Berkeley Talks transcript: Psychologist Sita Patel and clinicians discuss where health and human rights meet

Intro: Thank you for joining us for another podcast from the Commonwealth Club of California.

Rajni Dronamraju: Good evening and welcome to tonight’s meeting of the Commonwealth Club, the place where you’re in the know. I’m Rajni Dronamraju and I’m your chair for today’s program. Today’s program is generously supported by Northern California Grantmakers Funder Network on Trauma and Resilience. Our program is entitled “A Global Perspective on Healing After Trauma: Where Health and Human Rights Meet.” There are a greater number of forcibly displaced people in the world today than in any time since the end of World War II and the Bay Area has welcomed many of these individuals. Today, we’ll hear directly from clinicians working with Bay Area refugees, asylum seekers and others on how they are restoring health and awakening hope in response to human rights abuses.

It’s now my pleasure to introduce today’s panelists. Dr. Nick Nelson is medical director at Highland Hospital Human Rights Clinic in Oakland and an advisory board member of Partnerships for Trauma Recovery. He is also associate program director of internal medicine residency program at Highland Hospital. Dr. Nelson supervises and trains resident physicians and provides forensic medical evaluations and primary care for asylum-seekers and survivors of torture.  He has been recognized for his expertise by the International Rescue Committee which awarded him the honor of exemplary health partner.

Dr. Sita Patel is an associate professor of clinical psychology at Palo Alto University and also a board member of Partnerships for Trauma Recovery. Dr. Patel brings her clinical teaching and research experience to support the partnerships research outreach and advocacy initiatives. She is a clinical and community psychologist with research interest in global mental health culture and context as they relate to immigrant mental health. She is also the director of culture, community and global mental health research and her work uses mixed methods and approaches to study acculturation stress, psychological, social and academic adjustment and access to treatment for mental illness among immigrants and minority populations.  

Dr. Annika Sridharan is Founder and Clinical Director of training and partnerships at Partnerships for Trauma Recovery. Dr. Sridharan is a licensed clinical psychologist and social worker with over 20 years of domestic and international experience in global mental health with migrants and survivors of human rights abuses. Dr. Sridharan has lived and worked in Africa, Europe, Latin America and North America, providing psychological and psychosocial care for refugees and asylum-seekers fleeing war, torture, gender-based violence and other forms of persecution.  Prior to co-founding Partnerships for Trauma Recovery she developed and led the center for well-being at the International Rescue Committee of Northern California in Oakland. And finally moderating tonight’s program will be Katie Hafner, a journalist who writes about healthcare for the New York Times. Ms. Hafner has published six books of nonfiction covering a wide range of topics including German reunification, the pianist Glenn Gould, computer hackers and the history of the Internet. She is currently working on a novel. Please welcome all of our panelists as I turn the program over to Katie Hafner.

Katie Hafner: Welcome everyone and welcome to what promises to be a very thought-provoking not entirely light evening.  We’ll try to throw in some lightness. Thank you all three of you. It’s really amazing that you’re all up here together.  We have three incredible experts on the subject of trauma and I have to say we had a phone call beforehand, during which we were discussing what we’d be talking about tonight. And I said, you know what that I think of it as sort of a continuum of trauma. I mean, there are people on this end which would include me, I careen from first world problem the first world problem every day, you know, I had a bad — my stylist got my hair color wrong and I had a bad Lyft ride over here and he took the wrong route.  And then there’s what you all work with and write about and research.

But what I’d like to do if we get one thing done tonight what I’d like to do is be able to connect for us as sort of inner first world shells to be able to connect to what it is that you work on.  And to be able to generalize and extrapolate all the way into the human condition — well forget about the problems I had with my hair but you know what I’m saying. So what I’d like to do is lay the foundation, a foundational question and maybe I’ll start with you Annika of how it is that you even define trauma.

Annika Sridharan: Yeah, I like the way that you’re trying to see if we can connect what we’re gonna talk about in terms of the folks that we work with who had to flee violence and our experiences that we have in the context here.  Because as you say, there really is a spectrum of experiences of experiencing harm and fear and danger that most of us experience at some point in our life. So trauma is about experiences that are frightening that are terrifying where a person either experiences harm or fears that harm will happen.  And that might be physical harm, psychological harm, psychic harm, fear of dying, fear of losing a loved one. Any of those situations can be traumatizing for a person. And situations can be traumatizing because the environment is dangerous or because other human beings have made it dangerous. So the people that we’re gonna be talking about mostly tonight people who fled their countries are fleeing because of mostly interpersonal harm.  So other human beings that have hurt them or threaten to hurt them or their families or their communities.

Katie Hafner: And you call it interpersonal.

Annika Sridharan: Interpersonal trauma, that’s one of the ways of saying it where it’s human beings hurting other human beings, which is really important because if one experiences trauma from a natural situation in the environment the danger for example, the fire that’s happening right now.  It has a different impact. It’s very terrifying but it’s not the same thing of feeling that some other human is doing the harm. So the interpersonal trauma really devastates the feeling of what it is to be human and relationships with other human. So that’s kind of a key component of what we’re gonna be talking about tonight.  And we can go more into detail about what are the kinds of harms that people experience when they’re fleeing their countries and it varies according to region and according to country and what are the patterns of things that happen in certain places, but that’s kind of the key.

Katie Hafner: Sita or Nick do you have anything to add to that?

Sita Patel: Yeah, I just add that I think, you know, there’s the experience that one has in the experiences of violence and the experience interpersonally that people are having. And then there’s sort of the lasting effects or consequences on your life and on your environment and I think both of those things really go hand-in-hand. So we can’t talk about on those individual instances without thinking about the broader systemic context. And a lot of the violence that the people that we’ve worked with are operating within with the context that they’re operating within are ones in which there isn’t a lot of hope for rebuilding. And so, you know, just as an example, some of the work that I’ve been fortunate to be involved in has been in the Central African Republic and this is a country where more than 600,000 people have been internally displaced something like one in three children has experienced severe trauma.  And the people who are living and trying to go about their daily lives there, there isn’t a lot of system and structure in which they can rebuild.

And I’ll just share one quote from somebody in a focus group that that we worked with. He said, this crisis will just strip him of his ambitions because he cannot be ambitious anymore because how can you have ambitions when you go to bed, you’re shaking and asking whether you will make it till tomorrow. Living in the constant fear of being killed it takes away every ambition. And with no ambition you’re just like dead. And so again I think it’s not only the fear and the experience of the violence, but then how can you even think about rebuilding. And if we all think about our lives, you know, we need to have something that we’re looking forward to. We need to have some structure in our lives we need to have whether at school or work relationships. So when these terrible events happen and then there is no system or structure in which to rebuild I think that’s also very long lastingly traumatizing.

Katie Hafner: What I hear you saying is, it can’t be divorced from the human condition. And also one thing we tend to forget I think is the lingering effects of trauma because if you take someone out of the traumatic situation it doesn’t mean that they’re cured, right, because it digs deep.

Sita Patel: Well, there are folks who were taken out of the immediate traumatic situation. And then there are people who are still in a context where there is ongoing violence and where there is not hope in the same way that may be some of the people who are able to then come to this or other countries are able to rebuild a life.

Katie Hafner: And Nick did you want to add to that?

Nick Nelson: Yeah, I mean just to say that like I think individually, you can kind of break it up roughly into psychological trauma, physical trauma, which is a medical doctors a lot of what I see and then psychosomatic trauma where psychological distress is expressed primarily through physical symptoms. And then I think also it’s good to think about it chronologically in terms of — I mean, so I mainly see people who have been displaced and ended up in the Bay Area. And so they have these arcs that take them from the place where the index trauma that caused them to leave occurred through the active migration and then to the active assimilation in the U.S.

So just to tell a story, a few weeks ago I saw a guy who was from an East African country that has a pretty repressive government that he had fallen afoul of and was in danger of imprisonment and torture. So he fled the country and the only way that worked out for him to leave Africa was via the Middle East and then to Brazil. So he then went on foot and by bus from Brazil, through Peru, through Colombia up through all of Central America and to the Southern American border where he presented himself as an asylum seeker. So you can imagine there’s the stuff that happened to him in the country that he came from to begin with. Then on the way, he was on this incredibly dangerous and terrifying migration runaway he recalls, you know, seeing dead bodies by the side of the road. And on which he experienced non-interpersonal trauma in the form of like flash floods that nearly killed him in the Panamanian jungle and venomous snakes that he had to avoid before arriving here where he was detained by immigration authorities and therefore, you know, in conditions which at least to him were somewhat reminiscent of the conditions that he was trying to get away from in the first place. So you can see there’s the sort of chronological arc as well as the taxonomy within an individual.

Katie Hafner: In the green room you were talking about someone with joint pain. I’d be interested in having you tell me.

Nick Nelson: Yeah, that was just to illustrate the sort of psychosomatic side of things. So this is a patient who Annika and I have collaborated in caring for who’s from a Middle Eastern country where he was pretty extensively tortured. His whole story is pretty interesting from the point of view of psychosomatic symptoms. So he presented to my hospital which is a general county hospital complaining of weight loss of like 90 pounds over six months and abdominal pain. And all the internists and emergency room doctors who saw him thought exactly what I would have thought if I’d been the person in the room which is okay he’s got cancer, what kind of cancer is it.

Katie Hafner: Really. That was your first… 

Nick Nelson: Yeah. So just medically. So he had all the tests you can — or about 80 percent of the tests that you can imagine and was discharged essentially without a diagnosis. He came back two months later with the same presentation and he had the other 20 percent of the tests that you can imagine. And he was again discharged without a diagnosis. He came back to the clinic I think six times before someone asked him the right question and elicited this history of torture, at which point it became apparent that all of the physical things that he was experiencing were directly related to the types of torture that happened to him not indexically like none of those, the physical harms, had been caused by the mechanics of the torture, but psychologically. So his fear of food had to do with one aspect of how he was tortured — that was the thing that resulted in his weight loss and abdominal pain. And these days it’s kind of shifted for him and now he’s mainly experiencing joint pain. I know for a fact that medically there’s nothing wrong with his joints but that’s the kind of defining feature of his life is this since that all movement is painful, I don’t know if you wanna say anything about his case in particular about psychosomatic.

Annika Sridharan: Sure. I think it’s interesting what you’re saying about how there’s an overlap where there is a psychological, emotional component and the physical component how sometimes they overlap and they can be expressed differently in different individuals and also across cultures. So in certain cultural context when people are not so used to talking about their emotions and their feelings or when they’ve experienced decades of repression they don’t talk to each other. So there’s a very powerful silencing impact of the violence that’s going on at the political repression. So people have not had opportunities to talk about how they feel. So they may feel it in their body instead, they may be feeling terrible headaches, joint pain it can manifest in so many ways. And it kind of goes back to the point you were making about how it lasts in the body and in the mind sometimes for many, many years. Especially if there’s not an opportunity to actually have a healing process and have a processing somehow of what happened with another human being. So that can last for a very long time in different forms.

Katie Hafner: Yeah, I’d like to interject with them. So with my healthcare reporter’s hat on, one thing I’ve been hearing about a lot recently is this trend toward what’s called trauma informed healthcare. And where you’re taking care of patients with really with the whole person in mind. And so when that patient presents in the emergency room with what seems like classic advanced stage cancer symptoms, then once you start getting a real history and understand the psychological component and the history and trauma in the patient’s history then it can really help. And it’s a significant and I think a very positive move in healthcare and yet that’s in our culture. That’s in our, you know, super highly developed culture versus what you were saying, which is that a lot of cultures and a lot of contexts they just don’t talk, they stay silent. So it’s even harder. It must make it even harder to understand what’s going on.

Annika, I wanted to ask you to distinguish between trauma, and this is a distinction I don’t even know what it is, between trauma and human rights abuses.

Annika Sridharan: So I think it can also overlap a little bit like this being diagram we’ve been sort of mentioning before. So human rights abuses have to do with lack of certain freedoms. The United Nations designed the charter human rights charter in 1948, after World War II, and there are 30 basic human rights that were sort of discussed as basic things that humans should be able to benefit from. Some of them are freedom of equality, freedom from discrimination and harm, freedom of movement that also includes freedom to be able to seek asylum when one is persecuted. So, many freedoms that are definitely not upheld in the world.

So, sometimes human rights abuses may not necessarily include a trauma. And I was talking to one of the clients that we’re working with Partnerships for Trauma Recovery. And he was speaking about how no one is actually allowed to leave the country. You need to get an exit visa. And in order to get an exit visa, you have to have completed your obligatory military service and the military service is very terrible situation in some of the countries in the Horn of Africa. So he is not able to have the freedom of movement from his country, but that particular thing was not a trauma in itself because he wasn’t harmed directly. He was not allowed to leave. He managed to find a way to leave but certain human rights violations don’t necessarily entail a trauma. But many of the folks that we work with have experienced human rights violations that are also trauma, such as imprisonment, such as atrocities that happened during war, such as a child abuse and forced recruitment into gangs in Central America for example. All of those things are also human rights abuses. So sometimes they overlap, but sometimes they don’t necessarily.

Katie Hafner: Anyone else on that?

Sita Patel: I think I’ll just add to that. As you were talking about these sort of first world problems that we can have.  And another way to think about that spectrum is that we are exposed to events which we may call a stressor. And if that stressor is something where we appraise it or think about it as being threatening to our life then that can be characterized as a trauma.

Katie Hafner: When you say “we” and when you say “stressor,” I mean let’s just be concrete for a minute, who does that include?

Sita Patel: I mean any of us can be. So the piece that I want to add is that there’s an appraisal or a thinking about it that happened. So we might all of us in this room be exposed to the same kind of let’s say discrimination act, and half of us might think about that is threatening in some way psychologically and so have a response to that that may lead to depression or other kinds of symptoms and the other half of us might not have that appraisal. So I think within the spectrum of events that we’re talking about there’s also this room for appraising where thinking about its impact on your life.

Katie Hafner: So let’s actually zero in on the Bay Area, specifically and being very aware, I don’t know if you have any numbers to throw at me on the people who are in the Bay Area now who have fled terrible situations and crises and life-threatening or both.

Nick Nelson: There have been at least three good epidemiological studies looking at the prevalence of torture as defined by the UN in immigrant populations in coastal cities in the United States. And the way they do these studies is just to take people who were — the only inclusion criteria is that you were born in another country and then to do a structured interview with them and determine whether or not they’ve been subjected to something that meets the legal definition of torture. And in those three studies, the prevalence varied from between 4 percent and 11 percent. This is in foreign-born people not otherwise specified to that include Swedish people, French people, English people, people with a relatively low likelihood of having been tortured previously. So that just kind of brings some like you were saying the necessity of a trauma-informed approach, particularly in more diverse communities like ours.

Because who knew, I certainly didn’t, no one taught me in medical school that the prevalence of torture among foreign-born people is 1 in 20. So there’s, yeah, I’d say that and then respecting specific populations, it’s extremely hard to say like so, for example, I was down at the Alameda County Public Health Department a little while ago and talking to some of their epidemiologists about our local community of Guatemalan speakers of a language called Mam, which is a Mayan language, it’s completely unrelated to Spanish and a lot of people who speak it don’t speak Spanish at all despite having last names like Pablo or Perez.

And they were sort of appealing to me as a clinician saying, what do you know about how many of these people are living in Oakland because we’re trying to do a needs assessment for the community. And we have absolutely no idea what the community looks like, you know, we don’t know how many of them there are. We don’t know where they live. We don’t know where they go to church. So, particularly in diverse communities like this, there’s specific populations that as clinicians and researchers we really become familiar with but it’s also, you know, a dynamic thing.

Katie Hafner: Did you find numbers?

Annika Sridharan: I wanted to piggyback a tiny bit on that just to talk about the distinction between refugees and asylum seekers and why it may be so difficult to find numbers for example for the indigenous Guatemalans who are living in Oakland in the Bay Area. So, refugees are resettled or have been determined as refugees already before they come so they have a legal status. So it’s possible to count how many people have come in — there’s a whole system that allows people to come in and they are easy to, well it’s easy to know how many numbers there are.

So the statistic that I have is that there’ve been over 3 million refugees in the U.S. since 1980, but there are more who came before, but they weren’t counted. And in the Bay Area, the statistic is 175,000 since 1975. However, for asylum seekers, it’s a lot more difficult to find numbers and actually we were chatting and frantically trying to find the numbers, but most asylum seekers don’t have legal status and so they’re actually not accounted for any way. They may be considered immigrants, but nobody necessarily knows that they’re asylum seekers. So a lot of the Guatemalans who live here for example are waiting for their cases to be adjudicated and maybe not even know yet that they can apply for asylum-related to the genocide that happened in Guatemala and the violence that continues there.

Nick Nelson: Well interestingly I think the connection there that most people will make, I think, is with undocumented immigration but that also happens with legal immigration. So most of the East African people who are seeking asylum in Alameda and San Francisco counties come legally on tourist visas or on educational visas.

Katie Hafner: When we were emailing back and forth in the last few days, one number one of you sent me was 44,000 people every day are forced to flee their home due to violence and persecution. This represents one person every two seconds which says a lot. And so it makes me think that when we have for instance, you know, a Lyft driver or someone who’s in the convenience store with us or is helping us in a convenience store, that could be that person.  And just because they’re here in this context of, you know, “Are the Dodgers gonna lose,” that’s not what they’re thinking about, right. There must be some who have this sense of just being constantly kind of on guard, either consciously or unconsciously. And little do we know that it gets back to this point of how do we know how trauma is carried and that’s because of the work you do, you understand it much better than we do. So it’s something to be aware of as if we don’t have enough to think about, to be aware of, as we go about our daily lives.

Annika Sridharan: Could I just add one more thing I think to those important statistics that you just mentioned. One of the numbers that’s very staggering to me is that there are now 68 and a half million people who are forcibly displaced in the world some of them are internally displaced, so there in their own country, for example, Syrians who remained in Syria or in the Democratic Republic of Congo and haven’t been able to actually cross the border. About 25 million of them are refugees and 3 million of them are asylum seekers but we don’t have right numbers on that. But only 1 percent of all the people who were forced to flee their home or their country are able to actually make it to a country that is more stable and more democratic and has access to services like the United States. So, 1 percent of all the people. That always is really shocking to me. So the folks that we are able to see are even less than that 1 percent, like such a tiny fraction of the numbers of people who are suffering.

Nick Nelson: I was just gonna interject to say that I literally had that experience two months ago of walking out of my house going around the corner to 711 and see a young man behind the counter who had been in my clinic two weeks earlier for an evaluation.

Katie Hafner: We did not coordinate this.  Really?

Nick Nelson: Yeah.

Katie Hafner: And wait, how did you even know, because he’d been in your clinic?

Nick Nelson: Well, I recognized him. I spent two hours interviewing him about the torture that he had undergone during compulsory military service in East Africa.

Katie Hafner: Did he recognize you?

Nick Nelson: Unfortunately, he didn’t recognize me because I was wearing a tank top and shorts and it would have been embarrassing, right.

Katie Hafner: Oh my goodness. So there we go. So we’re getting some amazing, just from glancing at these questions, from the audience. So, I’d like to jump in right away with a few of these. I’m doing a quick triage on them but one that rises straight to the top is there seems to be some confusion. What is the definition of asylum?

Annika Sridharan: It’s a great question. So, I don’t think I’d probably do a great job of giving the exact definition, but seeking asylum basically means seeking protection from harm. So when somebody crosses a border into another country and asks for permission to stay because for some certain reasons that’s too dangerous for them to return. So there are certain laws around us the United Nations has defined what groups of people are able to ask for protection across borders and what qualifies as persecution. So I actually haven’t reviewed this exactly so I may not be exact so please forgive me. But for example, if one belongs to a certain social group so certain ethnic groups, religious groups or even social groups such as women who can show that in their country they don’t have protections and they don’t have the rights and they can’t go to the police when they have somebody is violent with them or they have a problem. They can come to a new country and say I can’t go back it’s too dangerous for me to go back can I please stay. So people who come to the U.S. and seek asylum ask for protection ask to be able to stay and they have to write a whole long story with an attorney about all the things that happened to them. And then it’s determined whether they are really part of the social group and whether they’ve been persecuted in certain ways on certain grounds and is it really correct and credible that they are in danger if they go home. So there’s an assessment process a legal assessment process about their credibility.

Katie Hafner: Has that changed during the Trump administration?

Annika Sridharan: Yes.

Katie Hafner: Just asking.

Annika Sridharan: It is changing very much, yeah.

Katie Hafner: Rapidly and radically?

Nick Nelson: So, one thing I’d throw in there is that so they have to — they see that, you know, they work with their attorney to prepare this account of what’s happened to them and then they present that to immigration officials. But another thing that can happen is that they can be evaluated by a clinician and that can be a nurse, a nurse practitioner, social worker, psychologist, the doctor who has specific expertise in the aftermath of trauma, whether it’s physical or psychological. And that person can prepare a forensic report and act as an expert witness to the court which is something that both of us do. And the statistics on that are pretty striking. Throughout the United States the overall — these are statistics that are kept by Physicians for Human Rights. The overall grant rate for people who don’t have a medical or psychological evaluation is something like 40 percent and for people who do, it’s over 80 percent. And I think that just speaks to the way that objectifying the aftermath of trauma and describing it in clinical language can get across to the people who are hearing a story that may be confusing or sometimes incoherent or inflected by psychological symptom mythology, exactly what’s happened to this person.

Katie Hafner: Back to my Trump administration question. What’s happened?

Sita Patel: Well, I think this idea of petitioning for staying in a place because returning to your home is not safe has shifted. So, fleeing violence, you know, used to be very clearly sufficient grounds for applying for asylum and that’s changing recently. So, I think it’s still the sands are sort of still shifting. But the other piece that I’m thinking about is as you were talking about this long process that people have to go through in order to really like prove and advocate for themselves is in and of itself very traumatic. And if you can imagine, you’ve had all of these experiences that you’d either rather forget, which isn’t necessarily the best approach, but you need to be handled in a very careful way with clinicians or reservists. And then you have people who don’t have that trauma-informed approach engaging with you in a legal system that’s very complex so that can just be very re-traumatizing.  And I think, you know, you mentioned trauma-informed healthcare and I think there really needs to be a lot of movement towards trauma-informed legal care. So that it’s not dependent upon only the smaller percentage of people who have that medical and psychological evaluation who can make it that far in terms of advocating for themselves.

Annika Sridharan: Can I quickly say something about the situation in the U.S. also varies hugely from state to state and office to office. So we’re really lucky here in San Francisco, the grant rates for asylum are in this percent. In some states like Texas and Georgia it’s 2 percent grant rate.

Katie Hafner: So, when you say we’re lucky here in San Francisco, is that the state of California or just…

Annika Sridharan: The whole state of California. I think there are only two asylum offices — in San Francisco and Los Angeles. So, we’re lucky to be in the state, but things are changing. It is getting harder and I think we’ve heard that many asylum officers have left.

Katie Hafner: You’ve heard that what?

Annika Sridharan: Many of the asylum officers in San Francisco office have left because it’s just becoming too difficult. Where there’s sort of a shift from being a service to try to assess people’s need for protection to more of a law enforcement and rejection situation, even in San Francisco.

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Nick Nelson: And then also I think that thing that Jeff Sessions did the…

Katie Hafner: Which thing that Jeff Sessions did?

Nick Nelson: So it had previously been established by the Ninth Circuit Court, if I remember correctly, that in countries where misogyny appears to be established and women’s rights are not generally respected and they don’t generally receive attention or credibility in the court system. That simply being a woman is grounds for seeking asylum so that counts as membership in a particular social group. And I remember doing asylum evaluations before that precedent was established even in the San Francisco area. And it was very difficult because you would see women who had undergone decades of domestic violence, which had been reported to the police numerous times, who have done absolutely nothing about it who are applying for asylum on those grounds who would be rejected on legal grounds, not on the grounds that they undergone the trauma, but on the grounds that the trauma didn’t count as a ground for asylum.  

Then this precedent was set and it completely changed the way that the courts behave and I found that these women who predominantly are coming at least to my clinic from Central America had much less trouble being granted asylum. And Jeff Sessions recently said that neither domestic violence nor gang violence should generally be considered an appropriate grounds for seeking asylum. And that obviously puts this huge population of people again most of whom are from Central America, coincidentally, in a very difficult and dangerous position with respect to the courts.

Katie Hafner: Well, we’ll see how his successor does on that. So speaking of women, here’s another question from the audience, which is a really good one. There are many women in several African countries subjected to the trauma of potential or actual female genital mutilation. Have you worked with these women, and can they seek asylum for this if they are able to escape?

Nick Nelson: Should I take this one? Yeah, we have a wonderful nurse practitioner in our clinic who sees — actually we have a nurse practitioner and a doctor in our clinic who see most of the FGM cases, FGM stands for female genital mutilation, cases that we got. And actually, this is one of easier ways to get asylum in the United States. Obviously, you know, although it’s normal in some cultures, it’s the practice that I think most of us respond pretty viscerally to. The thing about it is that the anatomical changes that it produces can’t be caused by anything else.

So you may have been beaten severely under circumstances that meet the UN definition of torture in the country that you came from and have scars or marks associated with that, but of course this could have been caused by a variety of other forms of blunt trauma that aren’t torture and so your account isn’t intrinsically credible because you have the markings. But if you had FGM, there’s nothing else that causes that and so the evaluations that we do for other kinds of trauma are often, you know, 10, 12, 15 pages long. But for FGM, it’s usually just a single page saying, I’m a doctor and this happened, stamp, you know. So, yeah, you can absolutely seek asylum on those grounds and it’s fairly easy to get.

Katie Hafner: Good. That’s good to hear. Here’s one: What must occur, speaking of trauma-informed healthcare, what must occur for care providers to take a trauma-informed approach to better understand psychosomatic symptoms so that patients in need of help don’t get sent away, especially women of color, who are already not always taken seriously by healthcare providers? That’s a heavy question. I promise the next one will be light, but go ahead.

Sita Patel: I think it makes me think about the discussions we were having around how do we train clinicians and I use that word broadly —medical, psychological, social work — how do we train people who are on the front lines working with these populations to be what we might call now culturally humble. And I think this is such an important construct and, you know, we’ve for years been talking about cultural competence in the field and cultural humility is sort of a new perspective where we have to enter into any clinical or research or even systemic, like two groups working together, interaction with the sense of humility in which we are not the experts necessarily on what the person has experienced, but we are co-creating and co-learning from each other. And I think that sort of to me speaks to that question around having to go in and ask questions and be open to learning from the person who you are there to help and treat or understand.

Annika Sridharan: I’m thinking a little bit also about what you mentioned like in terms of knowing what to ask. So it’s really important to learn about the types of experiences that people had so that we know what to ask and that’s the first step is to know what kinds of questions to ask about someone’s life. To understand the complexity of what they might be bringing to the encounter, but also be able to hear what they have to say. And that’s difficult because when people have very upsetting difficult, painful stories it’s difficult to witness their upset and it’s also difficult in ourself to have the feelings that we have. So there needs to be a process of learning how to actually bear that, to be able to ask it and hear it.

Katie Hafner: Nick, you look like you wanted to jump in.

Nick Nelson: Yeah, I mean I think just another thing to bring up is that in these epidemiological studies looking at prevalence of torture in primary care. If you identify people who have been tortured and you ask them whether their doctor knows about this history, most of them will say no. And when you ask them why, most of them will say that it’s because the doctor didn’t ask about it. And so kind of like you said, I think there’s, you know, obviously like living in the Bay Area just this of random example, I have become intimately familiar with the mechanics of forced conscription in Eritrea because I see a very large number of Eritrean men between the ages of 20 and 40 who’ve been through. So I know what the usual things that happened to them or the places that they go and what usually happens to them there. But you don’t need to necessarily know all that in order to identify these histories, you just have to ask.

Sita Patel: And I’ll just add to that that even if you do ask, sometimes you won’t hear an answer that necessarily leads to a certain kind of psychological treatment. Like we did a whole series of interviews with recently arrived teenagers from Central America who are at a couple of really wonderful schools in the Bay Area part of the Internationals Network for Public Schools. So Oakland and San Francisco international high schools are dedicated to new recently arrived immigrant teens. So we did these series of interviews and we would hear about their experiences going, let’s say, for days without food and water as they came here, you know, walking on their own, a lot of them were unaccompanied minors. And then we would ask questions like have you ever felt scared and they would say no. And we think, well, you just described a series of events and again that comes back to this idea of an appraisal. Maybe it might be that they’re thinking one, that it’s so normal among their peer group to have had these experiences that they’re not sort of scary in the way that we might ascribe that label. Or two, they don’t want to tell me, you know, that’s not a dialogue they want to have with us. So I think there’s, one, asking the kinds of questions to get at the information and the experiences and then there’s, two, understanding that even with those questions there may be lots of barriers, stigma and other kinds of things that get in the way of people really discussing them.

Katie Hafner: Well, have you actually ever homed in on something like the question of have you ever been scared and they say no and you know objectively they must’ve been scared because of the events. Have you ever actually drilled really deep and worked on that very question and how you phrase it?

Sita Patel: Yeah, and that comes back I think to the idea of adjusting our work to be culturally competent to think about the language that we use.  And also to allow people to allow the experiences themselves to speak in a way. So somebody doesn’t necessarily need to say I have felt scared in order to deserve and benefit from the kinds of treatments that clinicians can offer.

Katie Hafner: You wanted to say something.

Annika Sridharan: I did also want to say sort of the ties and to so you have to learn how to interact with someone in a way that helps them feel safer and it may take time it may take a lot of time. And I think we can probably all relate to that there are certain things we might not want to tell someone right away, but the more the person is skilled at being able to help us feel comfortable and safe, the more likely we are to be able to reveal things that are difficult. So that’s part of the trauma informed care as well.

Katie Hafner: So this is a good way to segue into this next little portion I’d like to get to which is the healing process and what it takes first of all to train clinicians to be sort of globally minded and get out of our kind of ethnocentric culture centric mindset. You’ve done work on this, right?

Sita Patel: Yeah, so I teach at Palo Alto University we think a lot about how to train globally minded clinicians and researchers. As I said, the idea of cultural humility is one really important piece. And I think I’ll just share an example, we were doing this program in the Central African Republic where we were involved in training a group of community leaders to carry out some psychosocial intervention. And so our role was the very small researcher role and then there were a lot of other people who were involved. And I remember this one moment where the facilitator was trying to teach this group of community leaders who came to do the work of delivering psychosocial intervention and healing to folks there. So they were describing the experience of what it is to be an active listener and they drew this great picture on the board and the picture had the face with these really big ears and really big eyes and a really little mouth. And it was such a cute picture it’s like a big mouse or something but the facilitator modeled a number of times what they were talking about.

So when you’re trying to have somebody open up and relay their experiences to say less to listen more to watch to be an active listener. They were trying to teach this group these skills and then they have the group do these role-plays. And each time they did the role-play, the person who was supposed to be the active listener had so much to say, like you shouldn’t do this and why did you, why did this happen and it was kind of alarming to us like why are they not getting this. And then finally the facilitator asked what’s going on here like why do you keep saying so much, don’t you see this picture.

And the person said, “Well, in our culture it would be so rude if somebody were to share this difficult experience and you weren’t to say anything.” So I always think about that, it’s like we can’t go in and just assume as globally minded clinicians that our ideas of what it is to be a psychotherapist or researcher or to even gather information and engage with people fit that context and fit that culture. And even in this setting where these people had come to learn these skills and to deliver them in their country, there was this gap. So I think we can’t go into any context without assuming that there are lots and lots of gaps in understanding and that we have to be very open to learning about this.

Katie Hafner: Does the problem ever just feel too big, I mean, just hearing you say this it just feels so intractable in a way or you wouldn’t be doing this is why I do what I do, I just write about it and you actually work on it, right.

Nick Nelson: Sita, you had a quote on the slides that you sent me at the end of it that said something to the effect of like you’re not obligated to finish the work but neither are you allowed to relinquish it. Does this ring a bell?

Sita Patel: No.

Nick Nelson: Go over your slides.

Sita Patel: I forget.

Nick Nelson: But it’s a great quote. I mean, and I just think like that’s, you know, I mean, none of us have the capacity to fix any of these problems in their totality, you know, but like we all have the capacity to add to the body of knowledge that helps people take care of people in these situations and to take care of the people in front of us.

Katie Hafner: To take care of the people in front of us that’s a good way of putting it.  Nick, yes.

Nick Nelson: Just to say something about globally minded clinician part of it, I think like, we’re sort of lucky to be on the region that we’re in and I think all of us are lucky to be associated with the institutions that we are because women they really need is understanding of the scope and gravity of these problems at the higher levels of organizational administrations so that you get support for educational issues like this. You know, you need medical school administrators who understand that trauma-informed care is a critical part of medical care or psychology school administrators and you need clinic directors who are supportive of the work that you do in these kinds of places, so that everybody is now exclusively focused on the bottom line, because spending an appropriate amount of time to develop a kind of rapport that Annika is talking about is not cost-effective, you know, from a sort of healthcare industry point of view.

Katie Hafner: So Annika you look like you wanted to say something.

Annika Sridharan: I did. I sort of wanted to respond to your question about like how do you — how daunting is it and how do you manage to keep doing it. I mean, I think we talk about this a lot at PTR and with our students that we also work with. It’s so rewarding, also, just to be able to contribute even to one person’s life and in some ways I think it’s because people have gone through so much, they also often respond even faster to the intervention. So we can really witness people recovering and healing in ways that are incredibly satisfying I think and help with the sort of daunting mess of the whole situation. I was thinking of maybe talking about one situation with a woman who came to see us recently. Is this an okay time to do that?

Katie Hafner: Absolutely.

Annika Sridharan: So this summer we had a client, a woman referred from Highland actually, we’ve collaborated on her care and she was completely alone. She was staying in an apartment with two people from her country. She is from West African Francophone country and she fled LGBT persecution. But she has endured a lifetime of different kinds of traumas which include from the beginning of physical abuse in childhood and then FGM at age 12, which killed her sister and then a forced marriage at age 16 that included domestic violence and rape, and then she was in a relationship with a woman and that was discovered and so she was taken to the police and beaten and tortured multiple times because of this. And then her father was imprisoned because of her identity and tortured and died as a result of that. And so her entire life was just incredibly painful.

So when she came for the first time to our clinic, she was so depressed that she just really couldn’t stop crying. She would just lie down. We have some coaches, she would lie on the couch and cry and cry and cry and cry for the first meetings. She also didn’t have any food. She also had medical concerns and pain. So we try to work with her sort of from the basic thing of getting her some groceries and some food, talking with the providers at Highland to understand what was going on with her health to help her understand what was happening that actually she was afraid she had cancer. She did not have cancer. We referred her to our psychiatrist. She started taking antidepressants to also help her sleep. And literally within three or four weeks this woman looked like a different person. Of course, she was still very sad and she was still very traumatized, but she was no longer crying all the time, she could speak. She came to one of our community gatherings. She was able to interact with other people. And the psychiatrist saw her after three weeks, I think, and was just astounded. This is the same woman like she had a twinkle in her eye and it’s like she was half dead and suddenly she came alive. So I think that that illustrates a little bit why it’s possible to do this work because actually, you can really see the impact and it really helps to be able to bear it.

Katie Hafner: So this is a related question from the audience. Does the general community have any responsibility to help refugees feel welcome and heard?

Sita Patel: It’s a great question. I think we’d all say yes, enthusiastically yes. Yeah, we were thinking something — we were having dialogue a little bit about that kind of question and one of the things that I think we’ve already said is just become aware of who your neighbor is and who you’re sitting next to, and who you’re interacting with. And if 30 percent of our Bay Area population is foreign-born and then we know the statistics around the kinds of life trajectories that people from particular countries have very likely had, then we need to know that the people sitting next to us have perhaps experienced some of these things. And I think that’s the number one responsibility is just to be aware and then now that you both — because well, in my opinion, you know, we really have to support the institutions that are on the front lines of doing this work. So whether that’s clinics like partnerships for trauma recovery or schools like Oakland and San Francisco International High School, these are like the — especially, you know, thinking about kids that these are the first-line places and the settings that they’re in every day and these teachers and administrators and counselors are doing really, really amazing work to welcome and create a place where people can rebuild their lives.

And so that component of hope that is perhaps not present for people in a context or country where there isn’t a system and an infrastructure in which to rebuild, in a place like the Bay Area, there is the potential for that. And so I think as citizens to support the people who are doing those frontline efforts in whatever ways we can whether that’s through time or funding or whatever it might be is really essential.

Nick Nelson: Yeah, I tell you, I mean, if this is something that you’re really passionate about as a community member without specific training in medicine or psychology, there’s also an amazing range of things you can do like, for example, when the ICE contract at the Contra Costa jail closed, there were 60 or 70 detainees there who were all gonna be transferred to Arizona and Hawaii and away from their families and away from their attorneys. And there was a huge groundswell of community members who went and just helped navigate bail paperwork at the jail, which a lot of these people couldn’t do because they couldn’t read English, for example, or didn’t have a lawyer or whatever. So when things like that come up, you know, even just being an American citizen who is a native English speaker and understands how to fill out a form can be an enormous service.

Katie Hafner: Here’s a question. Is there a connection between addiction, substance abuse and/or the opioid crisis and trauma, and can addiction be, for instance, a psychosomatic expression of trauma? Everyone’s nodding. For the radio audience.

Nick Nelson: Well, I can tell a story about that, about a patient whom I saw recently. So I was doing an evaluation of a patient who was in detention in a local jail and what happened was she had been arrested for a DUI and then she had served her time for DUI. And when she was released from criminal detention, she was immediately picked up by immigration and then put in more or less in indefinite ICE detention while her case was being processed.

And as a result, she was taken away from her autistic 9-year-old and moved about 600 miles to the south. And when I talked to her when I got — she had a  history of gender-based violence trauma in her home country and then during migration, she had been kidnapped, imprisoned and sexually exploited. And it was very clear from talking to her that the primary reason that she used alcohol under any circumstances was as a form of self-medication for extreme and paralyzing anxiety which was obviously a manifestation of the trauma she had experienced.

So, I mean, it’s a very complicated nexus but in that case, it was extremely simple. It was like you have never seen a mental health professional receive any psychotherapy or had access to any of the medications that can help people with anxiety and depression, so you’re drinking because it kind of works, at least it makes you feel better than you do normally and that’s what puts you in this specific situation that you’re in.

Katie Hafner: Annika. Did you…

Annika Sridharan: I think, you know, one of the ideas is that sometimes people use substances to help themselves with their feelings, overwhelming feelings or inability to sleep, anxiety, sadness. So, people are using substances to help themselves feel better and it causes other problems. And so when you help them address those other problems that is no longer needed. We had a client for example, also, who was using drinking to actually try to sleep because he had such terrible insomnia. And as soon as we started working with him and he got antidepressants and started sleeping, he completely left the alcohol.

Katie Hafner: And that’s another way in which, you know, this speaks to the human condition the way we self-medicate and the continuum applies in so many ways. What are the conditions, and I’m thinking that the person who asked this question wants to know specific conditions that immigrants and asylum seekers experience while waiting for admittance, and how long does the process take. You talked about how long it takes a little bit but the actual specific conditions.

Sita Patel: I can speak a little to — like I said, a lot of the work that I do is with unaccompanied minor adolescents who are enrolled in schools in the Bay Area. And so we were talking about, you know, what are some facts and figures that might be helpful to have us understand the numbers of people who are coming here. So, just as an example, there were 50,000 unaccompanied children who are apprehended at the Southwest border. So, those are the folks who were actually apprehended and this is in 2018, 107,000 families apprehended, both of those reflected 21 percent and 42 percent increase between 2017 and 2018. So, unaccompanied minors who came to the Bay Area in 2018 — almost 1500 — so there are so many kids and families who are coming to the Bay Area.

The process between being apprehended at the border and actually enrolling in one of these schools or in another school in the Bay Area can take months and years. So a lot of interviews that we did with kids, you know, they’ve just gone through all of these kinds of experiences that you both spoke about and then their first point of contact when they come into this country is essentially imprisonment. And the way that they described those circumstances really are very extreme in terms of lack of food and safety, being separated from their siblings. So if it’s a boy and a girl who come together or different ages, being moved around three or four different detention centers, so there’s a very long and very protracted experience for kids who come unaccompanied for basically trying to find a sponsor which might be a relative who can take them. But it takes a very, very long time, and that time in between is one where essentially they are re-traumatized in not knowing what will happen and having these really, you know, sort of ongoing terrible experiences.

Annika Sridharan: Sort of connecting back to what Nick had said earlier on about how long it can take, so for people who are not apprehended, who don’t necessarily come through the border or who make it through the border and are not apprehended and not kept in detention, people once they apply can be many, many years before they have either an asylum interview or immigration court hearing.

Katie Hafner: Many, many years.

Annika Sridharan: Many, many years. Yeah, four years now the wait is for people. So during this time they’re able to — six months after they have applied for asylum, they’re able to get a work permit so they’re able to work. And people are able to get in California emergency Medi-Cal, so a little bit of medical coverage, but no other kind of assistance. So they’re basically totally on their own to survive without legal status and without any services. If people have first interview at the asylum office and then are denied asylum, they’re referred to immigration court. And it can be a process that lasts 10 to 15 years. And only then do they even have the hope of perhaps reuniting with their children. So many parents had to leave their children, so they are separated from their children for decades.

Katie Hafner: Nick, did you want to…

Nick Nelson: Yeah, I mean, just to say that — I mean, even for people who aren’t in detention, I mean, maybe especially for people who aren’t in detention because their cases take a lot longer, it’s really hard to overstate how difficult it is to begin the process of recovery when you remain uncertain about whether or not you’re gonna be returned to the place that you were traumatized.

Katie Hafner: Exactly.

Annika Sridharan: There’s no safety, basically.

Katie Hafner: There’s no safety. Alright. Here’s one that’s close to my heart. How does the media cover these issues and is there enough coverage on trauma in a global sense? Anyone want to tackle that? 

Annika Sridharan: The one thing I struggle with a lot with the media is that I don’t feel that it’s highlighted enough what people have actually gone through. And there is not sufficient distinction between general immigrants in the world versus people who are fleeing and forcibly displaced. Most people are not choosing to leave their homes. Most people are not choosing to come here. They are coming here because they don’t have other options. And I don’t feel like that’s very clearly discussed, the actual real conditions. I struggle with that.

Nick Nelson: I don’t want to get too political on another person’s stage, but I think one thing that’s not covered much is the involvement of the United States and the causes that are, you know, the reasons that people are fleeing the countries that they’re coming from. Like, I mean, I have a Yemeni patient who fled from the war there, which we’ve been involved in. He also cannot visit his ailing mother in Saudi Arabia because if he does, he won’t be able to come back because he’s from one of the countries that are on the travel ban. And I think, you know, the situation that prevails in Central America and in the Northern Triangle has a lot to do with the war on drugs and the way that drugs have been prevalent in America and the way that, you know, the way the domestic market for that works. I’d like to see more in-depth coverage in the media of the actual ideology of the circumstances that people are fleeing.

Sita Patel: I think I’d love to see more around what helps people to recover. So you asked the question: How do people heal from this and what’s frustrating? There are ways that people can heal and there’s evidence around interventions and there are lived experiences of people who are in the front lines as clinicians and teachers and running programs. And so, you know, often there are these stories that we hear in the media or statistics or numbers, but there isn’t as much about what can be done and I think if there’s more about that, then there’s more sort of potential to advocate for increasing those interventions and services.

Katie Hafner: Would you like my editor’s email address? I think these are, yeah, these are all great points. I think one of the — just chiming in as a member of the media — I think that there’s a very, it’s hard to get, it actually is hard to get an editor’s attention when you’re not in crisis mode. And then to devote resources to, what might even be a series, on the healing process or training, you know, globally informed clinicians that’s, you know, that gets very — it’s kind of a difficult sell, I think, unless you have a super enlightened and devoted media outlet and they’re out there. They’re definitely out there. So I promise that we would get to a more optimistic note and it’s only taken us 61 minutes. And you’ve all told me that there is hope and so let’s talk about that. Okay.

Nick Nelson: I mean, you know, I don’t know. I think that — I still think there’s substance in the American dream as it relates to immigrants, you know what I mean. You see people, you hear the conditions that prevail in the countries that people are fleeing and it’s unimaginable, you know, I mean, I literally can’t imagine a state in this country where I would be genuinely worried that a bunch of thugs are gonna break down my door at two in the morning and take me away from my children and I would never see them again. And that’s the country, those are the countries that all these patients that I care for live in and when they’re here and, especially when they’re granted asylum, they’re not in those circumstances anymore and the way that people are able to — I think, you know, just being removed from the source of your trauma and receiving psychotherapy is a really important intervention, but being in our society that is even now open and governmental rule of law and Democratic and multicultural is an extraordinary thing for people. I just lost a patient actually because, not in a bad way, I just lost a patient because he called me up to tell me that he was going to Texas to be a truck driver and the way he said it was like, I’m going off to seek my fortune, you know, and I was like, don’t go to Texas, man, stay in California.

But yeah, you know, I think there’s still a huge potential for people to grow and heal and blossom in our society.

Annika Sridharan: I find it a little easier to have hope sort of on the one-on-one individual level or small group levels. I feel like it’s harder when you think globally about humanity in general. But I think that the resilience of human beings and the strength of human beings to recover and to still have a sparkle, like that woman, how does she still have a sense of humor and smile. And I think that if we’re able to engage and actually meet people and be kind and try to attend to these things, I think there is a lot of hope. The question is how do we create a situation where more of us are able to do that and more of this is possible, because I think we can recover and we can do better and we can reduce violence. But how do we get to enough mass to actually start changing things.

Sita Patel: I was also thinking about resilience and I think, I’m gonna think again for us about resilient systems and sort of social ecologies in which people can grow and develop. And there really are so many wonderful settings that people might land in and grow and recover, and again I’m just thinking about the international network schools but they really are healing places. So in addition to having one-on-one clinical encounters, there’s the potential for a lot of the kids that we work with, unaccompanied minors from Central America to be in a school that is healing. And there’s so many creative programs there like this San Francisco school just last year changed their whole curriculum structure so that kids who go to the school can also work because they were having so many kids drop out because they were either going to school and then working at night and coming back on no sleep to go to school and that wasn’t viable, or they were working during school hours. And so they said, let’s change the school system to meet the needs of our population. And I think there’s a lot of examples of that where systems can change to meet the needs.

Katie Hafner: Where was this?

Sita Patel: This is San Francisco International High School, yeah.

Katie Hafner: That’s a great story. And that must be, however, I hate to say the exception to the rule.

Sita Patel: Well, there are a number of these similar schools nationwide. And I think even if kids aren’t ending up in an international school that is devoted to adjusting to meet their needs, there’s more and more of a call for our general education system to meet the needs of newcomers. And there are wonderful programs. There’s a wonderful soccer program where, you know, every kid can benefit from playing soccer. My kids love playing soccer at Oakland International High School it’s called Soccer Without Borders. But I think what’s really valuable about…

Katie Hafner: That’s my kind of soccer.

Sita Patel: Yeah, what’s valuable about that program, not only is running around and kicking a ball but is the mentorship that happens and so kids find, you know, one thing whether it’s like the room that they can go to at school to lie down when they feel overwhelmed or the soccer coach who they can talk to when they’re, you know, feeling something or thinking something, or who they can just feel connected with. Those are really small moments that can be really embedded in a lot of the systems that kids are in.

Katie Hafner: Well, that’s a decidedly hopeful note. And on that note, I’d like to thank our panelists, Dr. Nick Nelson, Medical Director at Highland Hospital Human Rights Clinic in Oakland and advisory board member of Partnerships for Trauma Recovery; Dr. Sita Patel, Associate Professor of Clinical Psychology at Palo Alto University and a board member of Partnerships for Trauma Recovery; and Dr. Annika Sridharan, Founder in Clinical and Training Director at Partnerships for Trauma Recovery.

This program has been generously supported by Northern California Grantmakers, Funder Network on Trauma and Resilience. We also thank our audiences here and on radio, television and the internet. I’m Katie Hafner and now this meeting of the Commonwealth Club of California, the place where you’re in the know, is adjourned.