Psychoanalytic activism and immigrants

The author discusses mental health evaluations of political refugees seeking asylum and the role of the psychoanalyst
By Barry Cohen, PhD

Several years ago, I read a notice on my analytic institute’s email list stating that the Human Rights Clinic of an organization called Doctors of the World (since re-named Healthright International) was seeking mental health professionals for the task of assessing people seeking political asylum in the United States. The individuals were identified as survivors of persecution and other human rights violations in their countries of origin. Mental health professionals were being recruited to conduct psychological evaluations in order to document the impact of the persecution and to prepare affidavits which could be presented as expert testimony for the immigrationprocess.

Needing More

The notice arrived at a time when I was eager to add meaningful pro bono activity to my life. Years earlier I had made the transition from institution-based clinical work to a rewarding private practice. I had completed my analytic training and continued meaningful involvement at my institute. I had developed a full and fulfilling professional life planning and attending conferences, engaging in peer supervision groups, seeking opportunities for continuing my education and developing my clinical skills.

But for a number of years I had also been preoccupied with the task of generating income. I had reached the stage in my life where my needs (and desires), as well as those of my family, were growing, and I felt justified and entitled to increase my income, based on my (countless, if not endless) years of training, and a sense that I had developed a fair amount of skill in my profession.

Yet there was something uncomfortable and unsettling about the efforts to maximize my income. Although I maintained a sliding scale for my practice and charged patients a wide range of fees according to their ability to pay, I noticed that I would register a slightly different feeling (happier? more excited? more motivated?) when someone would refer me a full fee patient. Also, I observed an upward “creep” to the minimum fee that I would accept, and felt some shame at the thought that I might ultimately provide services to a population representing only a narrow band of the socioeconomic spectrum (maybe not solely the “one percent,” but certainly not 100 percent either).

A few years earlier, in response to these same qualms, I had searched for an international volunteer experience that would allow me to use my professional skills, and had considered Doctors Without Borders. However their requirement of a six month commitment was beyond the limits of what I could undertake. I settled on the layperson’s experience of home building for Habitat for Humanity in Guatemala, hoping that the mission would take me far outside of my comfort zone, satisfy my desire to provide services to an impoverished population, and to connect with a culture which bore little in common with that of the upper west side of Manhattan. I found the mundane physical labor surprisingly fulfilling, and the experience was significantly enhanced by the opportunity to get to know and work alongside the family whose home was being built. But at the same time I felt a certain degree of envy for two of my Habitat “teammates,” a physician and a nurse, who were able to use their medical skills to provide additional and valuable services to the families.

Serving a Traumatized Population

It was in this context, feeling a desire to use my professional skills in the interest of helping an under-served and traumatized population, that I sought training to conduct assessments for seekers of political asylum. I was eager for exposure to people from countries I had never visited, and knew that the contact would provide me with the opportunity to learn of a range of human experiences far beyond what I usually saw in my private practice. I was intrigued by the idea of providing an unambiguously tangible service which would have direct and measurable impact on the clients’ prospects for a political, and literal, sanctuary. For their assessment, the applicants come to my office. They are usually accompanied by an interpreter, as relatively few of the asylum seekers I have seen speak English. My task is to establish rapport, obtain a relevant psycho-social history and elicit a historical narrative of their experiences in their native land. I assess the psychological impact of these experiences, identify the presence of any diagnosable psychiatric disorders, and make a reasonable judgment regarding the likelihood that the disorders were causally linked to their history of persecution. Finally, I assess the likely impact, if any, on the applicants’ psychological health if their application for asylum is denied and they are forced to return to their country of origin.


The clients have come from Cameroon, Congo, Kosovo, Montenegro, the Ivory Coast, Pakistan, Guinea, Tibet and the Sudan. The interviews have been translated back and forth between English, French, Albanian, Darfurian Arabic and Tibetan. Applicants have described victimization due to their ethnicity, religion, political party, family relationships, refusal of conscription, and mistaken identity. Their narratives have included both personal accounts of persecution, and stories of witnessing the victimization of loved ones. They have told stories of harassment and threats, beatings, kidnapping, rapes, denial of medical treatment, imprisonment, shootings, and torture. At times they bear, and offer to reveal, physical scars. Their stories of flight from their countries of origin included harrowing tales of ventures into the unknown and uncertain, narrow escapes, multiple legs of a journey by every means of transportation imaginable, and the fortuitous help of friends, families, strangers and hired agents along the way. For most of the people I’ve met, their lives subsequent to their arrival in the U.S. have been characterized by subsistence living and the isolated experience of battling the psychological sequelae of their past traumas. Often they have suffered fear and uncertainty regarding loved ones left behind, and a terror about the prospect of being denied legal status in this country. I have found the work to be professionally challenging and emotionally difficult.


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