Female-specific trauma evaluations

One of the specialized types of evaluations I conduct are with women who have undergone Female Genital Mutilation (FGM) procedures.  These brutal mutilations are still performed, according to the World Health Organization, in 28 countries, mainly in Africa and the Middle East.  Because this practice is so physically and emotionally harmful, women who have undergone FGM are considered for asylum applications.  My evaluations help to describe the life-long negative consequences these procedures nearly always cause.

The women I have met with report having their FGM as young as in infancy up until as old at 12 or 13.  Many are so young they don’t remember the actual procedure.  For those that do remember it, they often describe PTSD-like reactions, with high startle responses, flashbacks and avoidance and fear of anyone who reminded them of the event.  They also describe a change in socialization, going from having been more outgoing and confident prior to the FGM, to becoming withdrawn and self-conscious afterward.  Over time, these feelings become more specific to relationships with men.  Nearly all the women I have interviewed admit that they feel like they are somehow not whole  or real women, that because their most sensitive female body part has been mutilated, that they are somehow not able to be fully feminine, or to please a man intimately.

For many of the women I meet with, talking to me about their experience is one of the few times they have ever admitted to or discussed this event.  Despite the fact that they were usually raised in communities where many young girls experienced FGMs, they never  vocalized what they went through.  Growing up with a feeling that they were not supposed to talk about their FGM added to the feeling that it was shameful and secretive.  These women all feel that they are carrying around a horrible secret that will only be discovered if they ever enter into a romantic relationship.  Because of this, many avoid relationships entirely.  Others enter into relationships, but nearly all report problems with intimacy, and none have reported enjoying intimacy, but instead enduring it for their partner’s sake.  I often meet with women who have had to let go of their dream of ever having children, having passed their childbearing years and not been able to engage in a long-term relationship.

The stigma of the FGM, and the additional shame of living illegally in this country, can cause these women to completely isolate themselves.  Many have suffered from a Major Depressive Disorder for years.  Frequently they report having difficulty forming relationships even with women, feeling withdrawn and alone.

For these women who have endured so much hardship and pain, the prospect of gaining their legal status and being able to access educational and vocational opportunities, is the one hope they have for their futures.   My reports lend a voice to these immigrants who have carried around such a heavy burden for so long.

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Domestic Abuse Evaluations

The Violence against Women Act (VaWA), passed in 1994, allows spouses who were filing for their legal status through their marriage to a US citizen, and were abused during this marriage, to file for their legal status independently.  My evaluations assess the mental, physical and/or sexual abuse a spouse experienced, and the emotional ramifications such abuse has caused the client to suffer.

Assessing Emotional Abuse:

Most people think of abuse as physical in nature.  However, in many of the evaluations I perform, there was little or no physical domination.  The abuse is emotional in nature and because there are no bruises, cuts, broken bones and often no police reports, this abuse can be harder to substantiate.  However, the emotional control and exertion of power of one spouse over another can cause a similar reaction of trauma and/or depression in the victim.  Because emotional control can be difficult to quantify, my evaluations are critical in confirming the presence of such abuse, and describing the ways in which this abuse causes emotional pain.

Some ways in which a partner can exert abusive emotional control are:

-Limiting their spouse’s access to work, money or material resources

-Isolating their spouse from friends or groups

-Throwing away spouse’s belongings

-Criticizing, humiliating and undermining spouse’s self-esteem

-Ridiculing spouse for expressing opinions

In cases where one spouse has their legal status and the other does not, threats of having the spouse deported, or calling the police, are often part of the pattern of control.  Clients applying for their legal status are often terrified that they might at any time be deported and separated from their family, friends and life in the U.S.  This threat often adds significantly to the feeling that they need to do anything the spouse asks to avoid being turned in, and to have the opportunity to obtain their legal status.

The impact of being in an abusive relationship often has a long-term, damaging impact on the victim’s self-esteem, which can lead to depression.  Being stripped away of all power and being made to feel ashamed and helpless causes the spouse to internalize the belief that he/she is of low importance.  Even people who previously had high self-esteem begin to question themselves, to feel unattractive, uninteresting, and/or unintelligent.

Over time, and especially if the client engages with a good therapist, these symptoms can improve or even resolve.

The ability of the client to file for their legal status and begin to forge an independent and empowered life is critical in their recovery from the damage of the abusive marriage.  My reports professionally detail the client’s experience during their marriage, and describe the suffering they experienced during and after the marriage.  As it is often difficult and painful for clients to describe this, my reports are critical in highlighting the extent of abuse and suffering that occurred, and strengthen the cases of these suffering clients.

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Hardship Evaluations

I often conduct hardship evaluations, during which I assess the negative impact U.S. citizen family members would suffer if their relative was deported.  Usually, this is a parent and/or spouse. I assess the emotional and financial impact a deportation would have on these family members, and how this can lead to poor future outcomes for all.

Emotional Hardship:

Often family members are already showing significant signs of depression and/or anxiety when I meet with them, even if the family member has not yet left the country.  The possibility that a spouse might lose their life partner for an indefinite and possibly permanent amount of time is devastating for most I see.  This loss is often exacerbated when the couple has children.  Not only does the spouse have the additional strain of raising the children on their own, but the spouse often worries about the impact on the children, who often suffer significantly emotionally as well. I have seen many examples of increased behavioral issues and academic decline linked to a departing parent. Children can start to act out at home or school or become withdrawn and depressed.

Financial Hardship:

The loss of income when the deportee leaves the country often causes the family to fall into financial despair.  The result frequently means moving out of and/or selling the family home, incurring massive debt and quite often falling into a state of poverty or bankrupcy.   This financial pressure exacerbates the depression and anxiety for the single parent, already struggling emotionally in trying to come to terms with the departure of their loved one.

Future Outcomes:

Finally, I look at how the decreased income and emotional strain can lead to poor future outcomes for the family. Educational and vocational opportunities are narrowed for both spouse and children with the limited financial situation. In addition, the emotional toll over time to a single parent and to children living in separation from a spouse/parent is devastating.

My hardship evaluations help to illustrate that it is not only the deportee who suffers in these situations.  In describing the detailed ways in which the spouse and children of a deportee are impacted by such a forced move, my reports illuminate the human suffering of U.S. citizens left behind in a real and concrete way.  My narratives help to remind the court that real people, both adults and children, are imminently impacted by the decisions made in these cases.

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Clinical Evaluations with U-Visa clients

The purpose of the U-visa is to give immigrant victims of certain crimes temporary legal status and work eligibility in the United States.   These crime victims have experienced a “felonious assault” and have cooperated with the police in helping to identify the perpetrator.

In my evaluations with these clients, the experience of the assault has frequently left the victim with symptoms of Post-Traumatic Stress Disorder (PTSD).  Often these symptoms constitute a diagnosis of PTSD.  In other cases, the symptoms may have lessened over time, and although may not warrant a full PTSD diagnosis, still negatively impact the person significantly.

Symptoms of PTSD include:

  • Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions
  • Recurrent distressing dreams of the event
  • Acting or feeling as if the traumatic even were recurring
  • Efforts to avoid thoughts, feelings or conversations associated with the trauma
  • Efforts to avoid activities, places or people that arouse recollections of the trauma
  • Difficulty falling or staying asleep
  • Irritability or outbursts of anger
  • Difficulty concentrating
  • Exaggerated startle response.

In my experience with U-visa evaluations, many victims experienced their crime while at work.  Because of their legal status, they often feel locked into their jobs, without opportunities to change their work location or vocational field.  The need to continue to report to work, in a site where a traumatic event occurred, re-traumatizes these clients each day.  They cannot afford to quit their jobs, but the stress, anxiety and fear they face daily, psychologically reliving their trauma again and again, causes extreme emotional discomfort.

In addition to the lack of ability to change their jobs, these individuals usually do not have access to mental health services.  I am usually the first mental health professional they have ever spoken with.  No health insurance and limited access to community agencies where languages other than English are spoken create huge barriers to receiving needed mental health treatment.  Additionally, cultural stigma often plays a role in a client’s motivation to seek out services.

During my evaluations, I make referrals and recommendations for longer-term mental health services based on my knowledge of community resources.  I encourage clients to follow up with mental health services and I discuss the benefits of processing their feelings with a mental health professional in order to diminish the trauma reaction.

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Reflections on working with asylum seekers:

Having worked for over 15 years as a licensed clinical social worker, I have repeatedly been reminded of how grateful I am for the good things in my life.  My work reminds me not to take for granted for my mental and physical health, the fact that I grew up with love and support, and that I have had easy access to high quality education, vocational opportunities and a comfortable financial situation.  No population I have worked with has provided me with this feeling of gratitude more than my work with new immigrants to the United States.  The stories of struggle, poverty and financial and emotional strain, both in their countries of origin and as they adjust to life in the U.S. are intense.

Hearing the stories of asylum-seekers, however, has brought me a whole new level of gratitude.  Like many in the U.S, I am often critical of our political system, embarrassed at times and frustrated at others.  However, I have learned from hearing first-hand experiences of political torture victims, how grateful I am to be able to express my views and absolutely never fear for my safety or well-being.  And I do take that for granted much of the time –like the fact that I can say whatever I want in my blog and there will not be any retaliation against me for what I write.

People sometimes express their admiration for what I do, and how hard it must be to hear these difficult stories.  And it definitely can be emotionally draining.  However, I get so much from my work, and my sense of gratitude is probably the most important reward.  This gift of gratitude has comforted me at times when I have felt I am not compensated well financially – the fact that I have interesting, fulfilling work where I not only help others, but also get to recognize daily the good fortune I have been lucky enough to live with.

When I hear the lengths people have gone through to get to the United States, I am again humbled to have simply been born here.  People risk their lives, and endure endless months of treacherous travel conditions, sometimes experiencing abuse and rape along the way.  It underscores just how terrible life was for them in their country of origin, that they would be willing to leave behind their family, friends and culture, with the glimmer of hope that the U.S. will bring them what they have not found in their homeland – opportunity and freedom.

As difficult as the immigration situation is in the United States with the ethical and legal challenges that arise from having so many seeking safety and opportunity, I am forever proud that I live in this country where we have freedom and hope, and where people travel from so far away and risk so much.

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Susan Jacobson website

Thanks so much to Susan Jackobson for having two links to my website on hers.  You can access her website at http://www.susanejacobsonnp.com/.  This website if full of information for those who work with immigrants, including definitions of terms used in immigration law, information on trainings related to immigration issues and resources for immigrants.  I am honored to be sited on her website.  Thanks Susan.  Liz

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How to prepare a client for a psychological evaluation:

 1. It is helpful for the client to call the therapist directly prior to the evaluation meeting to have a conversation about what to expect during the evaluation.

2. Encourage your client to be as open and honest as they can during their evaluation. Downplaying the situation will work against them. This is the time to really be honest about emotional pain and hardship. Sometimes cultural factors can play into how comfortable a client feels about sharing their feelings. In these cases it is particularly important to prepare the client for the fact that the evaluator will be asking very personal questions about situations that may be painful to recall. 

3. Try to encourage the client to relax. This is not an exam, and there are no right or wrong answers. The meeting can actually often be helpful and cathartic to clients. I have had many clients thank me at the end of our session, feeling relieved to have had someone to listen emphatically to their story.

4. Ask your client to organize their thoughts a prior to the meeting. What is it that they want to make sure to get across? They can even write down some taking points. The interview will be directed by the therapist, but the client needs to make sure they don’t forget any key points.

5. If the client has previously seen a therapist or had any other mental health evaluations, it is helpful to obtain consent for the evaluator to contact the other clinician. If there are any written reports or documentation from another therapist, please have the client bring this along.

6. If the client has written their own statement, this can be useful to the clinician, but is not a necessity.

7. If translation is needed, advise the client to bring along someone they feel very comfortable sharing their most personal thoughts with. The questions in an evaluation are often of a very private nature.

8. Even if translation is not required, it sometimes makes a client feel more comfortable and open to have a close relative, spouse or friend with them for moral support. Even if this person sits in the waiting area, it is sometimes comforting for the client to know that someone they trust is right nearby.


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Why refer a client for a psychosocial evaluation?

Some immigration lawyers use psychological evaluations regularly with their clients.  Others have been slower to identify the strong benefits such evaluations provide.  Here are two (of many) reasons immigration lawyers prioritize clinicial evaluations with their clients:

1,  The impartial nature of hiring an outside source to provide an independent assessment of the situation.  This adds invaluable strength to the case. 

2.  The diagnostic ability of the therapist to confirm suspected mental health issues substantiates a client’s claims of suffering.

The top three types of cases immigration lawyers use evaluations for:

1.  Asylum.  A psychosocial evaluation is invaluable in determining the extent of trauma a client experienced in their country of origin, and the possible ongoing nature of the emotional impact on their current functioning.

2.  Domestic Abuse (VAWA).  A clinical evaluation is critical in assessing the existence and extent of abuse an immigrant experienced during their marriage to a U.S. citizen.  The evaluation is crucial in determining the emotional impact such abuse has caused the immigrant.

3.  Hardship.  An evaluation of family members of an immigrant facing deportation is necessary to show the possible negative impact such a move would have on these U.S. citizens.  These evaluations include an assessment of mental health as well as financial, vocational, educational and medical suffering family members may experience if their parent or spouse is forced to leave.

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