Aside from savage beatings that have left him reliant on a cane, his torturers threatened to seize his wife and rape her in front of him. But one of Mr. Rabaa’s most dispiriting experiences occurred after his release. He and his family fled to Syria, at the time a safe haven for Iraqis rather than a bloody war zone. He could not work in part because of his injuries, so his son, 11 years old at the time, took a job in a restaurant to help support the family. Mr. Rabaa recalled through an interpreter by phone that fellow Iraqi exiles only exacerbated his anxiety, warning him that if he settled in the United States, his children would “end up as drug addicts.”
Thanks to an innovative Seattle program called Pathways to Wellness, which identifies refugees with mental health problems, not long after he arrived in the U.S. as a refugee, Mr. Rabaa was diagnosed with post-traumatic stress disorder (PTSD) and received medication and counseling. He answered a custom-designed questionnaire, which takes most refugees less than 10 minutes to complete, and then was referred to a mental health center with an Arabic-speaking staff. Mr. Rabaa says that the intervention “brought smiles back to my family.” His son is now studying to be an engineer.
Since 1975, the United States has accepted more than three million refugees, and almost 70,000 in fiscal 2014 alone, according to the Office of Refugee Resettlement (ORR), a subdivision of the U.S. Department of Health and Human Services. To combat the surge of refugees fleeing the brutal civil war in Syria, White House press secretary Josh Earnest recently announced that the U.S. planned to “scale up” the number of Syrian refugees the country accepts from 1500 in the last fiscal year to at least 10,000 during this year.
Many new arrivals undoubtedly struggle with mental health issues; based on a meta-analysis in the Journal of the American Medical Association, roughly 30 percent of refugees surveyed suffer from PTSD and about 30 percent battle clinical depression.
Pathways to Wellness, a public-private partnership, is part of a grassroots trend in recent years to assess and address refugees’ mental health woes. A keystone for providers is the Domestic Medical Examination that newly arrived refugees can receive under the Federal Refugee Act of 1980. (Refugees also undergo a mandatory physical exam before they arrive in this country.) “It’s the first chance you get to explain what mental health is in the United States,” says Beth Farmer, program director of International Counseling and Community Services at Lutheran Community Services Northwest, which helped develop Pathways. “It’s the first time you get to reduce stigma.”
Funded by groups that include the Robert Wood Johnson Foundation and the Bill & Melinda Gates Foundation, Pathways to Wellness is one tool that refugee settlement organizations can use to help those who’ve fled to the U.S. for a better life. “We wanted to find refugees in distress, get them to care, and have care that works,” says Ms. Farmer, who speaks about the initiative with the pride of an adoring parent. Perhaps that’s because she spent considerable time defending her program from naysayers during its design in 2008 and 2009. “People said, ‘it’ll never work. We’ve tried it before. There are too many different languages. The stigma is too high,’” she recalls. But Pathways has proved effective and popular; about 150 refugee aid organizations across the country and as far away as Germany and Australia have signed utilization agreements to replicate the program.
But such initiatives remain the exception rather than the rule, despite plenty of evidence that mental health screenings benefit newly arrived refugees. Many resettlement experts worry that the nationwide procedures for screening refugees for mental illness are scattershot and inadequate.
“Some states have developed highly sophisticated programs with excellent screening,” says Ann O’Fallon, former executive secretary to the Association of Refugee Health Coordinators. “Other states, with smaller numbers of arrivals or smaller budgets, have struggled to develop a quality program.”
‘If I were to take you out of your New York brownstone and shove you in Somalia, you’d be running scared the rest of your life.’—Dr. Gulshan Bhatia, former director of Santa Clara County’s Refugee Health Assessment Program
Kenneth Wolfe, deputy director at the U.S. Department of Human Services’ Office of Public Affairs, notes by email that “The Office of Refugee Resettlement has made refugee health and mental health a priority over the past several years.” ORR, continues Mr. Wolfe, has collaborated with the Association of Refugee Health Coordinators “to review the current mental health screening tools and protocol used by states … [to] help to identify states that may be in need of technical assistance in order to implement or enhance mental health screening.” Following a spate of suicides by recent arrivals from Bhutan, ORR also launched an initiative,” says Mr. Wolfe, “to reach out to states, resettlement agencies, ethnic self-help organizations, and others to follow up on reported suicides in an effort to understand contributing factors, ensure that the family and community are receiving support, and to assist in planning suicide prevention activities.”
A 2012 survey of 44 state refugee health coordinators published in the Journal of Immigrant & Refugee Studies found that 19 states failed to screen refugees for symptoms of mental illness. Of the 25 surveyed states with screening programs, most relied on informal conversations with patients rather than screening tools tailored to assess refugees. The findings “dismayed” the study’s co-author, Patricia Shannon, an assistant professor in the School of Social Work at the University of Minnesota. She believes that proactive questioning of refugees about their trauma makes common sense. “People who are in need of mental health services, like torture survivors, are not going to raise their hand and say, ‘I’m the one you are looking for over here.’”
The format of the initial medical exam varies considerably, observes Paul Stein, national president of the State Coordinators of Refugee Resettlement and state refugee coordinator in Colorado. The spectrum ranges from “bare bones minimum—no mental health included, just a health screening that’s done in one visit” to multiple visits and a comprehensive emotional health checkup, Mr. Stein says. His state in 2013 entered into a public-private partnership to open the Colorado Refugee Wellness Center in Aurora, something of a one-stop health shop where refugees can receive a range of services, including mental health screenings and treatment. “When you come in for one service, you can access other services at the same time in the same location,” Mr. Stein explains. This helps avoid the care disconnects that can occur “when you are referred across town for a follow-up appointment.”
Doctors who conduct Domestic Medical Examinations point out that establishing trust with refugees—who are often wary of authority figures—requires patience. “We couldn’t just plow through a new refugee in 15 or 20 minutes,” said Dr. Gulshan Bhatia, former director of Santa Clara County’s Refugee Health Assessment Program in San Jose, CA.. “It’s just like the AIDS epidemic. You had to ask all these really inquisitive sexual behavior questions: ‘How many sexual partners have you had?’ And people don’t do that very comfortably.” Dr. Bhatia routinely diagnosed patients with PTSD. “If I were to take you out of your New York brownstone,” she said, “and shove you in Somalia, you’d be running scared the rest of your life.”
Exactly when to schedule mental health screenings also spurs debate. Some newly arrived refugees may feel like they have just won the lottery, says Greg Vinson, senior research and evaluation manager at the Center for Victims of Torture in St. Paul, Minn. He pointed out that Somalis in the Dadaab refugee camps in Kenya often refer to acceptance into the U.S. refugee program as the “Golden Ticket.” Once freed from immediate danger, many refugees experience “a honeymoon period … but then the issues re-emerge,” he says.
Eh Taw Dwe, an ethnic Karen from Myanmar, knows that firsthand. As the “head man” of his village, Mr. Dwe found himself as a buffer between government soldiers and Karen rebels fighting a long and brutal conflict.
In 2002, government soldiers forced Mr. Dwe to watch four of his villagers executed. “They didn’t use a gun. They used a knife,” Mr. Dwe recalls. The soldiers imprisoned him at a military base for three days. There, an officer played Russian roulette with Mr. Dwe. “He put a gun right to my forehead. He counted ‘one, two, three’ and pulled the trigger. They laughed….” After Mr. Dwe’s family paid a ransom, he was able to escape, and marched with his pregnant wife and two young children through thick jungle to Thailand. Toward the end of the harrowing 13-day journey—he had packed only enough food for 10 days—Mr. Dwe’s infant daughter became seriously ill. “She was dying,” he says, his voice breaking. “She had diarrhea. She could not breathe. I hold my wife’s hand, and I prayed.”
His family survived, arriving in Minnesota in 2004. Mr. Dwe underwent a health exam, but it did not include a mental health screening. Within two months, Mr. Dwe got a job as an interpreter with St. Paul-Ramsey County Public Health. At first, he felt euphoric, “because I don’t have to worry that people were going to kill me.”
Then the flashbacks started, imprisoning Mr. Dwe again in his old cell in Myanmar. “The words that they say are still in my ears,” says Mr. Dwe, who started struggling with angry outbursts. He was eventually referred to the Center for Victims of Torture, one of 30 federally financed programs across the country that rehabilitate torture survivors and advocate on their behalf.
The center, founded in 1985, treats survivors at their headquarters in St. Paul. If he had not received therapy and medication, Mr. Dwe, who now runs his own translation business, imagines that life would be very different: “Maybe I would be in jail,” he allows.
Ann O’Fallon, the former head of state refugee coordinators, praises states like Minnesota and Colorado—“a really beautiful model,” she says—for devoting more resources to refugees, but she faults the federal government for collecting insufficient data on mental health screenings. “It needs to be beefed up,” she says. “What percentage of refugees get screened? Is there a requirement that states report in?”
Paul Stein of Colorado understands the human and financial toll caused by not taking action. The longer that barriers to employment, such as mental illness, are not addressed, he says, “the longer it takes for somebody to start building income and paying taxes.”
Several mental health providers concur that not acting to detect and treat mental illness in new refugees amounts to neglect; some untreated refugees likely suffer from psychosomatic illnesses and as a result over-utilize emergency rooms. Patricia Shannon, of the University of Minnesota, concludes that, in general, “the high cost for repeat medical visits that are based on mental health distress is something that isn’t quantified.” Instead, she offers anecdotal evidence. When a wave of Somali refugees settled in the Minneapolis area starting in 2004, many newcomers with mysterious illnesses turned up in emergency rooms. But doctors “wouldn’t find anything wrong with them,” Shannon says. “On some of the charts, I had residents tell me that they would write ‘Sick Somali Syndrome.’”
Data showing a connection between chronic stress, PTSD and depression and long-term poor health is “overwhelming,” says Dr. Michael Hollifield, a psychiatrist who primarily designed the Pathways to Wellness questionnaire.
Dr. Hollifield does not consider improved mental health screenings a cure-all for the many dire challenges faced by refugees, but he is certain that it is the sensible place to start. When contemplating the issue, he says he often thinks about a classic television commercial for Fram oil filters, in which a mechanic rolls out from under a broken-down wreck with a gunked-up engine and delivers the company’s catchphrase: “The choice is yours. You can pay me now or you can pay me later.”
A version of this article was first published by NationSwell.com