Why Getting Mental Health Care Can Be A Struggle For Refugees

Kazito Kalima was 14 at the start of the Rwandan genocide. Over just a few months in 1994, hundreds of thousands of Tutsi people in his country were killed, including most of his family.

Kalima was bashed over the head with a machete, beaten up and left in a ditch filled with dead bodies. He escaped into the jungle, where he lived for three months eating grass and drinking swamp water.

“It’s hard to understand,” Kalima says. “It’s hard to understand it if you never lived through it.”

It’s a horrific story. Unimaginable, for most people, including many of the mental health professionals Kalima met with to process his trauma.

“Some of the counselors I’ve met, they would start crying when I talk. I’m like, ‘You’re supposed to help me,’” he says with a laugh.

Kalima is the founder and executive director of the Peace Center for Forgiveness & Reconciliation in Indianapolis. He came to the U.S. on a basketball scholarship after lviing as a refugee in East Africa. Now, the nonprofit he founded raises awareness of genocide and other human rights atrocities. It also connects immigrants and refugees to mental health resources. 

“Everybody who has been through any kind of civil war, any conflict, might have some sort of mental health issues,” he says.

From home country to refugee camp

Refugees are people who come to another country fleeing persecution, war and violence in their homelands. Research shows the trauma refugees suffer before coming to the U.S., and the difficulties they face starting over in a new country, can cause anxiety, depression and other mental health issues.

Rates of post-traumatic stress disorder in refugees are especially high, says Diane Mitschke, an associate professor in the school of social work at the University of Texas at Arlington.

“Sometimes as much as 10 times the rates we see in a typical American population,” she says. “Across the board we do see very high rates of depression, both major depressive disorder and temporal depression.”

The reason for these increased rates starts with refugees’ experiences in their home countries. For example, about half of the refugees resettled in Indianapolis come from violence-plagued Burma, also called Myanmar.

“There were a lot of issues with the military in Burma targeting and harming the people,” says Chelsea Davey, mental wellness coordinator for Exodus Refugee Immigration Inc., which has settled more than 1,600 refugees in Indianapolis in the past three years.“There was a lot of forced labor, a lot of violence, a lot of loss of land and property and acts against humanity that people fled from that area.”

When people are forced to leave their country, they face period of rapid change. They move to refugee camps, often leaving family behind or splitting up family members. In the camps, there isn’t much to do, like work or school, to keep refugees occupied.

This can lead to substance abuse, says Mengxi Zhang, a Ball State University assistant professor of health science who studies refugee health.

"The drinking is a really big issue among, especially, the male population,” she says.

Stressed in the U.S.

Once in the U.S., the stresses continue. Adapting to new environments, languages and cultures can affect mental health as much as the trauma of life in a war-torn nation. 

“They probably think they have a really good picture of the life in the U.S., but the situation is probably different than they thought,” Zhang says.

And there are barriers to getting help.

Sometimes it’s a cultural issue. Accessing health care in the U.S. is probably different than in refugees’ home countries. Davey says her clients face several challenges before they even see a mental health professional -- like getting reliable transportation and child care for appointments. 

“If I have someone on the south side that needs to see someone in midtown, it’s at least two buses and it’s probably about an hour commute for a one-hour session,” Davey says.

During those sessions, refugees who don’t speak English also need a quality interpreter, which is expensive for health care providers. Interpreters are also needed to explain basic information such as how doctors’ appointments are made, what treatment is covered by insurance and what fees are associated with treatment. 

“It can be very difficult for our clients to navigate, and they feel frustrated and just kind of give up and just don’t go back,” Davey says.

Battling mental illness and stigma

There are also clients with mental health needs who never get treatment. How refugees view mental health can vary widely,depending on their education level and if they come from poor or rural backgrounds, researchers say. 

Some countries don’t have practicing mental health professionals, says Zhang. That leaves a gap in knowledge about available treatment -- and can contribute to a stigma. 

“In some of the Asian counties, having a mental health issue is considered as crazy or some even worse words,” she says.

That was Kalima’s experience in Rwanda, where he says people with anxiety and depression are described as being possessed by bad spirits.

“They call it 'devil,'” he says.

Without the words to describe their feelings and facing a stigma attached to mental illness, refugees often bring their complaints to a primary care doctor’s office, Mitschke says. They come in with issues that might not seem related to mental health.

“One of the ways to get around the stigma in those particular groups is to talk about those physical manifestations,” she says. “A patient might come in complaining of headaches or dizziness or even severe back pain. Those are often signs of depression.”

Kalima’s mental illness also first manifested in physical symptoms. His palms would sweat while he sat in class at Indiana University South Bend. And migraine headaches were routine. Once, he even blacked out while driving.

“The migraine headaches is something I had for years,” he says. “The sweating -- I would sweat a lot.”

Listen: Kazito Kalima speaks with WFYI about his advocacy work

“A work in progress”

Still, experts say it’s important to remember that not all refugees suffer from mental illness. Mitschke says refugee communities are remarkably resilient, and individuals lean on each other for comfort and support.

“I think so much credit needs to be given to the refuges themselves, who have lived that struggle and have learned about how to navigate life here in the U.S., and then are able to pass that on the newly arrived refugees,” Mitschke says.

Kalima was eventually diagnosed with PTSD. He’s still grappling with memories of the genocide. Water dripping from a faucet reminds him of the months he spent in the jungle. Loud, violent action movies are another trigger. 

“It’s been 25 years and I’m still having nightmares about something I saw when I was a teenager,” Kalima says. “I know where I came from and I don’t want to go back there.”

Talking about his experiences in Rwanda has helped him cope. He speaks at universities, and in 2014 shared his experience at the United Nations. 

It’s important for Kalima not to think of himself as a victim. That’s what he tells the refugees he works with. He says acting like a victim means your oppressors win.

“It’s a work in progress,” he says. “Right now I’m able to live a normal life.”

This story was produced by Side Effects Public Media, a news collaborative covering public health.