Finding hope and help for New Americans who are hurting
When refugees come to Nebraska, they have fled traumas — war, torture, genocide, persecution, imprisonment. Many experienced equally traumatic journeys in their search of safety.
Yet their first priority in their new country is to meet an urgent deadline: Becoming self-sufficient in 90 days in an often perplexing place where they don’t understand the language, culture or bureaucracy. The clock starts ticking the moment they arrive.
Because of the traumas that forced them from their homes, their often perilous journeys to safety and the stresses of being resettled in a foreign country, refugees often are at risk for emotional and mental illnesses.
These series of stories, produced by University of Nebraska-Lincoln journalism students, explore the mental health problems refugees face, the obstacles they must overcome to get treatment and the solutions being offered to help them.
Illustrations by Alexa Horn
When refugees come to Nebraska to start a new life, they often focus on learning English, getting a job and finding affordable housing.
Taking care of emotional and mental health needs is a low priority — if it’s even a priority at all.
Refugee advocates worry about the emotional well-being of these New Americans. Untreated mental health problems can affect how well refugees assimilate and can lead to other health problems or addiction.
And these advocates worry about the increased anxiety they’ve seen among refugees in Lincoln and elsewhere because of the Trump administration’s anti-immigration and anti-refugee statements.
The most common mental health diagnoses for refugees include post-traumatic stress disorder (PTSD), major depression, generalized anxiety, panic attacks, adjustment disorder and somatization, which occurs when psychological concerns are converted into physical symptoms, according to the Refugee Health Technical Assistance Center.
Yet treating traumatized refugees is a complex problem that is complicated by a myriad of factors and obstacles — from lack of access to language barriers to stigmas.
Most advocates agree that cultural factors are among the most important and challenging.
“The lack of cultural understanding is one of the biggest issues in addition to the logistics of interpreters, getting the refugee transportation,” said Patrice McShane-Jewell, a former caseworker for refugees at Lutheran Family Services, who currently contracts with the Asian Center. “Therapists in the U.S. understand and have studied the mental health of Americans, but the New Americans are coming in with completely different beliefs and understanding of mental health.”
Some refugees resist seeking help because of their own cultural issues.
“Many refugees will not discuss mental illness to avoid being stigmatized and rejected by their community,” said Dr. Amy McGaha, a professor at Creighton University School of Medicine who treats refugees as a physician at a CHI (Catholic Health Initiatives) clinic in Omaha.
In the Karen community, for example, it is considered an embarrassment and dishonor for one to be diagnosed with a mental illness. That is why most Karen would not admit that they have a mental issue.
Yet Karen refugees have a traumatic history and often struggle the most with the resettlement process, said Drew Miller, a case manager for refugees at Catholic Social Services.
Many Karen fled a vicious war in their home country and then had their freedoms stripped away in refugee camps, where many suffered for several decades before being resettled. Suicide was common in refugee camps, said Sho Say Gay, a Karen interpreter for Catholic Social Services.
Additionally, many refugees come from cultures that view mental health through a spiritual perspective and may not approve of the treatment an American doctor recommends, McGaha said.
U.S. health care workers also incorrectly assume refugees are willing to be open and honest about mental illness like Americans are, McGaha said.
Cultural differences among refugee populations can also be problematic.
Even after moving to the United States, Yazidis, an ethnic religious minority from Northern Iraq, are uncomfortable associating with or being around the Lincoln’s Muslim population, who are a reminder of the religious and ethnic violence the Yazidis faced in Iraq, said Jolene McCulley, program manager at the Yazda Yazidi Cultural Center in Lincoln.
“They need to feel safe. That’s something they really thrive on right now is to feel safe,” she said. “So they might be sitting next to somebody while waiting in the waiting room that triggers something in them from back home, and ... instead of being therapeutic, it’s something that takes them five steps back.”
While it is important to find solutions to the problems that affect many refugees, McGaha said, refugees are not monolithic; the only way to provide help is by understanding their differences.
“Refugees who come from a country with a more developed health care system, like Syria, will often know when it is appropriate to attend the emergency room versus when to purchase an over-the-counter pain reliever from the store,” McGaha said.
Other refugee groups may not understand these nuances because their native countries do not have an established health care system similar to what they experience in the U.S., she said.
In addition to cultural concerns, language issues present another potential obstacle. Words often lose meaning when translated from one language to another, and many translators may be unfamiliar with medical jargon, McGaha said. She said it’s important to use interpreters with specific expertise in health care to best ensure that translation is most accurate.
But finding interpreters with health care expertise is difficult, McShane-Jewell said. In addition to knowing how to properly interpret medical terminology, interpreters need to understand issues such as confidentiality and to even know when it is appropriate to begin talking, she said.
Sometimes scheduling an interpreter or finding one who speaks the language can be difficult, and using family members to interpret often is problematic, McShane-Jewell said. Ultimately, if the patient doesn’t feel comfortable speaking through the interpreter, then there is little chance the therapy will be helpful, she noted.
Access to mental health care can be a stumbling block for some refugees, particularly for those who might fall in a “coverage gap” that was created when Nebraska didn’t expand Medicaid.
In 2012, the U.S. Supreme Court upheld the Affordable Care Act, or ACA, but struck down a Medicaid expansion requirement, leaving states the option to participate. Under Medicaid expansion, the federal government has paid the full cost for the first three years, from 2014 through 2016. Currently participating states are required to contribute some of the cost during a phase-in period. Cost to the states will reach 10 percent by 2020 and remain fixed at that level.
Nebraska did not expand Medicaid, leaving the program available only to extremely low-income earners, disabled people, low-income children and pregnant women. The ACA was written based on Medicaid expansion to everyone with household incomes up to 138 percent of the federally defined poverty level, $12,060 for one-person households and $20,420 for three-person (family) households.
This created a “coverage gap” because ACA premium subsidies are not available below 100 percent of the poverty level. In Nebraska, residents falling below 100 percent of the poverty level do not qualify for health insurance subsidies or for Medicaid except under rare technical circumstances.
While mental health treatment for refugees can be complex and challenging, insuring it is vitally important, advocates agreed.
Refugees come to McGaha’s clinic experiencing unexplained chronic pain, which she says is often related to assimilation anxiety and depression. And, if refugees do not receive appropriate treatment, many may abuse alcohol or other substances to help them cope, she said.
McCulley, who works with Yazidis, said mental health is the most important issue in helping refugees in resettling and returning to a normal way of life. She cited the example of victims traumatized by ISIS.
“There’s a lot of trauma for the ISIS victims, so they’re dealing with a higher level of mental health issues. For the victims, it’s more debilitating to them, I guess. It’s hard for them to learn, to comprehend, to absorb information,” she said. “One of our victims is in English and she is having a very hard time learning, and we think it has a lot to do with how she’ll progress a little bit and she falls back into depression.
The Trump administration’s anti-immigrant and anti-refugee policies are creating more anxiety for refugees, according to health care providers like Bernice Afuh, a public health nursing supervisor at Lincoln Lancaster County Health Department. The administration’s decision to reduce the number of refugees America will accept has many refugees worried that their families will not be reunited, she said.
Jessica Goodkind, the founding director of a wellness program for refugees in New Mexico, also has noticed an adverse effect from the political discussion.
“We have seen for some people who maybe had experienced trauma in the past that it’s sort of an exacerbation of PTSD-type of symptoms because of the stress,” she said.
That increased anxiety has only made finding help for refugees more pressing, advocates say.
“Yazidi need any and all help they can get,” McCulley of Yazda said. “Counseling, support groups and psychologist assistance. You name it, they need it.”
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The problems: Refugees share their personal stories
A Yazidi woman enslaved by ISIS. A young Karen woman born and raised in a refugee camp. A mother who fled a brutal war in Sudan with her seven children.
These three women came to Lincoln, Nebraska, under different circumstances, but they all suffered hardship, pain and trauma. They said they hope sharing their personal journeys can inspire and help others.
By Utami Kusumawati
While being held captive by the Islamic State, Shireen Jardo Ibrahim wanted to end her life.
The young Yazidi woman who now lives in Lincoln said she could no longer bear the torture, frustration and humiliation of being an ISIS slave for nine months.
“I just hated myself and wanted to commit suicide,” she said through an interpreter.
Even after escaping ISIS and finding relative safety in a refugee camp, Ibrahim still thought about suicide.
“But my brother, Qahtan, always consoled me. ‘Do not worry. You will always be our sister and we will still respect you as our sister. Many women also experienced the same thing with you.’”
During captivity, Yazidi women, if not killed, were sold as sex slaves — for as little as a few dollars — from one ISIS group to another.
During her enslavement, Ibrahim was beaten, shocked by electrical wires and forced to ingest drugs and undergo a mysterious surgery.
Today, Ibrahim tries to put her traumatic past behind her as she studies English and awaits her application for asylum. She wants to be a lawyer so she can help fellow Yazidis.
Ibrahim was one of about 6,800 Yazidi living in the Sinjar Mountain region who were kidnapped by ISIS in August 2014. More than 27 of Ibrahim’s relatives were kidnapped. Only seven have been released. The fate of the rest, which includes her father and stepmother, is not known.
Before being captured, Ibrahim was a cheerful woman who loved to dress up and be with her large family. Her favorite dress was a bright long-sleeved shirt and black long skirt. She enjoyed spending time with her 10 brothers and five sisters after working at a farm near the town of Rambusi.
“I worked at the plantation with all of my sisters to pick fruit and vegetables and sell them,” she said.
Ibrahim’s mother had died and her father remarried, so she became the caregiver for her brothers and sisters.
“I could not go to school because I took care all of my siblings.”
Her happy life turned tragic on Aug. 3, 2014.
On that day Ibrahim was preparing for Ida Chle Havine, a mid-summer feast and religious celebration in which Yazidis come together to for fellowship and prayer. Ibrahim, her sister and several nieces and nephews were busy fixing rice and chicken when her uncle called with frightening news: ISIS had attacked the neighboring villages. He told them to leave immediately for Mount Sinjar.
“My family and I got few things ready and rode in a pickup truck toward the mountain,” she said. “Before we reached the mountain, the truck’s engine broke. So, we continued walking. In the middle of the journey, ISIS soldiers came with three cars and captured all of us.”
ISIS soldiers took the family members with other neighbors to a wedding hall near Sinjar, where the soldiers separated family members. One Yazidi man who refused to leave his family was shot in front of Ibrahim and her family members.
“There were five ISIS soldiers at that time,” she said. “Four watched while another one killed the young man with a gun.”
After that, a soldier forcefully separated Ibrahim and her younger sister, Sahera. When the sisters resisted, a soldier hit Ibrahim with an AK-47.
The ISIS soldiers took the sisters to a prison. From there, Ibrahim was taken to a village near Tal Afar in Iraq and sold to a man in Raqqa, Syria. That man eventually sold her to someone in Mosul, Iraq
Raqqa was where the worst torture happened, she said.
“I was shocked by electric wires until I could not walk and drink,” she said. “I suffered so much.”
But the most horrifying incident was the mysterious surgery in Mosul.
“The worst thing was they performed abdominal surgery on my body,” she said. That experience still haunts Ibrahim because she doesn’t know what happened; doctors who later examined her said they were unsure what procedures were performed and why.
Nine months after her kidnapping, Ibrahim said she was released near Kirkuk by one her captors who was trying to evade coalition forces in the area. She was taken to the Bacid Kendala refugee camp in southern Kurdistan, where she was reunited with Qahtan and another brother, Brazan.
Today, she is starting to rebuild her life in Lincoln. She came to the U.S. for the first time in September 2016 to speak at a forum in New York at the invitation of Nadia Murad Basee Taha, an ISIS survivor and a United Nations Goodwill Ambassador. During her stay in New York, she met with Yazda President Haider Elias and others.
“I asked them whether I could stay at the U.S., and they answered ‘yes.’ So, I went with Haider to Texas and from there moved to Lincoln on June 2017,” she said. In Lincoln, Ibrahim lives with a Yazidi family.
Ibrahim said many people in Lincoln have provided her with help and support. She studies English so she can continue on with law school. In October, she testified about the plight of Yazidis at a House Foreign Affairs Committee hearing in Washington, D.C.
“I want to help female Yazidis who are still in captivity,” she said.
Salima Mirza and Hussein Hskan provided translation for the interviews in this story.
By Natasya Ong
Sho Say Gay grew up in refugee camps in Thailand, where suicide was common and mental health problems were often hidden.
The 25-year-old Karen woman lived for two decades in the camps, where, she said, refugees felt sorrow and worry — even though they were safe after fleeing danger in their native Myanmar (Burma).
Most of the refugees had lost their family and friends; some watched as loved ones were killed. This trauma left many with lingering problems, including depression, Gay said.
Even today, Gay, who since has resettled in Lincoln, still hears about suicides in the camps.
For decades, the ongoing turmoil in Burma has left hundreds of thousands of Karen stranded with no place to go but to refugee camps. Most who fled had to wait decades more before ever experiencing freedom again, while others who were born in the camps never knew freedom.
“The Burmese burned our village,” Gay said. “They fought against us. It looked like they wanted to wipe out all of our Karen people.”
The hardest part about living in a refugee camp is the loss of freedom, she said.
“We don’t have freedom. We are not Thai citizens. We have to live only in a refugee camp,” she said.
The Thai government set strict rules in the camp prohibiting anyone from leaving. The refugees are not allowed to work to earn a living and are left with uncertainty, Gay said.
“We don’t know what will happen with our lives,” she said. “We don’t have a future.”
But for Gay’s family, the uncertainty was even more difficult to deal with because Gay’s mother suffered from a bipolar disorder. Her mother had suffered drastic mood swings ever since she was 18.
Gay said she and her family didn’t understand the illness and tried to keep others from knowing her mother was not well. For family members, it was difficult living with the mother’s mood swings, which seemed to be triggered by stress and worries about her family’s safety and future, Gay said. Her mother often wandered off, frightening family members.
Gay’s mother refused to seek treatment in the refugee camp because mental illness carries a negative stigma among Karen, who have little education about it, Gay said. Gay said she could only try to be a calming influence whenever she saw that her mother was stressed.
Despite those difficulties, Gay said she had a good childhood growing up in a refugee camp. She was named after the camp in which she was born — Shoklo refugee camp, where she lived with her parents, three sisters and a grandfather.
When she was three, the Burmese army attacked the camp and residents were forced to move. The family moved to Mae La, one of the biggest refugee camps in Thailand, with more than 40,000 residents.
The large camp was divided into residential zones. Refugees built their own houses out of bamboo, which the Thai government closely monitored. The houses didn’t have electricity or gas, but the government provided food, clothes and charcoal, she said. The refugees also grew crops such as chilies, cabbage and rice on small plots of land near their homes.
Every morning, Gay and her sisters would walk to the main pipeline to gather water for her family. The zone she lived in had seven to eight main pipelines.
“Everyone had to line up, collect water with their buckets and carry it home,” she said.
She is grateful that the Thai government provided them land and supplies.
“It is safe,” she said. “It is safer than living in our own country.”
The camp had four colleges and eight high schools, she said, in addition to churches and houses of worship for a variety of religions — from Christianity to Buddhism to Islam. There are high schools that were formed by Muslims and Buddhists, where students are taught about their specific religions.
Gay said she studied mathematics, science, history, economics, civics, English, biology, geography and the Bible. Her high school was formed by a Seventh-day Adventist, which is why she had to take Bible studies as well.
She continued her education at Khawthoolei Karen Baptist Bible School and College, which was named after the land where the Karens once lived in Burma. The college only offers one major — theology — but offers two programs — one in English and one in Karen. Gay was enrolled in the English program.
Gay was in her final year of college when her family was approved to resettle in the U.S. in 2015. It had been a long wait. They officially started applying for resettlement in 2007.
So, after living in the refugee camp for almost 20 years, Gay’s family was resettled in Lincoln by Catholic Social Services in September 2015.
Ironically, it was the resettlement process that brought Gay and her family clarity about her mother’s condition. Before being approved to resettle, Gay’s mother underwent a mental health screening, which provided an official diagnosis. Family members finally fully understood her illness.
Thanks to treatments and medication she’s received since coming to Lincoln, Gay’s mother experiences fewer mood swings and her mental well-being is slowly improving, Gay said.
Although Lincoln is very different from their home country, Gay said she and her family enjoy living here because it is safe and they have freedom. She feels that she has more opportunities in the U.S. because of her English education.
She works part-time at Catholic Social Services as an interpreter and at the Lincoln Family Medicine Center as a medical assistant. She is involved with the First Baptist Church, which offers a Karen service every Sunday. She helps teach Sunday school and participates in the church choir.
In Lincoln, Gay said her family lives like any American family, with a decent roof over their heads and electricity, she said. She and her elder sister work hard to provide for the family because their parents are not working. Her elder sister works for the Karen Society of Nebraska, and two of her younger sisters are still in high school.
After living in Lincoln for almost three years, Gay and her family still hope to return to visit Burma after they’ve officially become U.S. citizens.
Gay is determined to return to the refugee camps as a volunteer and give back to the community that had helped her and her family.
“When I can stand by my own, I also want to help my people,” she said.
By Utami Kusumawati
It was the lowest moment in her life. Khamisa Abdulla was tired of everything. She felt constantly nauseous and wanted only to sleep.
She and her seven children had been struggling to live in Cairo, where they had been waiting for almost two years to hear about their application for refugee status. The family had fled war-torn Sudan in 1998 and now were in limbo in Egypt.
“I didn’t know whether my husband was still alive or not,” Abdulla said. “It was so hard living there because people started to take advantage once they knew you were refugees.”
After recently thwarting an attempt by some Egyptian men to kidnap her sons into a sex-trafficking ring, she was feeling the weight of being a single parent to her daughter and six sons. She was so lonely and desperately wanted to talk with other adults.
She also was homesick for her village in the Nuba Mountains and mmissed her mother, Toma Kambal. Abdulla would daydream about her modest house, a store that she turned into a residence after the Sudanese government bombed the family’s previous house. They had everything — clean water, television, good furniture, nice clothes and health insurance. She worked as a math and science tutor for wealthy students.
But the family was not safe there. A civil war between the government and rebel groups had been raging since 1955 — and the Nuba Mountains region was among the most perilous of places. The government targeted civilians by bombing the area and prohibiting humanitarian aid.
The family was increasingly isolated because her husband, Mohamed Kambal, had joined the rebels. Abdulla and her children left without him because Abdulla worried for her sons’ safety — the government recruited boys older than 15 into the Popular Defence Forces, a reserved military army for the Sudanese government.
“I saw many male students lose their limbs because of joining the army and going to the war,” she said. “I have six boys and one daughter. I felt at that time, as soon as possible my boys would be taken into force to join the military.”
During their time in Cairo, Abdulla had occasionally felt blue and homesick. But on this particular day, the sorrow was intense, she said. She was paralyzed. But as she laid in bed, she heard the voice of her worried daughter, Nazik Kambal.
“Mom wake up, please,” her daughter said. “I think you are not sick, but you are depressed. Just get up. I will make you soup.”
As Abdulla considered her daughter’s concerned words, the faces of her children appeared one by one. If she lost hope, she thought to herself, her children would, too. As a mother, she did not want that to happen.
“I have lost my country; I don’t want to lose my children, too,” she said. “What will be left for a mother, then? My bigger picture is that I need to save myself from getting lost again.”
In that moment, Abdulla made a promise to herself to always be strong for her children.
From that day forward, things changed. She helped the children find work in safe places, like grocery stores. And on days when they did not work, she taught them math. She sewed clothes and shoes and sold them in the markets.
“We maintained to communicate and support one another. This helped us to survive.”
Since they were resettled in Lincoln in 2000, the family not only survived but flourished.
Four of her seven children are college graduates. Two are currently studying at the University of Nebraska–Lincoln and one will be joining the U.S. Army.
Abdulla herself pursued and obtained a college degree.
But the family’s success hasn’t come without pain. When Abdulla’s husband, Kambal, joined the family in Nebraska in 2004, he was extremely depressed.
“He was suffering because he had gone through the traumatic experience,” she said. He was nearly killed in a bombing at a school where he taught. A government plane bombed the building, killing all of the children. Kambal was spared because he had left the classroom to use the bathroom.
“It was really hard for him to forget that accident. He was deeply affected. Even until now, he still prefers to sleep under the bed because he felt it was safe,” she said. “There are many Sudanese people in Lincoln who have the same problem as my husband.”
Abdulla said that the ongoing trauma affected the entire family. Kambal was distant and isolated from the family members, so relationships became tense.
“We had to force him to come join and talk with us.”
And she witnessed other Sudanese refugees in Nebraska struggling with emotional trauma.
Realizing that the Sudanese community needs more psychological services to help the refugees cope with trauma, she decided to seek a degree in psychology at the College of Saint Mary in Omaha.
Abdulla, 59, now works as the Women’s Program manager at the Asian Community and Cultural Center, where she helps refugees deal with their problems, including mental health issues.
“The reason I choose to do this is because I am aware that we often misunderstand American or Sudanese cultures,” she said. “Therefore, I feel that maybe this major can help myself and other Sudanese refugees, too.”
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The problems: A new generation deals with old wounds
When it comes to mental health, the children of Vietnamese refugees often face a struggle between the values and opinions they’ve developed through their Western upbringing and the traditional beliefs of their parents.
The struggle manifests itself in many ways, according to young people who say they are affected by the tumultuous experiences of their refugee parents — war trauma, post-traumatic stress disorder and resettlement challenges — and their attitudes toward mental health.
For Jessica Bui, a junior secondary special education major at the University of Nebraska–Lincoln, the trauma her mother endured during her resettlement in the U.S. has left an impact.
“In high school, I had an experience where I was upset and crying about something that happened,” she said. “My mom heard me and just told me to stop crying.”
While this may appear like a normal parent-child interaction, Bui thinks her mother’s reaction may have stemmed from unprocessed trauma.
“My mom has experienced harsh conditions from her journey from Vietnam to the United States,” Bui said. “Her crass response to my emotions might have been due to her thinking that anything I went through was easy compared to her experiences. Even now, when I’m feeling upset or angry, it’s most often times paired with guilt; guilt that it could be worse.”
Like Bui, Alice Nguyen, a freshman global and environmental studies major at UNL, had similar encounters with her parents about how emotions and feelings were dealt with within the family.
“From my experience, emotions are repressed,” Nguyen said. “You’re told you’re fine, and you deal with things by burying yourself in work, bottling up your emotions, etcetera. You never talk about your feelings or express that you need help.”
While Nguyen’s experience might appear unique to her family, the reality is that this behavior is common within the Vietnamese culture.
A 2009 study conducted at the University of California-Davis found that Vietnamese Americans may deny signs and symptoms of mental illness to preserve their public appearance and save face for themselves and their family. Others may perceive mental illness as a reflection of poor moral character, spiritual weakness or improper upbringing by the family, the study said. Additionally, reflections on personal experiences in Vietnam, where mental illness was associated with institutionalization or imprisonment, shape perceptions of mental illness.
“From what I know, mental health is almost considered taboo in the Vietnamese culture,” Nguyen said. “There is definitely not a widespread conversation about the importance of it, which is likely why so few Vietnamese people know about it or understand it.”
That lack of awareness about mental health has directly affected her parents’ own mental well-being, Nguyen said.
“I think there’s a lot of unprocessed mental pain that my parents are still holding onto subconsciously,” she said. “They have varying forms and degrees of depression, but it’s difficult for me to explain to them how important it is to get help without offending them.”
Likewise, Andy Ngo, a senior advertising major at UNL and the son of refugees, said cultural barriers such as language have proven difficult to navigate. He said he’s had problems communicating simple sentiments to his parents.
“Although I have been taught Vietnamese, there is still a language barrier that exists between my parents and me,” he said. “This has limited my ability to connect with my parents over the years and even explain my life to them. I have been involved within our community and my schools since a young age, and I have never been able to explain to them what exactly what I was doing.”
Ngo’s involvement in the community includes volunteering and outreach. But the concept of volunteering is not completely understood in traditional Vietnamese culture, he explained.
The language barrier also has affected his parents since resettling and adapting a new culture and lifestyle, Ngo said.
“Both of my parents have been subject to ridicule because of their broken English,” he said. “I have seen first-hand how taxing that can be on their emotional health.”
How Vietnamese refugees cope with mental illness is a problem when many are either unfamiliar with the concept or hold stigmatized attitudes toward mental health.
In a study conducted by the National Institute on Alcohol Abuse and Alcoholism among Southeast Asian refugees, 45 percent reported having problems with alcohol use, and a large proportion found it acceptable to use alcohol to deal with stressful situations.
“I almost think that the Vietnamese culture doesn’t believe in mental health, depression, anxiety or any aspect of it all all,” Bui said. “Whereas with Americans, there definitely seems to be a substantial amount of support for ways to improve it.”
“Mental health was something I had to figure out on my own,” she said. “In my parents’ culture, it wasn’t something that was ever talked about or taken care of as if talking about your feelings was shameful and frowned upon. So because of this I don’t think there were many systems in place to support the mentally ill when my parents were growing up.”
Attitudes toward mental health within the Vietnamese culture are complex. But first-generation Americans like Bui, Nguyen and Ngo who have a strong grip on the cultural differences between America and Vietnam would like to see the mental health conversation become more widespread among their generation.
“It’s hard to embrace change,” Bui said. “But just getting educated and being aware can be a step in the right direction.”
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The problems: A psychologist's perspective
When Megan Watson was finishing up work for her doctoral degree in psychology at the University of Nebraska-Lincoln, she never dreamed that one day she’d be counseling mostly refugees.
But she was assigned in 2005 as part of her UNL field placement to be a counselor at First Project, a nonprofit organization that provided therapy for torture victims.
She quickly fell in love with the refugees, she said, and marveled at their resilience in overcoming the challenges of trauma — whether it was from torture, being separated from family or being forced to move to a foreign country for safety.
She knew this was the type of work she wanted to do.
But in 2007, First Project, which had been making significant progress in helping the refugee community integrate into Lincoln’s larger community, lost its grant funding and closed.
After graduation in 2009, Watson joined the private practice of First Project founder Dr. Maria Prendes-Lintel as a psychologist.
Today, Watson, who practices as a generalist but specializes in trauma and anxiety, says refugees make up 75 percent of her caseload. Many of them are survivors of trauma and torture. The torture survivors are generally from Iraq and Iran and have suffered physical and psychological torture, she said. While she also frequently works with clients from Afghanistan, Syria and Egypt, she has seen refugees and immigrants from all over the world.
One of the first steps in helping refugees integrate into Lincoln’s community is to help them heal from the traumatic events they may have experienced in their home countries. At the same time, Watson said, she helps refugees adjust to their new American lives — learning a new language, adapting to a new culture, finding housing and searching for jobs.
Many refugees who arrive in the country believe that all Americans are rich and that they’ll have opportunities to become rich as well, Watson said. But refugees find that it is difficult to survive on the low-wage jobs they are expected to take. They often have problems paying for rent, utilities, food and health insurance on the low wages employers provide — particularly those with high premiums, deductibles and copays.
The requirements created by the Medicaid system and insurance companies make it problematic for mental health providers to treat refugees, Watson said. To help refugees become well-functioning U.S. citizens, she believes, mental health professionals who accept Medicaid — as well as refugee-settlement agencies — need more funding to help refugees heal from trauma and find jobs, secure health insurance and learn to pay bills. Unfortunately, Nebraska’s state Legislature cut the rates paid to Medicaid providers in 2017, Watson noted. These cuts will force Medicaid providers to take a pay cut, leading to fewer providers that are willing to work with refugee Medicaid recipients, she said.
Moreover, many providers do not want to work with refugees because the Medicaid system requires that providers fill out extensive paperwork to justify doctor-recommended treatment.
While Medicaid is crucial for refugees, reforms could help, Watson said, citing requiring less paperwork and allowing Medicaid providers more flexibility to suggest treatments. Another action that would help refugees is to have insurance companies reform their evidence-based assessment models to include incremental steps of progress such as refugees’ smiling, talking more or feeling comfortable enough to go grocery shopping, she said. Currently, these incremental steps do not meet the evidence-based models insurance companies follow, making it difficult for providers to justify long-term treatment.
Watson said she enjoys helping refugee families through the therapeutic process and gets great satisfaction watching them become active and successful U.S. citizens and witnessing second-generation family members earn college degrees.
While some therapists might be hesitant to work with clients from unfamiliar cultures who are not fluent in English, Watson embraces them.
Watson attributes her success in helping refugees to her ability to develop cultural currency. She does that by researching each refugee’s political and historical background and language. She also visits cultural centers, religious ceremonies and other cultural events with interpreters so she can demonstrate to the refugee community that she is trustworthy.
She said she has noticed that there is little interaction between Lincoln natives and resettled refugees — so she also works with leaders in each community to plan events that have been successful in uniting them.
Improving her relationship with the refugee community is a priority, she said, so she can reach more refugees in need of help.
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A way forward: A committee takes action
After nearly two years of study, discussion and work, a Lincoln-based group has launched a plan to better help Nebraska refugees and immigrants who suffer from emotional and mental problems.
The effort grew out of the monthly meetings of the New Americans Task Force, a group of people representing agencies, departments and non-profits who work with and advocate for refugees and immigrants. When concerns about unmet mental health needs kept coming up in discussions, task force members decided to form a subcommittee to address the problem.
The subcommittee of psychologists, academics, therapists and non-profit workers focused on a plan to help address their main concern: that Nebraska doesn’t have enough mental health workers who can appropriately address the mental health concerns of New Americans.
The plan they developed focuses on training, screening and gathering data.
The training program — called cultural competency training — is designed to help therapists, psychologists and others better understand the refugees and immigrants they are trying to help. The training focuses on the cultures of the three largest refugee populations in Lincoln: the Yazidi, Karen and South Sudanese.
The group won a three-year, $250,000 grant, which will be administered by the Asian Community and Cultural Center and will fund training for three specific groups:
- Mental health practitioners such as therapists, counselors, psychologists and psychiatrists, so they can be more culturally aware when working with New Americans.
- Peer support workers from major refugee populations in Lincoln.
- Local interpreters to better serve New Americans regarding mental health.
The mental health subcommittee also spearheaded the implementation of a screening program to help advocates and researchers gather important information about the mental health of incoming refugees being resettled in the state. Although state officials have regularly conducted health screenings for refugees, Oct. 1 was the first time the state started screening for mental health issues in select cities.
These efforts were the first time the New Americans Task Force became involved in mental health issues. For years, the task force has been been helping coordinate efforts to resettle refugees in Lincoln and help them adapt to their new lives.
While resettlement can be a challenging task, the common problems — language and education barriers — are obvious and rather straightforward in their solutions when compared to the emotional issues many refugees and immigrants deal with when trying to adapt to their new lives.
Over time, many refugee advocates who helped refugees with both physical and mental health care quickly realized that therapists and mental health workers in Lincoln lacked the training and resources necessary to appropriately handle the needs of the New Americans who needed their help, said Patrice McShane-Jewel, a former Lutheran Family Services case worker.
“We were all running into the same problem,” she said. “Therapists just didn’t have the resources necessary to appropriately care for New Americans.”
When the mental health care subcommittee formed in 2015, it was envisioned as a group that would pool resources and pass along tips of where to send patients dealing with Post Traumatic Stress Disorder (PTSD) or domestic violence, said McShane-Jewell, who is now a researcher and evaluator at the Asian Center. But when the members discovered the lack of appropriate resources for refugees in need of mental health care, they decided to do something about it.
As part of the training grant the subcommittee successfully won, mental health practitioners will be trained in a trauma therapy model called narrative exposure therapy, which has been found to be effective in working with immigrants and refugees who have undergone extreme trauma.
In narrative exposure therapy, the patient, with the assistance of the therapist, constructs a chronological narrative of their life story focusing on traumatic experiences. The therapist asks the patient about their thoughts, how they sense things, and what their reactions to stressful situations are like.
Training will begin next summer. There is space for 20 to 25 therapists.
“Training therapists in this specific therapy model will make them not only culturally aware, but they will then know how to treat the trauma that the New Americans have experienced,” said Erika Ashby, a therapist and subcommittee member who is now coordinating the grant.
Peer support workers also will be trained on the basics of narrative exposure therapy and the other services available to refugees. One individual from the three major refugee communities will be certified to hold mental health support groups. The peer support workers will play an important role.
“If an immigrant or refugee is referred to a therapist by a face they already know, recognize and trust, it’s better,” Ashby said. “They (the peer support workers) are going to be gatekeepers in opening the conversation about mental health.”
The hope is that individuals can benefit from the peer support groups, and those who head the groups will be able to refer group members to clinical providers when necessary, Ashby said.
“We know that going to see a therapist is not a traditional practice for many of these cultures,” she said. “We want to be able to meet individuals at their level of readiness with effective treatment.”
Interpreters will be trained to work with New Americans specifically for mental health purposes. Ashby said that currently there are translation and interpreting services for refugees and immigrants for topics such as legal issues and medical assistance, but not for mental health.
“We want to make sure interpreters are following the guidelines for mental health,” she said. “We want to make sure the client will be able to accurately communicate everything and vice versa so they will receive the proper treatment.”
The training programs will be free to any and all who take part in it.
The $250,000 grant, called “Enhancing Mental Health for Refugees and Immigrants,” was awarded in July by the Community Health Endowment of Lincoln, a municipal endowment that formed in 1998 to provide funding for health and health-related programs. Because the mental health subcommittee is not a registered non-profit, the funds could not be directly awarded to it, so the Asian Community and Cultural Center stepped in to administer it. The center’s director and CEO, Sheila Dorsey Vinton, is a member of the subcommittee.
Since 1992, the center has been a place to celebrate diversity and cultural richness, forming a community where all — no matter their background — are welcome, Dorsey Vinton said.
“We provide a place and listen to what the issues are that people have,” she said. “And we say ‘OK, let’s solve these problems,’ and we work with them to provide the most help we can.”
While some mental health subcommittee member were pursuing the training program grant, subcommittee members Julie Tippens and Megan Kelley — both UNL assistant professors — received a seed grant from the university to support the research of mental health in refugees, by examining the mental health of newly arrived refugees. The data is being gathered now for the first time using a screening tool called RHS-15, which stands for refugee health screening, and the 15 references the number of questions on the screen.
RHS-15 is similar to other refugee health screening tools used around the United States. The questions have been proven to effectively capture symptoms of depression and anxiety, which are the most common health problems among refugees.
The effectiveness of the questions is very important, Tippens said. Previous screening tools included questions like “can your child ride a tricycle,” in order to get a picture of the development of their child, she said, but if the person taking the screening doesn’t know what a tricycle is, then the answer won’t accurately capture the mental health of the individual or their family.
The screening tool is being used in Lincoln, Omaha and South Sioux City and soon will be offered in Grand Island. Kristin Gall, state refugee health coordinator, is coordinating the implementation. The first round of results will be ready for analysis by Tippens and Kelley in January.
Since its beginnings in 2015, the subcommittee now has developed into a collaborative exchange for those involved with New Americans and their mental health care, McShane Jewell said.
Ultimately, the subcommittee hopes that the work it does and the information it gathers can be passed along to lawmakers, Tippens said. Ideally, legislation can be written to improve mental health care for refugees in Nebraska and the nation.
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A way forward: Help in the schools
Lincoln Public Schools has long tried to provide mental health services for all of its students in need, but administrators realized several years ago that refugee and immigrant students weren’t being helped as they should.
School counselors, psychologists and social workers reported seeing an increase in distressed students in early 2015 — and they weren’t sure how to serve these children because the students’ language skills often were not developed well enough to access mental health services in English, said Brenda Leggiadro, LPS supervisor of student services for counseling and social work.
“We could see suffering but we couldn’t address that suffering in a very meaningful way,” she said. “So we knew we had to do something different. When we see our kids hurting, we just have to act.”
LPS officials began brainstorming with professionals in the community who had experience working with refugees and victims of torture.
In August 2015, LPS started a back-to-school training program for school social workers to provide information on how to work with refugee students. A few months later, the district launched a special mental health program in which cultural liaisons, interpreters and mental health practitioners provide services during the school day for refugee and immigrant students in need. The district used federal funds given to the state to help refugee students and families integrate into local school communities.
To create a successful program, LPS administrators said they had to learn how to navigate a number of obstacles. Providing mental health help is complicated by the fact that LPS has students from more than 60 countries. Students and families speak a multitude of languages and come from cultures that perceive mental health in different ways, said Oscar Rios Pohirieth, LPS cultural specialist and bilingual liaison coordinator.
“We need to educate mental health providers in our community and help them understand these concepts, the cultural perspectives of the students,” Pohirieth said. “It is not that they do not want to work with our students, immigrants or refugee students, it’s simply that we are not equipped to understand the cultural perspectives for some of the students.”
LPS collaborates with family service therapists, child guidance therapists and other community mental health providers.
“We are collaborating with them by offering translation services through LPS-approved language interpreters,” Pohirieth said. “We are beginning to see a little bit more engagement in the area of mental health with our immigrant and refugee students.”
For many of the students who participate in the program, some kind of acting-out behavior usually has been identified, such as aggression, fear, difficulty getting along with peers or not responding appropriately to directions in a classroom, Leggiadro said. But other students internalize their feelings and become closed off, she said.
“In any of those situations we are going to approach that student and try to figure out how we can help,” she said.
LPS administrators believe the program has been a success and is well-received in the community. Within the first year, the program had 60 referrals and only four families declined services. Currently, the program serves 46 students. One reason for the success is that LPS can offer services during the school day.
“Providers come into school and sessions are arranged during allowable course periods where students receive mental health once a week, which prevents any missed appointments,” said Anne Caruso, grant specialist for LPS.
Refugee and immigrant family members also have a better understanding of what it is that LPS is doing in terms of their students.
“They trust us, that we are going to find a way to help them, because they don’t know how to help them,” Leggiadro said.
Challenges still remain. The program has a waiting list of 15 students, primarily because of a lack of appropriate interpreters in certain languages, including Kurdish.
“It’s not only about finding that language interpreter, it’s finding a female language interpreter that will be sensitive and able to work with females from that particular ethnic group,” Pohirieth said. “We have to take a look at that matching system. When it comes to mental health services, we cannot simply add anybody that we think fits that particular student. We are just trying to recruit but at this point in time it has been challenging.”
In the meantime, school counselors or social workers are working with the teachers of those students to provide support.
“We hope sooner rather than later that we can expand and provide services to them,” Leggiadro said.
Continued funding for the program also remains problematic. Last year $152,000 was provided for the program, but this year it only received half of that, so the district has had to prioritize and find other funding, Caruso said.
Since many of the schools with refugee and immigrant students are high poverty, Title I funds can be used to supplement the program, Caruso said.
Juvenile justice money from Lancaster County has been added to help with training costs for therapists and interpreters to receive training. Interpretation services can be very costly. Region 5 is another supporter of the program, Caruso said.
In implementing the program, administrators discovered another need. Feedback from social workers, counselors and educators indicated that there was a desire to know more about cultural groups and the specific situations that their students may be coming from. So the district created a series of videos about diverse refugee groups and their experiences to help bring about greater understanding.
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A way forward: Exercise and well-being
Tuesdays are busy at the Lincoln Asian Community and Cultural Center. Women gather for sewing classes, a Mary Kay employee pampers community members and a group of seniors exercise to disco music.
The exercise program is part of a grant from the state Minority Health Initiative to bring fitness experts to Lincoln culture centers to lead classes for minority populations.
The Asian Community and Cultural Center has offered the program for a month. Classes also are planned at El Centro de las Americas, Good Neighbor Community Center, the Malone Center and with the Ponca Tribe.
“We all collaborate together,” said Suzanne Mealer, a certified fitness instructor. “We are trying to provide healthy atmospheres for our community members whether it be exercise, eating properly, checking their glucose and blood pressure.”
Before the exercise session, the group of Karen seniors meets at 11 a.m. for a class in which a translator helps the group learn basic English and citizenship information. They are quizzed on questions like who the governor of Nebraska is, and they practice telling people their name and age
At 11:30, the seniors move to comfortable couches as workers push tables and chairs against the wall to clear the center of the main room. Once Mealer turns on the disco music, the seniors gather in the middle of the room to begin the class.
Cristina Thaut, the Asian Community Center’s education coordinator, said she was excited to bring Mealer in to begin teaching fitness classes.
Evidence is mounting that exercise can improve mental health, according to the American Psychological Association. One study found that exercise reduces anxiety, depression and negative mood and improves self-esteem and cognitive function.
During the class, Lanetta Edison-Soe translates because Mealer doesn’t speak Karen, but not much translation is needed. Mealer demonstrates different movements at the front of the room, and the group of 15 follow her actions. Edison-Soe occasionally translates Mealer’s cues occasionally, but she also does the exercises.
The activities vary with each session. Some weeks the seniors do a chair circuit that includes exercises such as bicep curls, calf raises, chair squats and knee extensions. Other weeks they go for mile-long walks, practice yoga or meditate. During each class, Mealer explains how the workouts can be done at home as well.
Even though she cannot speak their language, Mealer says she can tell by the laughter and smiles on their faces that the seniors are enjoying the exercise.
Tee Moo is a member of the Karen senior group and has attended all of the fitness classes so far. Mealer calls him the class clown.
“I like it a lot,” he said of the class. “It’s good for health.”
The energy of the group makes the atmosphere fun, Mealer said.
“I think all of us working together is really going to help our people.”
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A way forward: Healing through horses
Refugees take part in alternative therapy
A smile spread across Dler Suliman’s face as volunteers hoisted him into the saddle and helped him settle onto the horse.
His family watched from the side of the barn, snapping pictures and cheering him on.
“He’s the first in our family to ride a horse,” his father, Amal, said proudly. The family moved to Nebraska from Iraq just a year ago.
Dler is one of a small group of refugees selected to participate in horse therapy through Horses for Healing, a nonprofit in Firth, Nebraska. The alternative form of therapy is often used to help people cope with mental and physical disabilities.
For Dler, who has been wheelchair bound since birth, the therapy has multiple effects.
Horse therapy can help people with physical disabilities by coordinating physical movement with the specially trained horses. It also can help people dealing with emotional or mental health trauma because some studies have shown shown that being around animals can relieve stress, help people to relax and feel more comfortable.
“When I heard about the program, I knew it’d be a perfect fit,” said Amanda Godemann, the Suliman family’s case worker at Lutheran Family Services. “When I started looking at the research and saw what it could do, I wanted to start bringing people out here.”
For many of the refugees, the therapy is a way to escape for a while from the post-traumatic stress disorder they may experience after fleeing a war zone, said Kari Hoeft, one of the center’s co-founders. For others, the therapy is a way to ease their mind and forget about the stress of their current lives and the challenges of moving to America.
“Some of them told me that this is the only time they’ve ever felt truly free, and it’s the only time they can let their guard down and relax,” Hoeft said.
During the summer, the center provided small-group sessions for refugee teens. During the first year, they hosted two, two-week long sessions for six to eight refugees at no cost thanks to donations.
“At first, a lot of them were nervous because they’d never been on a horse before or even been around them,” Hoeft said. “But by the end of the program they didn’t want to leave.”
Hoeft has kept in touch with many of the teens who participated in the program and some have returned to the center as volunteers so that they can continue to spend time around the horses.
Hoeft has been passionate about helping the refugee community for years after her church started working to help the New Americans.
“They go through so much,” Hoeft said. “So to be able to see feeling good about something and smiling — it just feels surreal.”
Hoeft and four other women had planned for years to open an equine therapy center and finally opened the doors to Horses for Healing in February. In the first year, they’ve provided services to more than 75 people and have programs to help a range of conditions.
Horses for Healing is also a research facility, Hoeft said. Co-founder Justy Hagan has been working for the University of Nebraska–Lincoln for more than a decade to conduct research studies about the effectiveness of horse therapy. The goal is to have equine therapy recognized as a legitimate alternative form of therapy because it is not currently covered by most insurance companies. With continued research and increased awareness, Hoeft said she hopes to see things change within the next 10 years.
Horses for Healing is a non-profit and the co-founders work on a volunteer basis to help run therapy sessions. Most patients pay a small fee per session. Hoeft hopes the center can secure permanent funding, however, so they will be able to provide sessions at no cost in order to help more people.
Some of the programs are donor-funded. For example, Lutheran Family Services provides assistance in covering the cost for some refugees to attend therapy sessions. Godemann said the organization isn’t yet able to allocate a large amount of funds to the alternative form of therapy, however. She’s working with Horses for Healing to apply for additional grant funding to expand the refugee program.
Dler is the first person to benefit from the partnership and attends weekly sessions.
As he sat in a saddle atop Jet, a tall, gray horse, Dler couldn’t stop smiling. With volunteers on each side, the team walked around the arena and weaved through barrels before it was time to dismount.
Back in his wheelchair, Dler smiled and whispered something to his dad.
“He said that he can’t wait to come back next week,” Amal said.
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A way forward: Exploring an alternative
Students and staff participating in the University of New Mexico’s Refugee Well-being Project are working to improve refugees’ mental health in their community by using a holistic approach to care for refugees’ educational, physical and material needs.
“The goal of the Refugee Well-being Project is to reduce the high rates of psychological stress that refugees face during resettlement by addressing a lot of the resettlement stressors,” said Jessica Goodkind, associate professor in sociology at UNM and founding director of the well-being project.
The project pairs university students with refugee families for six months, encouraging students to help refugees and thereby create opportunities for mutual learning. To participate in the project, students must take a class called Health and Social Inequalities.
The project uses “learning circles” in which students and refugee families talk in a large group with the help of interpreters. It encourages both parties to learn from one another, Goodkind said.
The first hour of a learning circle is usually a cultural exchange. Students and refugees may talk about how their cultures view civil rights, raising kids, healthcare and other topics.
After the learning circle, refugees and students interact one-on-one. Refugees use that time to practice English through reading, writing and speaking. They may also work on job applications, and children may get help with homework. This kind of support is important, Goodkind said.
“As a community psychologist, I don’t think about that just in terms of individual therapy,” she said. “I think about the fact that there are so many things like social support and welcoming people. All of those things have a huge impact on mental health.”
The program helps reduce refugees’ psychological distress, Goodkind said.
Later in the program, individual students are matched with a family.
They interact for at least three hours outside of the learning circle by participating in activities that help them to become better acquainted, such as sharing meals. Some of this time also is devoted to supporting the refugees, such as helping them connect with people to get healthcare.
Ultimately though, the project’s goal is improved mental health. While the focus is mostly holistic, the project also provides narrative exposure therapy for Post Traumatic Stress Disorder.
But most refugees don’t use that therapy, Goodkind said. One-on-one therapy can be a different approach to mental health than some refugees are used to. They are often more comfortable with the learning circles and other support systems that the project provides.
The project goes beyond creating positive experiences for New Mexico’s refugees.
“For students it has a really transformative impact as well,” Goodkind said. “They really come to understand refugees and the refugee experience in a different way … the need for system level change.”
Brandon Baca, the project’s research coordinator, decided to stay involved in the program after joining it 10 years ago as a student.
When the program matched him with a family, he was nervous at first, but he ended up bonding with his family.
The project also provided an opportunity for him to witness examples of refugee resilience, Baca said.
“I think the U.S. media — in general, the international media — has a tendency to infantilize refugees and really look at them as victims who are completely out of control of their situation,” he said. “So I think the class did a really good job in showing that refugees bring a lot of strengths and that there’s a lot that they can contribute to our community.”
When Baca was a student, he had been tasked with helping a 16-year-old refugee find a job. The boy’s family had kicked him out of the house. Baca helped him with his resume, but in the end, the boy found a job at McDonald’s on his own.
“He was just a really friendly and really outgoing and hardworking person, and he went out and just did his best,” he said.
Baca is currently working with a number of Afghani widows who are struggling to raise multiple children. It’s a challenge, yet these single mothers are overcoming it.
A goal for the project is to get refugees involved in coordinating the program and to have more of a focus on refugee policy advocacy, Baca said.
Project organizers would also like to see the project adopted in other states and countries and have been in contact with other universities.