Afghan refugees, grappling with grief and trauma, face barriers to mental health care

WASHINGTON — For 17-year-old Salek Haseer, video games are an escape. They’re a way, however fleeting, to put a pause on his thoughts — about fleeing Afghanistan last August, about leaving his father behind and about his new home.

“It’s not like I like to play the games,” Haseer said. “I play to remove my feelings.”

Since resettling in Virginia with his three siblings and mother, Haseer has struggled with the overwhelming emotional toll the past year has taken. Grieving separation from his father — who was unable to leave with his family — he started seeing a psychologist at his school.

“I tell [the psychologist] that I get some depression too. I miss my father. I cannot continue my life, so I try to getting better feelings,” said Haseer, who is a high school junior. “It’s hard to me. Sometimes I say I am nothing without my dad.”

Haseer and his family are among a wave of Afghans who have sought refuge in the U.S. in recent months. While there are mental health resources available to Afghan refugees — who were recently granted temporary protected status in the U.S. — there are significant barriers to accessing that care. There is also, for many, an urgent need for it: Families like Haseer’s are grappling with grief, depression, and post-traumatic stress disorder after living through war and having to leave their homes.

“The war, the explosion, everything — it has put effects on every Afghan,” said 16-year-old Muzamel Kabuli, who left Afghanistan in August with his mother and four brothers and awaited resettlement in a New Jersey military base before settling down in Maryland. Muzamel witnessed a suicide bombing outside his school. His brother, Mahdi, has nightmares about Afghanistan like Haseer.

“Sometimes I dream that I’m in [the middle of] the airport, working to get inside,” said Mahdi, 18. “And sometimes I had a dream that I was with Muzamel, it’s just me and him, and we’re trying to get in, and he gets shot.”

Their mother, Roya Kabuli, is racked with loss after leaving her country and many of her loved ones. She misses the brighter taste of fresh fruit, a neighborhood with mosques nearby, and the sound of the Ahdan, broadcast from local mosques to call Muslims to prayer five times a day.

But what she misses the most is the sunlight. The large windows in her Kabul apartment let in sunlight all day onto the thick, intricately designed red rugs adorning the floors, but her family doesn’t get sunlight on the beige walls of her new Maryland apartment until an hour or two before the sun sets.

“She says that it was so glorious,” Mahdi Kabuli said, translating his mother’s words from Dari. That lack of sunlight makes her sadder, she said. And that makes her physical problems – diabetes, high cholesterol, and recovering from surgery – feel more acute. “She thinks most of her diseases are because she’s nervous. Sometimes she worries a lot. Sometimes she cries,” Mahdi Kabuli said.

There are not good estimates on how many Afghan refugees struggle with mental health, such as depression, anxiety, or post-traumatic stress disorder, nor are there data yet on their access to mental health care in the U.S., though past reports from the American Psychiatric Association suggest very few refugees in the U.S. are referred for mental health care.

When they were waiting for resettlement on the military base, every member of the Kabuli family was told to see a psychologist. But they all refused. They don’t know anyone at the base who saw a psychologist, and have never tried to seek mental health care.

“It’s our tradition that if we have a problem, to tell that problem to a person that we really know, that we really care about, that really cares about us,” Mahdi Kabuli said. “So we feel not very comfortable telling our problems to strangers.”

Experts say there are many cultural factors as to why providing mental health services is more challenging for Afghans, including a “mismatch” between Western and Afghan ways of thinking about mental health, according to Anne Saw, a psychology professor who studies mental health equity for immigrants and refugees at DePaul University. “The ways in which in America we typically treat mental health issues of one-on-one psychotherapy … is culturally dissonant with many immigrants and refugees. It might be hard for some folks to understand why you would even do that,” Saw said. “Sometimes, it’s in direct opposition with what they have been taught of not airing out your problems to people you don’t know or even people you do know.”

Even telling a loved one can prove overwhelming when that same individual is dealing with their own set of challenges. Roya Kabuli worries about her five sons, and she doesn’t want to worry them more. The Kabuli brothers said that when they’re feeling sad, they support one another. Roya, for her part, tries to lean on her sisters still in Afghanistan, but Wi-Fi connectivity issues make it difficult, and she can only speak to them about once a week.

“She say that if ‘I speak to you guys about my problem, it make you sad to see, that will affect your study,’ so because of that she doesn’t,” said Muzamel Kabuli.

Salek Haseer’s brother, Baktash, knew he was grieving his father — in the room they share, he could hear his brother saying his father’s name in his sleep. “Everyday [Salek] is coming to me and asking, what will happen to my father? And every night he is waking up from bed and he is screaming,” Baktash said. “That’s how I know he’s thinking about his father.”

But Salek didn’t feel comfortable telling his family that he was seeking support for more than a month — he didn’t want to worry them.

Beyond the personal barriers, there are also practical hurdles facing Afghan refugees who seek help. While large families like the Kabulis can provide built-in support systems, it also makes transportation difficult. When Neighborhood Health, which provides medical care to underserved communities in Virginia, had a half-day dedicated to providing medical services for Afghan refugees, the center’s outreach program coordinator Laura Gonzalez said they needed multiple cars just for one family.

“I have had a family of nine before who all need medical services, who all need mental health services,” Gonzalez said. “I wish we could have them, all nine, come into our office at the same time … but it’s impossible.”

None of the behavioral health providers at Neighborhood Health, which has several clinics in Virginia, speak the two major languages in Afghanistan, Pashto and Dari. A few of the primary care providers do, and the health center can also call on interpreters, but that can often be a challenge.

However, Neighborhood Health said it has found success introducing mental health as a medical issue by using an integrated form of medical care, in which a primary care provider can check on a patient’s mental and physical health, before calling in a behavioral health provider from another room if needed.

“We’re asking questions about anxiety, we’re asking questions about depressive symptoms in the context of a medical appointment, which a lot of times is less threatening for patients, because it’s something that’s familiar cross-culturally,” said Courtney Riggle-van Schagen, director of behavioral health at the center.

Often, people come in for an initial checkup, but they don’t have the capacity to come back for more comprehensive mental health care, said the Neighborhood Health experts. Their patients are worried about putting food on the table, enrolling their kids into school, or trying to help their families still in Afghanistan, and mental health care gets pushed to the end of the list.

“It is difficult for somebody who is struggling to just acculturate and resettle their family in the midst of ongoing trauma, to think that it would be worthwhile to spend an hour that they could be working and sending money back home or working for their family here to deal with their mental health,” said Saw. “So I think it’s incumbent on providers to sell that, to convince clients that this could be useful.”

Haseer has only met with his school psychologist twice so far. He’s adjusting to his new life as a U.S. high school student, waking up early and staying up late to finish his homework, and believes the appointments are starting to bring relief in the day, though he continues to suffer from nightmares.

“I see my father,” Haseer said. “Only my father.”