Supporting Asylum Seekers: Clinician Experiences of Documenting ...

Journal of Traumatic Stress xxxx 2018, 00, 1–10

Supporting Asylum Seekers: Clinician Experiences of Documenting Human Rights Violations Through Forensic Psychological Evaluation Kim A. Baranowski, Melissa H. Moses, and Jasmine Sundri Department of Counseling and Clinical Psychology, Teachers College, Columbia University, New York, New York, USA

The United States permits foreign nationals to apply for asylum if they have experienced persecution or have a fear of future persecution. In order to meet the criteria for persecution, the harm inflicted upon the asylum seeker does not need to be or have been physical and can include psychological sequelae. In an effort to document persecution, lawyers seek the assistance of health professionals when preparing their clients’ asylum applications. Mental health professionals work to corroborate psychological evidence of the asylum seeker’s report of ill treatment through evaluation and presentation of their findings in the form of legal affidavits. This study gathered the experiences of 15 mental health clinicians who conduct forensic psychological evaluations and document the impact of torture and other human rights violations on asylum seekers. We analyzed the resulting interview transcripts using a consensual qualitative research (CQR) approach. The results of the study highlight challenges associated with this work, suggest recommendations for training, and encourage advocacy endeavors by mental health professionals who provide these services.

Across the world, large numbers of refugees are escaping violence, persecution, and poverty, representing the greatest humanitarian need since World War II (United Nations, 2018). Currently, the majority of refugees worldwide are fleeing Syria, Afghanistan, Lake Chad Basin, South Sudan, and Somalia (Huber, 2017), and the nations that hosted the most refugees in 2015 included Turkey, Pakistan, Lebanon, Iran, Jordan, Ethiopia, Jordan, Kenya, Uganda, Democratic Republic of the Congo, and Chad (United Nations High Commissioner for Refugees, 2015). The United States also provides “refuge to certain persons who have been persecuted or have a well-founded fear of persecution” (Mossaad & Baugh, 2018, p. 1). In order to establish asylum eligibility in the United States, this persecution must be on account of the individual’s “race, religion, nationality, membership in a particular social group, or political opinion” (INA, 1997, U.S.C. § Sec. 208.13). In 2016, the United States admitted 84,989 refugees into the country and granted asylum to 20,455 individuals (Mossaad & Baugh, 2018). Few studies have examined the forensic psychological evaluations of asylum seekers and even fewer have identified

the experiences of mental health professionals engaged in this work. A review of the literature yielded three publications focused on client case studies (De Jes´us-Rentas, Boehnlein, & Sparr, 2010; Gangsei & Deutsch, 2007; McKenzie & Thomas, 2017), one clinician reflection (Eisold, 2012), and one study that explored clinician reports of vicarious trauma (Mishori, Mujawar, & Ravi, 2014). Additionally, Mishori, Hannaford, Mujawar, Ferdowsian, and Kureshi (2016) studied the written responses of clinicians who completed an online survey of their motivations and experiences conducting this work. To date, there have been no empirical studies of mental health clinicians that have utilized an interview protocol to gather nuanced and in-depth information about their experiences delivering forensic psychological evaluations of asylum seekers. Torture and mistreatment can take many forms, including beating, suspension, asphyxiation, and sexual assault (Office of the United Nations High Commissioner for Human Rights, 2004). In an effort to document a well-founded fear of persecution, lawyers seek the assistance of health professionals as they prepare their clients’ asylum applications (Physicians for Human Rights, 2012). In cases where there is physical evidence of torture, medical doctors might conduct examinations as part of the asylum application, during which they document scarring and other injuries. However, the injuries experienced by asylum seekers need not be physical and can also include psychological harm (Meffert, Musalo, McNiel, & Binder, 2010). In these cases, mental health professionals might collaborate with medical doctors or work independently to document the psychological consequences of ill treatment on the asylum seeker.

Correspondence concerning this article should be addressed to Kim A. Baranowski, PhD, Department of Counseling Psychology, Teachers College, Columbia University, 525 West 120th Street, New York, NY 10027. E-mail: [email protected] C 2018 International Society for Traumatic Stress Studies. View Copyright this article online at wileyonlinelibrary.com DOI: 10.1002/jts.22288

1

Baranowski et al.

Individuals who have experienced torture may experience a variety of clinically significant psychiatric symptoms, including depression, anxiety, and posttraumatic stress disorder (PTSD), in addition to distress associated with the asylum process, resettlement issues, and forced separation from family (C de C Williams & Van der Merwe, 2013). Therefore, mental health professionals also work during their evaluations to corroborate psychological evidence of asylum seekers’ reports of ill treatment (Gansei & Deutsch, 2007; Physicians for Human Rights, 2012) and often employ in their assessments the international guidelines highlighted in the Istanbul Protocol: Manual on the Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (Office of the United Nations High Commissioner for Human Rights, 2004). The importance of forensic evaluations in asylum applications cannot be understated. Between 2000 and 2004, health professionals associated with Physicians for Human Rights (PHR) conducted 1,663 forensic evaluations of individuals seeking asylum in the United States (Lustig, Kureshi, Delucchi, Iacopino, & Morse, 2008). Of these cases, 89% resulted in asylum being granted, compared to a national average of only 37.5% of cases without medical and/or psychological evaluation. The psychological evaluation can provide several essential supports that may lend credibility to the asylum seeker’s account. During their involvement in a case, mental health professionals are likely to provide consultation, education, evaluation, case formulation, provision of an integrated case narrative, and assessment of malingering (Prabhu & Baranoski, 2012). Their evaluations often contain information that might corroborate the asylum seeker’s narrative, including assessment of symptoms and associated Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2014) diagnoses (Gangsei & Deutsch, 2007). In addition, clinicians are able to offer the court insight into the ways culture and psychiatric symptoms may explain inconsistencies in an asylum seeker’s testimony (Meffert et al., 2010). Finally, clinicians can assess the current treatment needs of the asylum seeker and can offer referrals for mental health services, if indicated (Prabhu & Baranoski, 2012). While they engage in this work, clinicians may encounter a host of challenges, including difficulties with the evaluation process and court testimonies (Mishori et al., 2014), countertransference reactions (Meffert et al., 2010; Prabhu & Baranoski, 2012), and vicarious trauma (Mishori et al., 2013). Despite these challenges, practitioners report this work to be meaningful and motivating. Clinicians often volunteer their time to humanitarian organizations or provide pro bono services (including forensic psychological evaluations) to vulnerable and sensitive populations throughout the United States and abroad; however, few studies have highlighted specific motivations to engage in this work. Some publications have documented the experience of interacting with asylees (Eisold, 2012; Roth, 2010) and the impact and practical implications of this work on clinicians (Asgary

& Smith, 2013; Wild & Heilinger, 2013) as motivating factors. Accordingly, published empirical qualitative studies specific to mental health professionals’ motivation to conduct asylum evaluations are also limited. Mishori and colleagues (2016) identified (a) “commitments to humanistic and moral values,” (b) “personal and family experiences,” (c) “professional skills,” and (d) “career-oriented interests” as primary drivers to engage in this work (p. 214). In various nations, nongovernmental organizations (NGOs) provide training and services to refugees and asylum seekers. For example, Doctors Without Borders prepares clinicians to provide humanitarian and medical services to asylum seekers and migrants (Doctors Without Borders, 2018). The Refugee Council offers training for frontline professionals on a variety of topics, including the health needs of asylum seekers, immigration implications associated with human trafficking, and psychological distress in refugee populations in the United Kingdom (Refugee Council, 2018). In the United States, the Physicians for Human Rights Asylum Network and the Health Right International Human Rights Clinic facilitate training in forensic evaluation of asylum seekers for health professionals. Medical and mental health professionals who participate in these programs learn to recognize and document evidence of torture and ill treatment. These trainings also provide basic information on asylum law, interviewing, affidavit writing, and the medical and psychological sequelae of specific forms of persecution (Health Right International, 2017; Physicians for Human Rights, 2017). In 2009, the American Psychological Association (APA) released an updated manual for mental health professionals working with refugee children and families. The APA also developed a manual focused on immigrant-origin clients that includes the recommendation that assessment be conducted in their native language using culturally appropriate measures and a social justice, ecological perspective (2013). Most recently, the APA’s Refugee Mental Health Resource Network (2017) offered organizations a list of mental health professionals who can work with refugees, along with webinars to help clinicians better meet current demands. Despite an increasing focus on the mental health of refugees, few studies have addressed the training of clinicians to provide psychological assessment of asylum seekers. Although their systematic review of the literature did not include perspectives of mental health clinicians, Robertshaw, Dhesi, and Jones (2017) noted that healthcare professionals who provide services for asylum seekers face challenges due to a lack of training and a sense of isolation associated with limited support when working with trauma. Similarly, in a qualitative study of asylum lawyers, Scruggs, Guetterman, Meyer, VanArtsdalen, and Heisler (2016) noted a shortage of practitioners who were prepared to conduct psychological evaluations for their clients. The purpose of this study was to contribute to the literature by gathering the experiences of mental health professionals who provide forensic psychological assessment of asylum seekers in the United States. We used consensual qualitative

Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.

Supporting Asylum Seekers

research (CQR; Hill, Thompson, & Williams, 1997) to analyze data that resulted from the interviews. The results highlight challenges associated with this work, suggest recommendations for training, and encourage advocacy endeavors by mental health professionals who provide these services.

collaboration. In addition, the team agreed to discuss emerging group dynamics and to address member assumptions during the coding process. Measures

Participants were 15 mental health professionals who conducted forensic psychological evaluations of asylum seekers in the United States. This sample size fell within the range of 12 to 15 participants recommended by Hill and Williams (2012) for a CQR study. The participants included five men and 10 women who ranged in age from 28 to 69 years (M = 45; SD = 12.5) and identified as White (n = 9), Asian (n = 3), Middle Eastern (n = 2), and Biracial with White and Asian ancestry (n = 1). The clinicians interviewed identified politically as Democrat (n = 12), Independent (n = 2), and Republican (n = 1), and included psychiatrists (n = 6), psychologists (n = 6), and master’s degree–level clinicians (n = 3). At the time of participation, each participant had conducted between one and 150 psychological evaluations of asylum seekers (M = 32; SD = 43.9).

After receiving informed consent and demographic information, the first author conducted a phone interview using the following questions: (a) "What do you view as your strengths associated with your evaluation of asylum seekers?,” (b) What do you view as your limitations associated with your evaluation of asylum seekers?,” (c) “How did your clinical training prepare you (or not prepare you) for this work?,” (d) “How might training programs better prepare mental health professionals to provide these services?,” (e) “How has your work with asylum seekers impacted you professionally?,” (f) “How has your work with asylum seekers impacted you personally?,” (g) “How have your own your multiple identities (i.e., ethnicity, gender, social class) impacted your effectiveness in conducting these evaluations?,” (h) “Has your work with asylum seekers impacted you politically? If yes, how so?,” (i) “What do you think could be done to better respond to the needs of refugees?,” and (j) “What advice do you have for other clinicians or for the mental health field in general?” The interviews averaged 58 min in duration, and audio was recorded; following the interviews, a professional transcriptionist transcribed the audio recordings.

Procedure

Data Analysis

This study was approved by the Teachers College Institutional Review Board. Participants were recruited through emails sent to human rights organizations in the United States that provide evaluations of asylum seekers. The e-mails included the principal investigator’s contact information and the following criteria for participant eligibility: (a) be a mental health professional, and (b) have used forensic psychological evaluation to document persecution experienced by asylum seekers in the United States. All participants received informed consent and participants’ rights documents as well as a $25 (USD) gift card for engaging in a 1-hr interview. The principal investigator was a White European-American woman psychologist who provided forensic evaluation of asylum seekers. Our CQR team also included a mental health counselor who identified as a White, Middle Eastern-Canadian woman, and a second mental health counselor who identified as an Indian-American woman and who came from a community of Afghan Hindus. Two team members came from families who fled persecution as refugees. A non-Latina White psychologist with CQR expertise served as the auditor of the study. Consistent with Vivino, Thompson, and Hill’s (2012) recommendation that CQR coders identify existing biases that might impact the coders’ effectiveness, the team explored the impact their multiple identities might have on their beliefs regarding the roles of the United States and the field of mental health in addressing humanitarian issues. The team also discussed strategies to ensure full member participation and ways to increase

The team followed the guidelines set forth by Hill and colleagues (1997) in the analysis of our data. At the start of the CQR process, we set aside the final two transcripts to use as a stability check as recommended by Ladany, Thompson, and Hill (2012). Next, we developed domains that chunked the data from the first 13 interviews into six broad topic areas, or domains. We worked individually and then met as a group to revise and remove redundant domains until we reached consensus. The team then summarized the text assigned to each domain into a series of nuanced core ideas (Hill et al., 1997). Throughout the analysis, we attempted to minimize interpretation by avoiding making inferences about the participants’ experiences and staying close to each interviewee’s own words (Hill et al., 2005). After team members created core ideas independently, we worked together to adjust these summaries until we determined that they accurately portrayed each interviewee’s response. Next, the auditor determined whether the domains and core ideas represented the data appropriately (Ladany et al., 2012). We then integrated the auditor’s coding recommendations into our analysis. During the next phases of coding, we created categories that described similarities found between the participants through cross-analysis, and after reaching consensus, we submitted the cross-analysis to the auditor. After integrating this feedback into our analysis, we assigned a frequency label to each category. General categories described 14 to 15 cases, typical categories included more than half the cases, and variant categories included fewer than half the cases. We removed categories that

Method Participants


Baranowski et al.

represented only one case from the analysis, because they did not represent the study sample (Hill et al., 1997). After we coded the initial 13 transcripts to completion, we coded the final two cases. Since the domains, core ideas, and categories remained consistent, we were able to conclude that we had reached a “stability of findings” and had effectively analyzed the results for our sample (Hill et al., 1997). Results The CQR analysis resulted in a total of six domains that clustered the participants’ experiences into unifying topics. Within each domain, the data were further organized into categories that captured common experiences across participants. The domains and their accompanying categories are described in this section and can also be located in Table 1. Strengths Associated With Evaluating Asylum Seekers The participants identified several areas of perceived strengths in providing forensic psychological evaluation of asylum seekers. The interviewees reported (a) commitment to multicultural competence, (b) trauma-informed clinical interviewing skills, (c) own identity and personal experiences, and (d) collaboration with other clinicians. Commitment to multicultural competence. Participants’ most cited strength was their commitment to working towards multicultural competence through clinical experiences, research, and training. Participants highlighted the importance of experience with diverse communities and knowledge of global mental health in understanding how asylum seekers’ psychological symptoms are understood “in their own [cultural] systems” and in respect to their “understanding of health and mental health.” Clinicians also stated that remaining informed about global current events enabled them to effectively incorporate context in their evaluations. Trauma-informed clinical interviewing skills. Many mental health professionals also cited their understanding of the impact of torture and exploitation on mental health functioning as a valued strength. For example, participants discussed their ability to identify when clients were becoming dysregulated while speaking about their experiences of ill treatment and how offering breaks or guided meditation exercises was necessary to help manage client flashbacks. Other participants reported that their compassionate questioning style and ability to empower clients to feel in control of the interview contributed to their clients’ increased comfort and greater disclosure of trauma experiences. One clinician reported letting clients “ . . . know they can take a break. They can go to the bathroom . . . .they’re not being interrogated.” Own identity and personal experiences. Some clinicians reported that aspects of their own identity provided them with

a unique understanding of their clients. Participants discussed their families’ immigration and refugee experiences as being central to their ability to empathize with the obstacles and challenges experienced by asylum seekers. Clinicians also spoke about how their own marginalized identities increased their sensitivity to experiences of persecution: I identify as gay and I’ve had the ability to be out for almost half my life. But I also, I understand how squeamish sometimes even questions about orientation can be . . . .so that informs the carefulness and compassion that I hopefully employ in asking questions particularly for clients who are fleeing because of persecution for their own real or perceived [sexual] orientation.

Collaboration with other clinicians. Study participants reported that collaboration with other clinicians increased their clinical effectiveness, specifically regarding supervision and mentoring. Participants emphasized the importance that shadowing experienced clinicians and receiving feedback on affidavit drafts had on their developing competence. One clinician noted, “[my supervisor] really helped to model and shape for me how it is to preserve a part of yourself but also to give back and promote justice and healing through this work.” Challenges Associated With Evaluating Asylum Seekers The second domain included challenges associated with forensic psychological evaluation of asylum seekers. The participants reported (a) struggles associated with the forensic setting, (b) problems related to trauma work, (c) limited training and resources, (d) difficulties providing pro bono services, and (e) feelings of isolation. Struggles associated with the forensic setting. Many participants stated that they felt “intimidated working in a legal setting” and reported concerns associated with the possibility of delivering court testimony in an adversarial environment. Others stated that it would be beneficial to have more opportunities to consult with lawyers representing the asylum seekers as well as greater exposure to asylum law. The clinicians also stated that clients sometimes assumed that the clinician was able to “make the final decision” regarding whether the seeker would be granted asylum. Lastly, participants reported that evaluating asylum seekers in detention facilities posed unique challenges: Every single time, to have to basically submit to an entire background check and clear metal detectors . . . one of our immigration facilities is an hour and 15 minutes from any major city. So that’s hard . . . and then you get there and for some reason, the detention officer decides you’re not going to meet with your client that day.

Problems related to trauma work. Given that asylum seekers have experienced torture and other human rights abuses, participants spoke about challenges associated with working with trauma survivors. They reported that their



Table 1 Domains, Categories, and Frequencies of Participant Experiences Domain

Category

Frequency

No. of Cases

General General Typical Variant

14 14 12 6

General Typical Typical Typical Variant

14 12 11 10 5

Impact of work on clinician Work aligns with values Clinician is critical of U.S. policies Enhances clinician professionally Responses from others are positive Responses from others are negative

General General Typical Typical Typical

14 14 11 9 9

Barriers experienced by asylum seekers Problems meeting basic needs Discrimination and social exclusion Fear due to immigration status Forced migration

General Typical Typical Variant

14 10 9 5

Recommendations for forensic asylum evaluators and mental health professionals Develop forensic assessment and legal knowledge Expand professional identity to include advocacy Provide incentives and organizational support Offer mentorship Understand cross-cultural responses to trauma

Typical Typical Typical Typical Typical

13 11 11 10 9

Recommendations for policy Create public awareness campaigns Simplify asylum procedures

General Typical

15 13

Strengths associated with evaluating asylum seekers Commitment to multicultural competence Trauma-informed clinical interviewing Own identity and personal experiences Collaboration with other clinicians Challenges associated with evaluating asylum seekers Struggles associated the forensic setting Problems related to trauma work Limited training and resources Difficulties providing pro-bono services Feelings of isolation

Note. Frequencies are labeled using the following criteria: general categories, 14–15 cases; typical categories, 8–13 cases; and variant categories, 2–7 cases.

affidavits require an assessment of consistency in the asylum seekers’ narratives. Therefore, a client who has demonstrated difficulty relaying their story can be seen as lacking credibility if the clinician does not effectively convey that memory difficulties are common among trauma survivors. In addition, participants highlighted that certain torture experiences, such as those perpetrated by individuals in positions of authority, can impact an asylum seeker’s ability to trust the clinician. Furthermore, participants spoke about the risk of vicarious trauma when engaging in this work. As one participant reported, “I notice when I do this work and these evaluations . . . I feel incredibly depleted.” Another participant noted: It’s very hard to work with trauma patients without it becoming political. You can’t work with patients who have sexual trauma without understanding that there’s

persecution of women and children. You can’t work with military trauma without understanding there’s a cost to sending young men out to war. You can’t work with asylum evaluations without knowing that political systems fail people.

Limited training and resources. All of the study participants reported that there were gaps in their training associated with this work. Some clinicians stated that they had not received formal coursework or clinical training experiences in forensic evaluation. One clinician reported, “I mean, we didn’t really in residency get any forensics exposure . . . of how to work in a legal context.” Others reported that their training in psychological assessment did not include issues specific to evaluating asylum seekers. A few participants stated that they had not received instruction on the effective use of


Baranowski et al.

interpreters in the clinical setting. Lastly, they commented that there are few psychological assessments appropriately normed on asylum-seeking populations. Difficulties providing pro bono services. Almost all the clinicians who participated in this study reported waiving their fees when providing forensic evaluations of asylum seekers. Many of the study participants spoke about problems related to providing pro bono services, including having to limit the number of referrals they are able to accept as well as difficulties recruiting colleagues to also offer their expertise. As one participant noted, “I would love to get more faculty on board, but they are already overwhelmed with responsibilities and have a hard time taking on voluntary, unpaid work, especially when they are paying back debts.” Because they do not bill for their services, clinicians who perform forensic evaluations pro bono reported that they have often had to schedule the sessions to take place after the end of their workday and dedicate time on weekends to completing affidavits. As a result, participants reported the evaluations and their associated deadlines can feel “cumbersome” and leave them feeling “stretched thin.” Feelings of isolation. The final category in this domain included participant responses that expressed a desire for connection with other clinicians conducting the same type of work. One participant stated, “there isn’t a community amongst clinicians that do this work . . . I don’t know [who they are] because it’s always a blind-copied list that goes out [for referrals].” Practitioners also reported that they would benefit from support from other mental health professionals as they process their reactions to their clients. One clinician stressed that, “ . . . having some kind of process group, just a venting, sharing, peer-support group would be huge. Or even if it can’t be a group . . . someone to bounce a case off, either for technical reasons or for personal reasons.” Impact of Work on Clinician The third domain included the impact the forensic evaluations can have on the clinicians. The interviewees indicated (a) evaluation aligns with values and sense of responsibility, (b) clinician is critical of United States policies, (c) enhances clinician professionally, (d) responses from others are positive, and (e) responses from others are negative. Work aligns with values. All but one of the participants reported that their forensic evaluation of asylum seekers aligns with their values and the responsibility they feel to support survivors of human rights violations. Some clinicians cited the privilege they experience due to their U.S. citizenship or authorized immigration status as an important motivating force. Others stated that this work enables them to address systemic issues of oppression through leveraging their knowledge and professional skills. Clinician is critical of United States policies. Almost all of the clinicians stated that their work with asylum seekers has

led them to feel critical towards human rights and immigration policies in the United States. For example, participants discussed the ways United States policies fail individuals who are fleeing torture and ill treatment. In addition, every clinician cited the current political climate in the United States, specifically xenophobia and anti-immigrant rhetoric, as well as examples of the country’s international policy as strong catalysts for their support of asylum seekers. As one participant noted, “ . . . a lot of the reasons that people have to come to the United States or . . . migrate anywhere, flee persecution anywhere, is because of things the United States is doing all over the world.” Enhances clinician professionally. The mental health practitioners explained the myriad ways their work with asylum seekers has enhanced them professionally. Participants reported that this work has led to job opportunities, influenced their career directions and research endeavors, and expanded their approach to addressing mental health issues. According to one participant, “ . . . I became increasingly interested in assessment and in trauma. That led me to become very interested in neuropsychology.” Responses from others are positive. Clinicians stated that other individuals in their personal and professional lives were supportive of their work. Participants reported that they have received validation, praise, and encouragement. Others commented that people often respond with curiosity and interest. One clinician in particular reported that the current national debate in the United States over immigration policy has increased the appreciation that others show for their evaluation work. Responses from others are negative. The participants in this study also reported encountering negative reactions from other individuals. For example, clinicians reported that both laymen and professionals have a limited understanding of the experiences of asylum seekers. They also discussed the discomfort they feel when others appear to be “titillated” or take a “voyeuristic” curiosity in their work. Conversely, some professionals expressed frustration that colleagues, friends, and loved ones avoid conversations about their work with asylum seekers: They just don’t want to know about it. I mean, [they respond with the statement]: that’s interesting. But no one ever really asks follow-up questions. Even people who are really interested in my life . . . so that’s part of why I’ve found this work difficult.

Barriers Experienced by Asylum Seekers The next domain comprises participant responses associated with obstacles faced by asylum seekers. The participants reported that asylum seekers experience (a) problems meeting basic needs, (b) discrimination and social exclusion, (c) fear due to immigration status, and (d) forced migration. Problems meeting basic needs. First, the clinicians discussed the challenges asylum seekers encounter in meeting



their basic needs. These included “employment,” “housing,” and appropriate “mental health and medical care” after they enter into the United States. Discrimination and social exclusion. Participants also reported that asylum seekers struggle with discrimination and social exclusion after they enter the United States. For example, asylum seekers may encounter hostility and be accused of “taking advantage of this country” or engaging in “terrorist” activity. The clinicians also stated that their clients experience marginalization associated with their race, ethnicity, and religion. Furthermore, practitioners stated that asylum seekers may also be excluded by members of their own communities living in the United States due to prejudice against lesbian, gay, bisexual, transgender, and queer individuals and stigma related to surviving sexual exploitation. One participant noted that members of these communities “may be also divided against each other because of their former political affiliations in their country of origin.” Fear due to immigration status. The clinicians reported that all of their clients expressed anxiety that was related to having a vulnerable immigration status and their fears associated with deportation. One clinician reported: I think people are scared to come forth now and even say that they’re undocumented or . . . would like to seek asylum. So I think that if there was, like, an anonymous phone line or a hotline or some way that people wouldn’t have to be identified, wouldn’t have to come forth to a practitioner or someone that they may fear.

Forced migration. The study participants also discussed the impact of forced migration on their clients. They reported that the need to flee dangerous situations in their countries of origin prevented them from having the time needed to prepare for their journeys. One participant stressed, “People don’t come to the U.S. because they’re dying to take a scary, dangerous trip and leave their family behind. They come because there are no choices . . . in terms of safety.” Recommendations for Forensic Asylum Evaluators The clinicians interviewed in this study had, at the time of the interview, collectively conducted 492 forensic psychological evaluations of asylum seekers. Based on their expertise, they made a series of recommendations for other mental health professionals, including: (a) develop forensic assessment experience and legal knowledge, (b) expand professional identity to include advocacy, (c) provide incentives and organizational support, (d) offer mentorship, and (e) promote understanding of cross-cultural responses to trauma. Develop forensic assessment experience and legal knowledge. The participants highlighted the necessity for clinicians to develop specialized skills in forensic assessment

and a deeper understanding of legal issues that face asylum seekers. They emphasized the need for mental health professionals to gain experience in conducting assessments in detention facilities as well as practice providing testimony in a potentially “adversarial setting.” Expand professional identity to include advocacy. The participants urged other clinicians to engage in advocacy. They recommended that clinicians contact their representatives at the local and national levels in order to influence policy. In addition, they suggested that professionals use research to impact legislation. One clinician remarked that professionals need to demonstrate “a willingness to be politically engaged even when it’s not easy to do so . . . we have an ability to shed light on the experiences of people who . . . might feel silenced.” Provide incentives and organizational support. The participants recommended that agencies and organizations provide “support and incentives” to encourage their staff members to conduct forensic evaluations of asylum seekers. For example, some of the professionals who were interviewed suggested that clinicians be permitted to provide these services during their regular workday. Many also called for better awareness regarding the services professionals can provide for asylum seekers. Offer mentorship. Participants commented that schools, clinics, and professional organizations could provide mentorship to clinicians who are interested in conducting forensic assessment of asylum seekers. Such support could include supervision, shadowing of evaluations, and feedback on affidavit writing. One participant stressed that, “modeling how this work is done for students, there’s interest . . . but [without support] there is a barrier to entering the work.” Understand cross-cultural responses to trauma. Finally, the mental health professionals we interviewed recommended that all clinicians preparing to engage in forensic psychological evaluation of asylum seekers should develop knowledge of “culturally responsive diagnosis,” which would include the ability to identify differences in the manifestations of psychological symptoms. In addition, participants voiced encouragement for clinicians to increase their understanding of “trauma-based interviewing” in order to avoid retraumatizing their clients. Recommendations for Policy The final domain contained policy recommendations. The participants cited the need to (a) create public awareness campaigns and (b) simplify asylum procedures. Create public awareness campaigns. Every clinician interviewed for this study stressed the need for public awareness campaigns that provide an “accurate portrayal” of asylum seekers. Participants suggested that these programs include public education that dispels the myths and misconceptions


Baranowski et al.

that contribute to the scapegoating of immigrants. For example, one participant stressed, “ . . . I think that if the general public needs to know anything, it’s that all migrants’ lives are valuable, regardless of if they meet the criteria for . . . asylum.” Simplify asylum procedures. As the clinicians reflected on ways to improve the lives of their clients, almost all suggested that the United States simplify asylum procedures and allow more immigrants to enter the country. For example, participants reported that the asylum process was too long and cumbersome for survivors. Participants also stated that they believe the United States should open its doors to even more people fleeing human rights violations. One participant reported, “I would try to find a path for citizenship for the 11 million undocumented people who are working hard and playing by the rules . . . I’d want to see asylum based on individual cases rather than political feelings towards countries.”

Discussion Few empirical studies have focused on the issues encountered by mental health professionals who contribute psychological evaluations to the asylum process. For that reason, qualitative inquiry is necessary to begin to develop a nuanced understanding of these professionals’ experiences with a focus on their own narratives. To the best of our knowledge, the current study was the first empirical examination of the experiences of mental health clinicians who conduct forensic psychological evaluations of asylum seekers that used interviews to collect the clinicians’ perspectives. The results of this study offer unique contributions to the literature, in that the findings highlight training and advocacy recommendations associated with this work as well as insight into the current personal significance of these endeavors experienced by practitioners. In accordance with other research (Scruggs et al., 2016), the results of this study highlight the need for more professionals to be trained in the forensic evaluation of asylum seekers. Our findings suggest that exposure to asylum work should begin while future mental health workers are still students in their respective academic programs, and it should include coursework not only in the mental health correlates of ill treatment and human rights violations but also in the role of legal and policy issues on this population. Coursework should also focus on the identification and administration of assessment instruments that can be used in diverse immigrant communities as well as culturally responsive and trauma-informed clinical interviewing and diagnosis. In addition, once students begin their residencies and clinical practicum, there should be dedicated opportunities for forensic psychological evaluation of asylum seekers. The results of this study indicate that clinicians-in-training should increase their skills through working with knowledgeable supervisors, shadowing expert practitioners, and receiving support while drafting their initial affidavits. Furthermore, trainees should receive specific instruction on offering professional opinions in

a legal setting and managing the adversarial nature of crossexamination. These training opportunities would increase clinician knowledge of and comfort in dealing with the challenges associated with these evaluations. Across participants interviewed in this study, themes emerged regarding the impact work with asylum seekers had on clinicians. Individuals interviewed for our study who engage in socially just psychological practice reported that the prospect of supporting survivors of ill treatment and human rights violations aligns closely with their values and permits them the opportunity to leverage their expertise in the service of a vulnerable population. Clinicians who participate in the forensic evaluation of asylum seekers also reported increased clinical effectiveness associated with their growing capacity to deliver services to diverse populations, greater exposure to global mental health issues, and a more thorough understanding of the psychological effects of trauma. These results suggest some of the motivations behind why mental health clinicians volunteer their time to conduct asylum evaluations. Given the number of asylum seekers in the United States and the shortage of providers who can adequately respond to demands for assistance with the asylum process, further identification of motivating factors is needed in order to aid volunteer recruitment, placement, and retention. The results of this study highlight practitioners’ understandings of the complex forms of systemic oppression experienced by asylum seekers. The persecution these refugees encounter in their country of origin leads to forced migration. This study’s findings also underscore the various forms of ill treatment experienced by asylum seekers once they are in the United States, including discrimination, social exclusion, problems meeting their basic needs, and fear associated with immigration status. Clinicians interviewed for our study reported that their knowledge of the systemic issues faced by their clients has contributed to their critical appraisal of United States policy. The results therefore suggest that mental health clinicians should expand their professional identities to include advocacy for this population. Notably, all participants commented that current political discourse on asylum increased their sense of urgency and motivation to conduct this work. Given the complexity of the asylum process and slow rate by which cases are processed, clinicians may amplify the voices of their clients by lobbying for simplified asylum procedures. In addition, due to the clinicians’ knowledge regarding the mental health correlates of human rights violations, practitioners can encourage policy makers to increase the number of individuals who can seek sanctuary in the United States. Finally, the results of this study suggest that clinicians believe the general public is not adequately educated about asylum seekers, which indicates the need for public awareness campaigns to provide citizens of the United States with accurate information about the violence that necessitates the migration of asylum seekers and the strength and resilience these individuals possess in order to increase empathy and community integration of survivors.



One of the most salient issues reported by participants was their experience of isolation associated with their work with asylum seekers. Although the practitioners we interviewed commented that individuals in their professional and personal lives often responded positively to the practitioners’ work, they also spoke of feeling as if others were unable and unwilling to learn more about the impact of this work on the clinician. Consistent with the literature on vicarious trauma (Catherall, 1995; Pearlman, 1995), the results of this study suggest that clinicians who conduct evaluations of survivors of human rights abuses would benefit from continued supervision and consultation opportunities with other professionals. In addition, the findings indicate that these clinicians might also welcome the chance to share their experiences with a supportive community of peers. Finally, given the pro bono nature of this work and the extensive amount of time clinicians must dedicate to each case, it is essential that agencies and organizations discover ways to support professionals who conduct evaluations. It is typical for professionals to either assess asylum seekers in the evenings after their workday has ended or on the weekends when they do not have other clinical responsibilities. In other instances, clinicians must schedule their evaluation sessions during times in which they would typically see paying clients, which results in lost wages. All of the participants in this study cited limited time and resources available for pro bono work as one of the biggest obstacles to providing these services. Allowing clinicians to evaluate asylum seekers as a part of their existing workload, locating funding to help offset the financial costs experienced by practitioners, or creating other incentives to make this work more sustainable would greatly benefit evaluators and, by extension, asylum seekers. This study gathered the experiences of 15 mental health professionals who conduct forensic psychological evaluations of asylum seekers, and these findings should not be generalized to all practitioners. Of the clinicians interviewed, 13 practiced in urban centers on the East Coast of the United States, whereas the remaining two participants worked in the Southwest United States. In light of the diverse political and cultural climates across the United States, it is unclear whether participants from other regions would have similar or divergent experiences from those interviewed in our study. In addition, only one of the practitioners who participated in this study identified as politically conservative. Given the current politicized nature of asylum, this identification may have impacted their policy recommendations. Finally, we followed methodological procedures aimed at reducing bias, such as engaging an external auditor; however, despite these precautions, it is possible that the perspectives of the coding team may have impacted the analysis. For example, all members of our team identified as social justice– oriented clinicians who believe that mental health professionals should leverage their expertise to address issues of inequality and oppression. Given similarities in our worldviews, it is possible that this led to greater agreement during the consensus process. Conversely, the deep respect our team held for both asylum seekers and clinicians conducting forensic evaluations

may have increased our commitment to portray the experiences of the participants in a trustworthy and accurate manner. The results of this study elucidate many important findings that may serve to guide the preparation of clinicians, development of an advocacy-oriented professional identity, and recommendations for organizations that can offer support to practitioners who engage in this work. Our findings also highlight the impact work with asylum seekers can have on clinicians personally, professionally, and politically as well as the potential to expose them to isolation and the risk of vicarious trauma. Future studies are needed to determine whether the experiences of the mental health professionals who participated in this study are representative of the larger population of practitioners who conduct forensic psychological evaluations of asylum seekers across the United States. References American Psychological Association. (2009). Working with refugee children and families: Update for mental health professionals. Retrieved from https://www.apa.org/pubs/info/reports/refugees-health-professionals.pdf American Psychological Association. (2013). Working with immigrantorigin clients: An update for mental health professionals. Retrieved from http://www.apa.org/topics/immigration/immigration-reportprofessionals.pdf American Psychological Association. (2016). Working with refugees from Syria and surrounding Middle East countries. Retrieved from http:// www.apa.org/monitor/2016/06/resource-refugees.aspx American Psychological Association. (2017). APA’s refugee mental health resource network. Retrieved from http://www.apa.org/monitor/2017/0708/sanctuary-sidebar.aspx Asgary, R., & Smith, C. L. (2013). Ethical and professional considerations providing medical evaluation and care to refugee asylum seekers. The American Journal of Bioethics, 13(7), 3–12. https://doi.org/10. 1080/15265161.2013.794876 C de C Williams, A., & Van der Merwe, J. (2013). The psychological impact of torture. British Journal of Pain, 7, 101–106. https://doi.org/ 10.1177/2049463713483596 Catherall, D. R. (1995). Coping with secondary traumatic stress: The importance of the therapist’s professional peer group. In B.H. Stamm (Ed.), Secondary traumatic stress: Self-care issues for clinicians, researchers, and educators (pp. 29–36). Lutherville, MD: Sidran. De Jes´us-Rentas, G., Boehnlein, J., & Sparr, L. (2010). Central American victims of gang violence as asylum seekers: The role of the forensic expert. The Journal of the American Academy of Psychiatry and the Law, 38, 490–8. Retrieved from https://pdfs.semanticscholar. org/9c1b/9c5455a753cb507d111d27d9312a9deae0be.pdf Doctors Without Borders. (2018). Migrants, refugees and asylum seekers: Vulnerable people at Europe’s doorstep. Retrieved from http://www. doctorswithoutborders.org/news-stories/special-report/migrants-refugeesand-asylum-seekers-vulnerable-people-europes-doorstep Eisold, B. (2012). Evaluating asylum seekers. Retrieved from http:// www.apadivisions.org/division-39/publications/newsletters/activist/2012/ 04/evaluating-asylum-seekers.aspx Gangsei, D., & Deutsch, A. C. (2007). Psychological evaluation of asylum seekers as a therapeutic process. Torture, 7, 79–87. Retrieved from https://s3.amazonaws.com/PHR_other/psychological-evaluation-ofasylum-seekers-as-a-therapeutic-process.pdf


Baranowski et al. Health Right International. (2017). Human rights clinic. Retrieved from https://healthright.org/where-we-work/united-states/

of torture and other cruel, inhuman or degrading treatment or punishment. Geneva, Switzerland: Author.

Hill, C. E., Knox, S., Thompson, B. J., Williams, E. N., Hess, S. A., & Ladany, N. (2005). Consensual qualitative research: An update. Journal of Counseling Psychology, 52, 196–205. https://doi.org/10.1037/0022-0167.52.2.196

Pearlman, L.A. (1995). Self-care for trauma therapists: Ameliorating vicarious traumatization. In B. H. Stamm (Ed.), Secondary traumatic stress: Self-care issues for clinicians, researchers, and educators (pp. 51–64). Lutherville, MD: Sidran.

Hill, C. E., Thompson, B. J., & Williams, E. N. (1997). A guide to conducting consensual qualitative research. The Counseling Psychologist, 25, 517–572. Hill, C. E., & Williams, E. N. (2012). The sample. In C. E. Hill (Ed.), Consensual qualitative research: A practical guide for investigating social science phenomena (pp. 71–81). Washington, DC: American Psychological Association. Retrieved from http://journals.sagepub.com/ doi/abs/10.1177/0011000097254001 Huber, C. (2017, April 18). Forced to flee: Top 5 countries refugees are coming from. Retrieved from https://www.worldvision.org/refugees-newsstories/forced-flee-top-5-countries-refugees Immigration and Nationality Act (INA), 8 U.S.C. § 208.13 (1997). Ladany, N., Thompson, B. J., & Hill, C. E. (2012). Cross-analysis. In C. E. Hill (Ed.), Consensual qualitative research: A practical guide for investigating social science phenomena (pp. 117–134). Washington, DC: American Psychological Association. Lustig, S. L., Kureshi, S., Delucchi, K. L., Iacopino, V., & Morse, S. C. (2008). Asylum grant rates following medical evaluations of maltreatment among political asylum applicants in the United States. Journal of Immigrant Minority Health, 10, 7–15. https://doi.org/10.1007/s10903-0079056-8 McKenzie, K. C., & Thomas, A. (2017). Assisting asylum seekers in a time of global forced displacement: Five clinical cases. Journal of Forensic and Legal Medicine, 49, 37–41. https://doi.org/10.1016/j.jflm.2017.04.007 Meffert, S. M., Musalo, K., McNiel, D. E., & Binder, R. L. (2010). The role of mental health professionals in political asylum processing. The Journal of the American Academy of Psychiatry and the Law, 38, 479–89. Retrieved from https://repository.uchastings.edu/cgi/viewcontent.cgi?article=2155& context=faculty_scholarship Mishori, R., Hannaford, A., Mujawar, I., Ferdowsian, H., & Kureshi, S. (2016). “Their stories have changed my life”: Clinicians’ reflections on their experience with and their motivation to conduct asylum evaluations. Journal of Immigrant and Minority Health, 18, 210–218. https://doi.org/10.1007/s10903014-0144-2 Mishori, R., Mujawar, I., & Ravia, N. (2014). Self-reported vicarious trauma in asylum evaluators: A preliminary survey. Journal of Immigrant and Minority Health, 16, 1232–1237. https://doi.org/10.1007/s10903-013-9958-6. Mossaad, N., & Baugh, R. (2018). Refugees and asylees: 2016. Retrieved from https://www.dhs.gov/sites/default/files/publications/Refugees_Asylees_ 2016.pdf Office of the United Nations High Commissioner for Human Rights. (2004). Istanbul protocol: Manual on the effective investigation and documentation

Physicians for Human Rights. (2012). Examining asylum seekers: A health professional’s guide to medical and psychological evaluations of torture. Boston, MA: Author. Physicians for Human Rights. (2017). Asylum network trainings. Retrieved from http://physiciansforhumanrights.org/training/asylum/ Prabhu, M., & Baranoski, M. (2012). Forensic mental health professionals in the immigration process. Psychiatric Clinics of North America, 35, 929–946. https://doi.org/10.1016/j.psc.2012.08.012 Refugee Council. (2018). Understanding the health needs of refugees and asylum seekers. Retrieved from https://www.refugeecouncil.org.uk/ training_conferences/training/training_for_refugees_community_ organisations/4858_understanding_the_health_needs_of_refugees_and_ asylum_seekers Robertshaw, L., Dhesi, S., & Jones, L. L. (2017). Challenges and facilitators for health professionals providing primary healthcare for refugees and asylum seekers in high-income countries: A systematic review and thematic synthesis of qualitative research. BMJ Open, 7, 1–19. https://doi.org/ Roth, K. (2010). Giving refuge: Reflections on working with asylum seekers. Journal of Pain and Symptom Management, 40, 149–154. https:// doi.org/10.1016/j.jpainsymman.2010.03.011 Scruggs, E., Guetterman, T. C., Meyer, A. C., VanArtsdalen, J., & Heisler, M. (2016). “An absolutely necessary piece”: A qualitative study of legal perspectives on medical affidavits in the asylum process. Journal of Forensic and Legal Medicine, 44, 72–78. https://doi.org/10.1016/j.jflm.2016.09.002 United Nations. (2018). Global response. Retrieved from http://refugees migrants.un.org/global-response United Nations High Commissioner for Refugees. (2010). Children on the run. Retrieved from http://www.unhcr.org/en-us/children-on-the-run.html United Nations High Commissioner for Refugees (UNHCR). (2015). Global trends forced displacement in 2015: Top 10 Refugee hosting countries in 2015. Retrieved from UNHCR website: http://refugeesmigrants. un.org/infographics Vivino, B. L., Thompson, B. J., & Hill, C. E. (2012). The research team. In C. E. Hill (Ed.), Consensual qualitative research: A practical resource for investigating social science phenomena (pp. 47–58). Washington, DC: American Psychological Association. Wild, V., & Heilinger, J. (2013). Cosmopolitanism within borders: A normative foundation for health care for asylum seekers? The American Journal of Bioethics, 13(7), 17–19. https://doi.org/10.1080/15265161.2013.794883
