The Role of Mental Health Professionals in Human Rights

By Joanne Ahola, M.D,. Flavio Casoy, M.D., and Alisa Gutman, M.D., Ph.D.,

Formerly man had only a body and a soul. Now he needs a passport as well for without it he will not be treated like a human being—Stefan Zweig

Ms. L. fled her home country for the United States, fearing a second arrest and further torture because of her activities as a democracy activist. She faced additional persecution as a member of an ethnic minority and because of her sexual orientation. The Legal Aid attorney working on her asylum request referred her for a mental health evaluation based on symptoms of anxiety and depression she reported.

December 2023 marked the 75th anniversary of the adoption of the 1948 Universal Declaration of Human Rights by the United Nations General Assembly. It is the foundation of all human rights treaties and conventions that have followed, many of which carry the power of binding international law.

Yet, in this time when there is deep suffering around the world, the Universal Declaration remains more a call to action than a fait accompli.

Article 5 of the Universal Declaration states: “No one shall be subjected to torture or cruel, inhuman or degrading treatment or punishment.” This right is upheld by the 1966 International Covenant on Civil and Political Rights and the 1984 Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment.

Article 14 Of the Universal Declaration of Human Rights then goes on to state: “Everyone has the right to seek and enjoy in other countries asylum from persecution.” This makes the United States one of the countries obligated to provide prompt and effective redress—asylum or other forms of relief—to survivors of torture and other human rights harms who have fled their home countries seeking safety.

What is the role of mental health professionals in the protection of human rights?

Individuals fleeing persecution most often arrive without objectively verifiable proof of the harm they have endured. However, medical evidence is regarded as evidence in a court of law.

For example, survivors of torture may bear physical scars consistent with or typical of torture. There are women whose gynecological exam findings are consistent with female genital cutting/mutilation as well as histories attesting to such acts. Other asylum seekers may have burn scars from electrodes used when they were tortured.

However, acute physical trauma often does not leave long-lasting physical evidence, and those who inflict torture often learn ways to do so without leaving scars. Consequently, the only scars that can be found on medical exams may be psychological.

In addition, as being granted asylum requires proving a well-founded fear of future persecution, the burden of psychological evaluations often lies in documenting past persecution. Consequently, forensic psychiatric evaluations of asylum seekers can provide evidence in federal immigration courts that can transform an asylum seeker’s life from one mired in a traumatic past to one poised toward a safer future.

Research shows that when an asylum seeker’s account is corroborated by a healthcare professional’s written affidavit or testimony, that person is more than twice as likely (approximately 90 percent) to receive protection as those without an expert clinical evaluation.

Towards that end, we are writing as professionals who are trained to:

• Take detailed personal histories
• Perform mental status examinations
• Assess the effects of trauma
• Evaluate clinical symptoms and signs
• Document findings
• Make psychiatric diagnoses of survivors of torture and other human rights abuses

Further, in contrast to medical and mental health professionals’ assumptions and trepidation around courtrooms, expert testimony is often deeply appreciated by immigration judges, who are the decision-makers and who are heavily burdened by thousands of cases. Mental health professionals can evaluate, document, and testify about the consequences of persecution on an asylum seeker’s mental state. They are often called upon to educate the adjudicators on the consequences of torture and other ill-treatment.

It should be noted that all physicians, psychologists, and clinical social workers already have the skills required to perform this type of trauma evaluation and can supplement their bread-and-butter interview skills with a forensic asylum evaluation course that teaches the basics of human rights law and how to conduct the clinical evaluation in this special context. Evaluations are guided by the Manual on the Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (the "Istanbul Protocol"), a 2001 U.N. document updated in 2022, written by a consortium of experts.

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Trainings are accessible at over 25 asylum clinics in medical schools around the United States. Physicians for Human Rights and other international NGOs have developed volunteer asylum networks to interface with attorneys and can provide support and education. More recently, a coalition of asylum clinicians under the auspices of the Asylum Medicine Training Initiative (AMTI) developed state-of-the-art online training that healthcare professionals of all specialties and clinical backgrounds can access to learn how to perform forensic examinations within their clinical area. Conducting just a few evaluations a year can have an enormous impact.

A mental health professional conducted a complete evaluation of Ms. L., including her life history, her report of what she had endured, the symptoms she reported suffering, and a mental status examination. She met diagnostic criteria for post-traumatic stress disorder and major depressive disorder. Her symptoms and clinical signs were consistent with her story of persecution and torture.

Obstacles and challenges

The need for professionals to do evaluations is even more acute in a world where the number of people fleeing war, violence, persecution, violence based on gender, sexual orientation, and/or gender identity, unmitigated climate disruption, and other harms increases daily.

The role of professionals becomes more imperative as countries of the global north create obstacles in their immigration systems. Consequently, beyond harms already suffered in their home countries, refugees and forced migrants may face further stress when travel corridors are blocked and then encounter yearslong delays as they wait for their legal cases to be heard.

Ms. L. waited almost two years for her case to be heard. Asylum was granted.

The rewards

As volunteer asylum evaluators, we have met many survivors of persecution. Although it is emotionally challenging to evaluate asylum seekers, it also is extremely rewarding volunteer work. These have been close encounters with the deepest of suffering, the resilience of the human spirit, and the great joy we experience when someone is granted the opportunity to live in safety and build a new, freer life.

Establishing safety is the first step of healing for those who have suffered unspeakable atrocities. It has been a privilege to have the professional capacity to help those survivors tell their stories. As mental health professionals, it is an extension of the work done every day with patients. As citizens of the world, it is a way to use clinical skills to contribute to the greater good.

Joanne Ahola, M.D., and Flavio Casoy, M.D., are members of GAP’s LGBTQ+ Committee; Alisa Gutman, M.D., Ph.D., a member of GAP’s Committee on Disasters, Trauma and Global Health