Writing effective clinical reports for refugee claimants

1. Writing effective clinical reports for refugee claimants Janet Cleveland, Ph.D. Psychologist and researcher Transcultural Research and Intervention Team McGill University Health Centre and Oppenheimer Chair of Public International Law McGill University

2. A refugee is a person who has serious reasons to fear that if sent back to her country of origin: 1. She would be persecuted because of: -ethnicity - nationality -religion -belonging to a particular social group (e.g., gender, sexual orientation), or -political opinions. OR 2. She would be exposed to: - a risk of torture - a risk of cruel or unusual treatment - a risk to her life • excluding ‘natural’ causes such as epidemics • excluding lack of access to health care AND Authorities in her country are unable/unwilling to protect her AND There is no region of her country where she would be safe

3. Proving a refugee claim Criterion: does the claimant meet the definition? Claimant must prove entitlement to refugee status • Claimant’s testimony • Documents (including clinical report) Claimant’s credibility is key

4. Main functions of reports • Ability to testify - functional impairment Effect of claimant’s cognitive or psychological problems on ability to understand proceedings and/or testify • Distress (usually) irrelevant unless causing functional impairment • Ways to minimize the person’s disadvantage • Designated representative • Procedural accommodations • Credibility assessment: take impairment into account 2.Consistency of symptoms with the story Are claimant’s symptoms consistent with alleged trauma (basis for refugee claim) 3.Adverse effects of return to country of origin

5. Guideline on Vulnerable Persons Procedural accommodations for “vulnerable persons” = Individuals whoseability to present their case before the Immigration and Refugee Board (IRB) is severely impaired = Individuals with significant: • memory or concentration problems • dementia or intellectual handicap • delusions • likelihood of becoming disorganized at hearing • inability to testify (coherently) linked to severe distress, physical disability, etc. • or similar impairments

6. Procedural accommodations Goal: to help the person overcome the difficulties limiting her ability to adequately present her case Examples • Priority scheduling (or delay) • Creating a more informal setting • Allowing claimant’s lawyer to proceed first • “Allowing any other procedural accommodation that may be reasonable in the circumstances” • “…the IRB will attempt to avoid traumatizing or re-traumatizing the vulnerable person” • See IRB Training Manual on Victims of Torture • Board usually does not question directly about traumatic event Discuss recommendations with lawyer

7. Designated representative Appointed if the person is: • Under 18, or • Unable to understand the proceedings • examples: dementia, delusions, intellectual handicap • more significant impairment than for recognition as a vulnerable person • explain that the person is unable to testify and should not be questioned

8. Clinical reports - content 8.3 Expert reports should mention: • Professional’s qualifications • Questions posed by counsel • Factual foundation underlying the opinion • self-reported symptoms • observed clinical signs • antecedent events: patient’s account • test results • Methodology (interview, tests) • Nature of treatment & effect on symptoms • Clinician’s role: assessment vs. treatment • Opinion about • the person’s condition [diagnosis] • the person’s ability to participate inthe hearing process • suggested procedural accommodations and reasons for suggestions

9. Style • Avoid jargon OR explain precise technical terms • Examples • Board: I agree that X is a "historian" … • « The claimant experienced flashback and aversive emotional arousal during the interview ».

10. IRB criticisms of clinical reports • Cookie cutter, cut-and-paste • Single brief assessment • Qualifications sometimes questioned • Based solely on the claimant’s word (self-report) • If claimant found not credible, Board may ignore the expert report • Claimant’s demeanour contradicts predictions • Opinion on merits of claim SO • Establish qualifications • Stay within your clinical expertise • Explain methodology • Be specific • Emphasize observed clinical signs • Emphasize objective test results • Explain plausibility of self-report symptoms • Emphasize functional impairment: probable impact on ability to testify

11. Qualifications: don’t be modest! • Current position • Institution (specialization if relevant) – team qualifications • Title and academic degree(s) • Other relevant training • Relevant clinical experience • Relevant teaching experience • Experience with similar individuals (e.g., refugees, rape survivors, persons of the claimant’s cultural group) • Relevant publications • MDs: psychiatric diagnoses? • Cut and paste (with minor adaptations)- update periodically

12. Methodology • Interviews: number, length, dates, period • Assessment or treatment? • Tests or other assessment methods • Relevance, validity, reliability • Write standardized description for non-specialists • Update periodically

13. Factual foundation - symptoms Self-reported symptoms (e.g., insomnia, pain) • Clinician cannot verify existence of symptoms • If person found not credible at hearing, Board will be sceptical • Explain clinical plausibility of symptoms, consistency with observed signs and general presentation

14. Factual foundation - signs Clinical signs • Directly observed by clinician • Not dependent on claimant’s truthfulness • Detailed description of clinical signs, e.g., scars, physical signs, demeanour, behaviour, expressed emotions (nonverbal & verbal), memory or concentration problems, etc. • Link with alleged trauma , e.g., « Y shook as he described being hit by soldiers » or « Z seemed confused and ashamed when she mentioned being raped »

15. Factual foundation - story • DO NOT describe the patient’s story at length • Include only facts essential to justify your opinion • DO NOT mention dates or similar details • Check consistency with PIF (Personal Information Form) Exception: A more detailed report is sometimes appropriate but only if requested and very carefully checked by lawyer (e.g., if complete inability to testify) Disclosure of new, relevant facts in therapy (e.g., rape) • Discuss with lawyer • Explain that facts were disclosed following (lengthy) process of establishing trust, etc. • Explain reasons for initial non-disclosure

16. Sexual orientation claims • Report concerns & actions consistent with claimed orientation (esp. current) • Over long period (if in therapy)

17. Formulations • Neutral, professional tone • « Z reported that [event occurred] » • NOT « [event occurred] » • « Y’s symptoms are consistent with [alleged events] » • NOT « Y’s symptoms are caused by [alleged events] » • DO NOT write « Z is clearly a genuine refugee » or « Z would make a fine citizen » • Do NOT write « X is an honest person » but you may write • « X answered my questions frankly »,or • « Over months of therapy, X repeatedly described [event, repeated nightmare, etc.] » or « I repeatedly observed [signs consistent with diagnosis/alleged trauma] »

18. Factual foundation – test results • Significance of results • Partly standardized, partly individualized • Compatibility with other symptoms and signs • Individualized

19. Opinion and recommendations • Diagnosis • Provide standardized annex explaining diagnosis • Consistency with alleged events • Focus: Functional impairment - ability to explain one’s story • Interaction of psych problems and sociocultural problems (e.g., illiteracy, isolation, language, etc.) • Probable difficulty testifying: predictions • Relevant behaviour observed, e.g., confusion, incoherence, numbing • Link to psychological or cognitive problems • Be very cautious • Explain the difficulty of predicting how each individual will respond in different contexts BUT be specific • Mentally incompetent vs. memory gaps vs. difficulty talking about certain events vs. difficulty concentrating

20. Opinion and recommendations (cont.) • Appointing a designated representative • Procedural accommodations • Late disclosure of trauma • Clinical plausibility in this specific case • Inconsistencies, contradictions, omissions • Possible link to clinical condition • Adverse effects of return to country of origin • Based on your clinical assessment • Limited relevance • « Compelling reasons » not to return person to country of origin despite changed circumstances • If severe, persistent trauma sequelae

21. HIV-related issues • Lack of access to health care in country of origin not grounds for refugee status • Risk of discriminatory refusal of care or major adverse health effects of severe stigmatization • May be relevant, but • Must be established by expert sources with direct knowledge of conditions in country of origin • Lack of access to health care, impact on family members, etc. relevant for Humanitarian and Compassionate application (H&C)