Angela* fled El Salvador for the United States at age 24 with her two small children, desperate to escape chronic intimate partner violence from her husband, who was associated with a powerful international gang that operated with impunity in her country. Following the birth of her first child, Angela's husband began to physically and sexually assault her, and although she contacted local law enforcement for help, they were unable to intervene. Given the severity of the abuse, Angela was certain her husband or his fellow gang members would murder her if she remained in El Salvador. With the help of her family, she hired a "coyote" to help usher her and her son and daughter to the United States. The journey was extremely dangerous and took several weeks; Angela and her children were often hungry and the coyote threatened to abandon them if her family didn't give him more money. In the final days of their travels, they had to hide in the luggage compartment of a bus to avoid detection. Eventually, they made it to Texas.

Although she was apprehended by immigration officers a few hours after entering the United States, she was detained for only a few days and is now working in a restaurant to make a new life for herself and her children as she seeks asylum in the United States.

As part of her asylum application, Angela shared her story with Kim Baranowski, PhD, who teaches in the department of counseling and clinical psychology at Teachers College, Columbia University and serves as the faculty director of research at the Mount Sinai Human Rights Clinic in New York City. In collaboration with attorneys, Baranowski documented the impact of Angela's experiences on her mental health functioning and submitted a psychological evaluation for review by an immigration judge.

Angela is just one of tens of millions of people who are seeking to find more peaceful lives in a new country. According to the latest statistics available from the United Nations High Commissioner for Refugees, by the end of 2015, more than 65 million people around the world — the highest levels on record — had been forced to migrate because of persecution, conflict, generalized violence or human rights violations. The numbers of displaced people have exploded in the past two decades, up from 37.3 million in 1996 — a staggering 75 percent increase.

Seeking asylumNearly 21.3 million of these people were refugees escaping persecution or violence; more than half of these refugees were children and teens. And as many as 2.3 million were asylum seekers, meaning, unlike refugees, they applied for sanctuary after arriving in a foreign country on the grounds that they could not go back to their home countries because they had been targeted for persecution due to their race, religion, nationality or political views, or because they were members of a particular social group.

The number of asylum cases is soaring as conflicts around the world continue to escalate. In 2015, Germany — host to the largest number of new asylum seekers — received 441,900 asylum applications, more than double the number a year earlier. Most are from Syria, although there are also increases from Albania, Serbia and Kosovo as well as Afghanistan, Iraq and Eritrea.

In the United States, the second-largest recipient of asylum applications, 172,700 applications were filed in 2015, a 42 percent jump from 2014. An increasing proportion of applicants are people fleeing violence in Central America, particularly El Salvador, Guatemala and Honduras; the number of refugees and asylum seekers with pending cases who are from these three countries has skyrocketed from 20,900 people in 2012 to 109,800 people in 2015.

These asylum seekers, who include victims of violence, torture, and other forms of trauma and persecution who had to flee for their lives, often have little or no proof to support their stories. That's where health professionals, including physicians and psychologists, can step in and play a crucial role in helping asylum seekers document their experiences so that they can present their case to remain in the United States.

Psychologists, attorneys, medical professionals and others are working to help these asylum seekers, usually on a volunteer basis.

Harrowing stories

As difficult as it is to fathom the sheer numbers of refugees, the individual stories of these people can be even harder to comprehend. Stories like that of a young Rwandan teen applying for asylum in America who, at age 7, saw the butchering of her father and mother and then was gang raped. Or the story of a teen from Guatemala who was raped at 15 by members of a gang and became suicidal until he made his way to the United States and found hope that he could live a life free from violence. Or the tale of a Tibetan man who was beaten and tortured by Chinese officials.

In many cases, the only hope for these people to attain permanent resettlement in the United States is a psychological evaluation conducted by a mental health professional who bolsters their story for review by an immigration judge. Data show that attorneys and supporting reports by psychologists and mental health experts make a difference in the outcome of an asylum case. According to Physicians for Human Rights, approximately 90 percent of cases of people who work with a forensic evaluator are granted asylum. And according to statistics from the Transactional Records Access Clearinghouse, as many as 90 percent of asylum cases that had no attorney representation were denied in 2016; in comparison, only 48 percent of asylum appeals were denied when an attorney was involved.

"When you bring an expert who's putting their license on the line and who can talk about the effects of trauma on the body and mind, it adds another dimension," says Eddy Ameen, PhD, the director of APA's Office on Early Career Psychologists, who also volunteers independently as an asylum evaluator.

Documenting human suffering

Psychologists typically interview an asylum applicant for a psychological evaluation after an attorney working with an organization that assists asylum seekers has already vetted the applicant. Then, the psychologist and asylum seeker, along with an interpreter if one is needed, sit down for an interview that lasts a few hours. The psychologist asks the client a series of questions to understand his or her pre-trauma experience and life, details about the trauma or torture, his or her psychological reaction post-trauma, and life now in the United States. Usually, the psychologist meets with the asylum seeker for a single two- to three-hour session.

The core reason for the interview is to produce an affidavit for the court, not to write clinical case notes, says Ameen. Details in these cases can make the difference between asylum and deportation back to danger. "The notion of confidentiality looks quite different here," says Ameen.

The interviews are often difficult, which the psychologists emphasize to the asylum seekers before they begin, says William Salton, PhD, director of the Max and Celia Parnes Family Psychological and Psychoeducational Services Clinic at the Ferkauf Graduate School of Yeshiva University and co-director of the Yeshiva Asylum Project, which trains graduate students to work with asylum seekers.

"We say to them, 'This will hurt; this will not be a pleasant, easy two hours,'" he says. "But we also continually offer support and say that this is to help them get asylum, to keep them from being deported."

Asylum seekers and those who've experienced trauma also share other common symptoms such as anxiety, depression, trouble sleeping and eating, and problems with libido. Survivors of torture or abuse may also experience symptoms associated with PTSD (post-traumatic stress disorder) such as hypervigilance, intrusive thoughts, interpersonal isolation, nightmares and flashbacks.

Salton advises his students to commend the client's strength and bravery throughout the interview. "Psychologists should praise the asylum seeker's courage and resilience regularly or as needed during the interview to offset the painfulness of the interview," he says.

Other issues can make it difficult for the psychologist to obtain a full report. Like other trauma survivors, for example, the asylum seekers may have trouble remembering what they experienced. Some victims of sexual assault may feel shame or reluctance to speak about the attack. And asylum seekers' cultural backgrounds can influence how they describe their distress. A person who has been the target of violence may not say, "I feel anxious." Instead, the impact of their experiences might manifest somatically, for example, through headaches and gastrointestinal complaints, says Baranowski. For this reason, clinicians often benefit from the cultivation of culturally responsive interviewing and diagnosis skills.

Speaking for the asylum seekers

Health professionals who assist asylum seekers can receive training on conducting interviews that follow the guidelines set forth by the "Istanbul Protocol: Manual on the Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment" through PHR. Anyone who is a licensed clinician can assist asylum seekers, and organizations like PHR provide forensic training to volunteers before they work with asylum seekers.

Asylum-related organizations also provide guidance on how to write a forensic report for immigration court. These affidavits will typically include the evaluator's credentials, the name of the interpreter and some details about the applicant's life, such as what persecution in his or her country felt like, what it felt like to leave the country and what the journey to America was like. "The legal system demands reason, logic and coherence," says Salton. What evaluators add is the full picture of the asylum seeker's experiences, thoughts and emotions. "We need to create a human being who has a credible story. We need to show the judge that there is a person who has a story, personality and history," says Salton.

Since so many asylum cases involve people for whom English is not their first language, the role of an interpreter can be crucial in the process of documenting an asylum seeker's experience and generating a comprehensive report. To ensure a smooth working relationship with an interpreter, Salton recommends that the psychologist start off by reviewing the case and the importance of accuracy. It's also important to stay mindful of how difficult some narratives may be and check in with the interpreter before and after the interview to monitor his or her thoughts and feelings.

In a webinar on conducting asylum evaluations hosted by APA's Refugee Mental Health Resource Network, clinical psychologist Jennifer McQuaid, PhD, noted that PTSD and depression are common among asylum seekers. McQuaid, who frequently evaluates and provides expert witness testimony for asylum applicants in her work with the nonprofit Sanctuary for Families, says refugees experience PTSD at very high rates, ranging from 30 percent in some studies to over 80 percent in others.

"What I find really noteworthy, and consistent with my own clinical experience, is that asylum seekers demonstrate higher rates of PTSD than refugees, suggesting that the instability associated with that lack of refugee status — and perhaps the stressors of the asylum process itself — contribute to poorer mental health outcomes," says McQuaid.

In her evaluations, McQuaid includes details such as how the trauma they experienced shapes their everyday lives, causing them to avoid specific situations and people, or even the subjects of their nightmares. Since the judges usually don't have the time to thoroughly read entire evaluations, McQuaid includes concise and clear synopses in her conclusions.

In addition to the psychological evaluation, the application can include a physician's documentation of medical evidence associated with physical trauma, such as gynecological exam reports or photos of scarring associated with injuries inflicted during a beating.

The psychologist typically does not need to appear in court but should be available by phone in case any questions arise during the proceedings.

Compassion fatigue

The adage that you should put on your own oxygen mask before putting one on someone else can be a useful one to remember when dealing with asylum cases, say psychologists who do the work. The stories of many asylum seekers who are victims of violence and atrocities are filled with horror, and psychological evaluations necessitate gathering details and immersing oneself in the examinee's painful memories. It's important to guard against vicarious trauma, or compassion fatigue, by consulting with colleagues, seeking additional supervision, turning to family and friends in your support network, and cultivating healthy habits and good self-care, says Baranowski.

"You'll hear some of the most difficult stories," says Baranowski. "Spend time with family and friends. Go to yoga, exercise, and seek consultation with a supervisor and with colleagues. And be vigilant and keep an eye on your own response."

Whatever challenges there are to the work, psychologists like Baranowski point to the rewards, such as knowing that they are making a difference in the lives of people in need. "I don't walk away dejected. I'm inspired by how brave, amazing and resilient the survivors are," says Baranowski. "It's work that's filled with hope."

*Not her real name; identifying information has been changed to protect client privacy.

Asylum seekers by the numbers

  • 65 million people have been forced to migrate because of persecution, conflict, generalized violence or human rights violations.
  • 21 million are escaping persecution or violence.
  • 2.3 million applied for sanctuary after arriving in a foreign country on the grounds that they cannot go back to their home countries.
  • 441,900 applied for asylum in Germany in 2015, double the number in 2014.
  • 172,700 applied for asylum in the United States, the second-largest recipient of asylum applications, a 42 percent jump from 2014.