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Trauma affects immigrant mental health – SC Times

They come from countries ravaged for decades by war. They’ve been displaced for months or years in a refugee camp in a foreign land. They are whisked away to far corners of the earth, often without their entire family.
They end up in St. Cloud, where snow and freezing temperatures are frightening and dangerous. They don’t speak the language and don’t have a family support network. They don’t even know how to order at an American restaurant or navigate public transit. Access to food, health care, education, resources has been limited. Instability is their normal.
And that’s just a typical refugee experience.
Any one of us could be shaken to our core after experiences like that. Many of us would come out with nightmares, uncertainty, anxiety, depression.
In 2013, a Somali immigrant saw the need in his fellow community members and opened a mental health clinic in St. Anthony.
Owner Asad Ahmed, as well as the clinical supervisor and counselors, all have their own tales of immigration and entry into Western society. They know too well the fear, the isolation that comes with being new to a country.
This week, Ahmed will have an open house for a second clinic, Recover Health Resources, in St. Cloud.
As a student of computer science and engineering, Ahmed had no mental health background. But he wanted to help.
He and clinic staff face many barriers: A mental health system that wasn’t built with refugees in mind, based on a Western way of thought, using definitions and treatments that are unknown or unfamiliar, in a language they don’t know, in a health care system that’s difficult to navigate.
What patients need is culturally competent care, said Manijeh Daneshpour, a licensed marriage and family therapist who is clinical supervisor for the clinics. The goal is to employ workers who speak the language of the clients and understand the cultural nuances.
“They have to start from square one. In many African cultures, treatment for mental health is unheard of,” said Emmanuel Oppong, a licensed professional counselor. “In Africa, you’re either sane or you’re crazy. It’s black and white. There’s no gray.”
Oluwatoyin Adetunji agreed. Also a licensed professional counselor, Adetunji said that before coming to America, she didn’t know there was treatment for chemical dependency. It was just a fact her family lived with. Learning there was hope, Adetunji decided to go into the profession..
“There’s a name for all these mental diseases, and there’s help for you,” she said.
Oppong and Adetunji are primary counselors at the clinic. They see and evaluate patients, make referrals, and supervise Adult Rehabilitative Mental Health Services (ARMHS) workers. ARMHS workers support recovery from mental illness, by helping people with basic living and social skills, medication management and transitioning to community living.
The clinic gets referrals and makes referrals to other clinics and organizations, such as Catholic Charities of the Diocese of St. Cloud, Lutheran Social Service of Minnesota and CentraCare Health.
Payment comes through traditional methods including Medical Assistance and private insurance.
The clinic was one of seven mental health providers in the state to receive a grant from the Minnesota Department of Human Services for minority workforce development.
They received nearly $350,000 over two years in 2015 to address shortages of minority health providers and improve access to mental health care for minorities.
The staff has big issues to deal with, including trauma. Refugees and other immigrants arrive in St. Cloud with post-traumatic stress disorder and adjustment issues, on top of the cultural adjustments they need to make.
The East Africans are not alone in these problems. Jonathan Walz has seen these issues among Central Minnesota’s Latino community, in his position as a community health worker for CentraCare in Melrose.
He’s seen how mental health problems can worsen or exacerbate physical problems, such as diabetes and heart disease.
“(Take) into consideration, they had to leave everything behind in order to make a living somewhere else,” he said. Stress of being in a new country, perhaps not legally, can also affect health.
Latinos too have a stigma about seeking mental health services and the health care community lacks resources for them.
With both groups, problems manifest in many ways, including isolating behavior, aversion to bright lights or noise, and nightmares.
Ahmed said in some cases people have been in the U.S. for 30 years, and no one has asked how they feel about all of it.
“They’re still grieving. We’re trying to close that chapter for them,” he said.
He relates his own experience arriving in the U.S. in 1994. He is grateful for the opportunities it gave him.
“But it was very difficult. I was a young man, and I could understand a majority of what’s happening,” he said. “But it’s very difficult not knowing what to order from a restaurant, how to apply for a job or ride a bus, not knowing anyone you can talk to.”
Racism and unwelcoming communities can exacerbate problems, he said, citing escalating tensions locally, nationally and worldwide over refugees and other immigrants.
Getting people in the door for help can be difficult. There’s stigma attached to mental illness in African communities, more so than in the U.S. Even Ahmed was skeptical the original clinic would work.
“I wasn’t expected to even be able to convince a single client to admit it what’s happened to them,” Ahmed said.
Daneshpour is hoping events like the open house on Wednesday will help immigrant community leaders understand the need for mental health services, so they can bring the message that services are available back to mosques, community centers and day cares.
They stay away from the word “crazy” and even “mental health.”
Instead, Ahmed says, “I try to make their pain much easier.”
Part of the clinic’s mission is to contend with the idea that mental illness can’t be fixed. So the counselors define their help in tangible terms: We’re providing skills for you to live your life better.
For example, they can help refugees overcome a barrier, such as poor memory. Repeated exposure to trauma can permanently affect a person’s memory.
While the counselors can’t repair the damage, they can teach strategies to manage it. Using a calendar app helps. Attaching a key fob that beeps can help them locate lost keys.
Staff members need to get patients comfortable and willing to talk.
It starts when they walk in the door and see people working the desk who look like them: interns that speak the language, from undergraduate and graduate programs at St. Cloud State University.
Staff explain privacy and confidentiality laws, so there’s less fear of exposure.
And they consider language as well as cultural context.
For example, there’s no good way to translate the concept of depression into Somali, Adetunji said.
Daneshpour says her cultural background helps her understand differences in how Eastern and Western cultures think about health and mental health. She grew up in Iran but was trained in the U.S.
“We cannot separate mental health from people’s context and their experiences in their life,” she said. “People always have life stories that make their behavior absolutely understandable. It’s just that we don’t take enough time to understand why people think the way they do.”
It’s not realistic to expect someone who’s lived in a refugee camp for 14 years, with limited access to services, to quickly become structured and rigid about time and appointments, she said.
That can be a problem. Plenty of traditional clinics have strict attendance policies, where just a few late arrivals or missed appointments can result in cancellation of services. How do you reconcile that with a population that relies on public transit or is new to country?
The St. Cloud clinic tries to take that into account. They have beverages and snacks available in the waiting room, in case a patient shows up hours early. They gently steer them toward the appointment model, but don’t judge or shame those who are early or late.
The clinic accounts for the fact that standard assessment tools are culturally specific, using white, European males as the norm, Oppong said. Depression or anxiety might manifest itself differently in different cultures.
Staff often tie mental health symptoms to physical issues, such as migraines or blood pressure. Daneshpour said that’s been very successful.
“There’s a lot of trial and error,” Adetunji said.
For instance, deep breathing is a widely recommended self-soothing technique. But some Africans may view it with suspicion, like it’s a cult, she said.
Group therapy has been effective in the St. Anthony clinic.
“It helps normalize their feelings, and validate that,” Oppong said.
There are power dynamics and identity issues to consider.
A displaced father has not only gone through the trauma of war, but has also lost his identity as someone able to provide for and protect his family.
In the U.S., he might not know the language, putting him at a disadvantage for jobs and for parenting. Suddenly, his son has more power and influence, because he can speak English and is better able to navigate their new reality.
Even the environment can be a challenge.
Adetunji says she’s familiar with clients who are scared to leave the house in the winter. They’re afraid of the cold or don’t know how to dress for weather. They’re afraid of falling or frostbite. That can lead to months of isolation, which can exacerbate mental health problems.
Some clients come to the clinic with mental health medications prescribed to them. But the counselors have discovered sometimes the patients have been misdiagnosed because of cultural or language misunderstandings.
So they work with medical staff to find a solution.
On the other hand, some clients are hesitant to take any medication. They’re more familiar with traditional healing methods and have to be convinced to try medication.
Eventually, Ahmed hopes to add medical and dental programs, so the clinic becomes a one-stop shop.
They also hope to add services that look at domestic violence, educate local health care providers on cultural competency and collaborate with the school district to address mental health in kids.
They’re also providing education and experience for the next generation of clinical supervisors and social workers, so they’re ready for what’s to come.
And as the community continues to assimilate, needs will change.
“We’re all American now,” Ahmed said. “At the end of the day, we’re all human.”
Follow Stephanie Dickrell on Twitter @SctimesSteph, on Facebook www.facebook.com/sctimessteph, call her at 255-8749 or find more stories at www.sctimes.com/sdickrell
Open house for Recover Health Resources. 
When: 5-7 p.m., Wednesday. 
Where: 2719 West Division St. Cloud, Suite 5. 
To RSVP or for more information call Emmanuel Oppong at 259-1369 or email emmanuel.rhr1@gmail.com


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