Psychiatric Evaluations of Asylum Seekers: It’s Both Ethical Practice and Advocacy, and That’s OK!
DEAR EDITOR:
Dr. Morgan, in the April issue of Psychiatry 2007 (Psychiatric Evaluations of Asylum Seekers: Is it Ethical Practice or Advocacy? pages 26 and 33), argues that psychiatrists should not engage in advocacy efforts on behalf of refugees seeking political asylum, noting that refugees’ claims of torture and maltreatment may be false, and that physicians should not engage in advocacy efforts, especially if those efforts may be based upon others’ false pretenses. If his position were correct, our recent review of asylum seekers’ outcomes may give him cause for concern. We recently conducted an analysis of 746 United States asylum seekers who, from 2000 through 2004, received legal representation, as well as corroborating medical or psychological evaluations provided by clinical volunteers with Physicians for Human Rights, a Nobel Prize-winning Human Rights Organization.
Among this population, the asylum grant rate was 89 percent, compared to a national average grant rate of 37 percent for the same period. Is it possible that this remarkable difference in grant rates was partly due to psychiatrists’ systematic, if unwitting, endorsement of fabrications and misrepresentations on behalf of the applicants?
It is possible, but unlikely. We psychiatrists use our clinical judgment to discern the presence of malingering, a condition to be considered for anyone who stands to gain considerably by being labeled ill. I have conducted psychiatric evaluations of asylum seekers for about a decade, and have provided training sessions to other clinical volunteers on behalf of Doctors of the World, another organization that evaluates asylum seekers. In these sessions, we review the possibility of malingering. However, none of the asylum seekers I have assessed since 1997 showed evidence of malingering. Specifically, they did not list as many symptoms as possible in order to be more convincing sufferers. Furthermore, they did not try to hide, as malingering patients do, areas of strength or resilience nor the absence of symptoms. Perhaps most conspicuously, many of them knew neither why their attorneys referred them to me nor what a psychiatrist actually does. This knowledge deficit should not be surprising because many refugees came from countries where few, if any, psychiatrists practice. Lack of clarity about the clinician precludes successful malingering.
Furthermore, Dr. Morgan’s assertion that doctors should not advocate is objectionable. The word “doctor” is derived from the Latin, docere, meaning to teach, and advocacy is a form of teaching. We advocate with our patients every day (e.g., to adhere to treatment recommendations), and our national organizations facilitate our advocacy efforts with legislators. Indeed, as physicians, our specialized knowledge of clinical medicine and a unique understanding of individual patients, perfectly positions us to advocate, and we have much to contribute to the legal process in individual cases, as well as to public policy debates on a wide range of issues.
In the case of refugee asylum cases, “advocacy” is essentially documenting the presence of psychiatric symptoms, our area of expertise, that may corroborate experiences reported by applicants. Symptoms of posttraumatic stress disorder, anxiety, depression, and somatic complaints are often associated with torture and maltreatment. Additionally, psychiatrists can help educate immigration judges and asylum officers about psychiatric findings, such as flat affect or poor memory due to dissociation, that may compromise the perception of credibility in the courtroom. As psychiatrists, we are uniquely qualified to serve in this educational role.
With regards,
Stuart L. Lustig, MD, MPH
Assistant Professor of Clinical Psychiatry, Director, Child and Adolescent Psychiatry Training Program, Langley Porter Psychiatric Institute, University of California, San Francisco
AUTHOR RESPONSE
DEAR EDITOR:
I appreciate Dr. Lustig’s comments about the asylum grant rates. They do underscore my point that the role of physicians’ input into the asylum-seeking process is a significant one and has a real impact on the outcome.
In my article, I pointed out that just because one engages in this process and has an impact does not mean that one is practicing valid medicine. As demonstrated by the errors committed by professinals in the “recovered abuse” cases, it behooves us when participating in the asylum-seeking process to begin with objective evidence of the index trauma that is independent of the self-report data. To evaluate a person for posttraumatic stress disorder (PTSD) in the absence of objective evidence is to erroneously use any reported PTSD symptoms as evidence for the veracity of the traumatic event reported.
Although Dr. Lustig sounds very sure that he is able to clinically detect malingered cases, I must respectfully point out the fact that at the present time there are no valid reliable tests for detecting malingered PTSD.
Although some researchers and clinicians have promoted the idea that one can detect malingered PTSD by using psychophysiology or by trying to suprise the patient and thereby provoke an “exaggerated startle” reaction, their views are not supported by the scientific evidence and misrepresent the complex (and contextual) nature of PTSD symptomatology. Put simply, many people with PTSD have neither exaggerated psychophysiologic responses nor an abnormal startle response, whereas many individuals can show increased physiological responses without having PTSD. With regard to the avoidance and numbing symptoms, there are no validated tests by which one can say the report of such symptoms is true or false. Further, I think it bears pointing out that even if psychiatrists were capable of objectively “verifying” PTSD symptoms per se, we would still be confronted with the challenge of actually linking the observed symptoms to the reported index-trauma event.
Physicians find many ways of defining what they believe it means to be a “doctor,” thereby justifying their actions. Many physicians feel it is within their role to express medical opinions that extend beyond what is actually known from evidence-based science.
Physicians who are comfortable with doing this should, in my opinion, learn more about the impact of 20th century, evidence-based approaches on the practice of medicine and psychiatry. The evidence is robust that we doctors often hold to methods and beliefs that are not supported when tested scientifically. Just because some psychiatrists who are engaged in asylum evalutions believe there is an “association” between the symptoms reported by an applicant and the reported index-trauma event does not mean there actually is a causal link between the two. Indeed—and this is a most basic statistical concept—one cannot determine causality from an observed association between two variables. Yet this is, essentially, what physicians are doing: They proffer an opinion of causality—that the trauma reported has caused the observed distress in the evaluee. Although some psychiatrists will object to this assertion and say they only indicate to the court that it is “possible” there is a link between the patient’s symptoms and the reported trauma, this is essentially a distinction without a difference. As noted in the data cited by Dr. Lustig, there are very large differences in outcome for asylum cases that include mental health evidence. It would be interesting to learn whether, and to what degree, such evaluations made it plain to the court that we have no scientific way of knowing if the reported connection is true or false. I suspect that none of the professionals who performed these evaluations articulated for the court the degree to which their conclusions may have differed had they not assumed, a priori, that asylum candidates are more likely to have been abused. Indeed, I wonder if any mental health professional performing such evaluations has seriously questioned why an asylum seeker who exhibits psychiatric symptoms from a reported trauma should be considered “more eligible” (or more “believable”) than one who does not exhibit such symptoms.
Finally, I should make clear that I am not saying it is unethical for physicians to be involved in advocacy endeavors at a general policy level. I raise the question about ethics when advocacy may be disguised as or influencing clinical practice.
With regards,
Charles “Andy” Morgan, III
Associate Professor of Psychiatry, Section of Law & Psychiatry, Research Affiliate, History of Medicine, Yale University School of Medicine, New Haven, CT
