Demand and supply

Fleeing Baghdad's violence, Nuhad Toma arrived in the United States a year ago and, at first, the relief at simply being safe left her content.     But reality eventually set in for the 56-year-old Iraqi refugee: She is alone in a new country, doesn't speak much English, worries about friends and family still in the war zone, will eventually lose her state-provided food stamps and housing allowance, and can't find a job.

"Once everything is cut off, it's very difficult," Toma says through a translator.

Feeling herself sliding into loneliness and depression, she learned about new educational and social programs provided by local Chaldean groups. Meeting with other refugees who are struggling and learning about support services that are available helped her. "I saw other people's problems and saw I'm not alone," she says.

Toma is one of roughly 8,400 Iraqi refugees who have resettled in Michigan during the last two years, according to the Michigan Department of Community Health. Fleeing the chaos and danger of their homeland, the refugees receive assistance for about eight months; during that time food stamps, housing allowances and health screenings are provided as they try to find jobs, enroll children in school and begin new lives.

But all the difficulties any immigrants would have adjusting to a new country are complicated with other factors for this group. They've endured decades of war and disruption in Iraq. Some were imprisoned and tortured, or had relatives who were. Most witnessed violence firsthand — car bombings, assaults, shootings. All lived in fear before they fled, and many now suffer from post-traumatic stress disorder.

"If you look at the definition of what a refugee is — someone with a well-founded fear of persecution or that their fear has been documented — that's not surprising," says Colleen Steinman, spokeswoman for the Michigan Department of Human Services. "We're hearing about a lot of PTSD."

Finding that a high percentage of the refugees are in need of mental health care, local social service agencies are responding. They've received state grants to add staff and create programs, are adding additional hours for treatment, finding locations for new offices closer to where the bulk of the new arrivals live, and are designing new programs like the one Toma attends to both educate and provide social opportunities for Iraqis in metro Detroit.

Overcoming the stigma of seeking mental health help has been a big hurdle for the refugees and the service providers, says Anne Pio, a refugee specialist with Lutheran Social Services of Michigan, one of three resettlement agencies that works with the refugees. Pio says it's often not easy for her clients to acknowledge their need for counseling, "But when they do accept it and they go and they find a person who can take care of them, it's easier."

Her agency hosted a workshop for refugees in March where two Iraqi doctors talked about what mental health services are and how to get them. "They explained it's not a big deal to go to a mental doctor. The doctors will have the ability to solve your problems and help your issues," Pio says. "People took their business cards and got their information."

Raad Jajo, a psychiatrist with St. John Health System Eastwood Clinics was one of the speakers. A former Iraqi army general and physician, he came to Detroit in 2000 to restart his career in psychiatry. He now has several dozen Iraqi patients whom he treats for depression, PTSD and grief.

"Many have lost their houses, lost their friends, lost spouses, lost kids. They lost their country. They have such severe suffering," he says.

He also has run seminars to help doctors understand their refugee patients who may report physical symptoms for what are really psychological disorders related to their experiences. "They are stressed-out," Jajo says. "And they may have unexplained physical symptoms."

Jajo is part of an Eastwood mental health program funded by a $500,000 state grant this year. Eastwood received $250,000 for outpatient mental health while the Chaldean American Ladies of Charity and the Chaldean Community Foundation each received $125,000 for translation, outreach, education and treatment strategies.

The Ladies' programs, called Coffee and Family Enrichment — Café for short, are scheduled twice a month. One of the meetings is a social event for the refugees — last week's was bingo at a hall in Warren. Another monthly meeting is educational, with refugees learning about immigration paperwork, drivers' licenses or health care services, for example. Since they started in January, hundreds of people have attended.

"The majority of it is adjustment issues," says Janice Kizy, a social worker and interpreter with the Chaldean Community Foundation. "There is some PTSD that has come through but we're finding that we're meeting some of the mental health needs as we assist them to adjust."

Some of the more serious mental health cases among refugees are handled in Dearborn at ACCESS — the Arab Community Center for Economic and Social Services. The nonprofit agency has increased its mental health services in response to the need among the Iraqis as well. Since 2001, ACCESS has operated a Torture Treatment Center, where hundreds of Iraqis have been treated, says Abdallah Boumediene, community health and research center operations manager.

The agency also received a supplemental grant last year to help refugees with resettlement, including mental health treatment. "People are in need of more services," Boumediene says. "The percentage of people who suffer trauma or some form of PTSD goes from 20 to 85 percent depending on which study you're looking at."

ACCESS is searching for a Macomb County location where therapists and counselors can work with Iraqi refugees as many of them have settled in that area. The Dearborn clinic has expanded its hours and offers two evenings to help meet the needs.

"If someone suffers the circumstances that they went through, it's perfectly normal that you end up having some permanent health problems. You may not be able to sleep. Your appetite is not the same. You're not patient with your kids and family. You have a tendency for angry outbursts. All this stems from the trauma they experienced back home," Boumediene says. "If someone suffers from depression or other mental health issues, they may not be able to maintain a job. They will have all kinds of issues that will always make it difficult for them to have a normal life."