A Story of Depression
A Chinese patient comes with a translator to the doctor's office. The doctor asks if she is delusional, that is, hearing voices. The translator asked: "Are you hearing voices?" and the patient responded, "Yes, you and the doctor." The translator then told the doctor, "Yes, she is hearing voices."
In the show The Infinite Mind, Dr. Kleinman explains how psychiatry, itself, also carries a strong stigma. Some mental health professionals label their clinics with names like "psychosomatic services" or "psychological medicine" or "family services" to avoid having to call themselves "psychiatric."
Medical scientists now know that in psychiatry, as in other forms of medicine, culture plays an enormous role in shaping expressions of illness.
In this multicultural society that the U.S. is today, cultural competency in the treatment of mental illness is a must, because facing mental problems can be even more difficult for immigrants.
Refuge for a Body, Refuge for a Soul
Among African immigrants, the stigma attached to mental illness is strong. Doctors and social workers alike swim against the tide to bring mental health care to people who are sure those ‘down times' will pass; who don't realize they have a health condition, who may have been tortured or witnessed atrocities of war; or who consider mental illness as shameful.
"The biggest challenge of all, I think, is the stigma," said Salaad Nur, coordinator for Refugee and Immigrant Services for the Mental Health Access for Refugees and Immigrants Program (MHARI) in Nashville, Tennessee.
"The more you're involved with the person, the more likely they are to participate," he said. "It's basically about building trust."
The MHARI Program is one of several offered by the Somali Community Center. In 2004, the center received a grant from the Office of Minority Health, which was used to educate refugees about mental health symptoms, illnesses, treatments and recovery through bilingual programs.
The information distributed by the center and its partner organizations covers topics ranging from anxiety, depression and domestic violence to post-traumatic stress disorders.
To acknowledge a mental health problem can bes the hardest hurdle to overcome. That's when the individual has to face the stigma in the community, explains Nur.
To help the Somali community, people have first to enter the center and feel comfortable in it, said Nur. Throughout the year, the center schedules informational sessions about a wide range of issues, including employment, parenting, and education.
These classes build trust, to make the community "understand there's nothing wrong with asking for help." So if anyone needs to return to the center for their mental health, Nur said the experience can seem less stressful.
Once a person feels comfortable and knows you, the idea of becoming a patient seems more acceptable, explains Nur. "If there's not enough trust, a man might only come once or twice. It's really a hands-on training, and you put a lot of time into it, but sometimes it pays off."
According to Nur, mental illnesses aren't always identified because they aren't noticeable to everyone. If the symptoms are obvious, the issue may only be talked about within the family and then with a religious leader.
"Mental problems for men are seen as a sign of weakness," Nur said. "Women are perceived as being emotional, so, supposedly, it is normal for women."
Although clients come to the center for assistance in other areas, they may be referred to Nur and his staff soon after.
Immigrants, and specially refugees, shy away from asking for help, because they don't want to feel like a burden to society. So, Nur has found that their commitment to their families and friends is the perfect button to push to convince people to seek help.
Nur says he finds out how the life of the person has changed and is being affected by the mental illness. Commonly, the relationship with family and friends is suffering.
"One of the hardest things to find out is how it's affecting them, but you can say if you seek help you can fix this problem."
The person may then be referred to Centerstone, one of MHARI's partner organizations that provides an outpatient clinic, free services for the uninsured as well as outreach and education to patients.
Dispelling Myths, Giving Hope
Centerstone has developed programs to give "the community a better understanding of mental health, so that it is seen as a matter of overall wellness, and not merely of mental disorders," according to Meryl Taylor, an adult therapist and coordinator for refugee and immigrant services at Centerstone, also in Nashville.
"What we're trying to do is broaden their view," Taylor said, adding that many clients have seen cases of chronic mental illness that never improved.
"That's a huge part of what we do: dispelling negative myths about mental health services," she said. Some negative perceptions stem from people not understanding the process. They might think they'd be held against their will or forced to take medications.
To counteract these ideas, Taylor said an outreach worker may go to a community center and meet a potential client in an environment that is familiar to him or her.
"When you've lost everything and you're in a totally new environment, just that little bit of familiarity can do wonders," Taylor said.
"Not surprisingly, women are more open to receiving help and part of that is the universal issue that women are allowed to be more emotional and ask for help in different ways than men," she said. "Men get angrier or turn to alcohol or drug use. In the Muslim communities where they don't drink alcohol, they withdraw. It's harder to get them to come back for therapy."
For refugees and immigrants who have escaped war-torn countries, symptoms may be increasingly apparent but no easier to discuss.
"We have people who have seen their parents die, their children die, their siblings-you talk to these people and they've never processed what's happened to them," Taylor said. "Many times the first time they tell their stories is to a mental health counselor."
When we add to those devastating experiences, the regular difficulties immigrants encounter in adapting to a new country, "they don't have the ability to deal with deep trauma issues," Taylor said.
Reliving Painful Memories
According to Dr. Adeyinka M.A. Akinsulure-Smith, a psychologist at the Bellevue/New York University Program for Survivors of Torture, letters from home and television news segments can trigger past feelings. Even 9/11 brought former clients back to the Bellevue.
The experience can also bring back "headaches and nightmares because it may be some of the old stuff but it's a new chapter."
Eventually, by addressing the issue with their group programs, things may improve.
But before a person can overcome symptoms, Centerstone outreach members make sure clients are first told that they are experiencing "a very normal reaction to an abnormal situation." Taylor said "normalizing the experience" allows people to know that they're not crazy and can get better.
"When you are going through these things, you don't have that perspective," she said.
Taylor describes the programs offered by Centerstone as strength-based, focusing on the whole person and not just his or her mental health.
"We just don't focus on pathology. The fact that these are people who are survivors and the way they survived, spurred their belief in God. So religion is a very important part and we certainly draw on that."
Recently, a client had a goal of finding a church, which Centerstone helped her do.
"There are all these little things working together to change a person's life," Taylor said. "We help people make good choices. We help people process their emotions."
"When they come here, they're going to be respected; they're going to be understood," Taylor said. "People coming into this environment, they're going to be treated with dignity and that makes a difference."
Fia Curley is a writer for the OMHRC. Comments? Email: firstname.lastname@example.org
Somali Community Center of Nashville
Mental Health: Culture, race ethnicity