Mental Health Matters – Refugee Mental Health

Mental Health Matters – Refugee Mental Health


Hi, welcome to Mental Health Matters. I’m
Shannon Eliot. Today I’m joined by two experts on the unique
and complex issue of refugee mental health. Dr. James Livingston is a psychologist and
the Clinical Services Manager for San Jose’s Center for Survivors of Torture, a project
of Asian Americans for Community Involvement. He treats and conducts research with refugee
torture survivors. He has worked as a clinician for over 30 years and is an Adjunct Professor
at Alliant University, San Francisco. Jamila Ghanm is originally from Baghdad and
is an active member of the San Jose Iraqi community. She is known for her work in helping
newly arrived Iraqi refugees successfully integrate into society. In 2010, she co-founded
a project to establish Iraqi service providers. Jamila also served as a human rights lawyer
and legal case manager with the Iraqi Ministry of Human Rights from 2004-2008. Welcome, Jamila, and welcome, Dr. Livingston.
Thank you for joining me today.>>Thank you for the opportunity.>>Jamila, can you get us started with telling
us your story of how you came over here and what kinds of mental health issues you faced?>>My name is Jamila Ghanm. I came from Iraq
(Baghdad) in 2008 with my family – two kids and a husband. Before I came, I worked as
a lawyer in Iraqi courts for seven years. In 2004, I worked with the Iraqi Ministry
of Human Rights with the American forces violations. Then, because of the unstable circumstances
and war environment in Iraq and my father-in-law had been kidnapped by the terrorists, and
there is a lot of instability and lack of services, so we decided to come to the United
States as refugees. So we came here and when we first came I experienced a lot of mental
health issues, such as homesickness, depression, stress, and the shame to use public health
and public assistance, like medical and food stamps. As a professional, you know, I was
a very active member in my community in Iraq and I came here to be a housewife, which is
very stressful for me. So for one year from my coming I was suffering from a lot of mental
health issues and under stigma, so I refused to get any mental health help and services. Then after one year, because of a lot of challenges
of adjustment — like language barriers, no communication with people because of that,
and the stress that I had after getting here – I had to start over. As a newborn baby,
I get lost in this new world. Then after one year, I had a very strong conversation with
myself. I needed to figure out my way here. I started out as a professional in Iraq and
I need to end up as a professional in the United States. So I got out of my stress and
mental health issues. It started with the first step, which was to go to the community
college and improve my language skills. And that way I started to meet new people and
new friends and I started to improve my language skills to communicate with the amazing people
around me. They were trying to help, but because of the language barrier, there was a lack
of communication. And after I improved with my language skills, I got out into the community
and met with the AACI staff at the Center for Survivors of Torture, at first as a friend
because my husband worked in their agency. But then I started meeting with their staff,
who are amazing and helped me a lot to get through my mental health issues.>>So how did your family support you through
all of this?>>My family in Iraq or here?>>Family here.>>Of course, they are very understanding of
my situation and what’s going on with me, which has helped me a lot. Of course, my husband
was supporting me a lot and was advising me to seek mental health services, but because
of mental health stigma. I was refusing to get any services. And I was always asking
him, “Do you think I’m getting crazy to ask for mental health services?” I was – not
I was – I am and educated person and I worked with human rights issues but unfortunately
I had mental health stigma in the beginning. But after that, I got help and I realized
and recognized how important it is for people who are new in this community to get mental
health services and help to rebuild themselves and to be stable and adjust to the new community.>>Dr. Livingston, what are some of the most
common mental health issues faced by refugees?>>Well refugees are coming from their home
countries because it has become impossible to continue to live there and so they are
involuntarily leaving, as opposed to immigrants who choose to come to the United States. So
there is often times horrible things they have gone through in their home country. They
typically transition through several intermediary countries before they arrive at their host
country. So the refugees arriving in the Unites States typically have already been through
a great deal and often times are experiencing trauma symptoms. Once they get here, they
are faced with a new culture, a new language typically, a new world. And they are unfamiliar
with just about everything so they then experience that trauma that immigrants experience transitioning
from one culture to another. It’s a difficult process. Most of our clients, particularly
those who are torture survivors, have both traumatic symptoms and depressive symptoms
and they need treatment for both of those things. They can have other kids of anxiety
disorders, panic attacks. Anxiety problems of that sort are common. It also is not uncommon
for people to use cultural solutions for their symptoms and sometimes that means using alcohol
or other drugs, so substance abuse is at a much greater rate among the refugee population
than the general population. And then there are other kinds of social problems that are
heightened by all of the stresses that also are present among that population.>>So in a way it’s just a self-perpetuating
cycle.>>There are so many stressors and it’s astonishing
to me that people are able to stand after they have gone through so much.>>Yeah, so you could be fighting the trauma
that happened to you at home and the obstacle getting here was not easy, and then finally
getting here. And like you said, Jamila, not being able to speak the language. You were
this great professional in your home country and here suddenly it’s a whole new life.
That can’t be easy.>>It’s the new challenges. We are changing
our challenges back home with the new challenges here. It’s changing the challenges.>>So Jamila, I’m curious with your perspective
having lived in these two places now, what are the similarities and differences between
mental health in your home country of Iraq and here?>>Big difference. Back home in Iraq whenever
you say “mental health issues,” that directly goes with the craziness. We have a big stigma
against mental health, and you never can say mental health issues because people think
you’re crazy. So if people have any simple mental health issues like anger or child abuse
or domestic violence – stuff like this – they can’t talk about it because they feel shame.
Here, the situation is different. It’s more open-minded for this term, and there are a
lot of services and many different kinds of agencies. Even the government offers his type
of help. And people are more understanding for this situation.>>Did you say that it was ok to be depressed
(in Iraq)?>>Yeah, the term for “mental health issues”
in Iraq is “depressed.” It’s so easy and acceptable to say I’m depressed or stressed,
but no mental health issues.>>So “depressed” kind of just means stressed
out and you need a break, as opposed to “I have a mental health issue.”>>Which is very usual. It’s not shameful
to say I’m depressed, I’m stressed. But no approaching their mental health. Don’t
say any mental health term.>>That’s really interesting.>>Yeah, it’s kind of an umbrella term.>>Dr, Livingston, how do these issues differ
between youth and adults?>>Well there are a variety of differences.
Typically kids learn the new language much more rapidly than their parents. And typically
the kids are with other children in school. And they rapidly become acculturated. They
want to be like the other kids. They adapt and learn very quickly. And I figure that
if they’ve been in the country for more than a month, they’re California kids. Certainly
many of them come with trauma that they have been through themselves and that affects the
process of adjusting. Many of them have parents who themselves are traumatized and that changes
the family circumstances and affects the children. But overall it’sa much easier transition
for children than it is for children.>>How would you vary your approaches in treatment
if you were working with a child or young adult versus an older adult?>>Well it depends on the issue we’re trying
to work on. If it is a trauma kind of reaction, the thing that is confusing to many professionals
is that what actually happens to a person (children) isn’t what injures them. What
injures them is what they understand to be happening. So if they are in a circumstance
that an adult might not regard as being particularly dangerous but the child believes it is dangerous,
they are likely to be traumatized. And conversely, if they are in a life-threatening circumstance
but they don’t regard it as that, they typically are not traumatized. So one of the first things
that a child clinician is going to be doing is finding out how the child has interpreted
the experiences that he or she has been through.>>So it’s extremely subjective and personalized
from person to person.>>It is. And it’s important for adults to
understand that what matters is not objective reality or adult appraisal of the circumstances.
It’s what the child understood to be going on.>>This next question is for both of you. What
are effective ways that refugees can take care of themselves?>>From my experience working with the refugees,
most of the new arrivals from the Iraqi community need mental health services because they are
coming from the war environment. And absolutely they have trauma and a lot of terrible experiences
they went through. So the first step to take care of themselves is to seek mental health
services. We need to figure out what the right approach is for different kinds of categories
in the community. Out of experience, I divided the community into three categories, which
are women, men, and youth. And each of these categories has a different kind of approach.
For example, women prefer social events and gatherings, stuff like that. And they are
more open-minded than men. Men prefer sport activities and entertainment things. And they
are very close-minded. So with this approach, it’s not hard to get them to share their
experiences. And youth also have different kinds of activities in which you can reach
them, which is entertainment, sports, or social events, like dance parties or sports competitions. First of all, we need to educate them about
mental health issues and reduce the stigma that goes with that. Then after that we will
ask them to help themselves by asking for help through mental health services.>>Research suggests that the single most important
step in becoming adapted to a new culture is learning the language. And that is one
of the things we emphasize with our clients. The more fluent they can become in English,
the more opportunities they will have. It’s not possible for some of our clients to learn
English, not because of intelligence or motivation, but because if they are severely traumatized,
we are starting to understand that has biochemical effects on the brain. That actually changes
brain structures and some of those structures are involved in the formation of memories.
Some of our clients are physically incapable of learning English, but to the extent that’s
a possibility, that’s really a crucial step in becoming familiar, becoming able to feel
as if one belongs. The second most important thing, I think,
is finding a community to feel part of. And that community often times is a faith community.
It can be a linguistic or ethnic community. it can be an educational community. In my
experience, it really doesn’t matter. There needs to be some community where the individual
feels like they are a part of it, they belong there. And that is hugely important in becoming
adjusted to a new world.>>That’s interesting you mention that because
when we were speaking earlier I know you mentioned for some refugees, particularly parents who
have children, one source of distress might be that their children are acclimating too
well and they might forget customs or ways of their home country. Have you ever felt
this way, Jamila?>>Yeah, I totally agree with what Dr. James
said and mentioned which is very important advice for the new arrivals to take to heal
or to adjust. But first of all, the main major problem that new arrivals – I’m talking
about new Iraqi refugees – face is the stress, depression, and mental health issues. Unless
we treat these mental health issues, they can’t go out, learn the language, or engage
with the community. From my personal experience when I was under stress and mental health
issues, I didn’t go out. I wouldn’t meet people. There were a lot of American people
trying to approach me, trying to help and communicate with me, but I refused. I was
refusing to engage with them because I had mental health issues. So before any refugee
takes any steps to learn English or engage with the community, we need to get them mental
health services first to get them over the culture shock, stressors, and mental health
issues for new arrivals. About the kids and adjustment and those kinds
of challenges between two cultures — which is our own culture and the American culture
— yes, I am suffering. I’m telling you this is very hard. The kids are very welcoming
and very accepting toward the new culture and so fast too engage and adjust, which is
kind of dangerous for the parents. In this way they kind of lost their language or their
religion or their culture. For the parents, they need their children to stick with their
culture and religion and language. So yes, I am fighting with my kids — not in a hard
way, but in a nice way – to engage them in the Iraqi community, take them to the religious
places, and register them for Sunday school to learn the language and religion. So it’s
kind of challenging for the parents to balance the two cultures.>>And it’s a challenge for any parent anyway.>>Yeah, it’s a big challenge. For the kids,
it’s so easy and they are willing to go out and engage in the new culture because
of the new things, which are different from their culture, and more open and more exciting.
They are willing to go out and participate in these kinds of activities, which are sometimes
prohibited in our culture. For example, my daughter is now 12 years old and she wanted
to sleepover and go to a dance group with her classmates, but it’s unacceptable in
our culture to let a girl that age go out alone.>>Right. You probably have to do a lot of
research to learn about youth culture to see what your daughter wants to do, and that’s
a whole other layer.>>We need to balance.>>It’s also a challenge for the kids. The
children and adolescents often feel caught between the two worlds. And they don’t want
to cause their parents distress usually. They understand that their parents typically are
having a more difficult time adapting to the new culture and don’t want to upset them,
but at the same time they want to fit in with the other kids and they want to have the fun
that the other kids are having. And it’s a real challenge for them to figure out how
to navigate those two worlds.>>So how would you guys say that peer support
from other refugees helps in mental health recovery? I know you were among the early
ones to get here and you didn’t really have much of a network then, but you’re creating
that network for other people now.>>Yeah actually, because I suffered from loneliness,
I had to figure out a way to engage with my community members. I figured out how to establish
group gatherings. I started to visit new arrivals and invite them to my apartment. Even though
it’s a small apartment, I was welcoming them. We cooked food, shared food, and shared
the chatting and challenges together in order to reach solutions. Fortunately my husband
has great experience searching the Internet, so whenever anybody from the new arrivals
has any problems or challenges or wants to ask about any program, we can Google it and
search the Internet to find what kind of services and programs can benefit the new arrivals. So we create or establish a group gathering
first, then whenever the group becomes bigger and bigger, we establish community gatherings
outside. We might go on a picnic or to a community place we can gather together and chat and
share our experiences and our challenges. That was very important because whenever people
see other new arrivals having the same challenges and issues it becomes not shameful to talk
about it. They might benefit from the experiences of others. There are some services or programs
that can benefit others. We were sharing the resources and sharing the experiences. Sometimes
it’s a way of healing.>>Have you seen a change in the attitudes
and culture around mental health from the other Iraqis who have come over after you?
You’ve created this group and promoted discussion. Have they started opening up more and do you
see a change in that?>>Yes, especially in the women. I created
a tea party every month for women and we sit and share our experiences. They start to open
up and talk about domestic violence, child abuse, anger issues, and stuff like this,
which are mental health issues. Then I start to talk to them about the services available
and tell them if they don’t want to get into any legal trouble, they need to ask for
a counselor for advice on how to deal with these issues. And you can also get mental
health help. It’s more beneficial for my community members. For the men, they’re hard to reach. It’s
hard to get them to talk about their experiences. But I do use some community members, some
of which are men, to reach this category. We create some sport activities like soccer
or something, and when they get dressed they’re going to talk about their issues. So it’s
kind of a way of healing.>>So Dr. Livingston, it certainly sounds like
a proven method of success is these community events, but are there any other specialized
treatment techniques you use when working with refugees and/or survivors of torture?>>Typically what we have tried to do is utilize
community resources and access new arrivals through those resources. Things like community
centers, faith centers, and we sponsor some events of our own in terms of parenting in
the United States or various issues that might be of concern for people newly arriving in
the U.S. We have had the good fortune to be given a grant in the last few years to investigate
different delivery methods of mental health services for the nine major ethnic groups
in our county, Santa Clara County. We’ve done focus groups and we’ve talked with
community consultants to try to figure out culturally acceptable ways of delivering information
and offering services. And not things I came up with or necessarily any of or staff, but
we have been involved in sponsoring a lot of activities I never would have thought of
with our Ethiopian and Eritrean communities. We had one event where the immigration process
was described in a form of dance, and the adjustments and so forth were all exhibited
in the dance, which is not a medium of communication that I’m experienced with, but I gather
was quite meaningful for that culture. We have been fortunate to have the opportunity
to have consultants that guide us in non-traditional ways of service delivery.>>Jamila, to wrap us up, and how are you doing
now and what do you hope to achieve in the future?>>Well I’m doing well now because of my
amazing friends around me and the help of Center for Survivors of Torture. They helped
me a lot so I am feeling well and good. And I’m still working with the Iraqi community
members to reduce mental health stigma and advise them to use the mental health services
that are available. I realized this is very important from my personal experience. My future plan is to get a masters degree
in humanitarian international law and maybe work in the humanitarian field. It’s away
from legal stuff, but still working with community members because I consider myself a messenger.
I have a message. I need to deliver this message, which is very important for all the new arrivals.>>You’re very inspirational. I just wanted
to say that before we leave.>>Thank you.>>Well thank you, Jamila. And thank you, Dr.
Livingston. I’ve had a great time talking to you and I appreciate it. Best of luck to
you both.>>Thank you.>>To learn more about the Center for Survivors
of Torture, visit their website at: Cst.aaci.org. Survivors International is a San Francisco-based
organization that provides psychological, social service and medical services to survivors
of torture, war trauma, and gender-based violence. Learn more at: www.survivorsintl.org. If you would like to learn more about the
mental health off refugees, check out a 1996 report issued by the World Health Organization.
You can read or download it at: www.unhcr.org. Thank you so much for watching. We’ll see
you next time.

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