War, torture, loss of family and friends--refugees arriving in the United States often carry heavy emotional baggage. Then they endure the strains of adjusting to a new culture. Agencies working with refugees new to Philadelphia are puzzling out how to help this population cope with its burdens.

As a seasoned psychiatrist, Dr. David Goodwin knows the tools of his trade--talk therapy, medication and so on--but he says working with refugees from around the world has been a humbling experience. "As much as we would like to think that we have the market on everything mental health, we don't, and we have to be cautious in our assumptions," said Goodwin, a psychiatrist at the Belmont Center for Comprehensive Treatment. Belmont is part of a new, city-funded initiative to coordinate and expand mental health care for refugees.

In working with refugees, Goodwin has learned that within certain cultures, the idea of expressing how one feels about something may have no validity whatsoever, and may even invoke a lot more terror.

Melissa Fogg is an immigrant mental health specialist with Lutheran Children and Family Service, a lead partner in this collaboration. She says "mental health" is not even part of the vocabulary in many cultures. "In fact, in some of the languages of the communities were are working with, there isn't even a word that translates to depression," said Fogg.

Even if there are no words to describe it, there's plenty of suffering among the refugees says Goodwin. Refugees may have experienced loss of family, loss of home, arduous flight, extended periods in refugee camps, and then all of the challenges around readjustment.

For Khin Khin, who is from Burma, the readjustment struggles began right away. She fled to the U.S. with her husband, who was persecuted in Burma for his political activities. Arriving in Philadelphia, a service agency set her family up in a temporary apartment in a very bad neighborhood. "I know that America is not heaven, but we think that we can live very safely, but my husband when we first arrived, he was robbed," recalled Khin Khin. "He was so scared to call the police because that guy said, 'if you call the police I will kill you', so he is so scared."

Khin Khin remembers hearing gunfire all the time. She felt isolated, since no other Burmese families lived nearby. She had a sick infant, who required several surgies. At times, stress, anxiety and worry were and still are overwhelming. During a recent physical, she says her doctors recommended counseling. Khin Khin says she was told to share her feelings with a therapist, but she doesn't want to do that because she is too shy.

To help people like Khin Khin, mental health providers have to think of different ways to get them to open up, says Melissa Fogg.

"For those individuals, we're doing community building, and art therapy activities, to strengthen their existing communities, and to build awareness about mental health, and stress and effective coping mechanisms for their feelings," said Fogg.

This summer, the coalition hosted picnics for immigrant families, mixing fun, food and conversation with art therapy. This subtle approach works with this group, says Fogg. The collaboration's next project is a series of photo essays--families will be taking pictures about readjustment in Philadelphia. "I think it will be very therapeutic for the families to really express and really articulate what they are going through, and give their personal views of their lives," said Fogg. She explains that the new initiative also involves mental health screenings for refugees when they first arrive, with appropriate referrals.

Khin Khin is now living in a new neighborhood, near other Burmese families, and feels more connected. She is also reaching out to other refugees to help them through tough times. "Some people are so sad about being here, they don't speak English, and they think they don't know anything about America, so they don't want to go out, and they don't want to deal with other people," said Khin Khin. "So I tell them that I also have the same problem, but that I have to try to get through it."

David Goodwyn says having peer ambassadors like Khin Khin is helpful, but traditional therapy and medication still have a role to play. But that, he says, means therapists must first develop strong relationships with their patients, to really understand where they are coming from.