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Morgan Merrell spends hours in the homes of refugee families who have resettled in Kansas City. Seated on secondhand sofas, or around tables, or cross-legged on floors, sometimes sipping tea, she listens as interpreters draw out stories that always begin with “a journey of loss.”
The refugees who arrive in Kansas City have been displaced from their homes and homelands. They have left loved ones behind and, sometimes, lost them to war, violence and disease.
“Hearing about that loss, and then seeing them still be able to make sense of who they are as a person and to find value in their life now is really incredible,” said Merrell, manager of adult and family social work for Jewish Vocational Service, one of three agencies in the Kansas City region that resettle refugees.
Few refugees make their way to a therapist to talk about the trauma they’ve endured. Finding a therapist who understands their cultural background can be difficult, and the mental health care system can be confusing for even natural-born Americans to navigate. Instead, they lean on case managers such as Merrell, and one another.
The first few months are defined by isolation
Engoma Fataki remembers meeting his family’s case manager on an October 2014 morning in Columbia, Missouri. He was jet-lagged and disoriented, having arrived in the U.S. the night before after 17 years spent in refugee camps across southeast Africa with his family after they fled their Congolese homeland.
That disorientation continued for months.
“One of the things that I had to deal with was trying to fit in,” Fataki said. “Coming from a different culture with a different language, different norms, different types of people that I’ve been used to.”
He struggled to make friends, given that he spoke very little English and had trouble connecting with people at his high school.
Fataki’s case manager was the person he relied on most to learn about American culture and to process his experience of resettling in Missouri.
“You need somebody to be there for you,” he said. “Whether it’s telling you about the culture, giving you advice. We were lucky because our case manager spoke Swahili, so that connection was important.”
Fataki is now an interpreter and liaison at Kansas City Public Schools and also works with the International Welcome Center, dedicated to supporting international students like himself.
Finding resilience through community
Within 90 days of arriving in the United States, most refugees receive a medical screening at a local health clinic. As with routine physical checkups, providers ask their patients about their emotional and mental health, looking for signs of depression and suicide risk.
In addition to common disorders such as depression and anxiety, refugees are diagnosed with more severe illnesses, such as schizophrenia and bipolar disorder, in numbers similar to that in the general population, Merrell said. The same is true for suicidal thoughts or behaviors, which she said are no more common among refugees than among other Kansas Citians.
“One of the most crucial things to understand is that refugees are remarkably resilient,” Merrell said. “Our American reaction, coming from a place of so much stability, we’re going to assume that they’re going to need so much mental health support. But for the most part, it’s just a matter of helping communities be strong so that they can support each other.”
Refugees often look for the churches, mosques and markets where other immigrants who share their experiences and languages tend to gather.
Fataki’s family of 11 attended a church in northeast Kansas City, where his father gave sermons in Swahili. After the service ended, the families in the congregation would linger for hours, catching up and connecting as a community.
“It heals all the trauma that we might have gone through because you find that, ‘Oh, I’m not the only one here,’ ” Fataki said. “They can understand me in a way that no one else can. Because we speak the same language, we have gone through the same experience.”
For Kansas Citians who want to help refugees build a support network, agencies have suggested donating cash and furniture, as well as volunteering to tutor in English, to provide transportation or to set up new apartments. These agencies are experiencing a significant increase in refugees and Afghan evacuees resettling in Kansas City, as President Joe Biden is increasing admissions for the first time in five years.
Refugees seeking mental health care face long wait times
While severe mental health issues are rare among new arrivals, those who do need help face long wait times in an overburdened system, compounded by language barriers.
In Missouri, almost 2 million people live in areas that are designated “Mental Health Care Health Professional Shortage Areas,” according to the Kaiser Family Foundation. This is about 30% of the state’s population. Even in the Kansas City area, patients often have to wait several months before receiving psychiatric care.
This shortage is particularly dire for Medicaid patients, given that only about a third of psychiatrists in the United States accept new patients with Medicaid. Most newly arrived refugee families receive health insurance through Medicaid, at least in the early months, according to Chelsey Butchereit, the Missouri state refugee health coordinator at the U.S. Committee for Refugees and Immigrants.
Hilary Singer, executive director of Jewish Vocational Service, noted that “there are challenges for refugees and for everybody else in our community, in the volume of mental health services that are available.” She added that “the wait times to access service are tremendously long.”
Recent advancements in telehealth, which have granted some patients access to a more diverse field of therapists and psychiatrists, aren’t especially helpful to refugee communities, Singer said. Newly arrived Americans are not always comfortable with technology. And for many refugees, an in-person connection is culturally significant.
“Many of the countries where we resettle from are high-contact societies, where building that relationship, having that in-person connection, going over to someone’s house (is important),” Singer said. “You can’t replicate that on a screen.”
Finding strength in survivorship
Case managers provide that in-person connection. But they need to know how to help instead of harm, Merrell said.
Many case managers speak about “cultural humility,” a reminder that no one can be completely competent in a culture that is not their own. Instead, Merrell said, case managers are humble in knowing that their perspective is limited.
She added that the refugee experience is not universal. Some refugees, including immigrants from war-torn Syria and the recent evacuees from Afghanistan, left their countries quickly and were resettled shortly after. Others, such as refugees from Somalia, may have lived in refugee camps for years or even decades.
When helping refugees recover from their trauma, caseworkers from Jewish Vocational Service use a model of therapy based on narrative and storytelling.
“It’s seeing it as, this is the time in my life where I survived, and this is the time where I was able to be a victor, despite all of these things going wrong,” Merrell said. “If there is a story that involves an extraordinary amount of loss, perhaps the loss of a family member, (we help) clients to be able to speak that story, and to be able to still have meaning in their life, despite that loss.”
For example, instead of framing their story around someone destroying their home, refugees would tell the story of how they were able to escape and survive. By using this model, caseworkers have seen symptoms of anxiety and depression ease for most of their clients, Merrell said.
Refugee mental health support beyond traditional therapy
Butchereit agrees on a need for more cultural sensitivity among therapists and psychiatrists when addressing refugee mental health needs.
The American concept of mental diagnoses is very specific to the U.S. health care system, she noted, and many conditions that Americans consider mental disorders may not be viewed the same way elsewhere.
Some refugees seek support that aligns with their cultural background, which may not be traditional talk therapy. Examples vary among cultures, but could include song, dance or gardening.
Fataki said he found comfort in sports. He was on his high school’s cross-country team, and he spent a lot of time playing soccer with his friends on a field in northeast Kansas City. Because he didn’t need to talk when playing, soccer provided a way to make friends before he was fully conversational in English.
“As long as you can play well, you can be friends with anybody,” he said.
Merrell described her work with refugees as inspirational and a privilege.
“To see families that experienced that loss, and then come here and wildly thrive in a new place against all odds … It’s an honor to have that short partnership,” she said. ”And then to part ways and see them succeed.”