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s she prepared to testify, the woman knew this hearing could determine everything. If the judge found her story credible, she could be granted asylum and allowed to stay in the United States. If not, she could be deported back to her home country, where she had been gang-raped by armed soldiers. She worried she’d be murdered soon after she got home.

So she recounted everything she remembered. But there were a few questions she couldn’t answer.

“The judge was very interested in certain details of the experience, like exactly how many men raped her, and what color was the wall,” recalled Megan Berthold, who was then a clinical social worker at the Program for Torture Victims in Los Angeles.

The woman said she didn’t know.

For this asylum-seeker, as with many others, gaps in memory or inconsistencies in her story could have gotten her deported. Yet, when it comes to trauma, what might seem like a sign that testimony isn’t credible can itself be strong evidence that the story might be true. Berthold’s job was to explain this paradox to the judge.

She was there as a forensic psychological evaluator, a role she has played in hundreds of asylum cases. We think of US immigration law squarely in the world of politics, with people caught in the crosswinds of violence around the globe and each American administration’s policies. But based on interviews with nearly 20 health providers and immigration lawyers, STAT found that many of these cases pivot on the knowledge of clinicians like Berthold.

To stay in the United States, asylum-seekers need to prove that they are at risk of persecution in their home countries. But often they have little evidence to back them up. The paper trails from their past lives — such as hospital or police records — are often inaccessible. If they were tortured in a secret government prison or persecuted by the police, that kind of official record may not exist at all.

Instead, what remain are the stories that migrants tell, and whatever marks those experiences have left on their bodies and minds. So these cases depend on doctors and psychologists who can translate scars and symptoms into evidence — and who can tell when a person’s ability to testify may have been altered by trauma.

That means that many asylum-seekers depend on a network of clinician volunteers, trained by nonprofits such as Physicians for Human Rights and HealthRight International.

These evaluations do seem to make a difference. In the 540 or so evaluations Physicians for Human Rights provides a year, asylum is granted in about 90 percent of cases. By comparison, in 2015, the overall rate for asylum seekers was 48 percent.

The better outcomes stem partially from the fact that those who are able to get this kind of expert testimony are almost always represented by a lawyer, which isn’t true for many asylum-seekers. Even so, both lawyers and judges see these evaluations as essential.

Yet asylum-seekers who are fortunate enough to have a lawyer frequently can’t get a forensic evaluation: There just aren’t that many clinicians who do them. The ones who do volunteer often aren’t able to take on all the cases that the nonprofits send their way. Other times, they are faced with bureaucratic roadblocks that make the evaluations nearly impossible. And some worry that the demand for these evaluations will only increase with a president who has made fiercely anti-immigration promises.

“I would like one for all of my cases, because all of my asylum clients have documentable psychological and often physical trauma,” said Jesse Rockoff, an immigration attorney at UnLocal, a nonprofit in New York. “But you have to pick and choose, because you don’t want to overwhelm this system that is already overloaded with too many requests. I’m terrified that my picking and choosing is going to come back and bite me, and is going to get someone deported or killed.”

‘Getting to the truth of a case’

Remembering the wall color or the exact number in a group of assailants might be hard for anyone. But for the Los Angeles asylum-seeker, Berthold saw it as more than just an everyday memory lapse. It was partially a symptom of post-traumatic stress disorder.

This case took place in the early 2000s. Because of their clients’ perceived vulnerability, none of the providers or attorneys STAT interviewed was willing to describe in detail the numerous recent cases where asylum-seekers’ testimony was similarly affected by trauma. Many said that those who have successfully gone through the asylum process might have spoken out about their experiences before the election of President Donald Trump, but are now too afraid, even though much of the president’s anti-immigrant rhetoric has focused on those without legal documentation. They worry that their legal status may somehow be affected by changing policies, or that they will simply become targets of xenophobia.

Berthold revealed nothing that would identify her patient, but she did describe some of the horrors that the Los Angeles asylum-seeker had undergone, and how that affected her symptoms.

“They had AK-47s, and a knife at her throat,” said Berthold, who is now an assistant professor of social work at the University of Connecticut, and who trains both licensed clinicians and students to provide these evaluations. “She had no viable option of physically escaping, so she escaped in her mind, she disconnected herself.”

That explanation sounds relatively straightforward, but the underlying neuroscience of trauma is anything but.

In a PTSD patient’s brain, the amygdala — an almond-shaped lump that responds to both pleasure and fear — becomes an oversensitive alarm, like a fire detector that rings every time you put the kettle on. Meanwhile, the part of the prefrontal cortex that would normally act as a “reset” button doesn’t seem to be working properly: A person will go into panic mode at the slightest provocation, and have trouble calming down again, even when there is no danger.

“But that is a very CliffNotes version of a much deeper problem,” said Dr. Charles Marmar, the chair of psychiatry at New York University School of Medicine, who began studying PTSD in 1976.

Marmar and other researchers have used brain imaging and animal studies to describe a confusing epic of neurotransmitters that reshape brain circuitry in PTSD. The plot is convoluted, and still incomplete.

It involves an initial flood of stress hormones that can disturb the ability to perceive a traumatic experience fully. After that, there also seem to be imbalances in everything from the chemicals that help people regulate blood pressure to the brain’s own version of opioids.

The resulting symptoms can seem contradictory. Some people have holes in their memory, images and details they can’t recall; others are haunted by horrific flashbacks and nightmares they can’t forget. Some seem emotionless, numb; others are so overcome they can hardly speak. Some are too fearful to perform everyday tasks; others become alarmingly reckless.

Those symptoms can provoke bafflement or suspicion at any point during the asylum-seeking process. Before going to court for this kind of case, an immigrant is interviewed by an asylum officer, and the application could simply be approved. But if there is doubt about the veracity of the person’s story, or if the person has been apprehended by the Department of Homeland Security, then the case goes before a judge, with a government attorney acting as a kind of prosecutor.

“I have heard judges say, ‘I don’t know if this has happened to them because they didn’t emote enough,’” said Berthold.

“A judge is in this difficult position of trying to interpret the testimonial style, the coherence of the recollections,” said Judge Dana Marks, president of the National Association of Immigration Judges.

Even though forensic evaluations are put forward by the asylum-seeker’s lawyer, the judge is able to mine them for objective facts, said Jeffrey Brauwerman, an attorney in Fort Lauderdale, Fla., and a former immigration judge.

“These medical and psychological evaluations can be an essential tool in assisting a judge in getting to the truth of a case,” said Marks. “We do get training on … cultural issues and the psychological issues — that’s part of how you train a judge to be a good judge — but the reality is that we also have to make our decision based on the individual record of the case that comes before us.”

Late-night forensics

Getting that kind of evidence in asylum cases often means asking clinicians to perform a high-wire balancing act.

Serena Chaudhry volunteers as a psychological forensic evaluator with Physicians for Human Rights — but she also has a full-time practice as a clinical social worker, is pursuing a doctorate, and has a family.

When she lived in New York, she was part of a wide network of local volunteers, and over two years she only got a handful of evaluation requests. Now, she lives in New Orleans, where there are many fewer clinicians doing this work: In November alone, she did between six and eight evaluations.

She has tweaked her clinical schedule to keep a two-hour chunk free every week for those asylum-seekers. The write-ups then take between two and five hours, depending on the complexity of the symptoms.

“I do the write-ups at night, at 9 or 10 o’clock, after my day is done and my kids are in bed, and the rest of my life has come to standstill,” she said.

She does what she can, sometimes negotiating with the lawyers so she can have a bit more time. But she hopes that a training session in April will allow more clinicians to take on the task.

The dearth is especially great in northern Louisiana, around the LaSalle Detention Facility, built among the forested hills of Jena, where saw logs and pulpwood are harvested next to cotton and soybean farms. Getting there from New Orleans can be a trek: a four- or five-hour drive each way, on top of the time spent getting into the center, doing the evaluation, and then writing the report.

That problem is not unique to Louisiana. Immigration detention centers tend to be remote — making those sessions harder to work into a clinician’s schedule — and sometimes distance isn’t the only barrier.

“We’ve had evaluators go to a center after scheduling a whole day of travel, and the individual isn’t brought out: They just aren’t made available for the evaluation,” said Meredith Fortin, who runs the Physicians for Human Rights Asylum Network.

Each center can have a different policy about letting in evaluators.

“We also get requests for individuals who are in detention enters that won’t let evaluations to take place there, so we have to arrange for them to be transferred to somewhere where they can arrive in shackles with an armed guard,” Fortin said.

Lindsay Harris, a lawyer with the immigration and human rights clinic at the University of the District of Columbia, wrote in an email that a detention center in Farmville, Va., “changed the rules on us mid-representation and would no longer allow a psychologist to meet using [videoconferencing]technology.”

According to an Immigration and Customs Enforcement official, the Farmville Detention Center has not refused any requests, but there have been “technological challenges” with this kind of equipment. The official added that it is up to each individual detention center as to whether a psychological evaluator is allowed in. The ICE field office has to approve all forensic evaluations of detainees, either inside or outside of the center, and then it is up to the center to provide the necessary space or transportation, he said.

“Comprehensive medical care is provided from the moment detainees arrive and throughout the entirety of their stay,” ICE spokesman Brendan Raedy wrote in a statement responding to STAT’s questions.

Testifying takes a ‘huge toll’

For psychological evaluators, the division between procuring evidence and providing treatment can be thin.

When there’s physical evidence of trauma, the clinicians who examine scars and write a report tend not to provide treatment. But lawyers recognize that some asylum-seekers simply wouldn’t be able to stand trial without getting their symptoms under control.

“When I saw the psychologist, there were some things I thought were normal about me, because of what I went through over the years,” said a Nigerian woman who was granted asylum a few years ago and now lives in Bridgeport, Conn. “I thought it was normal to want to kill myself all the time, to end it all, each time I think what I’m going through, that there was no one to help.”

She remembers wanting to jump in front of a train every time she went near the station. “I thought it was normal,” she said.

She didn’t want to talk about her traumatic experiences when she began to apply for asylum, she said, “but they said I had to. Each time I talk about it, it brings back old hurtful memories and I get depressed, I go into my shell again, it reminds me of everything. Each time I talk about, it’s like it just happened.”

Her physical and psychological evaluators, at Yale and the University of Connecticut, respectively, helped guide her through the process, so that she was able to tell her story and get asylum — but she still has trouble talking about it.

“It takes a huge toll on them,” said Diya Kallivayalil, a psychologist at Cambridge Health Alliance in Massachusetts, who specializes in trauma and has provided many forensic evaluations. “The process necessitates them to talk about the trauma in quite a lot of detail, and that’s exactly what they cannot do.”

Her patients respond in all kinds of ways. “They can become suicidal, they can become psychotic,” she said.

Sometimes they go to great lengths to avoid their lawyers because describing their experience is so emotionally difficult. “In some examples, they have left the state, and we have had to write to the court to ask for more time, so we can care for the patient so he can participate in his own case,” Kallivayalil said.

Even convincing an asylum-seeker to see a psychological evaluator can be a challenge: Many of them come from countries where those services aren’t accessible, and where mental health issues are deeply stigmatized.

“In Khmer, one way that ‘mental health’ is translated is ‘chikkuid,’ which essentially translates as deranged,” said Berthold. “It connotes somebody who is floridly psychotic and completely out of their mind.”

Then, when an asylum-seeker can be convinced to come in for an evaluation, and the clinician has explained again the purpose of these sessions, the evaluation itself can be a long process.

“I do at least two to three sessions, and they are pretty lengthy, because when you are dealing with a trauma patient, you need to really earn their trust,” said Paula Madrid, a New York psychologist specializing in trauma who has done evaluations both as a volunteer for HealthRight International and as a paid expert witness. “About 50 percent of the clients who come in subsequently tell me they had nightmares the night of the evaluation. It was retriggered. I end up doing a little bit of trauma therapy just to ensure that they will be psychologically safe.”

In the case of the woman who was gang-raped, Berthold’s testimony was one of the pieces that helped her win her case — but Berthold also helped her get through the emotional fallout of having to testify about her traumatic experience for some 12 hours over five or six hearings.

“What she felt at the end was, ‘Now I feel like I can face anything, I got through my torture, I stood up to the judge, I kept sticking with what I knew to be true, and he believed me and I got asylum,’” recalled Berthold. “But it was really rough.”