Refugee Mental Health

Dr. Laura Roberts (00:17):

Hi. I'm Dr. Laura Roberts, editor in chief for the books portfolio of the American Psychiatric Association. Welcome to the APA Books Podcast.

Dr. Laura Roberts (00:31):

Well, hey, everybody, welcome back to Unbound. Today we are covering the topic of refugee mental health and expertise in supporting the wellbeing and health of refugees. Our guest is David Kinzie, who honestly is one of my most favorite people ever. He's a hoot. But it's a sober subject, so we'll see if we get the playful side of Dave come out. We're not sure. But the book that he co-edited is called The Psychological Evaluation and Treatment of Refugees. This was a book he did with George Keepers, another one of my favorite people.

Dr. Laura Roberts (01:09):

David and George are at the Oregon Health and Sciences University in the Department of Psychiatry. Dave, who's with us today, received his degree a long time ago, I won't say when, at University of Washington, and then completed his psychiatry residency there and also did a fellowship in trans-cultural psychiatry at University of Hawaii, which was really interesting. You so were ahead of things, Dave, with your training and the emphasis of your work.

Dr. Laura Roberts (01:45):

Your interests really focus on hospital psychiatry, psychiatric treatment of refugees, post traumatic stress disorder and mood disorders. I want to thank you for being you, first of all. I want to thank you for taking on this book with George on refugee mental health.

Dr. Laura Roberts (02:04):

I was aware of your clinic, and I would love to know ... And I'm sure the listeners would really be interested in the history of this clinic. It's really out of that that the book derived. But there are so many unique things about this book that are so valuable to the field. I just really want to thank you. So let me just ask you, why did you think the world needed this book? What was the hope that you had in developing this book for us?

Dave Kinzie (02:33):

May I tell you a little bit about the history of why we got into this, because that explains a lot?

Dr. Laura Roberts (02:39):

Yeah.

Dave Kinzie (02:42):

During the Vietnamese War, I was a doctor in Vietnam, a civilian doctor and a conscientious objector. I really got upset with what Americans did and what happened there. Later, I worked for a year with the Aborigines in Kuala Lumpur in Malaysia. And then I came back and did residency.

Dave Kinzie (03:05):

After the fall of Saigon, I think about 1976, we started getting a lot of refugees. And I had guilt about America's role, and I thought, "We ought to be doing something for these people." So we started the program because we had a lot of refugees in [inaudible 00:03:22]. Took a lot of people. And there was another program offering psychological services by a Vietnamese himself. That program collapsed and we joined with it and had a program.

Dave Kinzie (03:37):

And from the beginning, we did something unique. We had full-time Asian Vietnamese counselors in our program, who was interpreters and case managers. They were hired by the university. And we didn't have outside interpreters. This took a lot of training. They were picked because they were good people, people you'd go to just to talk to. You didn't know much about medicine or psychiatric practice. We gave them that experience.

Dave Kinzie (04:08):

But over the time, it developed that this was the right model. No one else uses it, but it's the right model. And so we were very happy with it. At the end, we had a lot of [inaudible 00:04:22]. It was interesting. We started out thinking it would be Vietnamese and then maybe other ... Cambodia, then Laos.

Dave Kinzie (04:31):

And then we thought, "Well, we trained them. They will get settled, and it would be over. We'll be back in something else." But the refugee crisis never ended. We've seen it just expand and expand ... Guatemala, Bosnia, Somalia, to Iraq, Iran. It just keeps going on. And the refugees coming to the United States has varied up and down, but still, it's a big number. And each time we got another group, we developed another program with people from that culture being our [inaudible 00:05:05].

Dave Kinzie (05:05):

Why I thought the book was important is it's written by psychiatrists for psychiatry. And we are very interested in helping other people understand both the problem and the needs to work with refugees. For psychiatrists, it's a huge problem. And even besides that, cross-culture issues are very big in American medicine.

Dave Kinzie (05:30):

So with our experience and, I guess, the narcissism of the need to tell other people, we wrote this book. And there's a lot of books out about PTSD and trauma, none that focus on refugees which are focused on the treatment, the training of treatment of refugees. And so we had this book with a lot of experts, some from around the world, most of them from our [inaudible 00:06:00].

Dr. Laura Roberts (06:01):

Yeah, thanks for that background. I mean, it naturally occurs to me, from my own work, but from my colleagues' work, as well, that there's a real challenge around secondary trauma, I mean, when you learn about this inhumanity toward ones' colleague and friend and fellow human. It seems like you had already witnessed a lot of that in your own life, so when you came to the clinic, you'd kind of crossed that river, if I can put it that way. But do you have reflections on how you would advise psychiatrists or psychiatrists in training who are thinking about undertaking this work, but where it might be so different from their own personal life experience and how to protect themselves and think about that experience as they approach it? I think people are scared. They're scared to take on that work. It's hard. It's hard work.

Dave Kinzie (06:55):

It's very hard. And you see the worst of human being. And you see the effects of massive, massive torture and trauma, and relatives killed, starvation, rape. And you hear about it.

Dave Kinzie (07:11):

The first group that really hit us hard was in Cambodia. [inaudible 00:07:17]. And at that time, actually, there was no PTSD diagnosis, which came in 1980. And we didn't quite have a handle on what was happening. And frankly, we didn't quite believe it at first because it was so traumatic and so awful. And even though I read about the Holocaust and [inaudible 00:07:39] other things, this was really out of our experience.

Dave Kinzie (07:43):

You're right, I had seen a lot of trauma in Vietnam and some in Malaysia. I wasn't prepared for this [inaudible 00:07:50]. We stuck with it. I limited my new patients to about two a week. I couldn't handle more than that. It was just overwhelming. And then you start getting technically kind of [inaudible 00:08:08] or empathy strain at that point. And that happened. And I hung in there with it. The patients got better, not cured but better, and I got better at doing it and could separate myself a little easier.

Dave Kinzie (08:26):

I think I should say I've seen the worst in psychiatrists doing this. Give a PTSD scale. Get an [inaudible 00:08:35] scale so they have it. Give them a medicine and tell them they're on their way. That absolutely isn't ... I think you're right. It means they're scared. They're scared to take a history and scared to listen to the story. And they're scared of their own reaction, and you keep patients at a distance so you don't have to deal with it. But it's wrong. If you want to help, you will listen to their stories.

Dave Kinzie (09:02):

And it takes a long time. It takes an hour and a half to do a first interview. And it's done with an interpreter who has their own problems. They're often going through the same thing themselves that they're listening to. It'd take about three years I think to get good counselors to do the job well and not be bothered by it themselves. I guess I'm saying that we have some very, very good ones who stayed with it and ended up doing a very good job. But it is hard.

Dr. Laura Roberts (09:32):

Yeah. I really appreciate what you're saying, very sincerely. I wonder if there's something special about your department that this has been able to develop and ... I think a lot of places have clinics, but they don't make such a sustained commitment to a vulnerable population like this. It's either not financially advantageous, or it's not so clearly tied to their mission, or there are different fads that come and go, "Oh, we'll do this, we'll do that."

Dr. Laura Roberts (10:04):

But I am so impressed with how decades of work and committing, as you say, to more and different, but also the original refugee populations. So what about your [inaudible 00:10:18] has allowed that to continue there?

Dave Kinzie (10:21):

Yeah, there are a couple people who really are important. The new chairman who brought me there, Jim Shore, he worked with Makah, well, a North American Indian tribe. He and I did some studies with [inaudible 00:10:35]. He had a dedication to it. He worked in the Indian Health Service. He had a dedication for cross-cultural thing, as did the next chairman, Joe Bloom, who worked in Alaska. And it was very interesting [inaudible 00:10:49]. I think he worked with cross-cultural murderers. He has a strange fascination. But they were dedicated to keeping this program going and gave us a cross-cultural [inaudible 00:11:05] refugee focus. And you couldn't do it without a chairman dedicated to it. And those two people greatly helped them. [inaudible 00:11:13] currently George Keepers actually had a clinic for Koreans himself, but he has been very supportive.

Dr. Laura Roberts (11:22):

Yeah, and helped you with this book. That's great.

Dave Kinzie (11:25):

Yes, and a lot.

Dr. Laura Roberts (11:26):

Yeah. That's wonderful. Do you have some particular stories? I mean, with this particular book, people might even be overwhelmed at the thought of even opening the first page. So how would you invite people in to reading this book? What are some of the stories that you hope people will read and be influenced and changed by?

Dave Kinzie (11:50):

I'm not sure those two buckets are compatible.

Dr. Laura Roberts (11:52):

Oh, okay.

Dave Kinzie (11:52):

The stories that tell-

Dr. Laura Roberts (11:52):

The stories are hard?

Dave Kinzie (12:01):

Yeah, they're hard, and I'm not sure people would be interest ... I mean, they're interested, but I'm not sure ... But let me try. Let me tell a couple stories, which I think give a flavor of, in a easy way at first, what happened

Dave Kinzie (12:12):

I had a Vietnamese woman, of course, with a Vietnamese counselor, who never got well. Always had backaches, headaches, always complained about her husband being killed, and nothing worked. And then one session, the counselor got called out of the room, and she switched over to pretty fair English, pulled up her skirt and showed this terribly deformed leg. Her husband had abused her and thrown boiling water on her leg. Had this terrible scar. She was glad he was killed. She was relieved he was killed. She could not tell another Vietnamese woman that she was happy that he was killed. As an American doctor, it was safe. He's not going to make any judgments about it.

Dave Kinzie (13:01):

And she seemed greatly relieved to tell the story. The Vietnamese counselor came back in the room, and she switched over to Vietnamese ... headache, backache, can't sleep. And I talked to her a bit, said, "We're going to have to talk with the counselor about this. I'm sure she'll be supportive." But it did take about four or five sessions before she could say it with the counselor in the room. Things are not like you see. And there are more complications. That's why you do it for a long time. That's why you have people helping.

Dr. Laura Roberts (13:41):

Wow. This one study I did with one of my mentees where we looked at stigmatizing health conditions. And so the question is who would you talk to about a stigmatizing health condition? When it's stigmatizing, you want to talk to somebody who is as distant and different as possible. And if it's something that's not stigmatizing, either routine or just meaningful and not stigmatized, you want to talk to somebody who's as similar as you are in terms of your clinician. Isn't that interesting how stigma splits it about find a clinician you want to be talking with? Yeah.

Dave Kinzie (14:19):

That is really true. I'll give you another example. We had a woman from Africa, who actually very prominent when she [inaudible 00:14:28] worked in the Parliament. The village came in and shot her husband right in front of her. She went through a lot of trauma with our counselor who's speaking in Swahili. Then she asked the counselor to leave. And then she said in pretty good English, "That isn't all that happened. I was gang raped. And I feel so dirty. I'm so dirty."

Dave Kinzie (15:04):

I just listened. I gave her a big hug. We went back to ordinary stuff. We never talked about it again, but I think that was one of the most important things, that I accepted it.

Dr. Laura Roberts (15:18): 

Yeah, and just stood with somebody and didn't react negatively.

Dave Kinzie (15:23):

Yeah.

Dr. Laura Roberts (15:23):

Yeah, yeah, that's amazing. So you must have developed special ways of working with these counselors who came from the same origin as some of the patients. What were some of the approach ... And it sounds like some of it was learning by doing ... said with love. I mean, here we are, always learning by doing. But what were some of the things that you all adopted as practices in the clinic?

Dave Kinzie (15:49):

Well, I think we had a group meeting every week with the counselors, especially when we started. And each of them told some of their [inaudible 00:15:57] story. And it was a fun meeting. It was meant to reduce the stress. That was helpful.

Dave Kinzie (16:08):

After some sessions were hard, we often had a debrief and talk about what we learned and how hard [inaudible 00:16:17]. Some couldn't do it. We had a Cambodian counselor who was learning, sitting in with that. And in the middle of the interview, he would picked up a TIME Magazine and started reading as the patient was telling his terrible story. Afterward, I was furious with him, "How could you be so callous?" His parents had been killed [inaudible 00:16:38] the same way that the patient [inaudible 00:16:42]. I really felt for him. He had to work that through for several years before he could kind of handle it, but he actually ended up doing [inaudible 00:16:50].

Dr. Laura Roberts (16:56):

Another thought I have is that psychiatrists in everyday practice are encountering the clinical needs of people who happen to be refugees. And so it's one thing to build a clinic that's really tailored and has this special team and all that. But do you have any advice that you would just offer to, I can just call it, everyday psychiatrists?

Dave Kinzie (17:21):

Yeah, yeah.

Dr. Laura Roberts (17:21):

... in an everyday clinic about being-

Dave Kinzie (17:26):

I do have some advice.

Dr. Laura Roberts (17:27):

Yeah.

Dave Kinzie (17:27):

I don't know if it's any good. But I remember taking anthropology, and you're supposed to respect people in other cultures. That's not enough. You have to like people from other cultures, enjoy their culture, and accept it, and actually show no anger or upset about it, but engage in it. And I think some doctors in internal medicine have been really good at this. We had a very good doctor [inaudible 00:17:59] time sharing patient ... did very well. They just enjoyed it.

Dave Kinzie (18:05):

And the other thing is not to be in a hurry. I know managed care, you got 10 minutes, 15 minutes. You have to be very careful. You can't do very much in that time, but that's why you [inaudible 00:18:17]. But in general, you slow everything down, taking a lot of time, not be impatient. And you never, "Just tell me the chief complaint. Just call." You can do it. That won't do. It's too scary. They don't know the chief complaint. They know they got a headache and a backache. [inaudible 00:18:40].

Dave Kinzie (18:42):

So it takes a different mindset. I find myself just slowing down and just taking a lot of time. There's a lot of nonverbal communication you get used to, and also you give. And they're picking [inaudible 00:18:56]. They are extremely sensitive to your gestures. They believe gestures [inaudible 00:19:01]. Say it's a little bit of [inaudible 00:19:06].

Dr. Laura Roberts (19:12):

Yeah. For the listeners, I need to say that Dave is emphasizing how even just a little subtle cue about rejection or a negative response to something that's either been said or something that's been demonstrated will really turn away the patient, and how sensitive they are to that. Anyways, and Dave made a funny face, so I'm just trying to paint a picture for our listeners.

Dave Kinzie (19:34):

Yeah. Don't do that.

Dr. Laura Roberts (19:39):

All right. Yeah.

Dave Kinzie (19:43):

I'd like to tell a couple other stories.

Dr. Laura Roberts (19:45):

Yeah.

Dave Kinzie (19:47):

This man was very angry. He was Somali. He was angry that people came by his apartment. He had no friends. He was isolated. He made several visits, appointments to the clinic, but he never came. He finally came and said, first thing, "Not going to talk about it." He sat down and listened, "I told you I'm not going to talk about it," and then he'd cry and cry and cry. I did too. [inaudible 00:20:17]

Dave Kinzie (20:17):

came into the village, line up the men, and started shooting them. And just as they got to him, his oldest son stepped in front and took the bullet. The bullet went into him. He looked like he was dead, but he lived, but his son didn't. And the guilt and shame he lived with ... It's hard to know what to say, but I think I said, "He must have had a very good father to be so heroic." We didn't talk about [inaudible 00:20:45] saw him a few more times. The change was dramatic.

Dr. Laura Roberts (20:50):

I just want to say that Dave and I are both crying now.

Dave Kinzie (20:53):

Yeah.

Dr. Laura Roberts (20:53):

I mean, to hear stories like that is so hard. And it is remarkable that just that letting go of one's story would do it. Now, so that shift in him, let's take one minute with that. Why ... He must have done a lot of work when he would make appointments and not show, make appointments, not show. And then he finally came, said he wasn't going to say, and then he did say. And then he shifted. I mean, do you want to comment on that arc?

Dave Kinzie (21:32):

Yeah, I mean, I think it was bursting up inside of him with so much pain ... and shame. And when he finally could talk about it and let it out, it was really painful for me to hear and painful for him to tell it. [inaudible 00:21:42]. He kept on coming. We saw him probably four or five times more. He talked about normal things, you know, how you live in the United States, how you start a family, how do you live?

Dr. Laura Roberts (21:54):

Yeah, it's so interesting. And I know you have another story to tell, but I just want to cross over. I'm the editor of a journal, and we just did a call for trainees to describe a moment, in a very brief essay, about something that was transformational or momentous on their journey as becoming clinicians, physicians. And oh my god, we got hundreds. I have to tell you, Dave, I sit there with my Kleenex box and I just read these stories, and I read them. But I have to tell ... They're so powerful. I feel light as air for days after reading these stories because even though some individual story could be painful or whatever, but there's something about storytelling that is so beautiful and connects us, even when the content itself is hard. Right?

Dr. Laura Roberts (22:56):

But anyways, it connected me ... This week I'm feeling how deeply it connects me with my joy in being a physician. And as I'm hearing you, it's, of course, terrible to hear about this man, but I'm so grateful that you said what you did to him. Do you know?

Dave Kinzie (23:18):

I think one of the lost arts in medicine is listening to stories. [inaudible 00:23:22] to a patient tell their story and sharing their lives with us. I think that is one of the advantages psychiatrists have is we're trained to do that.

Dave Kinzie (23:32):

I had another story, okay? This is a Bosnian man, a very, very good man. He was a leader in the community. He came and worked in ... He was a welder, and he gave lessons in the mosque for young people. But he had a massive trauma. He ran away as the Serbs were chasing him. He went into his in-laws' house and told them they got to go with him. And they didn't. And they were killed the next day [inaudible 00:24:11].

Dave Kinzie (24:12):

He was captured. He was at a prisoner of war camp for a long time. He said, "At that time, one of the worst things he saw was the guards gave one of the prisoners a piece of bread, and that prisoner didn't share it with his own son." So that was terrible [inaudible 00:24:35].

Dave Kinzie (24:35):

We gradually got to say [inaudible 00:24:35] what was the worst thing you saw? The Serbs had went into a village, killed the people, and his job as a prisoner was to clean up the mess, take out all the furniture, take out the bodies. And in this group of bodies, came a little girl about three years old, holding up her hand and crying. He picked up this little girl ... I'm sorry, I'm very sorry. He picked up this little girl and went to the guard and said, "What should we do?" And the guard grabbed the little girl, threw her against a tree and killed her. Said, "That was the worst thing I ever saw."

Dave Kinzie (25:20):

Incidentally, he had probably, we figured out, a little girl who was [inaudible 00:25:25] in [inaudible 00:25:25]. And he had to stop because we think that brought back memories. He kept coming. He was a very good patient and a very good person.

Dr. Laura Roberts (25:37):

Well, I guess I need to thank you for doing this hard work for all of us in psychiatry. And I'm sure you saw people get better, and some people not get better. But I'm really grateful to you. And I'm grateful that you took on this book and sharing this experience that you've had with the clinic.

Dr. Laura Roberts (25:58):

I'll just emphasize about storytelling. You can be, I don't know, a pretty hardcore biological psychiatrist where you don't have a lot of time. But how long did it take you to tell just a few stories that carry so much humanity in them. Right? It doesn't take a lot of time. Sometimes it takes a lot of time, and sitting with to build that relationship can take a lot of time. But finding a way to introduce enough space for someone to tell you a story of significance about their life I don't think takes that much time. Right? And [inaudible 00:26:36]-

Dave Kinzie (26:36):

It takes a good relationship.

Dr. Laura Roberts (26:38):

Yeah, well, that's true ... to get to the right story. Right? Yeah. Yeah. Yeah. Good. Well, thank you for doing this beautiful hard work, and thank you for doing this book with us. I think you've conveyed things in a way where people who might not have picked up the book, may pick up the book, not be quite as frightened by it. Are there other things you'd like to share with us about [inaudible 00:27:07]?

Dave Kinzie (27:08):

I'd like to share a couple lighter things.

Dr. Laura Roberts (27:11):

Yeah.

Dave Kinzie (27:11):

I worked in Malaysia as a psychiatrist, after I finished residency. And I could speak a fair amount of Malay at that time. We had a Malay couple coming in. I was talking to them in Malay and getting a [inaudible 00:27:28] in my old slow way, but getting it, about main problem, symptoms, sleep patterns. In about five minutes, the husband looked at me and said, "You know, we do speak English?" Oh, we both ... Everybody laughed. But it was really a stereotype I had of them, it was a Malay couple that don't speak English, but they were very well ... At least they gave me a break.

Dave Kinzie (27:59):

One more story I'll tell about this. I saw a couple ... The husband was very paranoid that his wife was having an affair, which she was [inaudible 00:28:10] to say, and we [inaudible 00:28:13]. And we talked ... I had a medical student with me, and we started him on some antipsychotic [inaudible 00:28:18]. Saw them about two weeks later with the medical student. Everything is better. The husband ... The wife [inaudible 00:28:28]. There was minimal paranoia and minimal threats or anger.

Dave Kinzie (28:35):

And so I turned to the medical student and said, "Sometimes these medicines work pretty fast." He interrupted, "But doctor, doctor, I didn't take your medicine." I told him, "Shut up. I'm making a point here." I didn't say that, but that was what was on my mind.

Dr. Laura Roberts (28:54):

Well, so what made the patient better?

Dave Kinzie (28:57):

I think the relationship we had in the first meeting, when we were talking about it and kind of saying, "I don't think what you're thinking about your wife was true." He said, "It's not true. I believe her." "I think maybe you're overreacting. I think." And maybe they started talking more. Sometimes we give a lot more credit for the medicine than we should.

Dr. Laura Roberts (29:28):

That's great. Well, Dave, thank you so much for visiting with us on Unbound. Thanks for doing this wonderful book. Thanks for all the work for so many years in this very hard but important area. I hope people, whether they have a large clinic with people who have refugee status or if they just encounter people who have just really different backgrounds, that they'll follow the guidance you have about listening. Slow it down. Be mindful of your own body language and any reaction you have.

Dr. Laura Roberts (30:03):

I liked what you said about, "Don't just accept and respect other cultures, but embrace it. See what you might enjoy and find joy in the difference," right?

Speaker 3 (30:19):

Psychiatry Unbound is hosted by Dr. Laura Roberts and produced by Iain Martin. Our original music is by Willow Roberts, and our executive producer is Tim Marney. This podcast is made possible by the generous support of Stanford University. We are a production of American Psychiatric Association Publishing. Be sure to visit psychiatryonline.org/podcast to join the conversation, access show notes and the transcript and discover new content. Or subscribe to us on your favorite podcast platform. Thank you for listening.