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Abstract
In July 2019, the United Nations High Commissioner for Refugees (UNHCR) released a report urging the Venezuelan government to take immediate action to address the ‘grave violations of economic, social, civil, political and cultural rights’ occurring in the country. This case study highlights the human rights violations occurring in Venezuela through the case of a Venezuelan woman who experienced political persecution and traumatic loss resulting from her opposition to the ruling socialist party. As the clinical team of evaluators explored the mental health effects of surviving threats on her own life and the politically motivated assassination of her husband, it was agreed that the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition did not fully capture the extent of her suffering. Case discussion broadens the lens beyond the client’s experiences of posttraumatic stress disorder (PTSD) and depression to include persistent complex bereavement disorder, and emphasises the importance of addressing the sequelae of traumatic loss in a multifaceted way that broadens understanding of emotional functioning postmigration.
- migration and health
- psychiatry
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Background
We report on a 35-year-old Venezuelan woman who fled her home country fearing for her life after experiencing political persecution for her activism in opposition to the ruling socialist party. She was referred to the Yale Center for Asylum Medicine (YCAM) by her legal team in order to obtain a psychological evaluation for the purpose of her asylum application. While she was a practicing lawyer in Venezuela, she experienced threats to her life and witnessed the politically motivated assassination of her activist husband. After spending 1 year in hiding, and suffering with significant sadness and post-traumatic stress symptoms, she sought a new life in the USA. While studies document the significant rate of post-traumatic stress disorder and depression in asylum seekers,1 less is known about rates of traumatic grief. In moving through our typical framework of evaluation, it became clear that our client’s symptoms took the form of a complicated bereavement, and our evaluation team pivoted to incorporate understanding of those symptoms. This case discussion emphasises the importance of addressing the sequalae of traumatic loss in asylum seekers in a multifaceted way that broadens clinical understanding of emotional functioning post-migration.
Case presentation
The client was referred to YCAM by her lawyers to obtain a psychological evaluation for the purpose of her asylum case. Two psychologists affiliated with YCAM conducted her evaluation.
The attorney of the client RZ (whom we will refer to by her initials to protect her privacy) provided YCAM with a copy of her declaration prior to the evaluation. Two appointments occurred, each lasting 2 hours. The mental health team drafted their findings in the form of a written affidavit which was notarised and submitted to the legal team. Our primary goals of a mental health evaluation for the purpose of asylum were as follows:
To document emotional harm related to persecution.
To document ongoing psychological and emotional effects of persecution.
To provide context for understanding the ways in which a client’s history of persecution affects her ability to tell her story in court.
With these goals in mind, a psychological evaluation for the purpose of asylum is similar to other mental health evaluations, but emphasises the above points. The first step is taking a detailed history, with special attention paid to events of persecution.
History of persecution
RZ is a 35-year-old Venezuelan woman seeking asylum in the USA on the grounds of a history of political persecution by the ‘Colectivos’ in Caracas, Venezuela. RZ experienced this persecution as a result of her political opinion and activism against the government. ‘Political opinion’ is one of the five categories, or grounds, of persecution, which presently enable individuals to seek asylum in the USA.
Within the first minutes of our evaluation, the client began to weep and stated: ‘I am not seeking asylum for economic benefits. I have those. I am seeking peace of mind from persecution – anxiety and worry, and fear for my life’. She then reported the following history.
RZ described her lifelong interest in political activism as a natural outgrowth of an early home environment anchored in a passion for social justice. As a young child, her father and mother placed her in the care of relatives out of fear that their own political activism might place her at risk. She recalled an incident in which the entire family was held at gun point and then detained for several days as a result of her parents’ activity in Venezuelan Counter-Intelligence.
As an undergraduate, the client and her husband participated in campus-based opposition parties, and their opposition to the Chavez government continued after graduation. In the early 2000s, she and her husband signed the Tascón List—the referendum to revoke President Chavez. After signing this list, RZ experienced a cascade of political persecution: she was denied her food rations, wages for hours worked, transportation vouchers, and health insurance.
When RZ opposed the government’s efforts to turn over her privately owned apartment building to the poor—in the name of ‘equalising’ their neighbourhood—her daily life became increasingly difficult. Her car was vandalised, her husband’s car was stolen. Her life was threatened. The client attempted on multiple occasions to file police reports against the government violence and threats; her reports were not accepted by the police. In 2015, her husband was assassinated outside their residence. Following the death of her husband, RZ spent several years living in hiding. She left Venezuela for the USA in 2017. In 2018, she was seen in the YCAM clinic.
RZ detailed the ways in which her life in the USA has been different from the one she lived in Venezuela and the multiple losses she has endured. An accomplished lawyer and professional in Caracas, at the time of our evaluation, she earned a living cleaning houses and rented a room in a residence occupied by other recent immigrants.
Psychological evaluation
After taking a detailed history of persecution, the examiners moved into a semistructured evaluation incorporating standardised assessments: (1) the PTSD Checklist, Civilian Version (PCL-5) and (2) the Shorter Psychotherapy and Counseling Evaluation (SPACE). The PCL-5 was developed by F Weathers and Colleagues at the National Center for PTSD in 1993, and was updated in 2013 so that its 20 questions correspond to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V). The SPACE was developed by J Halstead, C Leach and R Rust (2007). The 19 items of the SPACE have been shown to correlate highly with well-known measures of depression, and includes a robust assessment of anxiety symptoms. As the evaluation progressed, we made the clinically informed decision to supplement our typical protocol with an additional assessment. Assessment measures were used as a framework within which further questioning could occur; they were not used as sole means of diagnosis.
A comprehensive interview with the client revealed a history of exposure to multiple traumatic events and the ongoing stressors of continued threats to her physical and emotional well-being. The client reported experiencing 3–4 panic attacks per week, insomnia, isolation and frequent crying. She described worrying she might never recover from her loss, and feeling that her husband’s death kept replaying in her mind. She felt stuck and immobilised when she was living in hiding—both because of realistic external threats and her own level of psychological distress. The intensity of these feelings precipitated a brief period of suicidal ideation. It was at that time that she realised she needed to leave Venezuela.
Results of the PCL-5, as well as the overall evaluation, demonstrated symptoms in each domain of PTSD: re-experiencing, avoidance, negative cognitions and mood, and increased physiological arousal. Her scores indicated that her symptoms fell within the range of severe PTSD and resulted in significant impairment across multiple realms of daily functioning.
Further assessment revealed that the client’s re-experiencing symptoms focused on recently experienced threats on her own life, threats towards family members and witnessing her husband’s assassination. In contrast, her symptoms of physiological arousal—hypervigilance, irritability, pervasive anxiety and insomnia—date back to her time as a university student living through unarmed demonstrations and the armed, government retaliations to quell them. Bombings, gunshots and other acts of terrorisation were frequent on her campus and during marches, even while the students and university security themselves were not allowed to carry arms. These symptoms became increasingly distressing over the years—culminating in near paralysis from fear during the year following her husband’s politically motivated murder. Client’s PTSD symptoms continued to be reactivated when she is confronted by reminders of her traumatic past. The asylum application process was triggering for her, and she experienced near sleepless nights in between our two evaluation meetings.
Client endorsed several symptoms of depression: generally feeling weighed down by sadness, feelings of cognitive confusion or fuzziness and pervasive fatigue. She described a period of suicidal ideation, without active intent, during the time in which she was in hiding in Venezuela. Currently, the physical freedom she enjoys in the USA—without fear for her life—has both lifted her mood and resolved thoughts of self-harm. In spite of this, she reports feeling socially isolated and disconnected from others. She sees her depressed mood as part of her ongoing grief, but also as relating to her current financial stress and her changed economic status. Previously employed as a lawyer and the owner of her own home in Caracas, she now cleans houses and feels the challenges related to renting a room in a crowded dwelling in which she does not always feel physically safe.
While the client’s intrusive thoughts reflected a wide-range of content spanning the breadth of her own history, her nightmares, flashbacks and ruminations of self-blame focus on the traumatic loss of her husband. We observed her, on the one hand, speak with conviction about her work as a lawyer and activist, and then become guilt-stricken and dysphoric, verbalising repetitive and inescapable ruminations about her own potential culpability for her husband’s death. While objectively and intellectually the client communicated a belief that she did not cause her husband’s death, when she is triggered and overwhelmed by feelings of guilt, shame and anger, she cannot hold on to this truth. She begins questioning herself about her past, her political identity, and her related activities while in Caracas.
As the evaluators understood this repetitive, and distressing, pattern of cognition and mood, we pivoted to include the 5-item screener for persistent complex bereavement disorder (PCBD). In the DSM-V, PCBD is considered to be a diagnosis ‘under further investigation’. PCBD is a set of symptoms that has, in the past, been referred to as traumatic grief, as it is more likely to occur when a death occurs within the context of trauma. While dreams, agitation and ruminations are not uncommon in typical bereavement, individuals experiencing PCBD may become stuck in their ruminations of self-blame, attributions of causation, anger and distress. This syndrome is more likely to present when circumstances of trauma surround the death of a loved one. In these cases, it is as if the grieving process becomes ‘stuck’ or ‘frozen’ by the traumatic memories and related symptoms, as well as the ruminative, negative thoughts and dysphoric mood.
PCBD and PTSD share several symptoms. The first two items from the screener overlap between both diagnoses:
Avoidance of activities that previously gave pleasure
Feeling cut-off or distant from loved ones.
The following three are unique to PCBD:
Trouble accepting the death.
Finding that grief is interfering with life.
Images or thoughts of deceased when they died and other thoughts of their death that are distressing
In the client’s responses, she endorsed multiple symptoms that fit within the framework of traumatic grief:
Nightmares 3–4 times per week, in which she either relives her husband’s assassination or is reunited with him.
Flashbacks to his moment of assassination—in which she feels ‘frozen in time’.
Questioning her own identity as an activist: What if I hadn’t been an activist? One minute I am from a stable family and the next, I have no foundation…was it wrong to speak out on behalf of my beliefs? Was it my fault? If I had been quiet, my husband would still be alive.
While it is beyond the scope of this case report to state authoritatively which diagnostic construct most accurately captures our client’s distress—PTSD or PCBD—it is imperative to highlight this important differential diagnosis. By incorporating the framework of PCBD, the full range of our client’s emotional experience was identified, understood and linked to her past events of political persecution.
Global health problem list
In 2018, Venezuela emerged as the leading country with asylum claims to the USA. Asylum is granted on the basis of an individual’s history of persecution on account of race, religion, nationality, political opinion or membership in a particular social group. Asylum seekers present with high rates of psychological distress, resulting from stressful life-events experienced premigration, perimigration and post-migration.2
Venezuela is experiencing a humanitarian crisis that has resulted in critical food shortages, severely impaired access to medicine and medical supplies and preventable deaths. An overall environment of economic deprivation, institutional breakdown, social insecurity and political violence represents a global threat to physical and mental health.
Persecution for political opinion represents an alarming human rights violation in Venezuela impacting physical security and psychological well-being. Political opponents and critics of the Maduro government have reportedly been harassed, disqualified from employment opportunities, jailed and even murdered. Grave violations including indiscriminate detentions, torture and extrajudicial killings have been documented.3
Global health problem analysis
Venezuela is located in northern South America and is home to one of the world’s largest oil reserves, thereby representing a strong and historically reliable source of revenue. Since 1999, Venezuela has been operating under an authoritarian government known as the Bolivarian Revolution.4 Over time, an aspirational ideology of social equality has been transformed by widespread corruption, institutional breakdown and social insecurity and resulted in a record-setting economic depression. International sanctions against government officials and most recently specifically against the oil industry and the central bank, seeking to hold the government accountable for humanitarian abuses, have likely exacerbated economic hardship for the broader population.5
According to data from the 2019 Index of Economic Freedom, Venezuela ranks last among 32 countries in North America and South America and far below regional and world averages.6 The ranking is based on four categories related to economic freedom: rule of law (property rights, government integrity, judicial effectiveness), government size (government spending, tax burden, fiscal health), regulatory efficiency (business freedom, labour freedom, monetary freedom) and open markets (trade freedom, investment freedom, financial freedom). Repressive government policies and basic economic deterioration have combined to produce hyperinflation estimated to reach as high as 1000% and have led to massive shortages of food, medicine and basic goods, and unemployment. Although official data are blocked by the government, findings from a national survey published in 2019 reported that 80% of households were food insecure, and the authors urged international action to address the growing humanitarian emergency.7
Human rights violations under the current administration have been identified and described in numerous reports by human rights and advocacy organisations.3 4 8 In July 2019, the Office of the United Nations High Commissioner for Human Rights released a report urging the Venezuelan government to take immediate action to address the ‘grave violations of economic, social, civil, political and cultural rights’ occurring in the country.3 The report warned of deteriorating living conditions for the people of Venezuela and identified the Colectivos, progovernment armed civilian groups, as responsible for systematic and widespread repression and violence. The inspiration for the Colectivos has been traced back to Venezuelan guerrilla groups from the 1960s.9 Former President Hugo Chávez later adapted these groups to be known as círculos Bolivarianos (Bolivarian circles), and charged them with the responsibility of informing the Venezuelan people about social policies and the changes proposed under the Chávez administration.10
The Tascón List published in 2004 marked a turning point in the Chavez government’s expansion into a broadly repressive regime systematically targeting voices of opposition. The Tascón List represents a collection of over 2 million signatures gathered to voice opposition to the Chavez government and its policies. National Assembly member, Luis Tascón, hence the name, published the list with the identifying personal information of those who signed. The Chavez regime, working through the colectivos network, began to use it as a weapon of political repression. President Hugo Chávez declared: ‘Whoever signs against Chávez will be registered for history because they are going to have their name, surname, identity number and fingerprint’.11
Predictably, the understanding of the role and purpose of the Colectivos bifurcates sharply across party lines. Loyalists to the Maduro regime welcome them and even refer to them as ‘angels of socialism’ guaranteeing the perpetuation of the Bolivarian Revolution. Government opponents see these groups as essentially criminal gangs and delinquents, armed with the Tascon list information and charged by the government with the support of the police forces to systematically deliver acts of state terrorism with impunity that have been documented to include kidnapping, extortion, murder, and drug trafficking.12
Economic deprivation, social insecurity and political persecution have led millions of Venezuelans, perhaps as much as 18% of the entire population, to flee the country, seeking refuge in neighbouring countries, in the USA and in the European Union (EU). Venezuelans are estimated to be the second largest nationality represented among first-time asylum seekers in the EU.13 Between February 2014 and September 2018, the number of asylum applications from Venezuelans increased by over 2000%, with nearly 30 000 applications in 2018.14 According to The Regional Inter-Agency Coordination Platform for Refugees and Migrants from Venezuela, jointly established by the UNHCR and IOM, as of August 2019, there were nearly 4.3 million Venezuelans reported by host governments around the world, with 1.4 million estimated in Colombia.15 As a result of the mass exodus, the UNHCR recently stated that refugees from Venezuela are eligible for international refugee protections under the Cartagena Declaration. This legislation/declaration, which originated in 1984, expands criteria from the 1951 UN Refugee Convention to include ‘persons who have fled their country because their lives, safety or freedom have been threatened by generalised violence, foreign aggression, internal conflicts, massive violation of human rights or other circumstances which have seriously disturbed public order’.16
The pervasive state of insecurity and violence threatens the physical, psychological and emotional well-being of the Venezuelan people.17 The losses and the high stress context that often leads to a forced displacement have been linked to negative mental health outcomes.18 19 Furthermore, people with exposure to political violence, including fleeing home to escape danger and/or political persecution, have been found to be more likely to suffer from chronic medical illnesses and experience higher rates of psychiatric distress.20 Data from the 2002 to 2003 National Latino and Asian American Study revealed that migration circumstances that included migrating due to political persecution in the home country were linked to worse psychological distress among Cuban women.21 A study with displaced Venezuelans seeking refuge in Peru and Ecuador found elevated rates of depression and anxiety that were nearly five times greater than the globally recognised prevalence rates of 4.4% for depression, and 3.8% to 4.4 % for anxiety.18
Assessment of unique vulnerability and resilience factors during the premigration, migration, and postmigration phases is one way of determining mental health risk. Based on this model,2 Venezuelan migrants are likely to experience a multitude of stressors at each phase of migration. These would be expected to represent risk factors as they adjust to life in a new host country. Examples of these stressors at each phase include persecution premigration; traumatic losses during the migration journey; and discrepancies between cultures and long-term opportunity in the postmigration context. A qualitative study of Latin Americans in Sweden demonstrated the profound impact of social degradation on the mental health of exiles, highlighting the challenges posed to both financial and emotional well-being when one’s previous professional degrees do not transfer into a new country and a loss of professional status is experienced.22
Mental health is a significant concern among asylum seekers. Asylum seekers are at greater risk of depression and post-traumatic stress disorder than refugees and the general immigrant population. Depression rates in asylum seekers have been shown to be twice those of refugees.23 Rates of PTSD in asylum seekers can range from 30% in some studies to over 82% in others.24 25 In one study, as many as 80% of those with PTSD also met criteria for comorbid major depressive disorder.25 Psychological distress stems from persecution as well as the loss of family members and close friends; in a group of asylum seekers settled in Germany, grief disorders ranged between 16% and 20%.26 Furthermore, the specific period of time during which an individual seeks asylum has been associated with an increase in psychological distress.27 The course of PTSD and prolonged grief has been shown to be related to both the absence of humanitarian protected status and the application process itself.26
Patient’s perspective
This evaluation [psychological evaluation for asylum purposes] had a big impact on me. I had never been in such an organized evaluation with a specialist and evaluators or observers speaking another language different from mine. My experience of the evaluation was emotional and nostalgic. Given so many lived traumas, I was sad. All I wanted was to not stop crying. At the same time, I was also relieved because the examiner and the interpreter asked me specific questions. Even though the questions they asked took my breath away and at times were hard to answer because they tore at my heart and soul.
The evaluation process was fluid and clear. The doctor and interpreter understood everything I expressed. Their attention, observations and sensitivity to what we discussed helped me trust the process and learn more about myself. I felt security that I was never granted in my native country. I left aside the fear of expressing myself without feeling harassment, persecution, and repression as happens in my country. Because I regret to say that my country, Venezuela, does not guarantee me the most important value of the human being – life. Life is not guaranteed in my country because I am labeled as a traitor. I am labeled as a traitor because I have stepped on American soil, and because I don’t share in the political ideals of the Venezuelan state.
Venezuela is a centralized country where everything is controlled. At the medical level there is no confidentiality. I can even attest that we do not work with psychologists or psychiatrists because they reveal everything to the state for greater control of the inhabitants.
If I was given the opportunity to talk to medical students doing these evaluations, I would recommend they pay attention to the patient, and to show humanity and sensitivity because that helps the patient feel trust.
Learning points
A clinical evaluation for the purpose of asylum is a report anchored in psychiatric/psychological paradigms that communicates to the lawyers and adjudicators essential information about psychological scars due to persecution. For this reason, it can be most useful if the report hews closely to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. With this in mind, we diagnosed the client with PTSD, severe and chronic, and a history of suicidal ideation.
The effects of persecution on this client’s mental health were not fully captured by the DSM-V. In response to this clinical assessment, our full report included a discussion about persistent and complex bereavement disorder, with the specifier of traumatic bereavement, as further clarifying her experience of suffering and the ongoing effects of persecution.
The state of ‘limbo’ or ‘unknown outcome’ in which asylum seekers must live exacerbates symptoms of post-traumatic stress and trauma, as they do not have the safety and security needed to work on recovery.
Experiences during the premigration, migration and postmigration phases can result in unique vulnerability for migrants forced to flee their homes. Awareness of these factors among receiving communities and healthcare providers working with asylum seekers is imperative in order to promote resilience and support long-term adjustment.
References
Footnotes
Twitter @KMcKenzieYCAM
Contributors JHM, PhD, helped in conducting the evaluation, analysing data and narrative, writing up initial evaluation for purpose of asylum, conceptualising and planning case study, writing up case material and providing framework, working with fellow author to integrate global health research and information, as well as the patient’s written contribution, editing, submitting. MAS, PsyD, helped in conducting the evaluation, collaborated in analysing data and narrative, conceptualising and planning case study, researching and writing up global health issues related to the case, working with patient to obtain her writeup about her opinion and experience, and providing framework for integration of translated patient material, editing, submitting. KCM provided community linkages and academic departmental structure that facilitates probono asylum clinic, and also helped in conceptualising case, providing mentorship and examples of previous case discussions, editing and guidance on manuscript production.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent for publication Obtained.
Provenance and peer review Not commissioned; externally peer reviewed.
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