BOSTON — For the thousands of Syrian refugees expected to arrive in the U.S. in coming months, the first order of business will be securing the basics — health care, jobs, education and a safe home.
But what organizations helping resettle them might not be prepared for, and what refugees themselves might be in denial about, is the need to treat the mental scars of war, experts said.
Iham Al Horani, a 32-year-old refugee living in Worcester, Massachusetts, said he has had little time to think about his mental health in between months of job hunting and shuttling his mother, recovering from sniper gunfire, to doctor's appointments.
"It was difficult, what we came from," Al Horani said through a translator. "The living conditions in the refugee camp were bad. But at least we're all here."
Organizations that work with refugees said it's too early to assess the full scope of arrivals' mental health needs. But experts say it's important to keep tabs on the emotional state of new arrivals, since symptoms may not appear until months or years later — well after most resettlement support services have ended.
The U.S. has taken about 2,500 Syrian refugees since the conflict there began in 2011, including about 100 in Massachusetts. The Obama administration expects to take in at least 10,000 in the federal fiscal year that began in October. Experts estimate 10 to 20 percent of incoming Syrians will have war-related psychological problems warranting treatment.
"They're in the honeymoon phase," said Richard Mollica, a psychiatry professor at Harvard Medical School who has spent decades working with torture and genocide victims. "In the first year, they're so happy to be out of that situation. They feel something wonderful is going to happen in America.
"It's only about two years later or so when there's a mental health crisis," he said. "It's at that point that reality hits and they really need a lot of mental health care."
Ahmad Alkhalaf, a 9-year-old who arrived in the Boston area this past summer for medical treatment, said he used to have restless nights when he would relive his mother's screams from the night a bomb killed three of his siblings and left him without arms. But those sounds, he said, have largely faded.
"I'm fine," Ahmad said through a translator. "They're gone."
Ahmad's father, Dirgam Alkhalaf, said he recently took his son to a counselor, who found nothing concerning. They don't plan to go back.
Ahmad Houssam Hallak, a 51-year-old Syrian recovering from an artillery attack that left him with speech and movement problems, said winning asylum last year hasn't eased his stress. He is working to bring over his wife and three children, who remain in Lebanon.
"They live in an unstable country," Hallak said through a translator. "It's a constant fear that I'm living in."
Such stresses — finding a job, adjusting to a new culture or dealing with life apart from family — can also contribute to mental health problems, said Bengt Arnetz, a professor at Michigan State University who has been studying trauma in Middle Eastern refugees.
Failure to address them could lead some refugees to withdraw from society, increasing the chances they'll be drawn to extremist groups, Arnetz warned.
Alexandra Weber, chief program officer at the International Institute of New England, an agency contracted by the U.S. government to resettle refugees, agreed mental health services can be improved. Many agencies, for example, don't have enough Arabic speakers, she said.
But, she said, agencies are increasingly asking refugees about their emotional state as part of initial health screenings — something not done in years past.
"For the first time in my career, I feel encouraged," Weber said. "In some ways, Syrians couldn't be coming at a better time."
A spokesman for the U.S. Department of Health and Human Services, which oversees the federal Office of Refugee Resettlement, declined to comment but pointed to general information on the office's website about federally funded programs for torture victims and its efforts at promoting "emotional wellness."
At the Arab Community Center for Economic and Social Services, a Detroit-area nonprofit, public health manager Madiha Tariq said she hopes the government will hurry to get refugees out of squalid, dangerous refugee camps and to the U.S.
"With the Syrian population, they've already been the victims of extreme trauma. They've also been in refugee camps for a long time," Tariq said. "So the longer that displacement is, the more work we'll have to do repairing the stress and damage."