Cover Story

After the woman witnessed 15 men lined up and shot outside her home in Syria, she could no longer speak.

"She just sat there," remembers Gregory N. Lewis, PsyD, who met the woman at the 80,000-person Zaatari refugee camp in Jordan as part of a humanitarian mission in 2015. "She had a veil over her face, so it was hard to get a read on her, but I could see the pain in her eyes." According to the woman's husband, she also hadn't been eating or sleeping well for several weeks. Lewis, a psychologist at Alliance Clinical Associates in Wheaton, Illinois, made two referrals: one to a visiting psychiatrist for medication and another to a local female therapist for ongoing help. "There's such need there," says Lewis. "What we did was literally a drop in the bucket."

The war in Syria is adding dramatically to a mounting refugee crisis worldwide. According to a 2016 report from the United Nations High Commissioner for Refugees (UNHCR), by the end of 2015, 65.3 million people—more than the population of Canada, Australia and New Zealand combined—had been forced from their homes because of persecution, human rights violations, conflict and other violence. Of those, 21.3 million were refugees, with 16.1 million under UNHCR's mandate and 5.2 million Palestinians registered by the United Nations Relief and Works Agency for Palestine Refugees in the Near East. Another 40.8 million were internally displaced. And 3.2 million were seeking asylum. More than half of the refugees under UNHCR's mandate are from Syria, Afghanistan and Somalia.

Many are seriously traumatized. A study of refugees in Germany by Enrico Ullmann, MD, of the University of Dresden, and colleagues, published in Molecular Psychiatry in 2015, found that almost half had post-traumatic stress disorder (PTSD). Thirteen percent had adjustment disorders.

Lewis is among the psychologists helping refugees recover from the traumas they've experienced in their home countries and those they face as they begin new lives. The Monitor talked to Lewis and three other psychologists working to help refugees, asylum-seekers and asylees in the United States and abroad.

Helping those in crisis

When Lewis saw a flyer about a medical mission to help refugees in Jordan, he was eager to volunteer. The Syrian American Medical Society sought to embed psychologists in its medical teams, and Lewis—with expertise in trauma, a dozen years of experience helping asylum-seekers and almost three decades of working alongside physicians in a public hospital in Chicago—was a perfect fit. The Jordanian government eliminated free health care for refugees in 2015, making such humanitarian missions even more critical, says Lewis. "If nongovernmental groups don't go, these people get nothing," he says.

Lewis made the first of two weeklong medical missions to Zaatari in 2015. On that trip, he met with refugees in a small cubicle in the barbed wire-enclosed camp in the middle of the desert. Most patients were experiencing anxiety, PTSD and depression, with depression especially prevalent among adults. "They felt like they were in a concentration camp, that there was no hope," he says. Embedded within an interdisciplinary team, Lewis assessed patients; offered brief interventions, such as teaching patients to use deep breathing and other stress management techniques; and referred patients to other health-care professionals within the international medical corps and even local imams—Muslim religious leaders—for follow-up care. Because most refugees in Jordan aren't living in camps, Lewis spent half of his 2016 trip seeing patients in a refugee clinic in the town of Irbid.

Lewis knows that some criticize humanitarian missions for "parachuting" in and then leaving again. That's why he chose the Syrian American Medical Society, which makes regular trips and has established protocols to ensure patients receive ongoing care. That's also why Lewis emphasized building capacity on his second trip. At the Irbid clinic, for example, he consulted with mental health counselors, many of them themselves refugees. He also educated surgeons and other providers about vicarious trauma and self-care, helping them avoid burnout despite a constant stream of horrifying cases. "At the beginning, they were desperate for help," he says. "Now it's more of a train-the-trainer model."

Lewis is considering additional missions, perhaps to Lebanon, Turkey or Greece. "I'll definitely do it again," he says of these pro bono experiences. "There are lots of opportunities out there."

Treating ongoing trauma

When the Bellevue/New York University Program for Survivors of Torture in New York needed someone to treat patients who had fled the war in Sierra Leone in 1999, they found a perfect match in Adeyinka Akinsulure-Smith, PhD. She was not only a psychologist but, as a native of Sierra Leone, spoke fluent Krio.

Since then, Akinsulure-Smith—now a senior supervising psychologist in the program—has treated refugees, asylum-seekers and asylees from around the world. She works as part of a multidisciplinary team providing medical, mental health, social and legal services.

Treating torture survivors is different from treating survivors of other traumas, such as fires, car accidents or natural disasters, says Akinsulure-Smith, who's also an associate professor of psychology at the City College of New York and the Graduate Center, City University of New York. "Torture is done deliberately to break a person's spirit or use them as an example to frighten other people," she says. "There's a real breakdown in trust." Patients are often suspicious of the process of therapy itself at first, says Akinsulure-Smith. "They're thinking, ‘Who are you? Why would I tell you my story? How do I know that you're not with the Department of Homeland Security, that you won't have me deported?'" she says.

Group therapy can help rebuild a sense of trust, especially since many patients come from societies that emphasize group relations. In a weekly group session for sub-Saharan African men, for example, participants hear what others have been through and how they've coped. Participants also discuss what's happening back home, how to prepare for asylum hearings and other matters. "It's safe here," says Akinsulure-Smith. "They can talk openly about what's going on."

For some, trauma continues even after they've made it to safety, says Akinsulure-Smith. "For many of these people, trauma is not post; it's ongoing," she says. Leaving behind friends, family and homes; making a dangerous journey; and rebuilding their lives in the face of poverty, hostility and other stressors can be just as traumatic as whatever they've fled, she explains.

Vicarious trauma is a big issue, she adds. What makes this wrenching work worthwhile is to see patients who have had their lives on hold win asylum and bring their families together at last. "Often when their families arrive, they'll bring them straight to the program to meet the team," she says. "It's amazing to see families that were torn apart reunited again."

Promoting family resilience

For psychologist Froma Walsh, MSW, PhD, going beyond the traumatized individual when treating refugees is crucial.

"Most of the refugee work done in the mental health field continues to be individually based, where the person who is suffering the most is referred for treatment that's focused on symptom reduction," says Walsh. She is a co-founder and co-director of the Chicago Center for Family Health, which trains mental health professionals in its family-centered, resilience-oriented approach and provides services to refugees and others.

That individual focus is not enough, says Walsh. For one, trauma and loss affect everyone in a family. "The shock waves reverberate throughout the family," she says.

But the family also holds the key to healing, says Walsh. "We focus on the strengths that enable people to endure and overcome trauma and tap into the natural resource for resilience in the family," she says.

When Bosnian and Kosovar refugees fleeing an ethnic cleansing campaign began flowing into Chicago, for example, the Chicago Center overcame stigma and the resulting reluctance to seek mental health services by offering resilience-oriented, multi-family groups. Dubbed CAFES and TAFES, or Coffee/Tea and Family Education and Support, these interventions took place in storefront locations families felt comfortable going to and avoided what Walsh calls "pathologizing" language. "We didn't single out the most troubled family member," says Walsh. "Instead we gathered the positive input and support of the natural network and recognized that trauma was an experience they all shared." Families felt comfortable sharing their experiences, including life before the war, war and ethnic cleansing, the refugee journey and resettlement in a new land, says Walsh.

After that initial work with refugees, the center followed up with a collaborative multi-year program to train providers in Kosovo and build the war-torn region's capacity to offer family resilience-promoting services. Since then, says Walsh, "our training, consultation and counseling clinic have served populations from Syria, the wider Middle East and North Africa and Latin America and those affected by collective trauma situations in many parts of the world."

Helping asylum-seekers

When Mexicans and Latin Americans flee armed gangs, political persecution, war and other threats, they often head north. Some end up in the Austin, Texas, office of psychologist Cynthia de las Fuentes, PhD, who for the last 16 years has been helping asylum-seekers build their cases and achieve the federal legal protection and financial assistance that asylum brings. Psychologists can help asylum-seekers in three ways, says de las Fuentes, explaining that asylum-seekers typically hire her directly after choosing her name from a list provided by their attorneys.

First, psychologists can help prepare asylum-seekers for asylum court by documenting the harm they have suffered, a process that entails assessments of depression, anxiety, trauma and other psychological problems plus an intensive interview. The report she produces goes to the client and his or her attorney.

Psychologists can also support clients as they get ready to testify, helping them manage anxiety and other emotions as they prepare their testimony. Some need therapy to recover from the traumas experienced at home or during the often harrowing journeys to escape. Attorneys themselves can need help managing their vicarious trauma, she adds.

Psychologists can also educate immigration attorneys, who can in turn educate judges.

"Sometimes people are numb or seem disconnected from their narratives, which judges can misinterpret as meaning their experiences weren't too bad," says de las Fuentes. "But for some people, it's more culturally appropriate not to show a lot of affect."

Others are too embarrassed to reveal key parts of their stories. One of de las Fuentes's clients, for example, didn't tell her attorney that she'd been brutally raped, which she viewed as a private, shameful matter unconnected to her migration story. But de las Fuentes was able to help the woman open up to her attorney so that the story could aid her asylum case. "That ended up being the centerpiece of the case," says de las Fuentes.

The work can be challenging, adds de las Fuentes, who prepared for the role by being supervised by a colleague for a year. For one thing, it's so low-paid it's practically pro bono, she says. There are no federal regulations about what qualifies for trauma or extreme hardship. And there just aren't enough psychologists—especially bilingual psychologists—doing this work. "And if there aren't enough of us working with adults, there are even fewer of us who work with children," she says. "They're the most vulnerable population."

A database of specialists

Several APA divisions have launched a project to identify psychologists who can conduct asylum evaluations, address refugees' mental health needs and research the topic.

The goal is to create a database of individuals and organizations worldwide who can provide such services, and train psychologists who want to get into the field. If you would like to be included in the database or lead training sessions, contact Elizabeth Carll, PhD, president-elect of APA's Div. 56 (Trauma Psychology) at