By Amy Harris
As discussed in Part I of Amjambo Africa’s health series examining psychological trauma (Vol. 4, No. 3, June), trauma is pervasive among refugees and asylum seekers, and can have devastating effects on quality of life. Yet there is a severe shortage of culturally competent, affordable, and accessible mental health providers and services in Maine. And because mental health problems are stigmatized in many cultures, survivors may resist seeking care. This second part of the series will focus on several innovative and dedicated providers working statewide to help survivors find freedom from trauma.
What are trauma-informed care and trauma-specific services?
Knowledge about the impact of trauma on mental health has deepened in recent years, and healing practices have become more effective. This is important because trauma has a widespread and potentially intergenerational impact, recovery from trauma can follow multiple paths, and retraumatization at the hands of uninformed services and providers can occur.
Trauma-informed care (TIC) and trauma-specific services (TSS) reflect recent research on best practices. TIC aims to provide physical and emotional safety and promote a culture of empowerment and healing within health care systems or service agencies. The belief is that only when participants feel safe and trust their environment can providers create opportunities for survivors to rebuild a sense of control and begin their healing process.
Trauma-specific services are programs, interventions, and therapeutic services aimed at treating the symptoms or conditions resulting from a traumatizing event(s). Care and services can be individual behavioral therapy, group therapy, case management, or therapeutic movement classes. To heal from trauma, survivors typically need trauma therapy, like that provided by psychiatrists and other types of mental health providers such as psychologists, counselors, social workers, or therapists.
The common elements of Maine’s care models are culturally aware case management, the inclusion of cultural brokers on the care team, the importance of building therapeutic communities for connection, and safe spaces.
Gateway Community Services Maine, an immigrant-led organization
At Gateway Community Services, community health outreach workers (CHOWs) are New Mainers’ first introduction to the U.S. mental health care system. These CHOWs are culturally competent and speak to clients in their own languages, both of which go a long way toward establishing trust. They work to destigmatize mental health problems and treatment, and help community members understand the kinds of help available.
Gateway Community Services operates in Lewiston, Augusta, Biddeford, and Portland, and is one of Maine’s largest trauma therapy providers for refugees and asylum seekers. Founded in 2014 by Abudullahi Ali, Gateway follows the trauma-informed care model. The organization specializes in culturally aware case management and the provision of wrap-around services for clients.
From the agency’s earliest days, Gateway met clients in their homes for intake assessments. As Gateway Clinical Director Krista Hall, LCSW, remembers, “We decided early on that we would offer counseling in the home. There were just too many barriers to getting people to the office. Because of the stigma of mental health problems, folks can feel pretty guarded and isolated.”
With community health workers’ help, Gateway’s mental health professionals work to identify cases of post-traumatic stress disorder. If clients have MaineCare, the diagnosis provides access to mental health and case management services. Unfortunately, asylum seekers are not eligible for MaineCare – however, very often the children of asylum-seekers in Maine do qualify.
Following the family systems model, which teaches that reducing parents’ resettlement and acculturation stress indirectly improves children’s mental health, Gateway’s case managers also help families find safe housing, food, and employment. Both Gateway Community Services and Spurwink’s ShifaME program follow this family systems case management model for trauma therapy.
ShifaME and trauma systems therapy adapted for refugees (TST-R)
Spurwink Services provides behavioral health and education services for children, adults and families. In 2007, Sarah Ferris, director of Spurwink’s Refugee and Immigrant Services, successfully adapted trauma systems therapy for refugees (TST-R), a pioneering program developed at Boston Children’s Hospital, to help Lewiston’s growing immigrant population. The Boston Children’s program was developed to care for Somali refugee families arriving in the U.S., and was originally called Shifa, which means “healing” in Arabic. Ferris and her colleagues named their reshaped version ShifaME. ShifaME is a program for multicultural care management provided in schools and communities by teams of cultural brokers, care coordinators, and a mental health clinician. ShifaME currently has teams working in Lewiston, Biddeford, and Portland.
ShifaME’s success lies in its use of multicultural care coordination to help reduce some of the barriers that refugee, asylee, and immigrant families face during acculturation and resettlement. Using a strengths-based model, the ShifaME teams help families access needed medical, behavioral health, housing, employment, social, and educational services to meet their basic needs for survival in their new home. Care management involves educating families about symptoms of depression or post-traumatic stress disorder and destigmatizing mental health. Just as Gateway meets their clients in their own homes, ShifaMe also recognizes the importance of meeting New Mainers where they are. Their decision to co-locate all of their mental health clinicians in schools is strategic and evidence-based.
ShifaME’s success lies in its use of multicultural care coordination to help reduce some of the barriers that refugee, asylee, and immigrant families face during acculturation and resettlement. Using a strengths-based model, the ShifaME teams help families access needed medical, behavioral health, housing, employment, social, and educational services to meet their basic needs for survival in their new home. Care management involves educating families about symptoms of depression or post-traumatic stress disorder and destigmatizing mental health. Just as Gateway meets their clients in their own homes, ShifaMe also recognizes the importance of meeting New Mainers where they are. Their decision to co-locate all of their mental health clinicians in schools is strategic and evidence-based.
“Schools act as a gateway to mental health services, with cultural brokering building the pathway to a broader community acceptance. Schools are valued by refugee parents who might not have been able to learn to read or write – whereas mental health service centers are kind of scary. A mental health diagnosis is very hard to explain to a lot of families. Many families think it is like a terminal illness to have a mental health diagnosis,” Ferris explained.
“Cultural brokers are key members of the team. We couldn’t do our work without them, and we wouldn’t do this work without them… it really is all about building relationships and trust with community leaders, and word of mouth between families.”
Because health insurance companies do not pay for cultural brokerage services, agencies like ShifaME and Gateway Community Services must rely on donations from the community, grants, and other sources of financial support. Currently, ShifaME is hoping for the renewal of its five-year federal grant to continue its healing work for children from birth to age 21 in Maine.
Sea Change Yoga heals trauma with therapeutic movement
Sometimes words or a common spoken language are not what is needed to create feelings of connection and trust. In fact, for some trauma survivors, retelling their story can cause further injury and pain. Research has shown that trauma in refugees and immigrants is likely to be internalized as physical pain, and this is more likely to lead people to seek medical care than are symptoms of mental distress or disorders. Therapeutic movement, including yoga, can provide an effective alternative healing approach.
So in November 2018, Maine Medical Center resident Dr. Kate Rizzolo approached local community service yoga provider Sea Change Yoga about offering free yoga classes for new Mainers. She was familiar with the research that showed yoga helps regulate stress and emotions, and relieve physical symptoms. She believed that trauma-informed yoga might help some of her New Mainer patients who suffered from chronic fatigue, pain, and depression feel better. In collaboration with the Portland YMCA, Sea Change Yoga responded by offering a weekly yoga class for New Mainers from November 2018 to March 2020. Unfortunately, the pandemic forced in-person classes to move to online video classes, but plans are underway to relaunch in-person classes sometime this summer.
Specially trained Sea Change Yoga teachers lead participants, young and old, through poses that are accessible to all, no matter their fitness level. Despite the communication challenges posed by the more than 14 different languages spoken by participants in the New Mainers yoga group, the classes have been well-received. Sea Change Yoga plans to launch a teacher training scholarship program this summer. The goal is for trauma-informed yoga teachers from the New Mainer community to help increase acceptance of yoga as a fun and relaxing way to feel better, mentally and physically.
Men Connect creates a safe space for men to heal
More than 15 to 20, men ranging in age from 18 to 65 years old, who have come to Maine from all over the African continent, gather twice a month to attend programs in the therapeutic space known as Men Connect. Claudette Ndayininahaze of In Her Presence and cultural brokers Guy Mpoyi and Christian Bisimwa, along with other community members, helped Chris Kelleher create this culturally welcoming space specifically for New Mainer men. Kelleher’s prior work in violence prevention with Through These Doors and with his current employer, Maine Boys to Men, provided the inspiration for the Men Connect group. But Kelleher attributes the group’s success to Mpoyi and Bisimwa.
Men Connect is not a traditional mental health service, and does not employ mental health professionals. However, its therapeutic environment readies participants to heal from trauma and to get additional support and information if they need it.
Whatever the topic of discussion on a given day, the therapeutic value of Men Connect derives from “…folks feeling a part of something, being seen, being heard, being valued,” said Kelleher. “I try to step into these spaces humbly, and listen to the needs of the folks we are engaging with. It has been tricky, trying to stay close to our mission of violence prevention, but recognizing that there are a lot of things that need to be in place, like basic needs being met, before we dive into deeper subject matter like domestic violence or trauma.”
Ingredients of successful trauma-informed care
Maine Medical Center is one institution working to update its methods for helping clients heal from trauma by implementing trauma-informed care and trauma-specific services. Dr. Erin Belfort, child and adolescent psychiatry fellowship training director, has her eye on the future and is training residents and fellows in best practices. She has assembled educational modules that are available online that “more fully consider the experiences, health disparities and health needs of immigrants, refugees, and asylees.” Funding for the modules was provided by Maine Medical Center Institute for Teaching Excellence.
