move or] travel.”
Laborers in Farm Country
Although the mental-health plight of farmworkers has received far less attention than that of farm owners, the former population faces a greater suicide risk, ranking third of occupational groups analyzed by the CDC. And various other studies corroborate the fact that agricultural workers—83 percent of whom are Hispanic, 33 percent of whom live below the poverty level—often struggle with depression and anxiety.
One study of farmworkers in North Carolina found that 52 percent experience depression and 16.5 percent experience anxiety. Another study of women in farmworker families also in North Carolina, revealed that 31 percent exhibited significant signs of depression, compared to the 11 percent rate among Hispanic women overall in the U.S. A third study found that 80 percent of women farmworkers in California faced workplace sexual harassment, including 24 percent reporting sexual coercion or on-the-job blackmail that affected their psychological health.
“Despite the fact that there’s not a lot of data, the data that’s there is very compelling,” said Carlos Ugarte, director of health programs for the advocacy group Farmworker Justice. Farmworker mental health, he said, “is not getting enough attention in the national conversation,” or “in terms of the investment on the part of agencies, especially within the federal government.”
Trying to Survive, Nothing More
Many farmworkers have faced triple trauma, said Mary Johnson Rockers, the teletherapy program lead for El Futuro. First, there’s the trauma in their home country; second, there’s the trauma that occurs during migration as families are separated or people die or fall ill en route; and third, there’s the trauma of arriving in a new country, having to adjust to unfamiliar language and culture, and facing hostile, anti-immigrant sentiments.
Sisters Ana Delarosa Castillo, 41, and Reyna Delarosa Castillo, 38, came to the U.S. from Guatemala in 1994 and 1997, respectively, to escape crushing poverty, and they’ve worked the fields of western North Carolina for the last two decades. Sitting on a leather couch of Ana’s home, as Reyna’s two-year-old daughter arranged pieces of orange peel on the tan shag carpet, they described, in Spanish, their typical work experience.
As farmworkers, they usually work 7 a.m. to 7 p.m. sometimes in oppressive, 90-plus-degree heat, said Reyna. Most farms haven’t provided them with water to drink or bathrooms, forcing women to relieve themselves in the presence of men.
The sisters described having to plant tomatoes at breakneck pace on their hands and knees, chasing the tractor for hours at a time. “The machine never stops to let us rest our backs,” said Ana. “In the moment, you’re trying to survive, nothing more.”
The lack of job security is also a stressor, as is the hostile nature of the current political climate. In August, ICE agents arrested five workers at the local chicken processing plant, and Reyna said she’s afraid to leave the house. “I feel like I’m in a jail,” she said tearfully.
While living full-time in a community without papers gives rise to certain anxieties, workers who come to the country temporarily on H-2A visas face a different set of issues—they often grow depressed from the extreme isolation and separation from their families, and because they are tied to a single employer, they can’t leave if the conditions are bad.
While an outreach worker recommended Ana speak with a therapist during a rough patch she went through—and Ana was interested—she didn’t manage to line up treatment, though she wants to if things get hard again. Reyna agreed: “You’re working a hard job, you’re going through a lot,” she said. “To have someone listen and guide you to the right thing would be good.”
Creating a Model and Fighting a Stigma
For the last decade, the NCFHP has worked with local agencies and health centers across the state to connect farmworkers with primary healthcare and dental services, in both brick-and-mortar clinics and mobile units that visit farmworker camps.
The program began offering teletherapy in January 2019 after farmworkers requested it in feedback surveys. “We saw mental health as whole-person health, a very important part of someone’s well-being,” Rockers said.
Now, the outreach workers incorporate mental health questions into their health assessments, and if a patient appears to be experiencing anxiety or depression, they’re typically set up with a teletherapy appointment as soon as possible.
NCFHP leaders have had to overcome cultural barriers—and stigma—in getting the program off the ground. “In my country, you don’t see a psychiatrist unless you are a little off,” said Christian Ramazzini, who is from Guatemala and worked as an NCFHP outreach coordinator for seven years until last summer. “We’re trying to convince people you don’t have to be crazy to seek services.”
Nevertheless, integrating mental health into primary care makes it feel like less of a leap, Ramazzini said. And the trust the outreach workers have built up with the farmworkers they serve makes the workers more accepting of their offerings.
Telehealth as a Tool
While most farmworkers trust their caseworkers, teletherapy enables them to open up to someone they won’t encounter on a day-to-day basis.
“Most of the mental health issues they’re having, they can’t share with their sons or cousins or moms,” Ramazzini said. “Even sometimes in the clinic, they might feel a little funky, because the community is so small.”
Still, teletherapy as a method hasn’t made headway in all organizations serving farmworkers. While Finger Lakes Community Health in New York offers the farmworkers it serves the option to see specialists virtually, others, like Farmworker Justice, haven’t jumped on the digital bandwagon.
Ugarte said he first wants to be sure telehealth programs are culturally sensitive and designed to be impactful, sustainable, and scalable. “The work going on in North Carolina and other places is going to help inform that,” he said.
Sometimes You Just Need Help
While the traditional psychotherapy model involves digging into root causes over time, the mental health providers serving farmworkers rely on a targeted approach, seeing each farmworker an average of three times.
“Quite frankly, we never know when we’re going to see our patient next,” said El Futuro’s Siu, who worked as a teletherapist for a year, last summer. And yet, focusing on specific complaints has also been empowering, she said, “because we have these really productive 30- to 45-minute conversations.”
Luke Smith, executive director of El Futuro, also sees the power of the interactions, despite the limitations. “Even one conversation can be affirming, validating, and supportive,” he said. “You’re providing a space and humanity for someone who hasn’t felt that very much. That can bring somebody out of that pit of despair.”
Ramazzini has seen teletherapy be transformative for many farmworkers. “A guy I spoke with yesterday said, ‘I had a knot in my chest when I came in to receive services, and I don’t feel it anymore,’” he said last summer.
In fact, his staff had spoken to several farmworkers at a moment they were considering suicide and altered their course, he said. “If there are 10 patients in the last few months that wanted to commit suicide, it’s very likely one of them would have if we were not providing these services.”
After his second therapy session, Marco Garcia started praying more. He began to watch religious DVDs, and they fortified him. Garcia credits the therapy session he received at his lowest point for his renewed inner strength and sense of hope. “I didn’t want to look for help, but at the same time, I was desperate,” he said. “Sometimes you just need help to get pointed in the right direction.”
Siu said she’s constantly inspired by her farmworker patients, who she describes as driven, hard-working, humble, and grounded. “This is important work, strengthening this community that serves our society in such a core and central way, by providing our food,” she said. “It’s the least we could do.”
A more in-depth version of this story can be found on Civil Eats.