Refugees find solace in photos

On a recent morning, a small group of refugees from Bhutan proudly pointed to a laptop screen displaying photos they had taken of Philadelphia, their new home.

Karna Karki had taken pictures of a Hindu priest, seated on the floor with an array of bowls and a flame that symbolized life before him, part of a naming ceremony for a new baby. He also snapped a solemn group in the midst of 13 days of mourning.

The dominant Buddhist culture in Bhutan had tried to extinguish such rituals, Karki, 41, said with the help of a fuzzy interpreter on a cellphone speaker. "They told us to follow their rituals."

Karki is part of an exodus of 35,000 Bhutanese Hindus who have come to America since 2007 after being forced into refugee camps in Nepal. Public-health officials in this country are worried about the suicide rate among those refugees and, more generally, their adjustment to life in a vastly different culture.

Taking photos isn't what most Americans think of as therapy, but the refugees were given the cameras and a chance to discuss their pictures by the new Philadelphia Refugee Mental Health Collaborative. It aims to coordinate mental-health services for refugees in the city for the first time.

Philadelphia receives about 800 refugees a year. The collaborative works with people from Bhutan, Myanmar (Burma), and Iraq, the home countries of most refugees now settling here.

Talking about the photos is a way to help people struggling with a new language and culture communicate and form a community in a "sneaky, backdoor" way, Melissa Fogg said. She is an immigrant mental-health specialist for Lutheran Children and Family Service, lead agency for the collaborative.

Fogg, who has worked on immigrant resettlement for about five years, said she's been surprised by how the refugees have reacted. "It's one of the first times I've seen people opening up about their experiences and talking about their values," she said.

While such photo projects have been used in other settings to empower people or reveal issues in their lives, Fogg said the Philadelphia discussion groups have functioned "almost like group therapy" as refugees shared their experiences. That, she said, is "fairly unique."

The collaborative, which is funded with a two-year, $250,000 grant from Philadelphia's Department of Behavioral Health, pulls together resettlement agencies, medical and mental-health providers, and groups like BuildaBridge and Mural Arts that tie art to personal and community growth.

Despite the horrifying experiences that lead many refugees to flee and the obvious challenge of adjusting to U.S. culture, mental health has gotten little attention previously, collaborative leaders said. Fogg said other services were now well-enough established to begin adding routine mental-health screening to medical exams and to create a web of treatment options ranging from art to talk therapy.

The project comes at a time when refugee mental health is drawing national attention.

The U.S. Centers for Disease Control is now investigating high suicide rates among Bhutanese refugees who have settled in the United States. Sharmila Shetty, medical officer and principal investigator on the project, said 16 refugees have killed themselves since February 2009. The U.S. suicide rate averages 11 per 100,000 people.

The CDC is interviewing 579 Bhutanese refugees in Arizona, Georgia, New York, and Texas - the sites of the largest numbers of suicides - to determine risk factors, prevent suicides, and help refugees get more support. Shetty said suicides have not been a problem in Philadelphia, but there was one death in Pittsburgh and another in Erie County.

The American Psychological Association earlier this month released a report that called for paying more attention to the special mental-health needs of immigrants.

Dina Birman, a psychologist at the University of Illinois at Chicago who helped write the report, said far too little psychological research has been done on new immigrants. Birman, who came to the United States as a refugee from the former Soviet Union, said immigrants may respond better to community- or school-based programs or feel better when a "culture broker" - someone who can help the therapist and patient understand each other's cultures and language - is added.

David Goodwin, a supervising psychologist at Belmont Center for Comprehensive Treatment who works with the collaborative, said treating refugees takes creativity.

"Therapy is culture-bound. As clinicians, it challenges us to really think about what are the universal components of healing," said Goodwin, who immigrated from the United Kingdom and is the son of refugees from Nazi Germany.

"We certainly don't believe that therapy is necessarily the answer. Sometimes it may be more helpful for the community to find a 15-year-old a laptop computer that can teach her English than it is for me to provide therapy around her war experience."

Ellen Plumb, a medical resident in Thomas Jefferson University's Department of Family and Community Medicine, said exposure to the photo project and other collaborative agencies has made her more comfortable referring patients she sees at Jefferson's clinic to alternate approaches like art therapy.

One of the biggest problems, Plumb added, is that refugees are given insurance for only eight months. "Real mental-health issues emerge later," she said.

A picture Plumb found powerful was drawn by a Burmese boy who didn't know how to photograph what had disturbed him. He had seen a man shot dead in Philadelphia. He drew a person dying in a hospital along with a picture of a gun with a line through it.

For the photo projects, Burmese and then Bhutanese refugees were given cameras and told to photograph things they found stressful or anxiety-provoking or that gave them strength. Iraqi refugees will start next month. The pictures will be displayed in July at the Magic Gardens in South Philadelphia and will be used by Mural Arts to create a mural.

Asian immigrants often settle in southeast Philadelphia while Iraqis move to the Northeast, Fogg said. The Iraqis are generally better educated but have also had especially traumatic experiences. "They've been bombed. They've been shot. They've been raped," Fogg said.

Interestingly, the Burmese refugees seemed to focus more often on objects, while the Bhutanese took more pictures of people. One picture by a Burmese refugee shows pairs of tennis shoes hanging over a utility wire. Having come from a place where shoes were a luxury, the refugee saw the discarded shoes as horribly wasteful.

Another refugee photographed a pile of trash, a disappointment in a country that has not quite matched expectations. "I think they come with this idea that America is clean, that it's a land of opportunity, that it's safe everywhere, and it's not," Fogg said.

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