Trauma on Arrival -- Enhancing Refugee Mental Health Services

Trauma on Arrival -- Enhancing Refugee Mental Health Services

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PITTSBURGH, Penn. -- On a Sunday morning in December, nearly a hundred people gathered in a West End church to dedicate their prayers to Claudine Mukankindi, a 36-year-old Congolese refugee who died of a heart attack earlier in the year.

In a pew near the front was Adeline Kihonia. Dancing and chanting in worship, she had tears in her eyes as she spoke of her deceased friend.

"She was like a part of my family," Kihonia said. "When she passed away, it was like I lost a sister, a good sister."

Mukankindi arrived in Pittsburgh in 2001, after surviving the Rwandan genocide, enduring countless acts of violence and loss of family. She had fled to the Congo and then to Kenya, then Cameroon before being resettled in Pittsburgh with her daughter by Catholic Charities.

Over the next five years, 50,000 Congolese will be resettled in the United States by the U.S. State Department. According to area resettlement agencies, roughly 2,000 of them will be moving to Pittsburgh.

Many will come without any English language skills and with trauma, depression and other scars of war. Mental health providers and the Pittsburgh Congolese community are worried the services won’t be there to help them.

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Exporting Taboos

In Mukankindi's time in the U.S., she was diagnosed and treated for a slew of mental illnesses, among them post-traumatic stress disorder. Her last years were marked by hospital stays and court visits.

"Claudine saw a lot of stuff … they were raping women and Claudine saw all of that and they did that to her and they killed even her uncle in [front of] her eyes," Kihonia said. "She saw a lot."

"But you know, sometimes when you already have a lot of shocks in your life, it's very difficult to go back, you know, to be really, really normal. And we try. We try, we try everything… but we lost her."

Trauma is pervasive in the Congo and other conflict-torn countries. Lynn Lawry from Harvard Medical School has studied mental health issues there. A 2010 study she conducted in the Congo found that half of all adults exhibited symptoms of post-traumatic stress disorder. In contrast, that number is between 5 to 10 percent of the U.S. population.

Despite those high numbers, Lawry said there are little-to-no mental health services in the Congo.

"In most of the countries that I go to that are countries of conflict or post-conflict, there may be one psychiatrist or two psychiatrists, which was the case for Democratic Republic of Congo," she said.

Lawry said cultural norms in the Congo often prevent people from realizing that what they are experiencing is a form of mental illness.

"Back home, people don’t know all the diagnoses of mental health, other than just being crazy in general," said Jean Elomba, a Congolese man who was resettled in Pittsburgh around the same time as Mukankindi.

His own experiences have left him with enduring physical scar — a gunshot wound followed by days of hiding in fear without medical attention resulted in him losing his right arm.

For the first eight months refugees in the United States receive federally subsidized medical assistance that covers their medical needs. When Elomba arrived, he was fitted for a prosthetic arm. But he said he was never offered mental health care, even though in retrospect, he might have benefited from it.

"It was very difficult, because you don’t go to sleep, because you keep dreaming about all the things and you feel like someone’s going to come to get you," Elomba said. "You have all those bad dreams. You keep dreaming the same thing over and over."

Eventually, Elomba ended up working as a caseworker for several years with Catholic Charities, the same group that resettled him. He would often try to direct new refugees toward the proper channels, especially people that were coming from war-torn areas. But because he lacked knowledge of the mental health system, and wasn’t sure what providers offered the necessary language skills he would often just refer people to primary care providers.

He said he often thinks about Mukankindi, and whether her life would have been different had she received mental health services immediately upon her arrival to the U.S.

"I think there was a big missed opportunity when she came," Elomba said. "She should have gotten mental health care and entered into a treatment program."

Trauma Upon Arrival

During her first few years in the U.S., Mukankindi learned English and made friends within the Congolese community. But there were also the hospital visits and growing signs of mental instability. Along the way, she lost custody of her daughter, which friends say devastated her.

In 2006, she ended up at Bethlehem Haven, a homeless shelter for women with severe mental illness.

Lois Mufuka Martin, the shelter’s executive director, said Mukankindi’s story, while tragic, shouldn’t come as a surprise.

"If I was in the middle of a civil war, if I saw people die in front of me, if I had to live in a tent,” she noted, “if I was taken from my family for whatever reason, and had to live in refugee camps and then applied for a lottery system that says if I am one of the people drawn from the lottery, I’ll get a ticket to America with my daughter ..."

Martin said that in some cases, the support for newly arrived refugees— housing, food and health care for the first few months — isn’t enough. She has seen other refugee women show up at the shelters.

"People fall into homelessness after initial supports have dwindled..." Martin said, adding “[that’s] when we find them at our doorstep."

In the years Claudine Mukankindi was at Bethlehem Haven, Kihonia adopted her daughter. Upon her release she got a job, and in 2010, she became a U.S. citizen. But last December she died unexpectedly.

Martin said trauma doesn’t just affect the mind, it affects the body.

"In our world of homelessness, we’ve been known to say that for every year a person is homeless it ages them up to 10 years," she said.

Grassroots Support

Rebecca Cech spent her childhood in the Congo and frequently returns. She is on a Congolese resettlement committee set up by Allegheny County to address some of the issues raised by the surge in refugees. She said many of the refugees they are expecting are single mothers, women who may have some of the same vulnerabilities as Mukankindi.

Cech said while the initial supports provided to refugees are invaluable, they are often not enough.

"Everything [that is offered] works on the assumption that people are of sound mind and sound body," she said.

Cech is working with others in the Congolese community to set up homegrown support systems and connect new refugees to mental health services. Similar efforts are also underway in the Bhutanese and Somalian refugee communities in Pittsburgh.

"You can help them in all kinds of ways,” Cech said, “but unless there is a support system for them in that way, there are still really serious issues," Cech said, adding that “trust comes really slowly. And it's really difficult to talk about some of the things that have happened to them."

This project results from the Reporting On Health Collaborative, which involves Mundo Hispánico in Atlanta, New America Media in California and New York, Radio Bilingüe in Fresno, WESA Pittsburgh (an NPR affiliate), Univision Los Angeles (KMEX 34); Univision Arizona (KTVW 33), and ReportingonHealth.org. The Collaborative is an initiative of The California Endowment Health Journalism Fellowships at the University of Southern California’s Annenberg School for Communication and Journalism.