Refugees Face Trauma Treatment Gap

The soldiers dragged out a pregnant woman and slit open her belly. A witness who was personally tortured for his political activism in Congo is more haunted by that image than his own pain.

Safe in Connecticut now, he has daily flashbacks and wants to see a therapist in order to cope with this memory as well as the stress of leaving his home, friends and family to start a new life in America.

But it will likely take months before he gets help. And if he does his therapist must speak French to communicate with him or be willing to work through an interpreter.  To make matters worse, those months of waiting work against him – since he’ll qualify for health coverage for a limited time.

Like many refugees, he would only share his story anonymously, Angela Zurowski, executive director of the International Institute of Connecticut, a Bridgeport resettlement agency that is assisting him told C-HIT, because he is afraid his relatives will be kidnapped or harmed if it is known that they have a relative in the United States.

About 28,000 refugees currently live in Connecticut, according to Integrated Refugee and Immigrant Services (IRIS) in New Haven. Many refugees come to the U.S. after suffering through traumatic experiences in their home countries, but financial and language barriers often keep them from getting mental health care.

This is one of many shortcomings in the services offered to refugees, according to a report issued this month by the Congressional Research Service, which was critical of federal resettlement programs that provide short term aid and often do not address the unique problems that refugees face, including trauma histories.

The long-term consequences of not providing refugees with good mental health care are devastating, according to Mary Scully, director of programs for Khmer Health Advocates in West Hartford. She connects untreated mental illness in her clients who came to the United States in the 1970s and 1980s with a wave a physical illness in the Cambodian-American community today. “Now we see the whole gamut of trauma-induced chronic disease,” she said.

The witness and other refugees need to go to providers who accept Medicaid, which covers refugees for their first eight months in the U.S. “It’s almost next to impossible to get mental health care if you have Medicaid,” said Kelly Hebrank, who manages health and wellness programs at IRIS. The providers who do accept Medicaid have long waiting lists, she said.

That waiting list means the duration of therapy is shorter, explained Zurowski.  She has advocated nationally for extending the period of Medicaid coverage so that refugees have longer to establish themselves in jobs that offer health benefits. The Congressional Research Service also identified the short duration of Medicaid for refugees as a problem.

The limited window of coverage, meant to encourage independence, can have the opposite effect, according to Yelena Gerovich, who manages the Jewish Federation of Greater New Haven’s New American Acculturation Program. Staying in poverty will allow refugees to qualify for Title 19, while working in mid-to-lower wage jobs disqualifies them from assistance. “It’s a huge problem,” she said. “People say: Look we’ve come here and worked and worked, and we have nothing.”

“The whole system is not geared to a trauma survivor who does not speak English,” said Scully.  Many therapists do not provide interpreters, which sends providers like Hebrank and Zurowski scrambling to find trained interpreters or even volunteers who speak the patient’s language. This is particularly difficult, given the number of languages to be accommodated. Zurowski once searched statewide to find two women who spoke a single Burmese dialect.

There are 148 languages other than English spoken by children in the state’s public schools, according to the state Department of Education. Spanish is the most common, but new refugees speak Berber, Edo, Ga among many others.

A greater barrier is the refusal of some therapists to work through interpreters. Health care providers may resist using interpreters because it takes time during the appointment, time already limited by insurance regulations, said Dr. Hendry Ton, director of the University of California Davis Transcultural Wellness Center. “It’s almost an incentive not to use an interpreter,” said Ton, who is a psychiatrist. Most physicians, he added, are not trained to work through interpreters. Nor is there any standard of training for medical interpreters.

Ton gives the doctors who work for him extra time if they are using an interpreter. He also trains residents to work with interpreters and takes pains to build relationships with the interpreters he uses himself and to make his goals in a therapy session clear to them. All this takes time, which in health care translates into money. “In the long-term, it costs less,” Ton insisted.

He said that patients with interpreters are more likely to keep appointments and that one study showed their rates of hospitalization and emergency room use were 60 to 80 percent lower than non-English speakers who had not been assigned an interpreter.

Any organization that receives federal funding is required to provide interpretation for patients who need it, Ton added, but providers and administrators are not always aware or empowered enough to insist on it.

Finding a therapist who speaks your language can be a challenge for a refugee. Getting to an appointment can be even harder for a group of people who often don’t own cars in a state without an extensive public transportation system.

Hebrank was overjoyed when she found an Arabic-speaking therapist in Waterbury who agreed to see a New Haven woman with severe post traumatic stress disorder. Medicaid covered the cost of a driver for the woman, who did not have a car. The driver was an hour late to transport her to the first appointment and a no-show for the second.  After two missed appointments, the therapist said she couldn’t see the client, recalled Hebrank, shaking her head in frustration.

While the stigma around mental health has been diminishing in the U.S., many immigrants come from parts of the world where going into therapy is a rarity. Dr. Paula Zimbrean, a psychiatrist, volunteers to see refugees who come for physical care at Yale-New Haven Hospital’s Primary Care Center.

“The stigma is more about going to a mental health place,” said Zimbrean, who sees great potential in combing physical and mental care for immigrants. Residents from the Yale School of Medicine assist her, clinically and as interpreters.  In the last year, about half of the refugees she screened could have benefited from mental health services, she said.

Khmer Health Associates uses traditional Cambodian healing practices as well as Western medicine to help clients address mental health issues. “Cambodians have a deep belief in their own traditional ways and they are totally at home with Western medicine,” said Scully. But she added that her clients only accept a Western solution “if they understand it,” making good translation essential. Much of her organization’s work revolves around helping immigrants understand the health care system and other bureaucracies they encounter here.

Scully, a psychiatric nurse is a proponent of using interpreters in therapy. Her organization has had success using telemedicine and videoconferencing to make Khmer speakers trained in health care widely available to refugees no matter where they live in the country. The group is currently seeking federal funding to expand that work.

She formed Khmer Health Associates 30 years ago with its executive director, Theanvy Kuoch. The two met working in a refugee camp in Thailand and planned to offer mental health care to trauma survivors in the United States. “We figured we’d work a couple of years then put ourselves out of business,” said Scully.

But Cambodian-born people find many barriers to using the larger health care system, she said.  Now workers at Khmer Health are seeing mental health concerns eclipsed by physical ones, as Cambodians in the United States suffer from high rates of diabetes, stroke and other illnesses.  Scully said that survivors of the Cambodian genocide now in their 40s and 50s are dying from cardiac disease. “That’s unaddressed trauma,” she said.