Keywords

I will build a great wall—and nobody builds walls better than me, believe me—and I’ll build them very inexpensively. I will build a great, great wall on our southern border, and I will make Mexico pay for that wall. Mark my words. Donald J. Trump, President of the United States of America, 2016–2020

The closeness between the United States and Mexico is more than just a relationship between two governments. Enrique Peña Nieto, President of the United States of Mexico, 2012–2018

Introduction

According to the Merriam-Webster dictionary, the noun biculturalism and the adjective bicultura l are defined as relating to, or including, two distinct cultures [1]. The cultural aspects of “two neighbors” are presented in this chapter. The neighbors are the United States and the United Mexican States, as per their proper political names; for purposes of this chapter, they are referred to as the United States (US) and Mexico, their more commonly used names.

Territories once occupied by Spain, France, and Great Britain turned into a land shared by two countries that have grown next to each other for centuries. Despite their differences in geographical extension, population size, official language, and economic power, they maintain a vibrant interaction in cultural and commercial trade and a bidirectional flow of people and goods. This interaction is so robust that the culture of people growing up in either country is greatly influenced by the culture of the other country. This chapter addresses the concept of biculturalism and how it influences the manifestation and prognosis of mental illness, based on models proposed by Cohen [2] and by Chen and Padilla [3]. Relevant issues such as self-esteem, prosocial behavior, religion, socioeconomic status, and region of the country are covered [2,3,4]. The chapter starts with a historical review from the fifteenth to the twentieth century focused on events that illustrate the beginning of the relationship between these two countries, with differences and similarities, and the subsequent impact on their cultural foundations. The next part of the chapter recounts specific historical events, where the American and the Mexican cultures have interacted, followed by the migration phenomena, and the neighbors’ border region. Then, sociocultural models of biculturalism and illuminating clinical vignettes are presented. The chapter closes with clinical recommendations, a summary of high yield points, and comments regarding how biculturalism is likely to prevail and flourish in the relationship of these two neighboring countries.

Background

Biculturalism in the Context of Culture

Biculturalism embodies the degree to which individuals internalize relationships, attitudes, behaviors, and values from two cultural systems and develop the competence needed to successfully respond to demands from both. It incorporates the ability to simultaneously navigate and integrate inherited and host cultural domains, and it is therefore expected to be beneficial for behavioral adjustment and mental health outcomes [5]. Biculturalism is not only applicable to immigrants and children of immigrants but also may apply to individuals who live in a region shared by two different cultures.

Biculturalism predates the concepts of multiculturalism, which can be defined as ethnic or cultural pluralism. When two or more cultures are prevalent in a region, setting, family, or individual, there is often a combination of contention and balance between the two. The relationship between the majority and minority culture plays a role in identification and adoption of cultural practices . Acculturation refers to assimilation into a dominant or prevailing culture. Differences in acculturation are often seen in first-generation immigrants compared to second-generation immigrants. Additionally, specific behaviors can be classified into three categories: monoculturalism, blended or fused biculturalism, and alternating biculturalism. Fusion, or blended biculturalism, integrates both cultures, while alternating biculturalism describes an individual shifting behaviors between the two cultures depending on context.

Historical Significance Between the Two Countries

This section is a non-comprehensive description highlighting events and historical context that pertains to the relationship between the two countries. The section will give some historical and cross-cultural context in working with patients identifying as bicultural.

Numerous indigenous civilizations that emigrated from Asia once occupied US and Mexico land. These groups were distributed throughout the American continent, with different forms of societal and governmental organization, until they were “discovered” by Christopher Columbus in 1492. Within decades of this news reaching Europe, fierce colonization took place with Spain, Netherlands, France, Denmark, and Great Britain occupying these territories through the sixteenth century. By the early seventeenth century, Spain occupied all of Mexico and most of the western half of the United States, while Great Britain, and France occupied the rest of the US territory [6, 7].

  1. I.

    The United States

In 1776 the United States declared its independence from Great Britain, engaging in military combat until the Treaty of Paris was signed in 1783. The new nation gained quick recognition of its emancipation throughout the western world. At the time, the United States occupied most of the eastern seaboard, up to the Mississippi River. The United States had an established economic system that rapidly adapted to its new life as a free nation and went through a phase of military strengthening and territorial expansionism during the first half of the nineteenth century. Under the Monroe doctrine, aiming to avoid additional interventions from Europe, the United States expanded in all directions until modern borders with Canada and Mexico were defined.

From 1861 to 1865, under the presidency of Abraham Lincoln, the United States engaged in the Civil War. During these years, the United States was at risk of separating into two nations. Yet, the war kept the Union together and slavery was abolished. During the rest of the nineteenth century, the United States became a key player in the Industrial Revolution. The country’s economic strength was represented by iconic figures such as financier John P. Morgan, oil magnate John D. Rockefeller, and steelmaker Andrew Carnegie. The beginning of the twentieth century was one of economic growth until the stock market crashed in 1929. The first decades of the century are considered “progressive” movements: women were allowed to vote, labor unions grew stronger, the Federal Reserve was created, and the Panama Canal was built.

After the recovery from the 1929 economic crash, the United States successfully went through the First and Second World Wars and in 1946 was one of the protagonists of the Cold War era. The dominant themes at the time were preventing communism throughout the American continent, enhancing civil rights, and the technological arms race. By the end of this century, the New York Stock Exchange prevailed as the financial leader in the world, and free trade became the name of the game [6, 8].

  1. II.

    Mexico

In 1810, Mexico declared its independence from Spain and engaged in military combat until the Treaty of Cordoba was signed in 1821. Various factors prevented Mexico from entering a path of societal and economic growth . Civil unrest continued with persistent conflict and armed outbreaks between conservatives and liberals. Economic progress was hindered by persistent financial demands from the Vatican and other European countries. Two foreign interventions occurred during this century, one from the United States and one from France. The former came with the loss of half its territory, and the latter with the imposition of an Emperor, who was defeated in 1867 by Mexican army general Porfirio Diaz.

Diaz was elected president in 1876, and while he allegedly worked to have Mexico join the Industrial Revolution, the country started the twentieth century in a serious state of poverty and inequality, unable to transition to democracy. Under those circumstances, an insurgent military action, known as the Mexican Revolution, emerged in 1910 causing Diaz’s resignation and ending in 1922. Despite the newly instituted postrevolutionary government, it took decades to transition from a military government to a civil government. The dominant themes during this time focused on attaining a military loyal to its president, a fair distribution of agricultural land , public education, and the diplomatic relationship with the United States and the Vatican. The relationship with the Vatican was so delicate that a war broke from 1926 through 1929, known as the “Mexican Crusade” [7].

By 1935 labor unions propagated. In 1938 came the expropriation of power and oil and aggressive distribution of farming land, including the distribution of land owned by Americans in Mexico. The rest of the twentieth century was controlled by political figures of one political party, whose dominance ended in 1994 after the assassination of their presidential candidate. Also, in 1994, Mexico joined the North American Free Trade Agreement (NAFTA), which is further explained below. While the nation’s economic growth varied throughout the years, poverty and socioeconomic inequality persisted [6, 7].

  1. III.

    Shared Historical Events

  1. (a)

    Guadalupe-Hidalgo treaty (1848)

Mexico’s economic and political instability during the nineteenth century prevented its government from properly controlling its borders. In 1836, the state of Texas separated from Mexico, gained recognition by Great Britain in 1841, and soon after joined the United States. In 1845, the United States declared war on Mexico under the presidency of James Polk. As a result of this war, the Treaty of Guadalupe-Hidalgo was signed in 1848, and the territory from Texas to California, up to the Canadian border, became part of the United States [6, 7].

  1. (b)

    California Gold Rush (1849)

In 1848, there were slightly over 157,000 people in California (31st state of the Union), of which 150,000 were Native Americans, 6500 of Spanish and/or Mexican descent known as “Californios,” and fewer than 800 were non-Native Americans. By the mid-1850s, there were over 300,000 arrivals due to the Gold Rush, including Americans, Mexicans, Chinese, and other Latin Americans. Violence against “foreign miners,” including Mexicans, erupted. Beatings, rapes, and murders became common, even against Mexican-Americans, due to their phenotype [9, 10].

  1. (c)

    French invasion to Mexico (1861–1865)

In 1861, due to Mexico’s persistent political uncertainty, Spain, France, and Great Britain sent troops to secure their existing financial interests. Negotiations were successful with Spain and Great Britain followed by the removal of their troops, but not with France. In 1862, Napoleon III invaded Mexico, and in 1864 declared the Austrian Archduke Maximiliano of Hesburgh as the new Emperor of Mexico. A year later, US President Andrew Johnson revived the Monroe doctrine, and France ceased its military support to continue occupying Mexico. Nonetheless, Emperor Maximiliano remained in Mexico to defend his position until he was captured, judged, and executed in 1867 [6,7,8].

  1. (d)

    The 18th Amendment of the US Constitution prohibiting the production, transportation, and sale of intoxicating beverages (1919–1933)

While the 1920s marked a violent and dry period in many regions of the United States, it was an era of prosperity in various Mexican cities near the US border. The industries of food, beverages, and entertainment flourished, with US celebrities and wealthy citizens traveling to spend days to weeks at a time in a country where alcohol and gambling were legal [11]. A cultural residue of that bloodstained era in the US persists now with the so-called spring breakers, when American college students spend their spring break in Mexico, frequently at a beach destination (e.g., Cancún, Puerto Vallarta, Los Cabos), where music, alcohol, and drugs are readily available. Spring break currently marks the beginning of the high tourist season at many of these destinations. In 2018, 39% of all Americans traveling internationally went to Mexico [12]. In the border cities, this activity occurs nearly all weekends or holidays throughout the year. High school graduates can drink at the age of 18 in Mexico, which is three years earlier than the legal drinking age in the United States [13].

  1. (e)

    Mexican Repatriation (1929–1936)

Mass deportation of Mexicans and Mexican-Americans from the United States to Mexico, known as the era of Mexican Repatriation, started after the 1929 financial crash. It has been suggested that an anti-Mexican sentiment began before 1929. The sense of despair plaguing the United States during the financial crisis created a desire for a convenient scapegoat, and they found it in the Mexican community. It is estimated that nearly two million children and adults were deported, of which 60% were birthright US citizens. Given that the identification of those to be reported was by their phenotype, some scholars consider this historical event a process of ethnic cleansing [14, 15].

  1. (f)

    Inter-American Conference on Problems of War and Peace (1945)

Soon after WWII, Mexico was the host of an international meeting with 20 nations, including the United States and most of the Latin American countries. The original goal was to develop a unified front toward the upcoming international order. It was one of the first manifestations of the United States and Mexico working together toward the same goals within the continent. Mexico would take advantage of its natural geopolitical position, as a bridge between the Anglo and the Hispanic sides of the continent [7].

  1. (g)

    North American Free Trade Agreement (1994)

The North American Free Trade Agreement (NAFTA) has been in effect since 1994. It was signed by President George H. W. Bush in 1992, approved by Congress in 1993, and implemented into law by President William J. Clinton on December 8, 1993. While the United States and Canada had a free trade agreement since 1989, the uniqueness of this trilateral agreement was that it involved the participation of two developed countries and one developing country. Mexican President Carlos Salinas de Gortari illustrated this novelty during a conference at Stanford University, stating:

We want trade, not aid, to generate more employment-- free trade… We do not want to see the century come to an end and find that new (international) arrangements have been made without us. [16]

Nationalists with protectionist views on both sides of the border predicted risks of each countries’ sovereignty. Nonetheless, US trade with its NAFTA partners has more than tripled since the agreement took effect. It has increased more rapidly than trade with the rest of the world. Since 1993, US trade with Mexico grew faster than trade with Canada or with non-NAFTA countries. In 2011, trilateral trade among NAFTA partners reached the $1.0 trillion threshold. In 2016, Canada was the leading market for US exports, while Mexico ranked second. The two countries accounted for 34% of total US exports in 2016. In imports, Canada and Mexico ranked second and third, respectively, as suppliers of US imports in 2016. The two countries accounted for 26% of US imports. American businesses such as Walmart and Ford set shop in Mexico. At the same time, Mexican entrepreneurs acquired or started new businesses in the United States and created nearly 3,000,000 US jobs (e.g., Bimbo Bakery) by 2018 [17, 18]. NAFTA critics have highlighted that neither working conditions in Mexico have improved, nor has the economic gap between the United States and Mexico decreased as expected. While the debate continues regarding the met and unmet goals of this agreement, NAFTA has promoted biculturalism [18].

  1. (h)

    War on drugs (1970–2019)

The war on drugs has been lengthy and bloody; it has both allowed the countries to work together, as well as exhibit their corruptible potential. At one point, Mexico was identified as the biggest producer, and the United States the biggest consumer, of illegal drugs [19]. The turn of the twenty-first century marked one of the bloodiest periods in Mexico. A long list of drug cartels fought for the hegemonic control of the market that was eventually seized by the Sinaloa Cartel, led by the famous “El Chapo Guzman” [19]. During the most violent phase of this era, the US Department of State started to “certify” or “decertify” Mexico as a warning for Americans when considering travel to Mexico. As reasonable as this measure was for the regular citizen, it was also controversial as most of the cartels illegally purchased their guns from the United States. The most painful part of this era has been the number of civilian casualties [20,21,22]. In the last decade, two events brought this war to an apparent pause. First, the decriminalization of the recreational use of marijuana in California and ten other states decreased the demand for marijuana from Mexico [23]. Second is the ultimate incarceration of “El Chapo,” who escaped two out of the three times he was captured and held in maximum-security prisons in Mexico. On his third apprehension, he was extradited to the United States where he has been judged and sentenced to life in prison, plus 30 years at the nation’s most secure supermax prison [19]. The latest news of this war is the detention of the former Mexican Secretary of Public Security in 2019 for accepting millions of dollars in bribes from the Sinaloa Cartel [24].

  1. (i)

    The United States-Mexico-Canada Agreement (2018)

The United States-Mexico-Canada Agreement (USMCA), an updated and modernized NAFTA agreement, was signed by presidents Donald Trump from the United States, Enrique Peña Nieto from Mexico , and Prime Minister Justin Trudeau from Canada between 2018 and 2019 and is expected to be implemented in 2020. We have yet to see the agreement’s effects on the economies of the three partners and the impact on the biculturalism between Mexicans and Americans [25].

  1. IV.

    Migration between the United States and Mexico (twentieth to twenty-first century)

From 1942 to 1964, a series of bilateral agreements between Mexico and the United States, known as the “Bracero Program,” allowed millions of Mexican men to travel to and work in 24 of the US states under primarily agricultural labor contracts. Around 4.6 million contracts were signed, with many individuals signing multiple contracts, making it the largest US contract labor program in history. Outside of this program, Americans and Mexicans have migrated in both directions, both legally and illegally, through the rest of the twentieth and the beginning of the twenty-first century [26].

Beyond the Bracero Program, economics continued to be the main driver for migrations. Young Mexicans, usually men, migrated to the United States looking for better wages and in an effort to avoid the poor working conditions in Mexico. This is mostly represented by unskilled workers in farming and hard labor. These migrants typically settled in western US states such as California, Arizona, Nevada, Oregon, and New Mexico. Yet, migrants have located as far from the border as Ohio, New Jersey, and Illinois. It has been reported that in the last two decades, a shift to more skilled workers has occurred [18]. There are also very affluent Mexicans who own a “second home” in the United States so their children can attend world-renowned schools and enjoy a safer environment . The main destinations of these migrants include cities like Houston, Los Angeles, and Miami [27, 28]. In contrast, most Americans that migrate to Mexico are retirees who are on a fixed income and cannot find the appropriate conditions to live comfortably in the United States anymore. Those that migrate to Mexico find better economic opportunities while enjoying privileged weather. Others experience favorable circumstances to start new business enterprises in a safe environment. The main settlements are by the Pacific Ocean, in the states of Baja California (Ensenada) and Baja California Sur (Los Cabos). Other areas chosen by those with better economic conditions are in the states of Jalisco (Puerto Vallarta), Nayarit (Nuevo Vallarta), and Guanajuato (San Miguel Allende) [29,30,31]. Migration flow, in both directions, includes documented and undocumented residents. According to the 2018 US Census, Mexican-Americans defined as being of full or partial Mexican ancestry, made up 37.0 million or 11.3% of the entire US population. It is estimated that 4.9 million are undocumented, which represents 13.2% of all those of Mexican descent in the United States. In contrast, Mexico’s INEGI (Instituto Nacional de Estadística Geografía e Informática), equivalent to the US Census, reported that in 2015 the population in Mexico was made up of 739,168 or 0.6% Anglo-Americans. The report also presented that 673,866 were undocumented, which represents 91.2% of all Anglo-Americans in Mexico [32,33,34]. These numbers are summarized below in Table 8.1.

Table 8.1 Total and percentages of Mexican migrants in the United States and Anglo-American migrants in Mexico
Full size table
  1. V.

    The US-Mexico border region

In 1983, the two neighbors signed The La Paz Agreement to protect, improve, and conserve the environment of the border region. The US-Mexico border region (USMBR) was then defined as the area of land 100 kilometers (62.5 miles) north and south of the international boundary. It stretches approximately 2000 miles from the southern tip of Texas to California, defining it as the longest border in the world. It has 35 ports of entry for legal transit and large sections with no wall at all. The population living on this stretch of land was estimated to be approximately 15.0 million people in 2010 and is expected to double by 2020 [35]. The USMBR includes 2 sovereign nations, 4 states in the United States, and 6 states in Mexico, encompassing 44 counties and 80 municipalities, respectively, with a total of 15 pairs of sister cities and 25 Native American Nations. The combined population of the four American border states is 70.9 million, and the combined population of the six Mexican border states is 19.9 million [35].

The USMBR is a dynamic region with unique public health, infrastructure, educational, and economic challenges. Its interdependence makes it a natural process to work together with an efficient and faster border, rather than an impenetrable wall . One of the most interesting demonstrations of regional economic development is the CaliBaja Bi-National Mega-Region that concentrates on five strategic areas, advanced manufacturing, agriculture, applied biotechnology, clean technologies, and logistics, with goods and services moving to both sides of the border daily [36]. Another important reason for keeping an open, yet efficient, border is the commercial interdependence at the local level. It is not only the longest but the most frequently crossed border in the world, and hundreds of thousands of workers, students, tourists, and shoppers go to either country on a daily basis. Mexican shoppers represent over a third of retail sales, and Mexican students represent almost half of the school’s population of US border cities, such as McAllen, Laredo, and San Ysidro. By the same token, American shoppers represent high drugstore and optometrists’ sales in Mexican border cities [37, 38]. The authors of this chapter live and practice in a pair of USMBR sister communities of Imperial County in California and the Municipality of Mexicali, in Baja California. In this community, the most represented ethnicity is formed by people of Mexican descent, who have interacted, for over a century, with an economically dominant community of Anglo-European American descendants. The population of Hispanic origin in Imperial County (80.6%) is more than double the average of Hispanics in the entire state (38.1%) [32].

The debate over the security and efficiency of the current wall has long existed, even before the inflammatory statements made by President Donald J. Trump during his electoral campaign:

When Mexico sends its people, they're not sending the best. They're not sending you, they're sending people that have lots of problems and they're bringing those problems. They're bringing drugs, they're bringing crime. They're rapists and some, I assume, are good people, but I speak to border guards and they're telling us what we're getting.

However, the areas without a wall are often inhabitable deserts or mountainous terrain, which are impossible to cross. This is why a “smart wall” has been suggested as a better solution [39].

Biculturalism in the Context of Art, Business, Science, and Entertainment

The twenty-first century has been marked by unprecedented migration. This has increased the interaction of people with different cultural backgrounds in schools, places of work, entertainment centers, churches, and banks, among other settings and scenarios. Consequently, biculturalism and multiculturalism are likely to become the rule, rather than the exception, in our society [40]. This has not come passively , especially between the United States and Mexico. As reviewed, history shows the presence of Mexicans and Americans on both sides of the border for centuries. Some have resulted in such close interaction that bicultural and binational families have originated. In contrast to interracial or interethnic relationships, the descriptor “bicultural families” is used to describe the product of bicultural relationships that foster and promote cultural appreciation of both identities. In addition to shared political and historical events, there are many notable figures and celebrities that encompass the growing pool of biculturals in the United States and Mexico:

  1. (a)

    Vikki Carr

This singer has music hits in English and in Spanish. Born in El Paso, Texas, to parents with Mexican ancestry. She has earned three Grammy Awards and a Latin Grammy Lifetime Achievement Award.

  1. (b)

    Alfonso Cuarón

Mexican-born film director who earned 13 Academy Awards, 15 BAFTA Awards, and three Golden Globe Awards. His films include Children of Men, Gravity, and Roma.

  1. (c)

    Lila Downs

Singer and songwriter. Daughter of Anita Sanchez, singer from Oaxaca, Mexico, and Allen Downs, a professor of art and cinematography from Minnesota. She has earned one Grammy and five Latin Grammys.

  1. (d)

    Tony Garza.

A lawyer who was the US Ambassador to Mexico from 2002 to 2009. Son of Antonio Garza Sr., from Reynosa, Tamaulipas, and Isabel Garza from Wilson, Texas. Mexico bestowed on him the Águila Azteca award in 2009, which is the highest granted to nonnationals . He was married to Mexican millionaire María Asunción Aramburuzabala Larregui from 2005 to 2010.

  1. (e)

    Ha*Ash

Pop music duo formed by Ashley Grace and Hanna Nicole Perez. Born in Lake Charles, Louisiana, their music has been a success in Mexico. Their parents are American-born Antonio Perez and Mexican-born Mathilda Mosa. They have earned the Gaviota de Oro at the Viña del Mar International Song Festival.

  1. (f)

    Jeff Luhnow

General manager and president of baseball operations for the Major League Baseball Houston Astros. He was born in Mexico City and is a graduate of the University of Pennsylvania, Kellogg School of Management.

  1. (g)

    Mario Molina

Mexican-born chemist who won a Nobel Prize in 1995 and was a professor at the Massachusetts Institute of Technology and the University of California, San Diego.

  1. (h)

    Selena Quintanilla-Perez

Tex-Mex diva and Queen of Tejano music. Born to Marcella Ofelia Samora of Cherokee ancestry and Mexican-American Abraham Quintanilla Jr. in Freeport, Texas. She earned 1 Grammy, 14 Billboard Latin Music Awards, and 5 BMI Music Awards.

  1. (i)

    Alfredo Quiñones-Hinojosa

Mexican-born physician who leads the department of Neurological Surgery at Mayo Clinic in Jacksonville, Florida. Born in Mexicali, Baja California to Mexican parents. He was once a migrant farm worker in California.

  1. (j)

    Bill Richardson

30th governor of New Mexico and the ninth US Secretary of Energy, born in Pasadena, California. Son of William Blaine Richardson Jr., an American bank executive of Mexican descent from Boston, Massachusetts, and María Luisa López-Collada, originally from Mexico City, Mexico.

Culturally Competent Care and Biculturalism

Interaction Between Psychiatry and Biculturalism

Culture refers to the values, traditions, beliefs, language, and interactions that identify a society or a group of persons. These cultural factors include art (e.g., music, literature), religion, gastronomy, economy, education, and impact the way one interacts with their significant other, family, peers, coworkers, and society in general [41]. It has been described extensively that the predominant culture in the United States is individualistic and the one in Mexico is collectivistic (i.e., familism), and both factors impact behaviors regarding health and illness [42, 43]. As a first approach, we compare and contrast the following “dimensions of cultural variability” in the United States and Mexico as recommended by Cohen [2].

  1. I.

    Religion

The dominant religion since the inception of both countries is Christian, predominantly Catholicism in Mexico, resulting in a notable difference in the relationship between church, government, and society . Even before its constitution as a free nation, the United States insisted on the freedom of religion. It was the engine that brought together the first immigrants to this land who became the founders of the Union. For centuries, societal and economic growth in the United States has been attained regardless of religious differences or surrounding conflicts. On the other hand, Mexico has struggled with a domineering Roman Catholic Church and its fervent followers which thwarted economic and political growth (e.g., the Vatican challenging commerce with Europe after the Independence War), opposed reformation laws (i.e., conservative vs. liberals), supported the establishment of an Empire (i.e., Emperor Maximiliano), sparked an armed conflict (i.e., Mexican Crusade), instigated the assassination of a president (i.e., Alvaro Obregon), and discouraged the Bracero Program, because it promoted the separation of families [7].

  1. II.

    Socioeconomic status

There has been a clear economic superiority of the United States over Mexico and practically the rest of the world. As highlighted above , both historical and cultural factors delayed economic growth in Mexico. The disparity between the neighbors’ economies has been present since the independence from Europe. Mexicans have migrated to the United States looking for better work opportunities, legally or illegally. This has had an inevitable impact on how neighbors relate with each other: as mere neighbors (i.e., early nineteenth century), as one neighbor being weaker and therefore vulnerable to invasions or in need of protection (i.e., Mexican-American War, Franco-Mexican War), one neighbor being the provider of unskilled workers for the other (i.e., Bracero Program), one being the consumer of illegal drugs produced by the other (i.e., war on drugs), one depending on the shoppers coming across the border from the other country, and the rich neighbor and the poor neighbor or the trade partners (i.e., NAFTA). Socioeconomic status is a dynamic aspect that will not cease to evolve. In the International Monetary Fund’s 2020 report, the United States remains as world economy number one and Mexico as number 15 [44].

  1. III.

    Region within a country

For purposes of this chapter, following the Cohen model, this section focuses on specific regions of the two countries. This region is the USMBR, where the biculturalism between these two neighbors originates and thrives. These are two countries with different languages, different flags, and different economies that have converged in a region that has gradually become economically productive and culturally vibrant. While the people share a common indigenous background, their histories and societal evolution strayed considerably for centuries. Not until the last few decades has trade, culture, technology, and migration brought them closer again. One of the most iconic representations of the relationship between these two neighbors is the Cross Border Xpress bridge, which connects the cities of Tijuana in Mexico and San Diego in the United States. This pedestrian tunnel starts at a custom-built station in East San Diego and connects directly into the Tijuana International Airport. It is staffed by migration and custom inspectors of both countries, with the corresponding security filters, allowing transit from one country to the other in a matter of minutes [18].

  1. IV.

    Psychiatry and biculturalism

Biculturalism has become a subject of study in psychiatry and mental health for at least three decades. This stems from studies of cultural identity, acculturation and migration, and its impact on mental health, behavior, cognition, substance use, and personality development [42,43,44,46]. A study on cognitive functioning measured by a battery of tests that included the six-item screener (SIS), the Brief-Spanish English Verbal Learning Test (B-SEVLT), the Controlled Oral Word Association, and the Digit Symbol Substitution Test in Mexican-Americans in California showed an association of bicultural engagements (i.e., engaging in activities in both English and Spanish languages) and higher cognitive scores [47]. This was a cross-sectional study of a subsample of the Hispanic Community Health Study/Study of Latinos, limited to adults 45 years of age and older . Other studies have shown that adolescents with higher levels of familism and biculturalism are less likely to internalize conflict and develop low self-esteem [48]. A longitudinal study on adolescent Hispanic immigrants showed that self-esteem, optimism, prosocial behavior, and family relationships were higher in those with greater scores of bicultural identity integration [49]. A study on a sample of Mexican-American adults with nicotine addiction receiving cessation treatment discovered longer periods of abstinence by those with strong American cultural identity and a strong heritage cultural identity [33].

In general, these studies suggest that those that identify as bicultural, or fused with both cultures, have better mental health than those that subscribe to only one culture within the Latin minority. Theorists argue that borrowing values from both cultures and applying them judiciously (e.g., alternating) are more conducive to mental health than indiscriminately subscribing to either culture alone [50]. Furthermore, it demonstrates cognitive and psychological flexibility, an important factor in mental health.

The phenomenon of biculturalism naturally plays an important role in the lives of mental health providers as well. Providers practicing in the United States, who were either born or raised in a different culture, are expected to understand the host culture(s) to properly meet the needs of their patients, without unsubscribing to their original culture [51].

Patient’s culture and cultural context, in which their symptoms might develop, are essential considerations in the clinical setting. Biculturalism, however, has not been studied enough to thoroughly understand its impact on patient’s state of health, other than the likelihood that it may be associated with better outcomes , better self-esteem, and prosocial behavior. Regardless of how much is currently understood about it, it is undeniable that a segment of the population is bicultural, and research suggests it is a favorable feature.

Vignette 1: Bill

Bill is a 46-year-old medically retired, married, Anglo-American male, who was born in rural Oklahoma and relocated to Imperial County, California, right before puberty. His father was a farm worker and his mother a full-time homemaker . He had difficulties in school likely related to an undiagnosed speech and learning disorder. Bill’s parents did not comply with his teachers’ suggestion to have him evaluated, even after he dropped out of high school during his sophomore year.

Bill started working in the fields, as his father did, but realized that he needed a better source of income. Eventually, he successfully attained his GED which helped him secure a job at the local power company. This was recognized as a great achievement in his family and neighborhood. In fact, he ended up marrying “the cutest and most desired girl” in his social circle. His job included paid vacation, health insurance , and a retirement plan. He worked as a heavy machine operator and was involved in setting up new electric lines around the county. Bill worked uninterruptedly for 17 years until he injured his back and became disabled.

He filed a workman’s compensation claim, and while he was getting his injury addressed, he was accommodated at a desk job. His issues with reading, focusing, and learning new material resurfaced, which generated frustration and fear of getting fired. During the ensuing 3 years, he watched his ability to work diminish, his finances deteriorate, and personally worst of all, his marriage disrupted. Bill discovered his wife was cheating on him, which marked the start of the depressive episode that led him to seek treatment. This event damaged his self-esteem and ultimately resulted in him ending the marriage.

As he engaged in services at the outpatient clinic, he was diagnosed with major depressive disorder, attention-deficit/hyperactivity disorder, specific learning disorder, and a speech disorder. He was offered psychoeducation, psychotherapy, and pharmacotherapy. After various medication trials, he responded to a combination of bupropion, gabapentin, and trazodone. He also underwent a spinal surgery that consisted of an L1, L2, and L3 level laminectomy and fusion. Additional medical issues included hyperlipidemia and class I obesity.

Once Bill’s income was restored, he decided to get married again, but this time, he “made sure” to partner with a Mexican woman, as he knew she would “never be unfaithful.” He learned this through his cultural exchanges with Mexican classmates and coworkers. In fact, he had learned his way around both sides of the border, and crossing the border was familiar to him. Bill met a single mother with three children, one of them with school problems and substance use. It appears as if he identified with her son and decided to help him. He improved his Spanish language skills, converted to Catholicism, and remarried. Bill adopted all of her children and immigrated them to the United States.

Discussion

Growing up in Imperial County, a primarily Hispanic region, allowed Bill to become familiar with some aspects of the Mexican culture. These included exposure to language, religion, and marriage values. It became his understanding that a Mexican woman, once married, will stay married and will not be unfaithful to her husband, whether happy or not. He considered this characteristic extremely significant to him, so he decided to pursue only women of Mexican descent. It would be reasonable to argue that this marriage was the start of him becoming bicultural, but it is unlikely since his growing up in this community allowed him to learn about Mexican culture since he was a grade school student.

Vignette 2: Sebastian

Sebastian is a 20-year-old male, part-time community college student and employed part-time, who was born in southern California but grew up in Baja California, Mexico. His family includes his Mexican-born father , his Anglo-American-born mother, and two younger siblings.

During childhood, Sebastian crossed the border every day to attend school. He was a top student in his high school and was accepted to a college near San Francisco. He joined a fraternity and focused his attention on socializing over academic performance. Toward the end of his first year, he began using recreational cannabis almost daily. Sebastian was fixated on moving through the ranks among his “brothers.” As a result, he skipped classes, failed to turn in assignments, and flunked exams. His breaking point occurred when a girl he liked turned him down, and he subsequently became increasingly paranoid and disorganized. Soon after, he was expelled from his fraternity for erratic behavior.

Sebastian was concerned with a delusional belief that everybody in school suddenly “discovered” he was Mexican. Since he carried his father’s surname of Mexican origin, his ancestry was no secret. However, he spoke English with hardly any Mexican accent, and his phenotype was that of a White Anglo-American male; he, therefore, explained that no one had initially suspected he was actually Mexican. Additionally, he was convinced that he would become a millionaire with a brand new “dot.com” venture.

He was hospitalized, and his psychotic symptoms completely resolved only to re-emerge within 6 months when he used cannabis and was hospitalized again. After his second hospitalization, he returned to living with his parents, and after 1 year he was able to return to the local community college and work part-time. His outpatient treatment plan included a combination of quetiapine and divalproex , an outpatient substance abuse program, and a work training program.

Discussion

Sebastian has lived in a bicultural environment since birth. He divided his days, partly in Mexico and partly in the United States. He managed very well across cultures; he was bilingual , enjoyed the cuisine of both countries, and would watch Mexican and American television shows and movies. However, the context where he became ill was different than the one where he grew up. This new social setting and eagerness to fit in may have contributed to his desire to hide his Mexican heritage. Furthermore, this case raises the discussion about the effects, consequences, and availability of cannabis, in particular, social factors determining a greater availability to minorities and potential genetic factors determining a greater biological proclivity of Mexicans and Latinos to become addicted [52, 53].

The clinical vignettes presented here underscore how the encounter of two cultures impacts the manifestation of disease, help-seeking behavior, and treatment response. There are different degrees to which people identify as bicultural, and this usually changes over time (as illustrated in case one) and across contexts (as illustrated in case two). In the clinical field, the phenomenology of disease is an intricate and personal experience where psychological and sociological research findings have to be carefully considered.

Training and Education in Biculturalism

The seminal paper on biculturalism by LaFromboise and colleagues in 1993 defined biculturalism within various sociological models [54]. The models included acculturation, alternation, fusion, and multiculturalism , which gave the basis to understand bicultural competence and adjustment to biculturalism without suffering negative psychological outcomes. This was certainly a breakthrough as earlier sociological theorists proposed that being bicultural, or being of “mixed race,” would lead individuals to suffer psychological conflict and identity confusion. This novel perspective proposed that an individual could demonstrate a high level of cultural competence in a second culture while keeping ties with the culture of origin. This required six skills:

  1. 1.

    Knowledge of cultural believes and values in each culture.

  2. 2.

    Positive attitudes toward both cultural groups.

  3. 3.

    Bicultural efficacy.

  4. 4.

    Communication ability.

  5. 5.

    Role repertoire.

  6. 6.

    Sense of being grounded in both cultures [54].

These skills are associated with better psychological and sociological outcomes when compared to individuals that choose to maintain competence in only one culture. Chen and Padilla propose the GEAR model, a theoretical framework to understand and see future development of biculturalism and bilingualism [3]. This model consists of:

  1. 1.

    Psychological Growth: a complex, multilayered, multidimensional network of interrelated self-beliefs.

  2. 2.

    Cognitive Exploration: flexibility and creativity related to language and higher order processing.

  3. 3.

    Linguistic Awareness: bilingual speakers demonstrate greater sensitivity to different linguistic and cultural contexts.

  4. 4.

    Social Reinforcement: improved social awareness and appreciation within and between cultural groups.

The GEAR model attempts to provide the basis to study and understand the assets of biculturalism and bilingualism and the common and differential effects of the two features on human behavior. In particular, the model allows for a framework to understand the complex psychological phenomenon of biculturalism, which has evolved from a past negative perspective to a more recent focus on its individual social and psychological advantages.

Researchers have expanded the study of bicultural competence to evaluate its prospective associations with mental health , including internalizing (e.g., depression) and externalizing (e.g., conduct disorder) symptoms. Two components of bicultural competence have been proposed: comfort (or affective bicultural competence, such as comfort with language switching) and facility (or behavioral bicultural competence, such as ability to switch languages), which span multiple cultural domains (e.g., affiliations, attitudes, behaviors, knowledge, values) [55, 56]. While findings are mixed, studies have suggested that individuals with greater bicultural competence may achieve higher levels of life satisfaction, self-efficacy, prosocial tendencies, and self-esteem and present lower levels of anxiety and depressive symptoms [56, 57, 58].

Consideration of a patient’s comfort and facility with biculturalism, as well as their identity integration and flexibility, will likely be relevant to case conceptualization and treatment. A mental health clinician may benefit from improving their ability to identify , address, and utilize aspects of biculturalism to improve health outcomes [3, 59]. Training clinicians in cultural competence has shown to improve care and health outcomes. The question at this point is if biculturalism trainings will be categorized separately or will be an extension of existing cultural competency trainings [60].

Recommendations

The evolution of the understanding of biculturalism from the last three decades suggests that bicultural competence in individuals has a positive impact on the ability to enjoy life and draw social support. It is likely to have an impact on an individual’s resilience and the manifestation of mental illness. The impact on treatment outcomes and the clinician’s competency to diagnose and treat bicultural individuals is less known. As an initial approach in clinical settings, it is recommended to adopt the use of the Mexican American Biculturalism Scale (MABS) [55], which consists of three domains with nine items each:

  1. 1.

    Comfort, explores the individual’s degree of comfort in each culture.

  2. 2.

    Facility, explores the individual’s perception as to his/her ability to navigate the demands of each culture.

  3. 3.

    Advantages, explores the advantages and disadvantages the individual finds in each culture in specific situations, such as traditions, group work, and problem-solving.

Additional recommendations for mental health clinicians are to obtain an understanding of the historical context in both countries, seek exposure and experience working with diverse populations, and increase cultural competence broadly. Furthermore, clinicians who provide care for minority and/or bicultural patients should not rush through establishing if the patient belongs to one culture or another but, instead, observe how patients navigate through both cultures and realize that American and Mexican biculturalism is common in both countries.

Conclusion

It is foreseeable that sooner than later, the economic gap between these neighbors will shrink. The International Monetary Fund’s 2020 report places the three members of the USMCA trade agreement as follows: the United States as the first economy of the world with a GDP of $20.5 trillion, Canada in tenth place with a GDP of $1.7 trillion, and Mexico as the 15th economy in the world with a GDP of $1.2 trillion [44]. The gap between Canada and Mexico is much smaller than the one between either one of the countries and the United States. Once economic differences are less of an issue, it is conceivable that the bicultural exchanges will be rather scientific, artistic, social, and technological; and traveling between countries will be easier.

It is also expected that the border will be more efficient in stopping drug and human traffickers entering the United States and illegal weapons entering Mexico. Hopefully, the border will become a symbol of two good neighbors, with bicultural members in both societies. In regard to the healthcare field, it is feasible that providers in both countries will continue to enhance their understanding of the “other” culture. In fact, during the writing of this chapter, an agreement was established for the exchange of psychiatry residents from a training program in California, United States, and one in Guadalajara, Mexico, to rotate in the other country as part of their training.

In the meantime, the Day of the Dead will continue to be celebrated in Los Angeles, while Halloween will be celebrated in Mexico City. Mexican cinematographers may win the Academy award again, as they did for three consecutive years. American athletes will be the stars in the Liga Mexicana del Pacífico baseball teams like Águilas de Mexicali, while Mexican athletes will be the stars of Major League Soccer teams like LA Galaxy. National Football League and Major League Baseball teams will continue to play in Mexico City and Monterrey, respectively, during their regular seasons.

Furthermore, bicultural exchanges will continue on the individual, daily, and small scale. Thousands of Mexicans will continue shopping at one of the many Walmart branches in Mexican territory, while thousands of Americans will continue working for Bimbo Bakery in American territories. The Mexican company Alsea will continue to run Starbucks in Mexico, Latin America, and Europe; and Americans will continue dining at El Pollo Loco. Chips and guacamole will continue to be the most popular snack during the Super Bowl, margaritas will the most popular mixed drink, hotdogs will be served with jalapenos, quesadillas will be served with root beer, hamburgers will be served with horchata, and breakfast burritos will help us start the day. As we prepare to host the 2026 FIFA World Cup that will take place in 16 cities of Canada, United States, and Mexico, we continue witnessing a fusion of both cultures sprinkled in daily choices.

Clinicians practicing in the United States should be aware that moving forward there will be more bicultural patients requiring care. With that in mind, clinicians should be prepared to conduct a thorough assessment to improve diagnosis, treatment, and compliance. It is also important to be cognizant that research in bicultural competence is ongoing and assessment tools are already available. Experience with theoretical models, assessment scales, and associated psychological sequelae with bicultural patients can enhance clinical practice.

Summary of High-Yield Points

  • The United States and Mexico have been neighbors for centuries. In spite of the commonalities in their origins, the United States and Mexico have departed in language, economy, population, and culture.

  • There is an incessant social, economic, commercial, scientific, and cultural interaction between the two countries. Individuals growing up in either country are likely to be exposed to the culture of the other country.

  • The US-Mexico border region (USMBR) is the longest border in the world and is a dynamic region with unique public health, infrastructure, educational, and economic challenges.

  • Biculturalism is defined as the ability to demonstrate a high level of cultural competence in a second culture while keeping ties with the culture of origin.

  • Biculturalism is often associated with better psychological and sociological outcomes for individuals, particularly when an individual develops (1) knowledge of cultural believes and values in each culture, (2) positive attitudes toward both cultural groups, (3) bicultural efficacy, (4) communication ability, (5) role repertoire, and (6) a sense of being grounded in both cultures [54].

  • The Mexican American Biculturalism Scale [55] is a self-administered scale that can assist in measuring the level of biculturalism of Mexican-American adolescents and adults by examining the primary domains of bicultural comfort, facility, and advantages.

  • The cultural exchange between the United States and Mexico is expected to continue growing.