Advancing Research on and Treatment of Dissociative Identity Disorder With People With Lived Experience.

Dissociative identity disorder is a posttraumatic, psychobiological syndrome that develops over time during childhood. Despite empirical evidence supporting the validity of this diagnosis and its relation to trauma, the disorder remains a misunderstood and stigmatized condition. This article highlights expert consensus guidelines and current empirical research on the treatment of dissociative identity disorder. In addition, the authors describe the Lived Experience Advisory Panel (LEAP), which was designed to leverage the expertise of individuals with dissociative identity disorder to combat stigma and improve research, clinical programming, professional education, and public outreach related to the disorder. This article also describes how LEAP members have partnered with other researchers to create new knowledge through participatory action research in order to advance equitable service provision and effect positive change.

Treatment of dissociative identity disorder: leveraging neurobiology to optimize success.

INTRODUCTION: Dissociative identity disorder (DID) is a treatable mental health condition that is associated with a range of psychobiological manifestations. However, historical controversy, modern day misunderstanding, and lack of professional education have prevented accurate treatment information from reaching most clinicians and patients. These obstacles also have slowed empirical efforts to improve treatment outcomes for people with DID. Emerging neurobiological findings in DID provide essential information that can be used to improve treatment outcomes. AREAS COVERED: In this narrative review, the authors discuss symptom characteristics of DID, including dissociative self-states. Current treatment approaches are described, focusing on empirically supported psychotherapeutic interventions for DID and pharmacological agents targeting dissociative symptoms in other conditions. Neurobiological correlates of DID are reviewed, including recent research aimed at identifying a neural signature of DID. EXPERT OPINION: Now is the time to move beyond historical controversy and focus on improving DID treatment availability and efficacy. Neurobiological findings could optimize treatment by reducing shame, aiding assessment, providing novel interventional brain targets and guiding novel pharmacologic and psychotherapeutic interventions. The inclusion of those with lived experience in the design, planning and interpretation of research investigations is another powerful way to improve health outcomes for those with DID.

The COVID-19 pandemic and its impact on health experiences of asylum seekers to the United States.

BACKGROUND: The COVID-19 pandemic exacerbated preexisting barriers to accessing healthcare and social services faced by asylum seekers to the United States. This study aimed to uncover the impact of the first year of the COVID-19 pandemic on asylum seekers, including socio-economic stressors and access to medical information, healthcare, and testing. METHOD: We conducted 15 semi-structured, in-depth interviews with adult asylum seekers to the U.S. and systematically analyzed the resulting transcripts using a consensual qualitative research approach. RESULTS: The transcripts yielded six domains: (1) knowledge and understanding of COVID-19; (2) attitudes and practices relating to COVID-19 precautions; (3) experience of COVID-19 symptoms; (4) current physical and mental health; (5) access to and interaction with health care; (6) discrimination based on asylum status. CONCLUSIONS: Although participants had knowledge about COVID-19's communicability and regularly used masks, their living conditions frequently hindered their ability to quarantine and isolate, and their lack of insurance was often a deterrent to them seeking medical care. Notably, immigration status was not a significant factor discouraging participants from seeking care during the pandemic. The findings build on existing knowledge about this community and may help define areas where support and services can be expanded in current and future pandemics.

Persecution and migration experiences of lesbian, gay, bisexual, transgender, queer/questioning, and other sexual and gender minority asylum seekers.

Lesbian, gay, bisexual, transgender, queer/questioning, and other sexual and gender minority (LGBTQ+) asylum seekers are exposed to high rates of persecution. This study aimed to identify the forms of ill treatment and the impact of these experiences on the mental health of 66 self-identified LGBTQ+ asylum seekers from 24 nations through the analysis of human rights program intakes, sworn declarations, and pro bono forensic psychological evaluation affidavits. The results indicate that participants experienced physical assault (92.4%), harassment and intimidation (84.8%), and sexual assault (56.1%). Psychological sequelae included symptoms of posttraumatic stress disorder (PTSD; 83.3%), depression (72.7%), and anxiety (57.6%). LGBTQ+ asylum seekers faced additional hazards upon arrival in the United States. Still, these asylum seekers experienced resilience as they leveraged internal and external support. The results can serve to inform clinical professionals about the range and impact of exposures to harm experienced by LGBTQ+ asylum seekers as well as possible strategies for support and advocacy for this diverse community.

Immigration Judges' Perceptionsof Telephonic and In-Person Forensic Mental Health Evaluations.

Clinicians affiliated with medical human rights programs throughout the United States perform forensic evaluations of asylum seekers. Much of the best practice literature reflects the perspectives of clinicians and attorneys, rather than the viewpoints of immigration judges who incorporate forensic reports into their decision-making. The purpose of this study was to assess former immigration judges' perspectives on forensic mental health evaluations of asylum seekers. We examined the factors that immigration judges use to assess the affidavits resulting from mental health evaluations and explored their attitudes toward telehealth evaluations. We conducted semistructured interviews in April and May 2020 with nine former judges and systematically analyzed them using consensual qualitative research methodology. Our findings were grouped in five domains: general preferences for affidavits; roles of affidavits in current legal climate; appraisal and comparison of sample affidavits; attitudes toward telephonic evaluations; and recommendations for telephonic evaluations. Forensic evaluators should consider the practice recommendations of judges, both for telephonic and in-person evaluations, which can bolster the usefulness of their evaluations in the adjudication process. To our knowledge, this is the first published study to incorporate immigration judges' perceptions of forensic mental health evaluations, and the first to assess judges' attitudes toward telephonic evaluations.

The impact of immigration detention on the health of asylum seekers during the COVID-19 pandemic.

COVID-19 disproportionately affects racial and ethnic minority groups as well as people in jails and immigration detention centers in the United States. Between April and August of 2020, the mean monthly COVID-19 case ratio for ICE detainees was 13.4 times that of the general U.S. population. This study aims to understand the experiences of detained asylum seekers during the pandemic and to provide insight into COVID-19's impact on this population's health. This qualitative study employed first-person, in-depth narratives obtained from 12 asylum seekers, all of whom were detained in immigration detention centers or prisons during the initial surge of the COVID-19 pandemic and were subsequently released. Detained asylum seekers reported inadequate medical care, obstacles to receiving care, an inability to social distance, poor hygiene, restricted movement, and a lack of infection control-- all which increased their risk of contracting and spreading COVID-19 and exacerbated health inequalities brought to the forefront by the pandemic. Advocating for improved disease prevention and screening, prompt access to health care and treatment, cohorting of infectious cases, and community alternatives to detention to decrease the detained immigrant population sizes are crucial to halt communicability of the virus and its subsequent morbidity and mortality in this vulnerable population.

Histories of pervasive gender-based violence in asylum-seeking women who have undergone female genital mutilation or cutting.

Few studies have described the broader experience of survivors of female genital mutilation or cutting (FGM/C) who have sought asylum in the United States. To gain a better understanding of their exposure to gender-based violence (GBV), the study was conducted to help uncover themes and patterns of co-occurring individual and community factors among women asylum seekers who experienced FGM/C before they arrived in the United States. Following a retrospective chart review of FGM/C cases seen in a human rights clinic, 35 women met the inclusion criteria. The constant comparative method (CCM) was used to develop themes derived from clients' personal declarations and physicians' affidavits. A qualitative analysis revealed extensive histories of violence-physical, psychological, and sexual-demonstrating that FGM/C is only part of a larger arc of violence. Key themes developed via CCM include the experience of FGM/C, cultural attitudes toward FGM/C, cultural attitudes toward women, the lack of agency felt by women, silence around experiences of GBV and the constant reinforcement of that silence, the role of education in women's lives, and acts of resistance and social support. Placing FGM/C within its cultural context allows for a better understanding of its role in society's broader subjugation of women and elucidates how these social structures are maintained. For health care and other service providers, the high frequency of multiple forms of violence and the ingrained nature of women's oppression indicate the need for trauma-informed care and services as well as accessible resources beyond those explicitly related to FGM/C.

Perspectives on Working with Immigrants Held in Detention Using Photovoice.

Those who work with immigrants in detention centers may be at increased risk of secondary trauma. This study used Photovoice to capture reflections on how the lives of volunteers are affected by their work on behalf of immigrant family detainees. Participants were recruited over a two-month period in 2018 from amongst the volunteers of a non-governmental organization that provides legal services to the detainees at one immigration detention center. Participants submitted photos and captions that explored their experiences with their work. Thirteen volunteers consented to participate and submitted 44 photos with captions to the project. Major themes included emotional challenges of the work, frustrations with the U.S. government, comparison of their experiences to those of their clients', and finding uplifting moments. Our findings regarding the significant emotional challenges of this work are of particular importance given the increasing coverage of immigration detention in the media and the increased interest in volunteer opportunities to support this population.

Patterns and evidence of human rights violations among US asylum seekers.

BACKGROUND: Asylum seekers report exposure to human rights violations associated with a range of psychological and medical sequelae. Clinical evaluators can provide forensic evaluations that document evidence associated with their reports of persecution. The aim of this study was to characterize the forms of abuse experienced by asylum seekers, the psychological consequences of abuse, and the frequency with which clinician-evaluators found evidence that corroborated asylum seekers' reports. METHOD: We completed a retrospective chart review of 121 asylum seekers who received pro bono medical-legal evaluations through a human rights program and analyzed data using the constant comparative method. RESULTS: Eighty-eight percent of the clients reported experiencing multiple human rights abuses. Ninety-one percent of the clients who received psychological evaluations presented with symptoms associated with depression, anxiety, or trauma and stressor-related disorders. Clinician-evaluators found physical or psychological evidence consistent with the clients' reports in 97% of cases. Forms, perpetrators, and psychological consequences of abuse varied significantly by gender and geographic region. DISCUSSION: Asylum seekers report diverse forms of persecution in their countries of origin that differ by gender and geographic region. Clinician-evaluators overwhelmingly found physical and psychological evidence consistent with the asylum seekers' accounts of persecution.

The Experiences of Minors Seeking Asylum in the United States: A Modified Consensual Qualitative Research Analysis.

Minors fleeing violence in their countries of origin constitute a significant portion of asylum seekers in the United States. Medical and mental health professionals provide continuity care services and offer pro bono forensic evaluations for this population to document evidence of human rights abuses and torture. The present study included a retrospective, qualitative chart review of deidentified personal declarations and clinician medico-legal affidavits associated with 36 asylum seekers under 21 years of age. Data were analyzed through a modified consensual qualified research (CQR-M) approach to identify patterns in these individuals' reports of persecution and assess health outcomes. Among the cases studied, violence by organized criminal groups (47.2%), family-based violence (44.4%), and gender-based violence (44.4%) were the most commonly cited reasons minors sought asylum. Evaluators documented a wide range of psychological sequelae: 80.5% of minors presented with clinically significant symptoms associated with trauma- and stressor-related disorders, depression, and/or anxiety at the time of their applications for asylum. Of note, almost three-quarters of the minors reported current enrollment in school and two-thirds reported factors related to adaptive functioning. Despite reported exposure to premigratory and migratory trauma, postmigratory stressors, and psychological sequelae related to their experiences of violence, these young asylum seekers exhibited signs of resilience and a range of health-promoting strengths.

Medical Student Involvement in a Human Rights Program: Impact on Student Development and Career Vision.

Background: There is consensus among many medical school deans that exposure to human rights is a necessary component of physician training [78], however little is known about the impact of engagement in human rights programs on students' personal and professional development [1516171819202122232425262728]. Objective: This study aimed to examine medical students' experiences in the Mount Sinai Human Rights Program (MSHRP), their motivations for involvement, and the possible influence of engagement on their professional identities, personal growth, and career choices. Methods: Through semi-structured interviews, this qualitative study gathered the experiences of 15 fourth year and recently graduated medical students who participated in the comprehensive training, research, and direct service opportunities provided by the program. Responses were coded using a content analysis approach. Findings: The results of this research highlight the motivations behind students' involvement in a medical human rights program, as well as the challenges they experienced engaging with this work. The study captured students' perceptions of the role of the program on their personal growth, clinical skills, and career vision. Nearly all the students interviewed indicated they developed important, clinically applicable skills that enhanced their traditional medical education. Students indicated that their participation directly influenced their professional identities and future career directions by reinforcing previous interests in human rights and social justice work, impacting medical specialty and residency program selections and fostering commitment to working with immigrant populations. Conclusions: The results of this study indicate that longitudinal involvement with the MSHRP contributed to the acquisition of important clinical skills that were not otherwise attained in students' early medical education. Findings suggest that there is significant opportunity for clinical and leadership development outside the traditional preclinical and clinical setting, and that exposure to human rights education shapes students' professional identities and career paths. Finally, the findings highlight the essential role of human rights and social justice in medical education.

A toolkit for building medical programs for asylum seekers: Resources from the Mount Sinai Human Rights Program.

Forced migration has reached a peak worldwide and healthcare professionals and trainees are increasingly volunteering with medical human rights programs. The Mount Sinai Human Rights Program (MSHRP) provides pro bono forensic medical, gynecological, and psychological evaluations to document evidence of human rights abuses experienced by asylum seekers. From 2015 through 2018, MSHRP refined its workflow and processes to facilitate the coordination of 305 forensic asylum evaluations and 117 continuity care referrals. Here, we present a toolkit including data management tools, guiding questions to consider when establishing or expanding an asylum clinic, and key challenges and solutions from MSHRP's experience in service delivery. Building on existing descriptions of asylum clinics, this paper provides specific resources intended to help new programs hone their models to meet the increasing demand for forensic medical evaluations of asylum seekers and provide appropriate continuity care.

Addressing the need for forensic psychological evaluations of asylum seekers: The potential role of the general practitioner.

Asylum seekers who have survived torture and other abuses may experience a wide range of psychological symptoms associated with depression, anxiety, and posttraumatic stress disorder. During the asylum process, attorneys might refer their clients to clinicians who document these psychological sequelae of human rights violations. However, the need for forensic psychological evaluations exceeds the number of mental health clinicians available to provide these assessments. It has been suggested that primary care physicians, professionals who already play essential roles in the identification and treatment of mental health issues, may be able to conduct these evaluations. Yet, there is little empirical knowledge of what prior training and clinical experiences support mental health and non-mental health professionals who engage in this work, and what is needed to prepare general practitioners to provide forensic psychological evaluations to asylum seekers. This pilot study found non-mental health practitioners with experience in psychological forensic evaluations reached a level of confidence in conducting evaluations of asylum seekers comparable to general mental health practitioners. The study also identified clinicians' perceptions of training that supports them in their forensic psychological evaluations, their professional development needs, and the potential for general practitioners to leverage their current skill sets in this work.

Characterization of the mental health of immigrant children separated from their mothers at the U.S.-Mexico border.

Immigrant children who faced forced separation from their parents may be at heightened risk of developing mental health disorders, including depression, post-traumatic stress disorder (PTSD), and anxiety disorders. This cross-sectional study assessed the mental health of children being held in U.S. immigration detention who had been previously separated from their mothers. We interviewed 73 mothers about their eldest child age 5-17 using the Parent-Report version of the Strengths and Difficulties Questionnaire (SDQ). Among these children, many had elevated scores for emotional problems (49%), peer problems (21%), and total difficulties (15%). Male children demonstrated significantly higher rates of abnormal peer problems compared to females. Younger children (age 5-11 years) also demonstrated significantly higher rates of abnormal conduct problems, hyperactivity, and total difficulties. Scores did not differ significantly based on length of separation. Results reveal that children who had been separated from their parents experience high levels of mental health distress, which are especially high in younger children. Regardless of length of separation, these children would benefit from comprehensive mental health treatment with a culturally-responsive and trauma-informed lens.

Mental health of children held at a United States immigration detention center.

Rationale; Children held in immigration detention may be at risk for mental health disorders due to the impacts of pre-migration factors, including exposure to violence, their displacement from their home countries, their journey between countries, and the conditions of their detention. Limited research has demonstrated high rates of clinical depression, post-traumatic stress disorder (PTSD), and anxiety disorders among detained immigrant children. Objective; In this cross-sectional study, we assessed the mental health of children held at a US immigration detention center over two months in mid-2018. Method; We interviewed 425 mothers about their eldest child age 4-17 using the Parent-Report Strengths and Difficulties Questionnaire (SDQ). A subset of 150 children age ≥9 completed the UCLA Post-Traumatic Stress Disorder Reaction Index (PTSD-RI). Results; Among the 425 children studied, many demonstrated elevated scores for emotional problems (32%), peer problems (14%) and total difficulties (10%) on the SDQ. Younger children (age 4-8 years) demonstrated more difficulties associated with conduct, hyperactivity, and total difficulties (all p < 0.001) compared to older children. Children who had been forcibly separated from their mothers demonstrated significantly more emotional problems (49%, p = 0.003) and total difficulties (15%, p = 0.015) than those who had never been separated. Of the 150 children who completed the PTSD-RI, 17% had a probable diagnosis of PTSD. In all, nearly half (44%) of all children demonstrated at least one emotional or behavioral concern. Conclusions; These data demonstrate that children being held in immigration detention experience high levels of mental health distress. Results suggest they would benefit from more comprehensive mental health screening and release into the community, as well as culturally-responsive and trauma-informed mental health care.

Experiences of gender-based violence in women asylum seekers from Honduras, El Salvador and Guatemala.

INTRODUCTION: Every year, thousands of women flee gender-based violence in Honduras, El Salvador, and Guatemala (sometimes collectively referred to as the Northern Triangle) in an attempt to seek asylum in the United States. Once in the United States, their legal teams may refer them for a psychological evaluation as part of their application for asylum. Licensed clinicians conduct in-depth interviews in order to document the psychological impact of the reported human rights violations. METHOD: Using archival de-identified data from a human rights program, this study gathered the experiences of gender-based violence reported by 70 asylum-seeking women from Honduras, El Salvador, and Guatemala who participated in pro bono psychological evaluation. Descriptive data were analyzed using a modified consensual qualitative research (CQR-M) method. RESULTS: These asylum seekers reported exposure to systemic violence, including severe intimate partner violence, as well as physical and sexual assaults, and threats of death by organized criminal groups in their communities. Additionally, over a third of women reported experiences of violence during their migration. The majority of asylum seekers endorsed symptoms associated with anxiety (80%) and depression (91%), as well as trauma-and stressor-related symptoms (80%). DISCUSSION: The results of this study elucidate the many forms of gender-based violence experienced by women in this region, the physical and psychological sequelae of this persecution, and the systemic forces that prevent them from remaining in their countries of origin. The research results also highlight the potential impact of trauma on the women's ability to testify effectively during asylum legal hearings, elucidate factors that may contribute to their resilience in light of the human rights violations they survived, and suggest implications for clinical practice.

Supporting Asylum Seekers: Clinician Experiences of Documenting Human Rights Violations Through Forensic Psychological Evaluation.

The United States permits foreign nationals to apply for asylum if they have experienced persecution or have a fear of future persecution. In order to meet the criteria for persecution, the harm inflicted upon the asylum seeker does not need to be or have been physical and can include psychological sequelae. In an effort to document persecution, lawyers seek the assistance of health professionals when preparing their clients' asylum applications. Mental health professionals work to corroborate psychological evidence of the asylum seeker's report of ill treatment through evaluation and presentation of their findings in the form of legal affidavits. This study gathered the experiences of 15 mental health clinicians who conduct forensic psychological evaluations and document the impact of torture and other human rights violations on asylum seekers. We analyzed the resulting interview transcripts using a consensual qualitative research (CQR) approach. The results of the study highlight challenges associated with this work, suggest recommendations for training, and encourage advocacy endeavors by mental health professionals who provide these services.