Acapulco, Mexico - Francisco plays with the tissue after wiping his tears. He folds it, unfolds it. He looks at it, but he doesn't see it.
"There was a moment that … I can't remember … The news … Her body laying at the morgue … I lost track of everything," he says.
Francisco does not want to give his full name. He lives with pain and grief, but also with fear.
His wife had a vendor's stand on Acapulco beach in southwestern Mexico. Last year, she was caught in the crossfire between gangs fighting over the territory in which they extort local businesses. She was one of the 834 Mexicans killed in this tourist resort in Guerrero state during 2017, according to national statistics.
Francisco has four children and an internet cafe in one of the most dangerous neighbourhoods of Acapulco - Zapata. He is one of the 1,224 people who attended Doctors Without Borders (known by its French initials, MSF) mental health programme last year. The NGO has given psychosocial assistance to more than 11,000 people and therapy for nearly 200 victims of sexual violence.
"Therapy has been very useful for us. If you don't have it, it's as if the ground moves under your feet," Francisco says. "I've learned to have time to grieve."
Not everyone is so lucky to have mental health assistance, however. Francisco says he knows about 20 people who have suffered similar tragedies and he is the only one who receives therapy.
The last National Survey of Psychiatric Epidemiology that included post-traumatic stress disorder found that 68 percent of Mexico's 100 million people have been exposed to a traumatic event and one-third of the population have been exposed to three or more stressful events.
The study was conducted from 2001 to 2002 and has not been updated. Since then Mexico has suffered through the ongoing drug war. More than 120,000 people have been killed and there are 30,000 missing, according to official statistics.
Al Jazeera's request for an interview with federal authorities was not answered.
In the line of fire
The first Acapulco area where MSF begin working in 2013 has become a battlefield.
"Huge shoot-out at Colonia Jardin… Caution! #Acapulco."
"Police say roundabout at Jardin has become a battlefield."
"Thousands of people have no public transportation in western Acapulco because they're threatening to kill drivers and burn their buses if they go to Jardin."
Social media networks lit up with messages warning about the Jardin neighbourhood on February 7. A statement from the Guerrero prosecutor's office said it found a taxi with two high-powered rifles inside, and a corpse with his throat cut in the boot.
Weeks prior, buses were burned in that quarter. Residents talked about strange movements of men with weapons and "hawks" - local slang for criminal informants - who went house-by-house announcing a curfew. The killing of a gang leader had triggered a battle for power.
Lupe, whose name has been changed to protect her identity, has received therapy from MSF at the Jardin clinic for months after her husband was killed. Four months later, her former husband and the father of her two children were also murdered.
The 32-year-old says she feels extremely nervous.
"But she is very strong and resilient. She keeps her business, a salon, open and takes care of her family," Delia Sandoval, her therapist, tells Al Jazeera.
Lupe and her daughters witnessed her husband being shot dead in front of their home.
"Psychological damage in the girls is difficult to estimate at this moment," Sandoval adds. "The children loved him very much."
After the murder of her step-father, Lupe's teenage daughter decided to move in with her father who lived in another state. Shortly after, though, he was also killed.
'Social fabric destroyed'
According to the head of MSF's Mexico mission, Bertrand Rossier, the scale of violence in some states is "as high as in a war-torn country".
"The violence gets to such a level that the social fabric is destroyed," Rossier says.
Experts agree it is hard for someone with such a high level of pain to live a healthy life if they don't receive any help. The effects of the tragedy increase. Low self-confidence and feelings of guilt can degenerate into chronic mental illness, or turn victims into criminals. "We have to stop that," Rossier says.
Both experts and victims agree.
"Boys can become criminal or addicts. Girls can end up on the street and this situation just continues," Francisco says. "All those violent people come from broken families."
"The social fabric is so destroyed that it cannot be healed in one generation or two because wounds become deeply embedded."
- ELENA AZAOLA, CENTRE FOR SOCIAL ANTHROPOLOGY HIGH STUDIES AND RESEARCH
He says that is his biggest fear: that his children could end up this way.
Experts say mental health illness caused by trauma is an "invisible" problem.
"No one pays attention to it. No one is aware of the aftermath, and no one can visualise its magnitude," psychoanalyst Elena Azaola, from the Centre for Social Anthropology High Studies and Research, says.
Sometimes victims do not think they need help, especially men, because Mexico has no mental health culture.
Francisco remembers his friend asking him, "Are you a little mad?" when he said he was going to therapy.
Azaola says the entire Mexican population is an indirect victim of the gang violence. "The social fabric is so destroyed that it cannot be healed in one generation or two because wounds become deeply embedded."
An example is the normalisation of violence. Francisco's wife was killed in daylight at a tourist spot, but he says the danger is greatly reduced if you don't go out after dark.
After years of violence, there is no a comprehensive federal programme dedicated to psychological support for drug-war victims, only isolated efforts.
"The present National Mental Health Program is small, it is not accomplished, and it is far away from reality," Azaola says.
NGOs such as MSF help, but they cannot do the job on their own.
Dr Carlos Beristain says it's imperative to find new strategies to deal with the grief process for victims.
Beristain, who was one of the international experts investigating the 2014 case of 43 missing Ayotzinapa students, remembers the impunity and lack of justice for victims who became stigmatised instead of helped.
In 2013, Maria Elena Medina-Mora, currently the National Psychiatry Institute's director, complained about the lack of money and specialised staff. Nothing has changed since then.
Mexico puts large amounts of money into its security forces, but only two percent of the country's health budget is earmarked for mental health.
Nowadays, the army is ordered to watch over schools in Acapulco, but it doesn't arrive to all of them. Aquiles Serdan elementary school has no soldiers out front. It is located close to a tiny stream on a hill, and the military only shows up if there is an anti-crime operation.
Dalia Romero, the school's director, recalls a riot last July in a prison a couple of streets away from the school: 28 inmates dead, their loved ones crowded at the entrance to get any news, and the huge deployment of security forces.
"Mexico has a humanitarian tragedy and we have not grasped how big it is."
- ELENA AZAOLA, CENTRE FOR SOCIAL ANTHROPOLOGY HIGH STUDIES AND RESEARCH
Romero remembers the children's horror when the military raid on the prison began.
"The school has been surrounded several times [by security forces] because at the back of it there are safe houses [used by criminal gangs]," Romero tells Al Jazeera.
Its walls isolate the schoolyard outside, but students can hear everything that is going on. "They become distressed and they cannot learn in that condition," she says.
Romero, 43, became acquainted with MSF's staff when her husband tried to disfigure her face with a fork and she asked for help. Now she is a close ally of the NGO. It organises meetings to train teachers how to detect when a child is in trouble.
"Some children suddenly disappear from the school because all the family has had to run away and we have no more news from them," says Romero.
MSF says the authorities must be pushed to prioritise mental health disease caused by years of drug-related violence.
"Mexico has a humanitarian tragedy and we have not grasped how big it is," Azaola says. "And we have a powerless, incompetent, overwhelmed government that doesn't react, maybe not because of bad intentions but to try to minimise the situation."
"Time does not heal everything," Beristain adds.