Nisha Khan wakes up every morning in her home in metro Atlanta, and bustles her five-year-old daughter to school.
Once she’s back home, she’ll open her laptop. For the next 8 hours she’ll hold a series of meetings with women who may be anxious, worried, or depressed, and need her help.
She starts by asking them if they’re in a quiet, private space, with no one else around. Often the clients must say a code word to establish it’s them. Once identity and confidentiality are confirmed, the session begins.
Half of the women she speaks to are from India and half are from Pakistan. All of them arrived in the U.S. within the last few years. And all of them have been through some form of trauma.
Nisha is one of three therapists at Raksha, a South Asian community organization that offers therapy in languages other than English.
With the pandemic dragging on, mental health needs are nowhere close to subsiding. More than a third of Asian American and Pacific Islanders say their mental health has worsened since the pandemic, according to a national survey.
In Georgia, where the number of Asians has increased by over fifty percent in the last decade, there aren’t enough resources to meet the growing needs. Georgia ranks 51st (yes, last) in the country for access to mental health resources. And though access to care has improved, there is still a lack of mental health care clinicians, especially those who are equipped to provide care to immigrant communities.
That's partly because language itself is so tricky when it comes to mental health. Western concepts of mental health itself don’t always translate neatly across cultures. "Many of our clients don’t understand mental health or they don't trust the American medicalized system of health, but they do understand healing,” says Darlene Lynch of the Center for Victims of Torture (CVT), an organization based in Clarkston that has been working with people from the Democratic Republic of Congo, Cameroon, Eritrea, and Mexico. CVT runs what they call "healing centers" to support immigrants and refugees who are survivors of torture or war.
In Urdu, a language Nisha speaks with half her clients, there's no exact translation of depression. “It's difficult to find the exact equivalent, for example, from Urdu to English with certain terms. So you're just finding more descriptive words...I find myself explaining the symptoms...And the way they're describing it, they're describing symptoms. We’ll say okay, those are symptoms of depression.”
Nisha’s colleague, Ayah Mostafa, speaks Arabic with many of her clients. She admits it’s not easy. “When it's clinical language it can be really, really challenging. I’m not necessarily proficient in speaking, especially when it's clinical. But whenever clients do speak in Arabic, I'm able to understand them relatively well, depending on the dialect. Sometimes I'll respond back in Arabic, if I feel like Arabic might communicate the emotion a little bit better than English."
The danger is - If communication doesn't happen correctly - clinicians run the risk of misdiagnosing. “Some people will say they have a pain in their head or feel like a wind is blowing them and then they’ll be misdiagnosed and receive antacids or pain medications...when what they’re really describing is post traumatic stress,” says Darlene.
Right now these therapists are busier than ever. It's a perfect storm of factors: added layers of isolation and fear caused by the pandemic, the logistical challenges of limited child care and community support, all happening as the immigrant population has grown to unprecedented levels, “Many of them are already coming out of isolation due to the abuse having them secluded, and then with the pandemic, there’s more isolation. So now even if there isn't anyone stopping them from stepping out, if it was going to the grocery store and things like that, there is this extra layer of caution and fear, when they’re already working on healing from their trauma…” says Nisha.
Having loved ones pass away overseas has added another dimension to the challenge of care in this moment, “I had several clients who've lost at least one or more loved ones...they’re already feeling helpless here due to their situation...but then there’s an added sense of helplessness due to not being able to see them or say goodbye or being there support their family,” says Ayah.
Aisha Choudhary, also a therapist at Raksha, says there is at least one thing that's been made easier by the pandemic- the ability to do tele-therapy. "I have a client live that's in South Georgia. Typically, we would not been able to see this client, but that is the the upside of the pandemic, we're able to see people across the state of Georgia."
And yet, despite the growing communities and growing needs, and increased accessibility, there's a barrier that the internet can't break. Stigma often keeps people from seeking out care in the first place. “We have to do a lot of psychoeducation as to what therapy is, I think there's a stigma as to what therapy means. Or if you need therapy, then you are ‘crazy.’ There's definitely a lot of associations that people have...” says Ayah.
Even knowing how much a therapist should be public about their own identity is confusing. Nisha says because of community stigma, she's still grappling with how much she should anonymize her identity, "it can make some people more comfortable if they know me from the community, but it can also deter some people."
Darlene says she's seen this persistent issue come up with the communities CVT works with, “One of the issues is overlapping stigma. There’s stigma in the US and (many people) come from countries where the stigma is really great and here they’re living in tight knit community with people from the same countries and they don’t want to be stigmatized by the only people they know in the US."