Photograph by Matthew Suárez

Dr. Diana Pazos says “If my clients don’t follow through on their end, if they don’t at least try to change their behaviors, why waste my time and their money?”

“Everyone’s crazy everywhere,” quips psychologist Livier Celaya as she sits her office in the Zona Rio quarter of Tijuana. “It doesn’t matter what side of the border you’re on.”

Photograph by Matthew Suárez

I’m in Tijuana to find out why people from San Diego, Los Angeles, and even as far as Texas are crossing the border for medical reasons. Not just for hip replacements or to get their teeth cleaned or for boob jobs, either — but to get their heads right. Call it mental health tourism. (Post-pandemic, “crossing the border” may be more virtual than literal. Once, 90 percent of Celaya’s clients met with her at her office, which is just minutes from the border. Now, 100% see her online.)

Celaya, who has been a psychologist for 20 years, says that nearly half of her clients live in the U.S., mostly in San Diego. “Some were born in Mexico and later emigrated to the U.S.,” says Celaya, who specializes in therapy for adults and play therapy for children, and also offers spirituality therapy for nuns and priests. Others may be first- and second-generation Mexican-Americans who “want a therapist who understands their culture and the dynamics of their Mexican family.” Most of Celaya’s clients want to “improve their quality of life and have a deeper knowledge of themselves. They want to talk about dysfunctional dynamics in their family life or in their relationships.” Others want help coping with anxiety or depression.

Another factor to explain the emergence of mental health tourism is the cost. One therapist I spoke to says clients can save up to 75% on therapy if they get it in Mexico. If therapists charge $100 and up per hour in San Diego, you can find a good therapist for $40 to $60 per hour in Tijuana. There are two insurance companies that cover people who work in the U.S. but want to receive their medical and psychological services in Mexico: SIMNSA and MediExcel. Most clients, however, pay out of pocket.

The Human Touch

Martha Garcia, 58, came to the U.S. 30 years ago. Life was good in San Diego until, in 2006, what should have been routine surgery turned into a disaster requiring multiple follow-up surgeries, causing intolerable physical and emotional pain. After sinking into a deep depression, Martha sought the help of a therapist. Although the therapists she met were competent, she found connecting with them difficult. In general, she felt, therapists north of the border didn’t see her as a human being. “They didn’t really give me their time. You’re more like a number,” she says. What’s more, the therapists didn’t understand her needs, which she attributes to a cultural disconnect. How could a therapist be empathetic if they had never been in her shoes? “If you haven’t tasted an orange, then you don’t know what it tastes like,” says Martha, who had a very difficult upbringing: the second youngest of eight children who grew up in Mexico in poverty, often without enough food, clothes, and other basics. When she’d tell her story, the therapist would give her a blank stare. It seemed they couldn’t relate to or identify with the circumstances that shaped her.

Livier Celaya, who has been a psychologist for 20 years, says that nearly half of her clients live in the U.S., mostly in San Diego.

It wasn’t until 2010 that Martha found someone who understood her and could help her feel good again: Dr. Diana Pazos, who runs a private practice for adults and adolescents. In contrast to psychiatrists north of the border, who might “spend seven to 10 minutes talking to you,” Martha could feel Dr. Pazos’ warmth, empathy, and humanity. “Her compassion, that wonderful smile, her human touch. She took the time to learn who I was and how to talk to me,” she says. “I learned to know myself and how to love myself and how not to control others.” Martha’s time with Dr. Pazos was so important to her that she was willing to drive south of the border to see her at her office, even if the wait on the return journey meant not getting home to San Diego until 2 am. “It was hard, but it was worth it.”

She was reluctant to go on medication, but Dr. Pazos explained it to her in a way that made sense, “talking about the receptors and how the medication affects the brain. She overcame my resistance. She helped me understand that meds are not my enemy.” Today, Martha has a psychiatrist in San Diego who prescribes her meds, though she still has a divided mind about taking them. Dr. Pazos, however, continues to be her therapist. “She’s there for me anytime that I need her, in-person, texts, Zoom. The talking is my medicine,” she says. Their doctor-patient relationship has lasted 14 years and endured heated disagreements and occasional breakups. Dr. Pazos explains: “If my clients don’t follow through on their end, if they don’t at least try to change their behaviors, why waste my time and their money?”

Martha says Dr. Pazos, who she now regards as family, “knows me more than I know myself.” Recently, when Martha broke her ankle. Dr. Pazos started dropping by her home, bringing her food and helping her out around the house. And of course, talking. “Who in the U.S. would do that?” she asks.

Guillermo Flores is a 39-year-old bilingual therapist who also has an office in Zona Rio. He specializes in family therapy and addiction. Currently, he has three clients from the U.S., but that doesn’t count the people he helps at rehabilitation centers in Tijuana and Rosarito, where he estimates 60% to 70% of the clients “who are trying to get sober” are white Americans. For them, he conducts group and individual therapy sessions. And when they leave the rehab center and return to the U.S., they often keep Flores as their therapist via Zoom. “If they know me and feel comfortable with me, they will usually continue.”

Guillermo Flores currently has three clients from the U.S., plus the people he helps at rehabilitation centers in Tijuana and Rosarito, where he estimates 60% to 70% of the clients are white Americans.

Both Flores and Celaya agree that their clients’ mental health issues differ slightly, depending on which side of the border they live. “More anxiety north of the border, more depression south of the border,” Flores says. In her clients from the U.S., Celaya sees “a lot of stress and anxiety about the economy: housing, student loan debts, the cost of living, unemployment.” And in his addiction practice, Flores sees more opioids, alcohol, and marijuana addiction north of the border and more stimulants like cocaine south of the border.

Adrian and ADHD

Flores says he’s seen a change in the last seven or eight years, a growing acceptance of therapy in Mexico. People are realizing “there’s more aspects of their lives that they need to take care of.” At the rehab centers in Baja Norte, many of Flores’ clients are initially skeptical. “They’ve never done therapy before, and tend to close up. Then they open up over time.” At his group therapy sessions, he asks why people refused to get help when their families and loved ones urged them to see a therapist. “They almost all said the same thing, that ‘I’m not crazy,’ that something must be wrong with them if they need therapy.”

Sometimes, it’s not about urging a peer to seek help. Sometimes, it’s about seeking help for a child. Adrian Aguirre, who lives with his parents in the city of Whittier, outside Los Angeles, was born in Mexicali, then adopted by his current family. At a young age, he was diagnosed with ADHD, or Attention Deficit Hyperactive Disorder. “He was given medication when he was in elementary school,” says his mother, Irma, 55. “But they discontinued the meds because they weren’t making much of a difference.”

After eight months at Sunset Bay Academy, Adrian Aguirre was sent to Hospital de Salud Mental de Tijuana.

In middle school, there was a marked change in Adrian’s behavior. “Eighth grade is when things started going downhill,” says the 17-year-old. He began getting into arguments at school, defying authority, refusing to do his schoolwork, and becoming distracting the classroom. “And I’d bring home a lot of frustration and anger and aggression,” he says. This was, not coincidentally, also around the time he was introduced to drugs, especially marijuana. Further, he was sexually molested for years by the cousin who was supplying him with those drugs.

When Adrian entered high school, his issues only grew worse. His parents decided to send him to a residential treatment center, where he would live full-time and hopefully get the help he needed. Located in the hills of Los Angeles, it would be the first of multiple residential treatment centers along his journey. When LA didn’t work out, he was transferred to a facility in Utah.

Utah is home to almost 100 youth residential treatment centers. In a series on Utah’s “troubled teen” industry, the Salt Lake Tribune reported that, “When the nation has kids it doesn’t know what to do with, it often looks to Utah, where a lucrative for-profit industry thrives with minimal regulation from state officials.” The series uncovered allegations of kids being mistreated. According to the paper, some kids were helped, while others said they were tormented and abused, both physically and mentally. (Netflix recently released a documentary called Hell Camp: Teen Nightmare, about wilderness therapy in Utah that proved anything but therapeutic.) The paper interviewed child advocates who claimed that the kids didn’t see anybody in the community or even their parents, and become very isolated.

That appears to be what happened to Adrian. “I felt isolated in Utah. It was very militant. And they just didn’t really treat the kids right. So, I refused to do the program and sat there doing essentially nothing for over a year and a half.” His next destination: Playas de Tijuana. “I guess my parents got the message and took a chance and sent me to Mexico,” he says. For the next several months, Adrian stayed at Sunset Bay Academy in Playas, a coastal suburb of Tijuana. The facility’s website describes Sunset Bay Academy (SBA) as “a program for rebellious youth and therapeutic school for teenagers with behavioral disorders.” It claims that in its 15 years, it has “helped over 950 families with teenagers, ages 12-17, suffering from various behavioral and academic problems.”

An administrator at the Utah center recommended SBA to Adrian’s family. “My husband researched it and it looked like they had good outcomes and success, and more of a family-oriented program,” says Adrian’s mother. SBA also seemed to “have a lot of social interaction, which Adrian needed. I think that was the missing piece,” she says. Living in LA, they were close enough to visit him, another plus. “SBA was like night and day,” says Adrian. “There was a lot more freedom. You could wear what you want, except when you had the uniform on. It was just a lot more freedom and less like a prison — like Utah was.”

Adrian says most of the kids at Sunset Bay Academy were from the United States. Adrian’s father, Roy, 62, says SBA was 25% less expensive than treatment centers in the U.S. “The cost difference was very nice.” Still, while there were ways in which SBA was a big improvement, Adrian felt he wasn’t making enough progress. He was still having difficulties, including thoughts of suicide. After eight months at Sunset Bay Academy, Adrian was sent to Hospital de Salud Mental de Tijuana (HSMT), a mental health hospital in the Otay Mesa section of Tijuana, just a mile from the border.

Help at HSMT

Before HSMT opened in Tijuana, there was only one mental health hospital in a city of over two million people, and it was in a state of disrepair. In 2003, a group of doctors, led by Dr. Jose Guadalupe Bustamante, formerly the Secretary of Health for Baja California, saw the need for a new mental health hospital in Tijuana. It took them a few years to raise the capital, but in 2007, Hospital de Salud Mental de Tijuana opened doors. Dr. Bustamante serves as the general director, and Dr. Diana Pazos, the psychiatrist and therapist who treats Martha Garcia, directs the hospital’s child and adolescent section.

Dr. Diana Pazos and staff at Hospital de Salud Mental de Tijuana. Before HSMT opened in Tijuana, there was only one mental health hospital in a city of over two million people, and it was in a state of disrepair.

Photograph by Matthew Suárez

When Dr. Pazos met Adrian, her impression of him was that “he was an intelligent teenager, very articulate, very polite, but had problems with authority.” He would get defensive very easily, and always try to rationalize his behaviors, she says. “It was hard for him to talk about his emotions and easy for him to avoid responsibility for his actions and point fingers at others.”

Adrian came to HSMT with the diagnosis of ADHD and ODD — oppositional defiance disorder. After consulting with Adrian and his parents, Dr. Pazos added depression to the diagnosis and began treating him with meds. The parents, she says, were not crazy about the idea of medication. He wasn’t given any at Sunset Bay, nor in Utah. Dr. Pazos convinced them to give it a try. When the parents saw the positive changes in Adrian, they grew to support the use of meds along with therapy. “Every day, she would adjust the medication until they found the correct fit for him,” says Irma Aguirre.

“I think Dr. Pazos was very strong and insistent in her decisions,” she adds. “So, teenagers who try to manipulate situations realize, ‘I can’t get away with that with her.’ When we met Dr. Pazos, she actually enjoyed talking to Adrian. We were very impressed. She took the time to meet with us, which was also another thing that we didn’t see in the U.S..” She says Dr. Pazos allowed the family to “express our concerns. And she said, ‘This is my plan. This is what I’m going to do, this and that.’ So, she was very clear and up-front with us.”

As for Adrian, he thought “Dr. Pazos was nice, but at first, she was also very imposing. So, she kind of tells you the problem. And you can’t argue with her. She’s like, ‘Okay, this is what’s wrong with you. And this is what you’re doing.’ You realize you’re not going to win. I didn’t like it at first. I had to just kind of like submit, just let go. And as I improved, she became kinder and I stopped talking back, so I guess she reciprocated what I gave her. I learned to trust and appreciate her.”

The hospital has 26 beds. Dr. Pazos shared the daily routine for the patients: Up at 6:30 am, lights out at 9 pm. One hour of exercise and cardio, followed by four hours of group therapy in the morning and four hours in the evening. Art therapy, sports, and yoga – three days a week allocated for each. No internet or cell phones. “So, it’s breakfast, and then you get your meds and then it’s time for physical training,” explains Adrian. “You go run some laps and they put music on for you. So that’s good. And you get to talk a little bit with your peers.” It’s co-ed, but the boys and girls are separated. “So, you go outside and that’s when you get to talk and walk around. They have you do push-ups and they have weights for you to use if you’d like. Afterwards, you reapply deodorant, brush your teeth, get your hair done and then it’s time for therapy.”

Over time, Adrian’s suicidal thoughts faded. “I felt a lot better. It was a big improvement.” The parents credit the meds, but more than that, the social environment. After three-and-a-half weeks, Adrian was referred back to Sunset Bay Academy with instructions for the staff on dispensing his meds. He stayed another three months at SBA until he became more stabilized. Then, it was time to go back home.

Life after discharge

Dr. Mark Katz, a retired adolescent psychiatrist who practiced for over 30 years in San Diego, says what happens after an in-patient stay is completed is equally, if not more, important. “The in-patient experience “is oftentimes just a start. It’s not the definitive cure. It’s a start that has to be followed up with good outpatient treatment,” he says. Back home in Los Angeles, as Adrian settled in, he continued to have contact with the therapists from Sunset Bay Academy and with Dr. Pazos and her team at HSMT. First, once a month, then every two months.

“I’m going to adult school, working for my GED. I’m very close to getting that,” Adrian says. During the day, he works with his dad at his carwash. “I’m keeping busy throughout the day. And my relationships with people, especially my family, are really good.” As for drugs, “I’m clean. I’ve been sober for around three years. I haven’t contacted old friends and especially those people I used to hang around with.”

Laura and Logan Dishman 

Laura Dishman lives with her son Logan in Austin, Texas. She adopted him when he was two. His birth mother, she explains, smoked three packs a day while pregnant with him. Logan, now 16, “was born with severe ADHD. He struggled as a child with impulsivity and getting along with others,” she says. “It was around two years ago that Logan began to struggle over being adopted and not having a male role model in his life. You know, we’ve never had a dad around, because I’m a single mom.”

Logan recalls, “I was talking back, punching walls, throwing chairs. Just really angry. I was disrespecting anyone who got in my way. I was not really in a happy mood. I was just miserable.”

HSMT’s child and adolescent section has 26 beds. Patients are up at 6:30 am, lights out at 9 pm. One hour of exercise and cardio, followed by four hours of group therapy in the morning and four hours in the evening; art therapy, sports, and yoga – three days a week allocated for each. No internet or cell phones.

His mother sent him to a residential treatment center in Tennessee, but the extra help that he required wasn’t there, and he “struggled immensely,” says Dishman. Logan was “bounced” to another program in Missouri, where he stayed three weeks. “It was very authoritative, and there was no therapy at all. It was just obvious it wasn’t going to work out.” She describes it as a “King James Bible-type of program.” A religious person herself, Dishman is quick to add that, “I’m not trying to stereotype, but they were fat old men that ruled by the thumb. And you did what they said or you were gonna get in trouble.”

Logan interjects: “They were just dumb.”

“It was not a good fit for him,” Laura says, emphasizing that he is an ODD child. “He was very rebellious, you know, acting out, fighting.” He was frequently sent to “brown town,” where he was fed only peanut butter and bread.

“My mom did not make good choices,” he says matter-of-factly.

She continues, unaffected by her son’s comment. “It just wasn’t a good fit for him.”

I’m reminded of something Dr. Pazos said. “These treatment centers are supposed to specialize in helping kids with problematic behavior, but if you’re a problem, they kick you out.” As for Utah, “The reviews of Utah scared me because they don’t have a lot of the child protection laws” that other states have.

Dishman was advised by a provider in Texas that Sunset Bay Academy in Playas de Tijuana had a good reputation and a very caring staff. “I just prayed for the right fit. I was nervous about sending him to Mexico, to another country.” But when she arrived, she felt the difference immediately: “Mexico is just a different culture, a different feel.” She was generally happy with the therapists at SBA and tried to be understanding, knowing it was “a very difficult situation being there, with a lot of boys just like Logan that all needed help.” She says the staff at SBA were very strict, but on the other hand, “I can’t imagine doing some of the things that the boys do either. There’s a fine line. I mean, I know they have to be strict, to keep them all there and keep them safe.”

At SBA, she says, “they struggled with getting his meds right.” That was a factor in the decision to transfer Logan in May 2023 to HSMT. And that’s when Laura Dishman and her son Logan, like Adrian Aguirre and his parents Irma and Roy, met Dr. Pazos. Dr. Pazos put Logan on an anti-depressant. Dishman notes that it made her want to explore meds for herself. “I’ve been on one for a couple of years,” she volunteers.

Logan says that initially, he was very tired. It took a couple of weeks to get used to the new environment and the medication. I asked him if he was aware of the underlying factors causing his depression. “I was but I wasn’t, if that makes sense. I was aware of my behavior, of what I was doing,” he says. Through group and individual therapy with Dr. Pazos, he became aware of why he wasn’t feeling good. He gained insight into feelings he’d buried and now had to confront – feelings about being adopted, feeling rejected, and not having male role models in his life.

Dr. Pazos did things that were game changers, Dishman says, things the treatment centers in the U.S. didn’t do. “Building the relationship and trust through talking about feelings and getting Logan’s meds right.” Dr. Pazos, she says, “helped Logan more than anyone we’d ever met.” Getting his meds right “calmed him down enough so he could express his feelings and tell you what he was feeling inside.” Logan nods in agreement as she continues: “For a defiant child, telling them what to do doesn’t work. I mean, they’re gonna go against you unless you have a relationship with that child. And that’s how it’s always been for Logan with his teachers. When Logan cares about you and he knows that you care about him,” he’s more likely to listen instead of being defiant. “He just has to learn which boundaries you don’t cross, and that’s hard.”

Logan stayed six weeks at HSMT, then he was referred back to SBA. But he left there prematurely because SBA ran out of his stimulant medication for three weeks and he started regressing fast. “It’s the thing that helps him the most with his ADHD,” Dishman explains. “He was starting to act out and they were like, ‘You gotta come get him before he does something really stupid.’ So, I brought him home.” Dr. Pazos explains that, beginning in 2021, Mexican pharmacies experienced a shortage of mental health medications, especially for ADHD and bipolar disorder. (HSMT wasn’t affected, because it had an agreement with a distribution center.) Pharmacies’ access to these important medications has since improved, she says.

“Logan felt loved at SBA, and the staff do love him,” says his mother. He calls them for Christmas and says he’d like to go back there. Dishman, of course, has a different agenda: for Logan to become independent and not need SBA. Once back in Texas, Logan got back on his meds. “He’s doing awesome, and I know he’s gonna be a great dad someday,” Dishman says. She’s enrolled him in a “great private school that helps him with accommodations and with schooling.”

What’s also noteworthy is that they continue to use Dr. Pazos as a resource. “We continue to call her to ask if we should go down on this or up on that med,” she says. “I have a doctor here that prescribes the meds, and I push her to agree with what Dr. Pazos tells me.” Dr. Pazos also speaks directly with Logan at least once a month to see how he’s adapting to school and handling everything.

Dishman hasn’t been able to find a therapist for Logan. “They’re either not taking new patients or they’re full,” she says. From her office in Mexico, nearly 1200 miles away, Dr. Pazos plans to recommend a therapist in Austin “that we’re going to try.” But in the meantime, Logan has Dr. Pazos, “someone to talk to, to express feelings so that it doesn’t just continue to build, build, build and then blow up,” says Dishman.

Like Martha Garcia, like Adrian Aguirre and his parents, Laura Dishman appreciates Dr. Pazos for always making herself available. “She explained everything so well and was always accessible. She’d text me or call me, no matter the hour, responding at 11 pm, even midnight, when I was so anxious and worried. Had I known about Dr. Pazos and the mental health clinic, I would have just gone straight there” and bypassed the other clinics, she says.

Time runs out and our Zoom call comes to an abrupt end, mid-sentence. But Dishman calls me right back. I hear tears starting to form: “You have to understand that being from Texas, being a single mother, that sending your son at that age all the way to Mexico, and not knowing really what his diagnosis is, and not being able to speak with him…as a mother…” She starts to cry. “…As a mother, I was just scared to death.” Once she got in touch with Dr. Pazos, everything changed. “I owe her my life.”