Three years after he came to this country, he had a nervous breakdown. Only then did the 21-year-old Iranian student begin to talk about the pressures that led to his collapse: trying to finish college in three years, living apart from his family, hostility from Americans still angry about the hostages, and the lingering guilt he felt over the death of his 18-year-old sister during the Iranian revolution.
He recalled how a campus hospital nurse listening to him began to cry.
"That was the first time I was seeing emotions from an American," he said in a recent interview in Alexandria, where he was under the care of an Iranian-born psychiatrist while living with his brother.
The Iranian student's problems are not unique. For many of the 937,000 refugees who have come to this country in the past decade to flee political persecution, disaster or war, adjusting to their new home has been a painful process involving stress and anxieties they never encountered in their native land. Their problems frequently are made worse because their traditions and background make it difficult to seek help or even acknowledge that something is wrong.
In a recent survey of minorities and refugees by the Northern Virginia Mental Health Association, more than 320 respondents listed "stress" second and "depression" seventh on a list of 16 problems. But only 34 percent said they had sought help with those problems.
For many refugees unfamiliar with psychotherapy, seeing a psychiatrist "is a social taboo," said Dr. Mahin Zandi, an Iranian-born psychiatrist who works at the Alexandria Community Mental Health Center.
In fact, psychiatric help is thought of by most refugees as the last step before the insane asylum.
"It's as if you run nude in public, if you tell people you are sad or talk about your personal problems," said Dr. Tran Minh Tung, a Vietnamese psychiatrist. In the languages of many refugees, there is no word for "depression" as Americans know it.
Concerned by such quiet suffering, mental health professionals and the refugee communities themselves are increasing their efforts to make help more accessible -- and acceptable -- to those who need it. In the Washington area, where there are an estimated 30,000 refugees, the increased consciousness of refugee mental health problems can be seen in a number of ways.
The Alexandria Community Mental Health Center, for example, has two Iranian-born psychiatrists on its staff. The Mount Vernon Mental Health Clinic has Vietnamese and Spanish-speaking outpatient psychologists. At the federal Department of Health and Human Services Office of Refugee Resettlement, a task force is studying ways to deal with refugees' mental health problems, said Richard Shapiro, the office's deputy director of operations.
Unlike most immigrants, who come to this country motivated by hope of bettering their lives, many refugees from Vietnam, Cambodia, Laos, Ethiopia, Iran and Afghanistan have come here primarily to flee the turmoil of their native countries, immigration experts say. Often, they have left their homes on short notice, with little hope of an early return and generally bring few financial resources with them. So they are more vulnerable to the psychological traumas that all newcomers encounter.
"There is the feeling that it's not really home and that we have left our soul, our heart, back there," explained Tran, who is a consultant with the Arlington Mental Health Clinic. "Even though we know we are lucky to live in this land of opportunity, we still regret."
In contrast to East European refugees who came to the United States after World War II, the newer refugees -- many Asian, Hispanic or African -- say they do not become "socially invisible" in America's predominantly white society because of their racial makeup.
And many have come from rural areas in countries where the urban sector is not highly developed. Thus, in addition to the normal problems of refugees, such as finding jobs, shelter and learning English, there are the stresses of a fast-paced urban life style without the support systems on which they once depended: family, neighborhood or village.
"Family life is different at home in day-to-day management," said Ethiopian engineer and District resident Daniel Atnafu. "For example, we haven't seen our parents paying bills. Here, this is like the ultimate of how human beings run their lives; it's a very advanced system here compared to what we have at home."
"Here you live in an apartment and you don't know your neighbors," said Hailu Fulass, an Ethiopian consultant and former professor of African studies at Howard University.
"That's very strange in Ethiopia. When you move in, the neighbors bring you coffee and it's a reception. For someone used to personal contact every day . . . this aloneness creates a sense of emptiness," Fulass said, adding that the repression and political violence endemic in many Third World countries "does not create the kind of personal pressures you find in urban areas in the U.S."
And back home, he said, "there are people who interfere in your life, there are people who mind your business . . . but here there is this thing of 'mind your own business,' and people do mind their own business."
In Vietnam, "You go to the market once a day -- it's a big socialization place," said Kim Danh Cook, a Vietnamese psychotherapist who is executive director of the Vietnamese Mutual Assistance Association Consortium. "You know everybody; people tell you how to cook the chicken; everybody talks to you.
"Here you go to the supermarket and you don't see real food and you have to ring a bell to get service. You get very efficient service here, but you don't get the human touch."
In many cases, mental health problems surface only after refugees have made what is apparently a successful transition, said Mount Vernon psychotherapist Lee Nguyen. Caught up in their first years here with the survival problems of finding jobs, food and shelter, "they are so busy they don't have time to get sick," he said.
When problems do arise, the familiar, informal ways of dealing with stress and depression are no longer available.
In Vietnam, "You go to a fortune-teller; you read poetry; you go to the pagoda to meditate or you walk downtown to the market," Cook said. "You go to see a friend or an elder in the family."
Mindful of his compatriots' wariness of psychiatrists, Tran's advertisements in a local Vietnamese paper call him a "specialist of the nerves."
"We consider . . . pain is a part of life and . . . people are taught to be stoical," said Tran, explaining his fellow countrymen's reticence in speaking about their feelings. As a result, foreign-born psychiatrists say, they must alter the traditional method of psychotherapy.
"You can't confront people with their own problems," Cook said. "They want to blame it on the environment or on their ancestors, or they say they did something bad before and now they have to pay the debt.
"You socialize, talk about the past, where they came from, their families. You don't concentrate on the individual, you concentrate on his family and his environment until you gain his trust that you're not going to talk to other people about his problems."
Because most Vietnamese regard sadness, stress or depression as the result of a nerve disorder or caused by some supernatural cause, they will expect some medicine from their psychotherapist, Tran said.
"Psychotherapy could rarely be implemented . . . as anything but an adjunct form of treatment," he added. "They love to get a shot," Cook said.
While Americans expect psychotherapists to be only good listeners, foreigners, especially Vietnamese, see them as persons who can help with concrete problems causing their depression.
"They ask me for a service," said Tran, "to call the police, intervene, do something. The approach is concrete, problem-oriented. They expect the psychotherapist to be directive, active, to do something."
Foreign-born mental health experts warn that refugees suffering from stress sometimes are misdiagnosed.
"There's a certain level of cultural adjustment disorder that is sometimes so severe the patients are being mislabeled as paranoid or schizophrenic," Cook said.
The Iranian student recently returned to his midwestern university to complete his studies in electrical engineering. He was accompanied by his mother, who came from Iran to be with him.
"I think my problems are due to being here," the student said. "I felt very lonely."