The Role of Psychiatrists in the Growing Migrant and Refugee Crises

Since 1975, the United States has been a world leader in refugee resettlement, welcoming over 3 million refugees (1). Within a week of his inauguration, President Trump enacted draconian border controls. The President’s Executive Order suspended the U.S. Refugee Admission Program, barred entry to citizens from seven predominantly Muslim countries, and barred entry to Syrian refugees indefinitely. Protests at U.S. airports and cities erupted immediately, and lawyers across the country filed lawsuits challenging these restrictions.

There is historical precedence for barring certain ethnic groups from entering the United States. The Immigration Act of 1882 placed a 10-year ban on Chinese laborers; of note to psychiatrists, this same law also placed a permanent ban on “any convict, lunatic, idiot, or any person unable to take care of himself or herself without becoming a public charge” (2). In 1924, a formalized quota system based on national heritage was enacted that excluded nearly all non-white immigration.

It was not until the Immigration and Nationality Act of 1965 that this system of race and nationality quotas was abolished, broadly opening the country to immigration from the rest of the world. Neither of the two authors of the present article, both of whom are from South Asia, would be here without this 1965 law. President Trump’s Executive Order, banning entry based on nationality, arguably violates the Immigration and Nationality Act and is certainly contrary to its spirit. In this way, the order recalls discrimination and exclusion not seen in this country in half a century.

The United States is party to international treaties that protect the rights of refugees, such as the 1967 Protocol Relating to the Status of Refugees; such commitments were operationalized in the United States Refugee Act of 1980. This created a system for resettlement of refugees, and asylum status was given to individuals who were already present in the United States and would be considered refugees by international law.

As of 2015, one of every 122 persons worldwide is a refugee, internally displaced person, or asylum seeker (3). Once in the United States, asylum seekers must demonstrate that they are unable or unwilling to return to their country of origin because of persecution or a well-founded fear of persecution on account of race, religion, nationality, membership in a particular social group, or political opinion (4).

The adjudicator (asylum officers or immigration judge) assesses the asylum seeker’s credibility, which is critical to the outcome of the case. According to the USCIS Adjudicator’s Field Manual and the REAL ID Act of 2005, credibility is defined as “involving a witness’ trustworthiness and believability” and “demeanor, candor, or responsiveness” (5, 6). The law mandates accurate reporting of even minor details and inconsistencies, and failure to do so can be the basis for removal. This standard for assessing credibility can pose unique problems for those who are victims of psychological trauma.

Refugees and asylum seekers almost always have significant trauma exposure and thus are at high risk for posttraumatic stress disorder (PTSD). Several studies have estimated the rates of PTSD to be 28%–36% among the asylum-seeking population (7, 8). Symptoms of PTSD, such as disordered memory, numbness, and reduced responsiveness to the outside world, can make it difficult for asylum seekers to be granted legal status.

Psychiatrists can play an important role in asylum proceedings. In particular, immigration courts often rely on psychiatric evaluation and testimony to help assess the veracity of the asylum seeker’s claims. As expert witnesses, we can provide context and corroboration for an asylum seeker’s trauma and thus reinforce the credibility of the asylum seeker, as well as explain how mental illness affects behaviors, possess the ability to talk about the trauma, and comment on overall demeanor.

Over the last 8 years, psychiatry residents at the Cambridge Health Alliance have participated in conducting approximately 70 pro bono psychological assessments for people seeking asylum through the staff psychiatrist-supervised Cambridge Health Alliance Asylum Clinic. Psychiatry trainees participating in the clinic perform psychological evaluation, prepare legal affidavits to the court, and observe staff psychiatrists testify on the client’s behalf.

Our experience working with asylum seekers has been illuminating in a number of ways. First, we have seen the power of the psychological assessment in asylum proceedings; asylum seekers who have a medical or psychiatric evaluation and testimony on their behalf have much higher rates of being granted asylum (9). Secondly, the psychological asylum interview is unlike clinical therapeutic work, as the goal is not therapeutic, but rather as experts, we observe and report traumatic history and psychological findings objectively. Given the need to ascertain such information, the traumatic history must be elicited. Therefore, the client may disclose harrowing details of torture and persecution that are rarely seen in a typical psychiatric setting. Coming so close to the human atrocities, terror, strength, and resilience of asylum seekers is a truly unique experience and window into the abject suffering they endure before coming to America.

Our work on asylum applications has also revealed serious problems in the asylum process, as well as the role of the psychiatrist in this process. Asylum seekers are trapped in the iron cage of Weberian bureaucracies that comprise the immigration system in the United States; it can take years for cases to be adjudicated. There is currently a backlog of more than half a million cases, and immigration courts are unable to deliver timely decisions to people seeking refuge (10).

While the outcome of this work is often satisfying, as the entire life trajectory of an individual may be altered as a result of asylum status being granted (or not) by the courts, the involvement in the process makes us privy to the shortcomings of the process. One shortcoming is the court’s reliance on our diagnoses regarding psychopathology; as a result, we are tasked to find labels of disorders that help legitimize patients’ claims. Asylum seekers are not entitled to an attorney, and those who are unable to afford one or unable to secure an attorney pro bono are severely disadvantaged against the U.S. government’s attorney. Therefore, representation and access to the psychological evaluation is a privilege that many severely marginalized people do not have.

Given that certain experiences are more likely to cause traumatic sequelae, the role of the psychiatrist can realign into truly thinking preventatively. Political and sexual violence, social marginalization, and deprivation have proven to contribute to psychological sequelae. We therefore believe that psychiatrists ought to be involved in social policy to prevent downstream traumatic effects.

As trainees, there is a concerted effort to help cultivate cultural competency. The Substance Abuse and Mental Health Services Administration describes cultural competency as the “ability to interact effectively with people of different cultures” and that it “helps to ensure the needs of all community members are addressed” (11). Competency cannot be predicated on having knowledge of all cultures, as it would be impossible to be facile with the customs, worldview, and mores of all people one treats. We believe that language around competency should include humility (12). Tervalon and Murray-García (13) argue that humility helps ground one to “a lifelong commitment to self-evaluation and self-critique, to redressing the power imbalances in the patient-physician dynamic, and to developing mutually beneficial and nonpaternalistic clinical and advocacy partnerships with communities on behalf of individuals and defined populations.” Cultivating humility is a more worthwhile pursuit, as the language of competency harkens an idea of fulfilling perfunctory criteria to master; however, the pursuit to deliver culturally attuned care is a constant one.

This matters because while as psychiatric evaluators we may not have gone through the trials and tribulations that asylum seekers have experienced, approaching their plight from the lens of humility helps us to more effectively advocate for them. One example is that cultural idioms of distress may not be neatly covered under our DSM-formulated construct of PTSD or other definitions of mental illness. Thus, we must allow space to consider a patient’s phenotypic presentation without insisting that we adhere to such Western constructs.

Performing asylum evaluations should not be viewed as a charitable exercise in which we lend our professional expertise to aid legal proceedings, but rather a responsibility and moral obligation to advocate and speak out on behalf of the most vulnerable. We need to step out of the clinic and academic spaces and partake in the work in jails and detention centers. We ought to resist policies that harm people and families, whether they are wantonly discriminated against based on their country of origin, religion, sexual orientation, or gender identity. As doctors, we have distinct responsibilities as professionals; we also must not forget our responsibilities as human beings. By participating in the asylum process, we can advocate for and help those without the political agency to obtain a better life. Justice requires this of us.

The authors thank their mentor, Dr. Wesley Boyd, for his unwavering support, guidance, and wisdom. The authors also thank the Cambridge Health Alliance Department of Psychiatry training directors, Dr. Marshall Forstein and Dr. Amber Frank, for their support.