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A different approach to therapy for refugees


Many Middle Eastern refugees are Iraqis who have fled war-related violence. But in the past decade, the largest number of refugees have actually come from Iran.

More than 15,000 Iranians have moved to California just since 2006. Though their country isn’t currently at war, many Iranians suffer religious and political persecution. And they face many of the same social and cultural taboos about seeking mental healthcare as Iraqi refugees.

Azin Izadifar is a 45-year-old Iranian refugee living alone in a small studio apartment in San Jose. Izadifar has shoulder-length black hair with a few grey streaks, that she keeps tied in bun. When she opens the door, she’s smiling. Izadifar came to the U.S. in 2009, seeking asylum. She says that’s the first time she ever saw a psychologist, though there were signs she might have needed to earlier. “When I was in Iran and even up to probably a year ago, at a certain time during the night I would wake up. I would wake up shouting, like having nightmares. I always, always had this problem,” she recalls.

Izadifar spent the ages of 16 to 19 in Iran’s infamous Evin Prison. She knew she carried the memories of that time with her, but it wasn’t until she came to the U.S. that she realized she had been living with PTSD for nearly three decades.

“It had become so normal for me that I couldn't even understand that there was a problem there – I had a sleep disorder. And it could be related to the trauma I had in prison,” says Isadifar. She says she finally realized her sleeping disorder was a sign of PTSD.

Izadifar wouldn’t have always used the term PTSD – it’s not as common in Iranian culture. Doctor Loren Krane is a psychologist working with refugees. He says refugees like Izadifar often don’t seek therapy because of deep cultural taboos. “In most other countries, people associate psychologists and psychiatrists with really severe mental illness,” says Krane.

Krane also says some cultures don’t see conditions like depression as a chronic disease – it’s more like a temporary problem that people will address by speaking with a family member or religious leader. Only in some cases would the afflicted seek medical care. It’s hard for many to accept the idea that mental health problems may require specialized treatment.

Refugee Azin Izadifar says many who do get therapy often keep it a secret from their community. It’s taken a long time to realize, but her past experiences remain very much in the present. She was a young teenager after the Iranian Revolution of 1979. Like many of her peers, she participated in secret meetings and demonstrations against the country’s new Islamic government, but before long, she was arrested. She still remembers her first few weeks in the prison, while she waited to be interrogated. “I was sitting there behind that door and waiting for my turn and just hearing people screaming, shouting, crying, begging not to be tortured and stuff like that,” she remembers.

Izadifar was eventually placed in a small cell, along with dozens of other female prisoners. She says sometimes the room was so crowded they would have to take turns sleeping at night, because there wasn’t enough space for all of them to lie down at the same time. She witnessed some of her cellmates “completely go crazy.”

Even though she never had a moment alone, Izadifar says prison life kept her completely isolated. The more people knew about each other, the more likely they’d be tortured for that information. One time, someone did speak with her.

Izadifar was walking in the ran with another cellmate who was about her age, 17 years old. “I don’t know why,” Izadifar says, but “she started tell her whole life story.” The woman told Izadifar about her upbringing, her family and about her involvement with a political group. Shortly after, they were called back to their cells and the woman Izadifar was speaking with was summoned and executed. “The next morning I woke up with gunshots, hearing these voices,” Izadifar remembers.

After that day, Izadifar stopped talking to her cellmates. She was released two years later, and more or less went on with her life. She married and moved to Austria, where she began working on Iranian human rights campaigns for Amnesty International. But when her marriage ended, she realized she couldn’t survive alone in Austria, and she couldn’t go back to Iran. She decided to seek asylum in California. It wasn’t an easy decision.

“Although I didn't have any other choices, but you know, if you get asylum you cannot go back to your own country. You cannot see your family,” she says.

As part of the refugee process, once she arrived in the U.S., Izadifar had to visit an immigration lawyer and prove why she couldn’t return to Iran. But every time she tried to talk to her lawyer about her time in prison, she would start crying. Finally, the lawyer advised her to seek therapy and Izadifar began to get counseling at the Center for Survivors of Torture in San Jose, also known as CST. Izadifar says she sees many of her same symptoms in other Iranian refugees.

Not everyone in Izadifar’s position seeks therapy. Doctor Loren Krane says many people fear being judged. Krane has been working with refugees for over two decades. He started out taking a traditional Western approach to treating them, but he says he quickly realized that this wouldn’t work. Instead, he frames the questions to focus on quality of life issues, like how they’re doing finding housing, or work. In the course of that conversation, Krane says he’ll discover that the difficulties they are having will often relate to the symptoms of depression and PTSD.

Aside from the cultural stigma of seeking therapy, a practical barrier stands between refugees and mental health care: access to affordable services. Refugees with minors in their families get five years of free services, including health care, but refugees without kids only qualify for eight months of services. So, in less than a year, they need to find a job, a home, and learn English – all while possibly dealing with symptoms of PTSD.

“Practical and psychological support often works best when working with the refugee populations,” says Sally Sharrock, a therapist at CST. She says only after addressing their basic needs can refugees even begin to think about mental health. But it’s not always easy to get them into the office. So sometimes, Sharrock goes to them.

Inside a small waiting room at the Lenzen Health Clinic, a handful of refugees are waiting to see a therapist. Sharrock and others provide free sessions here. Down the hall from the waiting room, Sharrock is standing in a small exam room sparsely decorated with a world map.

“They’re familiar with this setting,” Sharrock says, “which is what makes it a lot easier for them to meet with a therapist here. It breaks down a lot of the stigma, obstacles and barriers.” Sharrock says she spends a long time gaining the trust of her refugee clients. “Building rapport is kind of like the first step towards engaging them in any conversations about mental health.”

CST uses other unique methods to reach out to Middle Eastern refugees, like hosting potlucks and educational seminars. To make that approach work, they rely on refugees like Azin Izadifar. She’s now doing outreach to other Iranian refugees in the San Jose area. She goes to Iranian cultural events and hands out Farsi-language pamphlets about the free therapy at CST. She also hosts events on nutrition in the U.S., education, and other topics of practical value. Izadifar says reaching out to other refugees helps her deal with her own past trauma.

“The wound will always be there, but there's a difference between a wound that has not healed – that has not been exposed to the sun – to a wound that's been healed and now you see a scar,” Izadifar says. “It's different. The wound will be there, but you’re not as sensitive, it's not as painful.”

She’s also using writing as an outlet and is currently working on her memoir. She says those stories aren’t hard to remember. “A part of – especially people who have been in prison – a part of us is still in the prison. Even if you are living in a beautiful land like California, a big part of your being can still be in that prison,” she says. After being released from Iran’s prison, it took Izadifar almost 30 years to make it to California. But in some ways, she’s only now leaving.

This story originally aired on November 28, 2011.