By Kathryn Sanders
The Carrboro Farmer’s Market was bustling on a recent Saturday in November. Among the farmers selling carrots and lettuce, there was a stand tucked in the corner of the market selling crops such as pennywort, roselle and bitter melon. These farmers were refugees from Burma, and were part of a community farm project called Transplanting Traditions.
The group provides Burmese refugees in Carrboro, North Carolina access to land, healthy food, agricultural education and small farm business development. It also provides participants a much-needed sense of community and safety.
“Social isolation is a major issue within this community,” according to Sara Snyder, the VISTA educational programs coordinator at Transplanting Traditions. Many people were separated from their families when they went to refugee camps and were again separated when they were resettled in America. Trauma-related depression is common because of this upheaval.
“One hundred percent of the refugees that we serve report being less stressed after joining the farm,” Snyder said.
There are several reasons cited for the improvement in their stress including the opportunity to see friends, working outside in the fresh air, and being able to grow traditional and medicinal crops that remind them of home, Snyder said. They’re also able to teach their children about their heritage.
One hundred percent of the refugees that we serve report being less stressed after joining the farm.
Refugees, by federal law, are granted different kinds of support when they come to the United States, such as help finding a job and getting health insurance.
But mental healthcare is not a federally-mandated requirement for refugees, so community groups such as Transplanting Traditions are stepping up to fill in the gaps where traditional medical care is lacking.
Refugees settling in North Carolina
North Carolina ranks as seventh among US states for accepting people granted refugee status, according to an investigative report done by ABC11. More than 500 refugees moved to North Carolina during the first half of 2018.
And because the state has so many refugees, it consequently has a large number of people who may need access to mental healthcare.
There are several reasons North Carolina ranks highly for refugees, according to Monique Lohmeyer, a refugee services coordinator at Church World Services, a refugee resettlement program in Durham. One reason is due to the current economic level in the state for jobs and affordable housing, and another is because there is already a large community of certain refugee populations here.
Once a refugee arrives in the United States, they go to a resettlement agency, which is a group such as Church World Services in Durham, NC or Interfaith Refugee Ministry in Wilmington, NC, that orients the new arrival to help them get a job and apply for healthcare benefits.
Refugee health care options
In North Carolina, most refugees immediately qualify for either Refugee Medical Assistance, or Refugee Medicaid, or a different North Carolina Medicaid program, according to Interfaith Refugee Ministry’s NC State Refugee Health Coordinator Jennifer Morillo.
Refugee Medicaid lasts only for eight months upon their arrival here in the United States, Lohmeyer said. It retroactively starts the day they arrive even though it make take up to a week for them to officially apply upon their entry to this country.
“We reconnect with them around the six month mark, where we direct them to find healthcare benefits through their job, which is part of what our employment team focuses on,” Lohmeyer said.
The employment team at a resettlement agency targets employers that offer benefits. If there aren’t enough jobs available, they look into the Affordable Care Act, or a program such as Duke Latch, which is an outreach program that helps provide healthcare access to immigrant populations. But despite the efforts of these groups, sometimes it’s not enough for the refugee.
“It’s a population that is severely underinsured after that first eight months,” Lohmeyer said.
It’s a population that is severely underinsured after that first eight months.
Mental health care is not a requirement
There are certain boxes the resettlement agency must check off, such as getting the person immunized, helping get a primary care provider set up, housing, and starting English classes, among other things. But mental health care is not a requirement for resettlement.
“There are many resettlement agencies in the nation that have a focus on mental health and even have mental health services incorporated so it’s really a whole-person, holistic wellness model,” according to Marlowe Crews Kovach Marlowe Crews Kovach, MSW, LCSW-A, a program coordinator with the UNC Refugee Mental Health and Wellness Initiative.
In the Chapel Hill area of North Carolina, however, mental health is not incorporated directly with any of the resettlement agencies, which is how Refugee Wellness came exist. The UNC Refugee Mental Health and Wellness Initiative is a group that provides mental health services and support to refugees in the North Carolina Raleigh-Durham area.
“We want to provide support directly because we see there is an unmet need and a gap. We train Masters of Social Work students in how to work with this population and how to collaborate with interpreters and navigate these barriers,” Crews Kovach said.
Refugee Wellness is a grant-funded program that not only links refugees to other providers, but provides some counseling services itself. For people who are struggling day to day to get their needs met, something like work might come up, and getting to their therapy appointment isn’t their top priority. Day to day survival is.
“That’s why it’s so important to have programs funded specifically for refugee mental health, because there are so many factors within this population that make it really hard for them to be able to access mental health services,” Crews Kovach said.
Barriers to mental health care
The North Carolina Center for Public Policy Research recently asked North Carolinians via their newsletter, “What do you think is the biggest barrier to seeking mental health care?” Some of the responses were lack of insurance, cost of care, not knowing where to get care, and stigma/embarrassment, among others.
For refugees, the barriers to seeking mental health care are more complex. They include lack of transportation, confusion about insurance networks, and cultural stigma, Crews Kovach said. But the biggest issue might be language barriers.
Most mental health providers are required to provide services to people that need interpretation, or speak languages other than English and Spanish. But interpretation is very expensive, so that is not an option for many providers. Even though they are required by law to provide services, there is also a loophole law that says if it is a financial burden on the agency, then it is not required, according to Crews Kovach.
“Many people want to provide services, but interpretation is so expensive and in North Carolina, since Medicaid has not been expanded, interpretation is often not reimbursed at a rate that can cover interpretation,” Crews Kovach said.
The current state of North Carolina health care
As of November 2018, North Carolina is one of only 13 states that has not voted to expand Medicaid, according to the Kaiser Family Foundation.
Yasmin Bendaas is science writer and community engagement specialist with EducationNC, a nonprofit associated with the NC Center for Public Policy Research. Bendaas said by email that there are members of the public health community that feel that expanding Medicaid in North Carolina would do more for people with mental health problems than simply increasing the Affordable Care Act, or remaking the current Medicaid model.
A Kaiser Family Foundation literature review on over 200 Medicaid studies reiterates Bendaas’s point, and shows that Medicaid-expansion states have shown greater improvements to access to both mental health medications and services than non-expansion states.
North Carolina is currently moving into a “Medicaid reform,” according to David Anderson, a research associate at the Health Policy Evidence Hub at the Margolis Center for Health Policy at Duke University. It will probably be in place by early 2020.
The system is transitioning from what is known as “fee for service” where the state directly pays doctors and hospitals for the care of Medicaid patients, to what is known as “Medicaid Managed Care” where the state pays a number of insurance companies a fixed fee per month, and then the insurance company pays the doctors and the hospitals to take care of the Medicaid patients, Anderson said.
Right now, North Carolina already bids out behavioral and mental health Medicaid services to Local Management Entities, or LMEs such as Cardinal Innovations Healthcare. Eventually, according to Anderson, the plan is to roll all health care into one contract, so nothing is carved out like it is now.
“Mental and behavioral health tends to be a very complex care management problem. In order to make the transition as smooth as possible, states tend to make that population one of the last to switch over,” Anderson said.
Refugee mental health care options, beyond insurance
Mental health support is important in all populations, but particularly for refugees, a group that is prone to stressful living and is cut off from their home community.
“If you’re focused on survival, if a person’s fight or flight response is highly activated and they’re just trying to make it through the day, it’s hard to focus on mental health, even though their emotional wellness is already impacting them,” Crews Kovach said.
Because of gaps in the federal program for refugee help, and because health insurance is so difficult to navigate anyway, community groups are looking to other ways of supporting refugees with mental health.
Art therapy is a mental health care option that goes beyond traditional therapy. The practice is defined by the American Art Therapy Association as a “mental health profession that enriches the lives of people through active art-making, creative process, applied psychological theory, and human experience within a psychotherapeutic relationship.” And it can be particularly effective for refugees.
Because refugees often have language or other verbal barriers, art therapy provides a safe space for them to express themselves, according to Courtney Powers, MA, LPCA, ATR, a clinician at the Art Therapy Institute in Chapel Hill, NC.
“Stories that people want, and need, to share will inevitably emerge,” Powers said.
The Institute provides art therapy services to clients, training to other professionals, and peer support groups. The support groups, in particular, provide a sense of connection and belonging for refugees while they are negotiating acculturation, according to Powers.
Stories that people want, and need, to share will inevitably emerge.
Video courtesy of Art Therapy Institute
Peer support and community leader training
One of the community adjustment support groups UNC Refugee Wellness conducts is a curriculum called Pathways to Wellness. It’s an eight-week program that talks about adjusting to new cultures and the mind-body connection.
It also works to destigmatize mental health, and to give information about mental health while facilitating conversations about traditional beliefs and practices from whatever culture the participants are from. It’s designed to be an introduction to talking about mental health without people saying, “Oh, mental health, you mean someone who’s crazy?”
“It’s a good way to bring people together and it’s designed to be a peer support group, while also providing information about mental health,” Crews Kovach said.
One main goal for Refugee Wellness is to support and develop leaders within communities of refugees. So Refugee Wellness ultimately wouldn’t be providing the services; they would be training culturally-competent people from the community to provide services specific to the needs of their group, according to Crews Kovach.
The community groups are crucial, Crews Kovach said, because if one person is hesitant to discuss their trauma, but sees a friend helped by talking about their experiences, they’re more willing to try it.
“We get a lot of referrals, people bringing their friends and neighbors,” Crews Kovach said. “That’s why I think it’s so important to move toward this model of training community leaders in basic mental health first aid and awareness so they can also work to destigmatize mental health and be that source of support and connection.”