Case study activity

  

           We will now revisit the Ali family and consider mental health challenges they may face. After reviewing the case study, discuss the questions individually or in groups of 3-4.


Case Study: Somali refugees

            A family of five Somali refugees that your agency serves presents with a number of problems. The family includes a husband, wife, and three children: a 3-year-old son and two daughters, ages 6 and 12.

            Increasing conflict, violence, and food insecurity in the southern part of Somalia drove Abdi Ali’s family to flee to Kenya. Their escape was a harrowing experience; because Kenya’s border has been closed to refugees since 2007, the family had to sneak out, often seeking cover in the bushes and occasionally begging for rides. Abdi had been a small business owner, but he lost his business—the family’s sole source of support—due to rebel activity. The family had held on for a while after that, but when the entire family witnessed the violent killing of Abdi’s mother, they decided to flee. When they arrived in Kenya, they were sent to a UN refugee camp that was overcrowded and unsanitary. The camp offered few resources and no job opportunities, nor did it allow its occupants to join Kenyan society. After waiting for nearly three years, the family was approved to resettle to Raleigh, NC.

            Since arriving in the U.S., Abdi and his wife, Rahma, have had to shoulder many new responsibilities. They must find jobs to become self-sufficient, learn English, ensure their children get on the right track, and address health concerns. The family has delayed the federally mandated health checkup because they are worried about employment and afraid to leave home unnecessarily. They do not want to take the bus across town alone to see a nurse who does not speak their language. Furthermore, the children’s dental care has gone unacknowledged despite several signs of decay, but Medicaid doctors and dentists have closed enrollment for new patients due to the recession.

            Although both parents enrolled in English classes upon arrival 2½ months ago, Abdi has stopped attending due to a new job and Rahma has stopped to care for her young son, Hassan (the two daughters are in school most of the day). While their limited English proficiency prevents them from being able to navigate everyday life, understand mail and procedures, and land non-entry level jobs, there is no opportunity for Abdi and Rahma to learn English and still take care of family obligations. There is no child care available for Hassan and no ESL classes available nearby during the hours Abdi is off work. Also, Abdi prefers that Rahma stay home rather than find a job, despite the fact that it long ago became clear that his wages alone will not be enough to pay for the entire family’s living expenses once government funding ends in four months.

            Abdi and Rahma have distant relatives and some friends who live in Minnesota, but they did not know anyone in North Carolina prior to resettling here. They have made some friends (other Somali refugees) in their apartment complex and attend the nearby Islamic Center for religious services. The Islamic Center is always willing to reach out and help newly arrived Muslims with some meals and support after arrival. The Center also holds many social events for young people. The children are beginning to make friends there, but they still feel isolated at school.

           The daughters’ school has recently become concerned because the girls are quite withdrawn and often panic when the school bell rings, fire drills occur, or children rush out to recess loudly. Furthermore, 12-year-old Asiya has been complaining of pain and the school nurse fears that she has a urinary tract infection. She recommended that the family take Asiya to the hospital for treatment, but Abdi and Rahma did not find it necessary because vaginal pain and infection was a typical side effect of female circumcision, or female genital cutting (FGC), as it is commonly referred to. The nurse further feared that 6-year-old Faheema may undergo the procedure when she gets older. Many Somali girls undergo FGC between the ages of six and twelve.

           Abdi’s new job at a meat processing plant is menial and cold. This job is a big step down from owning a small business, and this demotion has put him in an increasingly bad mood. He is also stressed about how many bills there are in the U.S., the complexity of every institution, and the meddling of all the different agencies in their lives—although he is grateful for the assistance. Furthermore, he was called names in the supermarket when his Food Stamps card ran out of money, and last week he was accused of being a terrorist when he tried to cash a check at a bank where he did not have an account. Abdi takes out his frustrations on his wife and often yells at his eldest daughter as well. He has begun to drink more and harass Rahma, calling her “useless.”

           Rahma has also discovered that she is about five weeks pregnant. She is not accustomed to receiving the extensive prenatal care that is the norm in the U.S. Despite the fact that she has Medicaid (as a newly arrived refugee and as a pregnant, legal resident), she has not been to the doctor because she has been too busy at home, does not have consistent transportation, does not feel comfortable meeting with the doctor without a family member, and relies on a third person to interpret.

 

Role of your agency:

            A social worker at the local hospital, which is treating Asiya for urinary tract infections and providing prenatal care for Rahma, referred the Ali family to your agency, which provides mental health services for children and families. Your agency provides individual services for adults and children as well as family therapy. Abdi sees no need to attend sessions, but Rahma brings her children because she feels that she needs to follow up on the hospital’s referrals and she wants to make sure her children are healthy. Even though she’s visiting a mental health clinic, she does not think she has any mental health issues and feels some shame in seeing a mental health practitioner. After an initial assessment, you find that Asiya is becoming increasingly withdrawn and depressed, 3-year-old Hassan is starting to show behavior problems, and Rahma is also experiencing depression. Rahma has also started to discuss some of the problems in the home concerning Abdi’s alcohol abuse and verbal harassment, and the children’s withdrawal since moving to the US. It is difficult, however, to talk to the family about these issues because of the language barrier and their lack of knowledge and acceptance of mental health concerns. You fear the family will not keep their appointments regularly.

 

In a 15-20 minute discussion, consider the following questions:

What are some potential problems with using DSM mental health assessments with this family?

Would you choose to treat Rahma and the children together or as individual clients? What methods do you think would be helpful?

How would you address the issues involving Abdi?

What other mental health issues might you want to assess for?

How might you take steps to gain the family’s trust and encourage them to continue to receive treatment? How would you go about learning about this family? About their culture and their assumptions about MH care?