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00000176-e6f7-dce8-adff-f6f770e40001In this special Living in the Shadows series, news organizations from around the country joined together to bring to light the interplay between immigration status and health. We will show where health systems fail some of the most vulnerable and highlight effective solutions to common conditions.

Translating Trauma: The Challenge of Treating Refugees With PTSD

Ryan Loew
90.5 WESA

As a child in war-torn Somalia, Aweys Mwaliya saw friends and family killed in massacres. Fleeing the country,  his family spent weeks walking to Kenya. The trip was so grueling, that along the way, his youngest sister died. The family couldn’t give her a proper burial.

"The feeling I have about those terrible things are very, very bad, and I’m still wondering why things like that happen, why people do things to other people," Mwaliya, now 30 and living in Pittsburgh said. 

In Kenya, his family spent a decade living in refugee camps.

"Even when we came to the refugee camp, it was not like a safe, safe place that we could say was really a good place," Mwaliya said. "The gunfight was also there  — so it was like living in the same kind of condition." 

Nine years ago, Mwaliya was resettled in Utah. Later, he moved to Pittsburgh.

When he was resettled, he had paid housing for a few months. He took language lessons. He had health care. But he says he was never offered mental health services.

"I didn’t feel like I needed those ." he said. 

Credit Ryan Loew / 90.5 WESA
Aweys Mwaliya tries not to think of the past, but certain things will trigger bad memories. "You know as someone who had been experiencing a lot of these kind of issues back home, I don’t feel like — in this world, I don’t think there is a place where you can say, it is really safe and peaceful," he said. "I don’t think that there is any place like that."

Now  married with five children, he lives in Northview Heights and works at Sam’s Club. He's president of the Somali-Bantu Community Association of Pittsburgh. He says he tries not to think of the past, but certain things will trigger bad memories.

"You know as someone who had been experiencing a lot of these kind of issues back home, I don’t feel like — in this world, I don’t think there is a place where you can say, it is really safe and peaceful," he said. "I don’t think that there is any place like that."

In 2012, more that 58,000 refugees were resettled in the United States. A couple thousand of them came to Pennsylvania. 

"Refugees come from places that tend to be difficult, I mean nobody chooses to be a refugee, people become refugees," said Marco Gemignani, who teaches psychology at Duquesne University and works with refugees at Catholic Charities Health Clinic.

"These are truly survivors of war or survivors of torture, so in that case we see a high frequency of post-traumatic stress disorder," Gemignani said, adding that PTSD cases are difficult to treat and at times also difficult to recognize. 

Gemignani said different cultures present trauma or PTSD differently than many Americans. In the United States, he said, people tend to express themselves verbally, but PTSD can manifest itself in other ways in someone from Somalia or other countries. 

"People may not talk about nightmares or memories, but they may tell us they have a strong headache," he said, "that they lost their appetite, that they have a strong pain in the neck or stomach problem."

Those sorts of questions — detailing physical symptoms — have now been incorporated into the state assessment physical providers fill out when refugees first arrive.

That’s part of Gemignani’s task. After people are here for a while, searching for what lies behind physical symptoms, a task that requires sensitivity, patience and time.

Before coming to Pittsburgh, Gemignani worked with refugees in Bosnia and researched the effects of forced migration on mental health.

"People take two main stances towards their trauma," he said. "One is that trauma is stuck in the past. So they typically say the past is past, I don’t want to go there, I don’t care, I don’t want to think about that. I just try to look at the future. The other position … is that people say the past is my strength."

Like Aweys Mwaliya, refugees may not always want to address the past. Mwaliya said unless trauma turns into full-blown PTSD, most people won’t go for counseling. One of his roles as a community leader is to accompany others to doctors appointments, help translate and along the way de-stigmatize the process. He said helping others has helped him heal. Among his fellow Somalian refugees, he said there are a lot of people who need mental health help, but most won’t go for it.

"If you go inside and look at the problem (depression trauma) in 10, I will say you will find seven having the problem," he said. 

Those who work resettling refugees say the act itself of resettlement can be traumatic. But there aren’t always services available.

Leslie Aizenman works for Jewish Family and Children’s Services. She said although they are aware people come from difficult pasts, they don’t have all the resources to help people work through them while also helping them establish new lives here.

"There’s not a lot in Pittsburgh to help them but we’re working on it," she said. 

When Pierre Gahima came to Pittsburgh from the Democratic Republic of Congo, he had a difficult time. He felt lucky to be alive, but there was guilt and sadness in knowing he could never go home again. Within a few months of being resettled here, his teenage brother died of an undetected heart condition. There wasn’t an outlet for him, he said.

"They just want you to come here and be efficient and integrate work and live your life, change your life but they don’t make sure to know where you come from, what you went through," he said." That support, it was not there; it was not there."

Bashar Abdulrazak, an Iraqi refugee, said his last few years in Iraq and then in Jordan before coming here were traumatic.

"When we were sleeping during the night we were fully dressed," he said. "Because you don’t know like when somebody could kick in your front door and ask you for interrogations or something like that or just kidnap you. It's better to be fully dressed rather than be in your pajamas."

He feels some frustrations. As a trained physician, he isn’t certified here. His relatives were resettled in other countries or are in Iraq subject to daily turmoil. But now, when he goes to sleep at night, he can wear pajamas. When his son leaves for school he doesn’t worry he’ll be kidnapped. He knows interrogators won’t break into his house or explosions won’t go off nearby. And that has helped him.  

"These tiny things, like when you put your head on a pillow and you don’t think about all this, it’s amazing," he said. 

Trauma can be re-instigated by certain things — sounds and sights that remind people of what instigated their initial trauma. Aweys Mwaliya says watching news coverage will bring back bad memories. 

But overall, his life has been greatly improved by moving to the United States. And if he was still in Somalia or in camps in Kenya, he said he doesn’t think he would still be alive.

"Everywhere you do, there is a better place than the other place, that’s what I can say," he said. "Pittsburgh is better than the refugee camp and also the refugee camp is just better than Somalia, so that’s just how it is."

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This project results from the Reporting On Health Collaborative, which involves 90.5 WESA, Mundo Hispánico in Atlanta, New America Media in California and New York, Radio Bilingüe in Oakland, Univision Los Angeles (KMEX 34); Univision Arizona (KTVW 33), and 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.

Read more from the Living in the Shadows project.