Within the past two years Minnesota has become home for large groups of refugees.
In 2021, 1,089 refugees with the status of humanitarian parole arrived in Minnesota; around 56% of them, 642, being from Afghanistan. Other countries included Democratic Republic of Congo with 88 arrivals, Somalia with 67 arrivals and Burma with 60 arrivals, according to the 2021 Minnesota Refugee Health Report.
In 2022 and 2023, Minnesota has also become home for many Ukrainian refugees. By the end of the year, the Minnesota Department of Human Services expects more than 2,000 Ukrainians to resettle in the state.
Refugees arrive to the United States following traumatic events that turned their worlds upside down. And when resettling, mental health is often one of the last things people are thinking about, said True Thao, a social worker who has been serving refugees for more than 20 years.
“They (refugees) say, ‘I can’t do the work and I’m about to get fired and I can’t concentrate.’ They’re trying to focus on the basic needs, what they don’t understand; psychologically they’re very depressed with PTSD and they can’t work because of that,” Thao said. “It’s tremendous hardship for these refugee families. So if that’s how they’re struggling, a little depression here or there, you think it matters to them? No. But that’s why it’s very chronic.”
When refugees first arrive into the country, they receive a health screening from the state in which they arrive. The initial screening looks for immediate needs – oftentimes things like medication refills, vaccinations or connecting someone to a provider they might need down the line. Adults also receive a behavioral health assessment within the first 90 days of arriving to a state, where they are asked five questions about how they are feeling.
“If (incoming refugees) say yes to two or more of those questions, and if the clinician feels like they’re really struggling answering those questions, they would mark them as positive and they would refer them back to their primary care setting or behavioral health specialist to dig in a little further to see if they’re suffering from other issues,” said Blain Mamo, the refugee health coordinator for the Minnesota Department of Health.
But that assessment has not been widespread among Ukrainian groups. The state did not set up a health intake process for the Ukrainians because their arrivals are through the “private sponsorship” program, which makes it difficult to track their arrivals to the state – meaning that refugees from Ukraine have to self-refer to receive the refugee health assessment that includes the five questions.
Because the Afghan refugees arrived under “humanitarian parole” status rather than traditional refugee status, they weren’t eligible for the standard refugee health assessment. They were also staying in temporary housing at the time, so the state created a Health and Safety Check process to address some mental health needs, where two questions pertained to mental health, Mamo said.
Behavioral health volunteers from the University of Minnesota School of Social Work, were available to then assist the people with positive assessments. Once the refugees settled into permanent housing, they were referred for the standard refugee health assessment, Mamo said.
Based on initial screenings of nearly 1,000 Afghan arrivals, about one in five people were identified and referred for social support or mental health services according to preliminary analysis, Mamo wrote in an email. That rate is consistent with what the needs have been among other arrival populations in the past two years, including Burmese/Karen and Congolese arrivals, she wrote.
The stress kicks in
Resettlement agencies, like the International Institute of Minnesota, often notice refugees won’t express needs for mental health services during the beginning of the resettlement process.
“We will usually see people who have been here longer, then they start realizing they might benefit from having mental health providers,” said Micaela Schuneman, the senior director of immigration and refugee services at the International Institute of Minnesota. “We often found was people who had been here one or two years, and they’re going through one of our career paths (courses). That’s sort of the point where they realize they’re pretty stressed out and it might be more than just regular stress. It might be like, ‘Actually I need to talk to someone about this.’ Because they’ve settled a little bit. They’re working, the kids are in school, certain things have settled, and now they’re trying to advance their skills and then they realize there’s a barrier here.”
The institute has served 286 Afghans and 430 Ukrainians in recent years following the wave of arrivals in the past two years. It has programs to help with housing, employment, language learning and job readiness among other things. Schuneman said that clients start to reach out for help – or sometimes teachers will notice something and make a referral to a mental health provider.
Various barriers get in the way of refugees seeking preventative mental health care, especially early on in the resettlement process.
“There is still a lot of misunderstanding about mental health services or behavioral health and what that means. For a lot of our clients, that concept of preventive health in general is not something they’ve ever encountered,” Schuneman said. “It’s mostly because people might not have had access to preventive health care, they were living in a refugee camp where there was no preventive health care, (where) you only went to a clinic if something was wrong: if you broke your arm or you were sick, then you went to the doctor.”
Thao believes psychoeducation and teaching people about how the mind and body work together is the perfect place to start. Even if it doesn’t directly apply to what they’re going through, getting people comfortable with the language and concepts can help someone identify what they may experience down the road.
“We have to do a lot of education to really give them perspective and say, ‘Someone who is depressed is equally sick to someone who has a broken leg,’” Thao said. “Just because it’s invisible doesn’t mean that it doesn’t hurt as much or that it’s not debilitating. It is equally debilitating, it’s just that people don’t see it. It’s hard for people to make sense of that. That’s the stigma on that. You overcome stigma by education.”
One of the jobs of resettlement agencies is to help refugees understand the various systems in the culture – health care being one of them. Navigating the health care system and having the language to do so takes time. But refugees are often taking care of immediate needs when they first arrive.
“In the first 90 days, people are addressing immediate needs, like housing, learning how to buy food, learning where the kids go to school. When we talk about something like mental health or physical health, sometimes people are like ‘I can’t think about that right now. I’m dealing with all this.’ Everything is so overwhelming that it’s really hard to dig deeper into those other things,” Schuneman said.
The Center for Victims of Torture is starting the Minnesota Afghan Project in hopes of meeting the needs of the refugees and increase awareness of mental health preemptively amongst Afghans, said Naweed Ahmadzai, the project’s program manager.
“(The project) focuses on trying to connect with Afghans, offering them different kinds of psychoeducation groups,” Ahmadzai said. “With the Afghan population or a lot of the populations coming from other parts of the world, it’s very hard for us to talk about some of some of the mental health things that are coming up, whether it’s PTSD or navigating new health care in a new country, and usually there’s a lot of side effects.”
One of the first events will be a young women’s group at the end of September for women ages 16-24, coordinated through the Afghan Cultural Society. Ahmadzai said that people are interested in learning how to manage stress and integrate into society, according to survey results from a previous event.
The group sessions will be followed by individual support where participants will have a case manager or weekly check-ins to develop a wellness plan with the help of a psychotherapist, he said.
An added stressor for both Ukrainians and Afghans is their legal status in the U.S. – being under the humanitarian parole, which typically does not provide a pathway to permanent residency or citizenship. Because of this, these families are also pursuing immigration legal services to be able to stay.
What are they facing?
Thao started True Thao Counseling Services in 1997, and has been serving refugee clients since even before then. He is a refugee himself, who came to the U.S. at the age of 11 from a refugee camp in Thailand. He arrived in Rhode Island, but eventually settled in Minnesota in 1995. In college he worked as a mental health provider to work with Hmong and Laotian communities – where he began to see the various health needs of refugee communities.
“I (could) see clearly that they are suffering a lot. There are a lot of depression, a lot of PTSD, anxiety, a lot of schizophrenia. A lot of mental health issues. I saw how isolated they were as refugees and adults. I saw a lot of barriers,” he said.
Once he went to graduate school for social work, he learned a lot about the unique framework to keep in mind when working with refugee clients.
“I think refugees are people whose body comes to America, and their mind slowly comes later,” Thao said.
He said many of his clients experience grief and identity deterioration – all while trying to build a new life and take care of their families.
“They’re learning to understand what life here is as they’re grieving and then how to work through the pain of grief … losing their familiar environment, culture. Just like when we started a new job, we had to start from ground zero and learn a lot of protocols and procedures. You almost feel like ‘I’m at a loss.’” he said. “We can’t be who we are like before. We’re changing. Husband and wife relationship changes because of economic and educational opportunities. Parental-child relationship changes. You may be someone’s commander before you come to America, (now you’re) at ground zero. That kind of change is gut-wrenching.”
Thao is no longer at the clinic full time, and has reduced his patient load. Around 99% of his clients are under medical assistance – and many have been Vietnamese, Cambodian, Laotian, Hmong, Somali and Middle Eastern refugees. Therapy for these populations has a different cadence, he said.
How to integrate while addressing mental health
Thao said his refugee clients don’t typically come into his office ready with an “issue” to discuss. Instead, he takes the approach of learning as much as he can about who a client is and then learns how their mental health might be affecting their day-to-day.
“Normally in therapy, our first question to a client would be, ‘What brings you here?’ And they will say, ‘Well, I’m here because I’m depressed. I’m here because I have relationship issues.’ I think with refugees, it takes a number of sessions before they can answer that,” he said.
Clients will have various stressors, from paying the bills to learning a new culture. Some families also may experience stress from being separated – which they sometimes have to do to put food on the table.
“There are a variety of (cases) that the husband will be at the meat processing plant in Austin (Minn.,) where the wife and kids are here. We know that distance and time create relationship difficulties. Sometimes people don’t see how hard refugees work to survive,” he said.
And at the same time, they could be dealing with PTSD, making daily life difficult to handle.
“People who are actively PTSD or triggered … they’re not only worried about the symptom, they don’t understand the symptoms, so they think something’s wrong,” Thao said. “A lot of my refugee (clients) who have been through war trauma, when they see police in uniform, they get triggered and they don’t understand why.”
He helps clients understand how the brain triggers the body, which he says helps them gain control in those situations. The next step is to unlearn those associations and make new memories through new exposure, he said.
Ultimately, Thao said working through various stressors can improve their wellness and outcomes in their new country.
“I think the degree of their wellness dictates the degree of acceleration in terms of how they can integrate. Integration and outcome depend on individual people, some people aren’t just gonna have a basic life and go fishing and get a house,” he said. “I think the key question is, how does their mental health impede the acceleration and the individual integration into life in America?”
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