Healing wounds

Treating refugees' mental health needs


A makeshift laundry line stretches across the back entrance to the Walis' Boise apartment. It sags with drying kids' clothes. Zahra Wali would love to use one of the apartment's dryers to finish this load, but that would cost too much money. She spends about $5 every day washing clothes.

Laundry is an expensive undertaking. Zahra and her husband Khaled—both Iraqi refugees—have eight young children. The family arrived in Boise nearly five months ago, and their new life has been rocky. Without jobs, they have to watch every cent. So doing the laundry adds to the stress of resettling.

That's on top of everything else this family has endured to come to the United States. Khaled Wali was a truck driver in Baghdad. He worked with a U.S. military contractor. That made him and his family targets for the militias. Speaking through an interpreter, he tells how the militias killed his brother and then went after him. The family fled to Syria where they lived for a year and half before finding out they would be resettled in Boise.

Zahra (far left) and Khaled Wali (far right) and all eight of their children sit together at the family's small Boise apartment. The Walis arrived in Boise five months ago. - SADIE BABITS
  • Sadie Babits
  • Zahra (far left) and Khaled Wali (far right) and all eight of their children sit together at the family's small Boise apartment. The Walis arrived in Boise five months ago.

Iraqi refugees, like the Walis, are some of the most traumatized refugees being resettled in the Treasure Valley, according to Marla Lipscomb, a counselor at Family Medicine Residency of Idaho and Tidwell Social Work Services and Consulting.

"What we know is that many more refugees aren't getting mental health care and often the first time they receive mental health care, it's in the ER," Lipscomb said. To illustrate the psychological stresses placed on refugee families, Lipscomb takes a small bag and adds a rock to it. As she places more rocks into this "bag of burdens," Lipscomb told an overflow group of counselors, teachers and caseworkers at the inaugural Idaho Conference on Refugees in Boise, refugee clients may begin to understand the role of mental health in their lives.

Mental health referrals made by resettlement agencies have increased in recent years although there aren't any solid numbers yet. Lipscomb said education in the community about refugee mental health has played a role but more needs to be done.

"Given the traumatic histories of refugee populations and the stressors they experience during resettlement, almost every refugee would benefit from counseling services that are adapted to effectively serve refugee populations," she said.

There are now 380 Iraqi refugees living in Boise, and most of them arrived last year, right as the U.S. economy turned south. New arrivals are having a hard time finding work.

"You know the difference between an American not having a job, and a refugee, is that most Americans have a safety net of some kind built in," said Leslye Moore, the regional director of the International Rescue Committee in Boise. "Refugees don't have anything to fall back on so it's a much more terrifying experience for them knowing there's no work for them out there and wondering what their future is going to be."

The Walis face this reality every day. Khaled Wali looks exhausted and he is. He explains he doesn't sleep at night. The Walis live on federal assistance, getting $1,100 a month for rent and utilities and $1,200 a month in food stamps. They also get Medicaid. In three months, some of this federal help gets cut back. So the International Rescue Committee is working with the family to make sure they have affordable housing and that things like food stamps and Medicaid don't disappear. To make matters worse, Khaled Wali hasn't found work.

Unemployment in Idaho is the highest it's been in more than 20 years. That's increased competition for entry-level jobs, which have historically been a good fit for refugees. Already one Iraqi family in Boise faces eviction, and more refugee families are dealing with the same possibility. The unknown intensifies the mental anguish refugees already carry.

This wasn't the life the Walis imagined America offering. Both Khaled and Zahra Wali talked of paradise in the United States, where they and their family would be cared for. That vision included a new house, TV and plenty of money. None of that has happened. The family lives in a cramped low-income apartment. The walls are bare. The TV is small and used. So is the furniture.

"Due to globalization, many of the refugees' perception of the U.S. is the wealth that they have seen on television or have heard about from others prior to resettlement. Refugees aren't told that they will be living in poverty as it is defined in the United States," Lipscomb said.

The disillusionment intensifies when refugees like Khaled Wali can't find work or can't pay their rent. "For the Iraqi population, this reality can be even more difficult, as this is their first time living in relative poverty," Lipscomb said.

The majority of Iraqi refugees are highly skilled and well educated. But their credentials and education often aren't recognized in the United States. "Imagine for a moment how you would feel if you no longer could do what you loved most or could no longer contribute to society in ways that you are skilled and qualified," explained Lipscomb.

Refugees, like the Walis, often arrive in Boise suffering from post-traumatic stress disorder, depression and anxiety. These stresses often intensify during resettlement. Refugees must learn a new language, find a job and learn to navigate the city. Moore spoke about finding refugees homes and helping them get that first job. But she said all of that work is like a Band-Aid: "If their heart is broken, if they are depressed and dealing with trauma, that person will never thrive unless that's resolved. It's the core of everything."

Yet, seeking psychological help is often seen as taboo. Iraqi refugees, for example, are usually familiar with psychotherapy, but they worry about the stigma.

"One barrier to accessing and receiving these services is fear that others will know," said Lipscomb. That's why she believes it's critical for counselors to protect privacy and reaffirm the rules of confidentiality. Counselors are now scheduling Iraqi clients, for example, at different times so they don't see one another.

Still, Lipscomb believes Idaho still has a long way to go.

"There are continued systematic barriers to accessing and receiving services that must be addressed," she said. That includes having a greater understanding of refugee resettlement and the cultural and historical backgrounds of refugee populations.

Moore said that three years ago when she came to Boise, mental health providers were largely focused on talk therapies—a Western mental health practice. Now they are exploring more alternative therapies that help connect with refugees. There's a waiting list for mental health services, especially for Medicaid patients. Moore said sometimes refugees wait a couple of months before getting in to see a counselor. And the current economic picture could spell bad news for Medicaid, forcing the state to cut back services.

Lipscomb dreams that one day Boise will have a medical and mental health clinic dedicated to refugees. The staff would include refugees who would work as cultural experts and health advisers. It's a model she believes would make mental health care accessible and welcoming to all cultures.

Back at the refugee conference, with a bag full of rocks, Lipscomb takes them out, one by one. "This can be confusing to refugees." Lipscomb explained. "The taxi came and picked them up, and they are meeting the provider for the first time. My job is to take these rocks out one by one."