By Justin Perkins

For a time, Saw Ner Clay seemed to have lost everything he worked for in America.

After arriving in the U.S. in 2008, his family moved to Nebraska and began to rebuild their lives. They connected with the Karen community in Omaha, and Clay—having worked as a pastor in Thailand—got a position as a pastor at the Karen Christian Revival Church.

However, just after moving to their new apartment, the entire building burned down. They lost everything, including the clothes and family valuables they had carried all the way from Burma.

Two weeks later, while living in the house of a fellow pastor, Clay’s appendix ruptured, spurring an emergency hospital trip and a series of operations.

Not long after Clay healed and his family found a new place to live—again replacing everything they had—a thief broke into their apartment. Once more, they lost almost everything and were forced to rebuild.

For Clay these episodes of trauma and loss are nothing new.

In Burma, he lived a childhood marred by violence in a country where, since World War II, Karen have been persecuted and killed. As a young boy he was forced to survive in a jungle when the Burmese army came and burned the village where he grew up. He spent the next 30 years in a refugee camp in Thailand where conditions were only slightly better. These are memories he cannot forget to this day.

Despite having experienced trauma and loss, Saw Ner Clay, right, shown here with Taw N Moo, youth pastor at the Karen Christian Revival Church, believes he has been "blessed by God." / Photo by Justin Perkins

Despite having experienced trauma and loss, Saw Ner Clay, right, shown here with Taw N Moo, youth pastor at the Karen Christian Revival Church, believes he has been “blessed by God.” / Photo by Justin Perkins

Neither Clay’s nor the Karen people’s experience of turmoil is singular.

On average, refugees experience 15 different events of trauma in their lives—events that may include malnutrition, the loss of family members and friends, rape, torture, oppression and forced relocation—while almost two-thirds of refugees qualify for clinical depression and one-third suffer from symptoms of Post-Traumatic Stress Disorder  or PTSD. These numbers were found consistent among refugee populations across the world, according to the Harvard Program in Refugee Trauma and its world-wide administration of mental health surveys.

Worse, even after the refugees have relocated, the trauma often does not subside. These psychological wounds of the past can carry into their new lives, affecting their ability to work, provide for their families and learn new skills—all things critical in adapting to a new culture and becoming productive citizens. Further complicating the matter is the reality that refugees must confront the stress of adapting to a new life in a new country while the hidden scars of their past might be left unspoken and unhealed, and mental health resources in America remain either scarce or difficult to access.

Seth Odgaard knows the impact untreated mental health issues can have on resettlement.

As the refugee resettlement director for Catholic Social Services in Lincoln, Nebraska, Odgaard said that many clients he sees, especially those from the Middle East and Africa, suffer from some form of PTSD. “There are some people who come who have been surrounded by terror for decades,” he said.

“We don’t see obvious manifestations of it though,” Odgaard said. Because of the limited resources of the agency, he said, it is hard to track these changes in behavior as they occur over time. In addition, as is sometimes the case with Americans, a cultural stigma surrounds the idea of talking about mental health issues. This can keep many refugees from seeking treatment or talking about the traumas of their past and present.

“It’s like the elephant in the room of the entire resettlement picture,” Odgaard said.

Compounding the issue is the fact that new forms of stress and mental anguish can present themselves in unexpected ways after arrival in the U.S.

“Oftentimes people feel a disappointment of expectations when they arrive,” said Kara Tofte, a program director in the immigration and refugee services of Lutheran Family Services in Omaha. “They are overwhelmed with new responsibilities and paperwork, and can be underwhelmed by a reality they thought would be less hard or stressful.”

This stress, Tofte said—such as the pressures of paying bills, finding transportation and learning a new language or set of job skills—can lead to feelings of depression and anxiety, especially when a person comes from a country where these things are not part of the normal way of life.

Even everyday decisions that may be considered commonplace for most Americans can be sources of great anxiety.

Things like not knowing how to handle junk mail or junk credit card offers, Tofte said, can cause a great amount of stress. “In America,” she continued, “there is an everyday rush of information that refugees have to learn to quickly adapt to and process. For many refugees there is nobody there to tell them what is important or what to throw away, and this can create a constant state of anxiety.”

Cut off from their former cultural and social systems of support, some refugees— especially the elderly—also struggle with the individualistic nature of Western cultures like that in the U.S.

In her work as professor of the psychology of immigration at the University of Nebraska-Lincoln, Cynthia Willis-Esqueda has found that for refugees who come from collectivistic cultures such as those in Asia, Africa and the Middle East, this transition can lead to feelings of loneliness, isolation and depression.

This can be especially true, Willis-Esqueda said, for those who do not know English or are separated from cultural and community support. Oftentimes parents become more dependent on their children as cultural mediators, which can disrupt family structure, leaving parents with feelings of helplessness.

“If you become separated from that social support and ability to be amongst your ethnicity, that can lend itself to different kinds of psychological distress,” Willis-Esqueda said. “And that not only effects you mentally, but effects you physically as well. Maintaining ethnic connection is very beneficial just to manage the day to day kinds of activities required in a Western culture.”

For Krishna Subba, life in America was tougher than he had imagined it would be. After 20 years of living in a refugee camp in Nepal, where jobs were scarce and Bhutanese refugees like him faced discriminated, he was accepted to come and live in the U.S. as a refugee.

Krishna Subba, vice president for the Bhutanese Community of Nebraska, found his dreams of what America would be like were not true. / Photo courtesy Krishna Subba

Krishna Subba, vice president for the Bhutanese Community of Nebraska, found his dreams of what America would be like were not true. / Photo courtesy Krishna Subba

As is common for many Bhutanese refugees, Subba said, he had built up high expectations for life in America before arriving here. He had this certain image of America, he said: that he would easily find a job and that he would be able to drive a nice car and own a nice house when he got here.

But after arriving in Omaha in 2011, Subba found these things did not come true. He learned that jobs were not easy to come by. He struggled to find an affordable place to live. He was self-conscious about his broken English and found it hard to connect with other Americans. Over the next two years, he began to sink into bouts of depression.

Luckily for Subba, things changed. He started to meet more Bhutanese refugees in the Omaha area and became steadily involved with the Bhutanese Community of Nebraska. He enrolled in ESL classes and found himself more confident in navigating through American culture. Now he acts as the vice president for the BCN and is active in helping other Bhutanese refugees in their transition to the U.S., being especially conscious of those who may be struggling with psychological issues of their own.

Willis-Esqueda has seen that combining the already demanding process of a refugee’s upheaval and change to a new life and culture with the lingering—and often hidden—psychological wounds of a person’s past can present much greater adversity for refugees as they try to adapt and acquire the skills necessary in their transition.

And this can lead to a dangerous cycle of effects.

“When your chances of advancement or survival within a culture become greatly diminished, that lends itself all kinds of issues,” she said. For instance, the symptoms of depression and PTSD—such as the inability to concentrate, loss of interest in daily activities, recurring memories of traumatic events and feelings of alienation—can be great barriers for those looking to find a job or reach out to a community of support. And this, Willis-Esqueda said, can lend itself to poverty and the diminishment of life value, which can then further lend itself to depression, unemployment, substance abuse and other psychological issues.

At One World Community Health Centers in Omaha, behavioral health specialist Longfellow Marquez said another part of the problem is the association of a cultural stigma with mental health issues. Marquez often sees such stigmas in patients from Latin America in the form of machismo and the denial of one’s emotional state.

“There is this feeling,” he said, “where people will think ‘I don’t need help’ or ‘I don’t need to talk to someone else.’”

Similar beliefs also span across cultures. Marquez said that within the past five years One World has seen an increase in patients from Africa and Asia. Among these populations, he said, “There is often the idea that if you have the need to see somebody about mental health issues, it means you are crazy.

“But this is not true,” Marquez said.

Marquez“It’s just like if you are having issues with high blood pressure or if you need surgery. It’s a medical problem that needs to be addressed. This does not mean you are crazy.”

To overcome this divide, One World—which primarily provides physical health services—trains its medical providers to identify any emotional and behavioral concerns in their patients. Patients identified with a need are then referred to a behavioral health specialist or councilor for further support, with services provided on a sliding fee scale.

Among the greatest barriers in mental health treatment for refugees is the need for culturally sensitive practices that adapt treatment with a client’s language or cultural way of understanding.

While depression, anxiety and PTSD may be common among refugee populations, a refugee’s experience and understanding of these issues varies widely among different cultures. “Since refugees’ experiences are going to be very different, their issues are going to be different as well,” Willis-Esqueda said. “As a result, their needs for intervention in terms of psychological treatment are also going to be different.”

In Lincoln, Odgaard believes there is still a significant lack of culturally appropriate mental health services. “It’s one of the biggest problems we still don’t have a solution for,” he said. In addition to the lack of bilingual and multicultural mental health services available, Odgaard said, there are also class barriers that discourage many refugees from seeking out mental health services.

But this is changing.

Last April, Lutheran Family Services in Omaha began a behavioral health screening program. To all newly resettled refugees, Lutheran Family Services hands out a three-page questionnaire asking them to identify any physical or mental problems they may be experiencing. To avoid the risk of embarrassment or stigma, the form is translated in both English and a refugee’s preferred language and is made so refugees can fill it out on their own.

People who score positive for behavioral health symptoms are then referred to a behavioral health counselor at Lutheran Family Services where they can access care on a sliding fee scale. Of the 190 refugees screened by LFS from April to September in Omaha, 40 scored positively for symptoms of mental health issues.

Kara Tofte said that one of the most effective ways of dealing with mental health issues for refugees has been through community leaders trained to identify and manage these issues within their community.

Soon, Tofte said, Lutheran Family Services plans to establish a peer training program that will do such a thing, where refugees can find help with those who understand their own culture and language, creating self-sustained programs that can also give back to the community at large.

Sometimes the most effective means of healing can take place through other mediums, led by leaders within the refugee communities.

Among all refugee communities in the U.S., Bhutanese refugees are found to have the highest rate of suicide—in some cases two times as high as the national average of approximately 12 out of every 100,000 people, according to the Centers for Disease Control and Prevention.

Though the exact causes behind this are unknown, Subba remembers firsthand how both depression and suicide were issues in the Bhutanese community that in the past had largely remained unspoken.

In April, Subba along with other leaders in the BCN, hosted a suicide educational program for Bhutanese refugees. They brought in specialists from the Omaha area and helped lead educational sessions themselves to help people be more conscious of these issues among family and friends, and better equipped to deal with someone who may show signs of suicidal behavior.

With a new conviction in life, Subba said that as a leader in the Bhutanese community, he now sees mental health issues as “our responsibility to help those in need, to talk with them and let them know there are things to love about life.”

One of the biggest ways people can become more aware, he said, is by being able to identify the different classes of depression. Common symptoms such as loss of energy or interest in daily activities, he said, can and should be talked about informally amongst friends or family of the person experiencing these symptoms. But in cases of more severe depression, specialized help with a therapist or behavioral health specialist should be sought, and in cases of emergency, an emergency service should be immediately contacted.

Sometimes these signs can come indirectly, Subba said, such as in the way people talk. “For example, in conversation if a person often says things like ‘I want to end the pain’ or ‘I am tired of life,’ these can be signs somebody needs help.”

For Saw Ner Clay and the almost 800 Karen people who worship at the Karen Christian Revival Church, religion has become a central part of this healing. Their focus around a common religious belief has provided them with a strong center of community and has helped many find peace with the present and a calling to serve the greater community.

Despite a lifetime of dealing with trauma and loss, Clay still considers himself “incredibly blessed by God,” and has found spiritual healing in the form of prayer and worship. It helped him get through the turmoil of his past and find meaning and purpose in the present, the dignity of a job, and ties to his Karen heritage that have helped him adapt to American society.

And it’s something he now uses as a pastor to reach out to other Karen refugees like him, who come burdened with the traumas of their past.

Around 5 or 6 a.m. each day, Clay leads a prayer service with other members of the Karen congregation who pray for peace and healing. The church also hosts weekly meetings, a women’s group and a youth group to keep members of the Karen community connected with their heritage and to a community of support.

“Only prayer and God have helped me survive my life,” Clay said. “It’s a miracle.”

Here are links to the National Institute of Health guide to three of the most common behavioral health disorders found among refugees.