This month, Secretary of State John Kerry announced that the U.S. would increase the cap of refugees allowed into the country to 100,000 by 2017 from 70,000 currently allowed. To that end, President Barack Obama recently committed to accepting 10,000 Syrian refugees during the fiscal year beginning October 1. These decisions come on the heels of a massive international outcry in the wake of the increasingly urgent Syrian refugee crisis. While Germany has committed to taking 800,000 refugees in the next year alone, the U.S. has taken in only 1,500 refugees since the Syrian war began four years ago in the aftermath of the Arab Spring.

While admitting more refugees is certainly the moral course of action in the face of a conflict that has produced more than 4 million innocent victims so far, the fact remains that many who make their way to the United States are denied basic services due to insufficient resources.

Ami Ingram has been a social worker in the Pacific Northwest for two decades. She specializes in treating people and families who have just arrived from countries so defiled by war it is hard to imagine anyone could ever have lived there. Some of her patients are homeless, many are suffering from severe post-traumatic stress disorder. Ingram’s profession is incredibly demanding, and learning about her patients forces us to reconsider what it means to be a refugee—an individual and not a benighted class of downtrodden people. ATTN: met Ingram at a neighborhood bar in Seattle’s South Park where she spoke with the breathless ferocity of a trench warrior about the refugee crisis.

ATTN: Tell me about your current job.

Ami Ingram: I work as a licensed social worker at a medical clinic. My title is care coordinator; I take a lot of referrals from primary care and psychologists there, and I work on the behavioral health team to help with social service issues. I bridge those resources, I gather information about the patient’s situation, and try to implement services for them. Generally speaking the people I work with are fresh from their country—they’re refugees. They come into our clinic because there’s a requirement under their immigration paperwork that they get immunizations and a physical exam within a two- to three-week window. If they can’t get into the King County immunization clinic right away, somebody has to see them and they reroute them to our clinic. We try to meet the needs of these populations as quickly as we can with the resources that we have until they’re able to go through the immunization clinic, which right now is about a two- or three-month waiting list.

ATTN: What populations do you see mostly?

AI: I would say Iraqi right now. I work at two different clinics, so the population varies based on the clinic I’m in. At the one closest to the [Seattle] airport I work with a lot of Somalis, a lot of Middle Eastern people, other African populations. I see a lot of Spanish-speaking patients, Bengalis. There’s a huge variation; lately there are a lot of Amharic [a language spoken in Ethiopia] speakers. You run the gamut.

ATTN: What’s it like to be first person in the U.S. to talk to someone in that situation?

AI: I understand now why they hired me for the position. I wasn’t necessarily ready for what I was going to see and how I was going to navigate the particular systems for this job, but the patients I see are right from places like Afghanistan, Iraq—I have a lot of Iraqi patients who have worked for the U.S. military in various positions over there and had to seek asylum right away. They’ve left their families; they’ve been in camps, they’ve been moved from refugee camp to refugee camp. They’ve been homeless in Turkey before coming here. A lot of those types of patients have experienced immense trauma. They’re trying to flee their country as fast as possible, and they’re very separated from their families. A lot of them have seen torture in various forms; they’ve seen family members beheaded. I’ve had children who have stepped on IEDs and have had to undergo reconstructive surgery. They’ve been retraumatized over and over again, first being kept in refugee camps for years before being brought to this country sponsored by various organizations. They come in with travel loans that bring them here, and then these organizations promise to provide for their basic needs once they arrive.

A lot of the families who I work with come in with very limited resources; we have to complete basic evaluations to determine whether they qualify for basic DSHS [Washington State Department of Health and Human Services] support. Just basic things like housing, food stamps, and for how long. That helps to buy them time when they have no other resources.

AR: How do you go about that? Can you give me an example of a determination or a report that you might do to help a patient?

AI: First we would evaluate the individual for diagnosis: is this a valid condition that prevents them from seeking what the state and federal government would consider to be gainful employment. The majority have post-traumatic stress disorder, as you can imagine. There’s major depression, some have psychosis attached to that. Those conditions in the DSM justify the extension of this particular Social Security benefit until they get citizenship. If they don’t get citizenship after that period of time, they’re pretty much cut off. [See here for more specifics.] A loophole to that is if a psychologist determines that a person’s condition is chronic or acute, and if so then they get a longer extension of Social Security benefits and citizenship is put on the back-burner.

We assess, for example, how long were you in a refugee camp? What symptoms are you experiencing as a result of the trauma you experienced in your home country? We do lengthy assessments on activities of daily living: Are you able to cook for yourself? Are you so depressed that you’re not getting out of bed? Are you seeing or hearing things? Observation is a huge part of that. If someone’s affect is a certain way every time we see them, if their persistent conditions like not eating or sleeping at all, that puts them in a more chronic category.

ATTN: It seems like it’s perfectly natural to have PTSD after experiences like that; maybe not displaying symptoms would be a greater indicator of mental illness.

AI: Yeah, exactly. I think that’s the biggest piece that’s missing: not only do these people have to leave their families and live in refugee camps without knowing when they’re going to leave, then they’re brought here with the promise of having organizations that are going to sponsor them, and a lot of these people lack the resources and support they need. They end up in homeless shelters; it’s a cycle of retraumatization that happens over and over again.

ATTN: What’s your longest relationship been with a patient?

AI: It all depends on the assessment. If someone’s suicidal or homicidal, if there’s an imminent threat, I’m going to keep my eyes and ears carefully on that situation because that person’s not well enough to understand the information they’re getting. They’ve just come into the country, they’re traumatized and they’re suicidal. I determine how often I’m going to see someone by imminent threat of harm. I immediately get them in line with a provider. The provider understands that something’s wrong, but it’s up to me to make sure they get the information about the patient that they need. I make recommendations based on psychiatric consults with providers; I let them know my plan is first to get the person housed.

There’s this thing called Maslow’s law, which is about determining and providing basic needs to stabilize somebody enough so they’re not swimming in fear or uncertainty. I help put resources into place; I usually want to start somebody on medication right away if necessary, especially if they’re not sleeping. A lot of research supports that lack of sleep exemplifies these symptoms and exacerbates everything. We try to get sleep under control right away.

ATTN: What do you wish you’d known 20 or 25 years ago?

AI: I wish I would have known the complexity of the issues. We work within the confines of a system that really does not understand our role and how significant it is. We’re seen a lot of times as [dismissively] “social workers,” but what people don’t understand a lot of the time is all of the education that goes into that, all of the fact-finding. I have to know all the legal Social Security information, I have to know all the housing resources, all of the psych meds. I have to know all the mental health diagnoses, I have to know how to do therapy, and I have to know about the populations that I serve. When I got into social work I thought, housing, basic things, and what I’ve found is that it’s a far bigger and broader area than people can imagine.

ATTN: Do you think the average social worker is overstretched? How many patients do you see in a day?

AI: Absolutely. I see about 10-15 patients in an eight-hour day. Because of our patient demographic, I work with interpreters all day. I work with people who are right out of war-torn countries, and I’m given a 20 minute appointment to assess and evaluate somebody who is visibly traumatized. Being able to do even the most minimal work in that amount of time is a stretch. It’s a constant battle to try to just meet the most basic needs. Occasionally, I can get a 45 minute appointment; I’ve asked at my clinic that I get a 45 minute appointment for new patients, but after that they only get about 20 minutes at each appointment.

ATTN: If you could change one aspect of your job or of the immigrations system, what would it be?

AI: It would be a cultural shift, and it would be an understanding of what a clinical social worker does on a day-to-day basis, or a doctor in a primary care setting with county or nonprofit funding really does over the course of a day. People need to understand how the system works, and in the confines of that system, the lack of funding and the lack of respect for the people who choose this profession.

The government does not provide adequate services or care for asylum-seekers; people who come to this country are often out on the street. They’re asked to get employment if they’re deemed suitable for that, but a lot of them aren’t even able to function at a basic level. There’s a systemic misunderstanding that the government is right there with open-arms to meet the needs of all these refugee populations, but that isn’t necessarily accurate. It’s shocking for me, as the only licensed clinical social worker between two clinics and 14 doctors. I have patients come through and they say “I was promised help with my housing and I never got it, and I don’t know where that money went.” People who were doctors and engineers in their home countries are now janitors or stocking shelves at Target while trying to support their families. The government is saying that it’s doing one thing for these people but their needs are not being met.

ATTN: Do you think most people see these populations as getting way more than they actually do?

AI: I have to say that when I got this job, in my ignorance, I was shocked when I found out that a lot of these refugees have nothing; some of them are living in cars and the language barrier is so immense. The idea that we have this system in place and that they get a lot of money and are just taking from the government is a myth.

ATTN: Much of the debate over refugees goes on at a high political level: Angela Merkel first promises to take hundreds of thousands of Syrians in Germany, only to abruptly pull back in the face of political realities. What don’t people understand about the life of someone working intimately with these individuals and families?

AI: You go to work with your heart in the profession, and you see the most traumatized people who you can imagine, and who aren’t really in society because they’re so depressed. They’re so traumatized that they can’t get out of bed half the time, let alone go to the grocery store. It’s like you’re pushing a boulder up a hill. What people don’t understand is that when you’re in my role and you have desperate—desperate—people and they’re looking at you, saying, “help me,” and you have to tell them, I want to help you but I don’t have anything for you right now. You have to be on the street for another two weeks until we can get you something … That’s actually on the lower end: a month or two until we can find you somewhere to live is more like it. It’s a desperate feeling. It’s desperate to feel that you’re there because you want to help people, but you can’t because your hands are tied. You go to work and you encounter this every single day.

The wonderful thing about my job is seeing the incredible power of resiliency in people. Sometimes it takes time to see people come out after what they’ve experienced. You do a lot of testing for depression and anxiety, and to see those scores going down and to hear that person tell you, “you helped me, you saved me, I don’t know what I would have done without you,” building that trust with someone who walks in the door and looks at you thinking, quite frankly, you’re another caucasian and I don’t know if I can trust you. Building that kind of trust with somebody from another country is so rewarding. That’s the exciting part of my work. I just remind people that we’re going to help you get better and meet your basic needs, but it might take time. Always reminding that person that you’re there for them. But you do have to go to work every day and see the most traumatized, depressed, psychotic people who walk this earth—people who no one else really sees.

You have to have a lot of hope and resiliency yourself. You have to have the ability to see little incremental steps as successes. To keep doing this work takes a lot of tenacity and knowledge that there are better times ahead. You can never let this get you down. I will be able to look back on my life and career and say that I actually helped people and I will always remember them.