Natalie Riback, Registered Psychotherapist RP, CTP Dipl, BA

258 Dupont Street, Toronto ON M5R 1V7

T: 416-821-7934 E: natalieriback@hotmail.com W: www.natalieriback.com

March 3, 2020

Naga Obazee
Obazee Law
Suite 520, 1110 Finch Ave West
Toronto, ON M3J 2T2

RE: KEVWE MANUWA

Dear Mr. Obazee,

I interviewed Ms. Kevwe Manuwa today to assess her emotional and psychological functioning to accompany
your submissions regarding her refugee claim. I submit this assessment with Ms. Manuwa’s consent and
authorization.

I am a registered psychotherapist with the College of Registered Psychotherapists and Mental Health
Therapists of Ontario, specializing in the assessment and treatment of serious disorders of thought, cognition,
mood, emotional regulation, perception and memory. I have been in independent practice since 2006. I am a
graduate of the Centre for Training in Psychotherapy and I am a participating member of the Canadian
Association for Psychodynamic Therapy (C.A.P.T). My clinical impression is based on my experience in
conducting comprehensive psycho-social and emotional evaluations, my training and clinical experience, and my
ability to evaluate and assess symptoms of trauma, anxiety, depression, and other symptomatic criteria as
outlined in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (5th ed.,
DSM-V) and the Psychodynamic Diagnostic Manual (PDM). I have been engaged in the assessment and
treatment of refugees and foreign nationals since 2011 and my reports and evaluations have been widely
accepted by the Immigration and Refugee Board of Canada.

As my report will show, Ms. Manuwa is exhibiting symptoms consistent with post-traumatic stress, generalized
anxiety, and depression. I believe these symptoms are consistent with Ms. Manuwa’s reported experience of the
fear, harassment, threats, domestic abuse, and trauma she has endured.

Approach to Assessment

The assessments I conduct are based on a one-time, in-depth clinical and psychodynamic interview, typically
extending for 60-90 minutes. Interpretation and report preparation require another 2-3 hours. Interviews cover a
broad range of topics, including history, social and occupational functioning, patterns of distress (i.e. symptoms),
intimate relationships, sexuality, coping behaviour, suicidality, and future orientation. The reliability and validity of
interview data are evaluated by a number of means, including internal consistency, nonverbal communication and
its congruence with self-report, the symptoms reported, and congruence between reported symptoms and known
patterns of distress. Each assessment is prepared after a careful and detailed investigation of psychological,
social, and occupational functioning and the context in which these occur. Each report is tailored to provide a
comprehensive, differentiated, and personalized evaluation of the individual.
History Relevant to Assessment

The following history is based on Ms. Manuwa’s statement submitted to immigration, as well information
gathered from my interview with her. Kevwe Manuwa is a 31-year-old woman originally from Nigeria. She came
to Canada on May 30, 2019 along with her three children – Caleb (age 9), Iremide (age 3), and Lois (age 1) – to
escape the fear, harassment, threats, domestic abuse, and trauma she has experienced. In July 2010, when Ms.
Manuwa was approximately five months pregnant with her first child, Ms. Manuwa and her now ex-husband went
to meet with Ms. Manuwa’s father, as well as the Chief of Command to her uncle, the king of her region. Ms.
Manuwa was informed that she must be circumcised as per their tradition. Circumcision or Female Genital
Mutilation (FGM), a procedure that involves partial or total removal of the external female genitalia, or other
injury to the female genital organs for non-medical reasons. In addition to the significant and emotional and
psychological damage that Female Genital Mutilation often causes, victims of this practice often have many
serious and long-term health complications such as numbness, infections, sexual problems, difficulty passing
urine, irregular and painful menstruation, blood clots, increased risk of infertility, HIV, cysts, childbirth
complications, and newborn deaths. Often times, the procedure is conducted in an unsafe and unsterilized
manner, sometimes leading to severe infection, excessive bleeding, or death. Ms. Manuwa objected but was
told she would be brought to the village by force if she refused. Five months after the birth of her child, Ms.
Manuwa was told that since she was not circumcised, she and her son must now partake in spiritual cleansing
rituals. Ms. Manuwa was informed that the rituals must take place when her son is between five and seven
years old. Following the birth of her daughter in August 2016, Ms. Manuwa’s father informed Ms. Manuwa and
her now ex-husband that their daughter must be circumcised by the age of one. One month later, Ms. Manuwa
was informed by members of her now ex-husband that their daughter would have to be circumcised. Feeling the
threats and pressure from both of their families, Ms. Manuwa and her now ex-husband fled Nigeria with their
two children on August 5, 2017. Shortly after arriving in the U.S., Ms. Manuwa’s marriage began to break down
and the couple were officially separated in January 2018. In April 2018, Ms. Manuwa met a man named James
with whom she began a relationship. One month later, Ms. Manuwa got pregnant; however, James doubted the
baby’s paternity and his behaviour turned emotionally and physically abusive. Ms. Manuwa gave birth to her
third child in April 2019 and left her relationship a month later. Feeling unsafe and unsupported in the U.S., Ms.
Manuwa travelled to Canada with her three children in search of refuge.

Ms. Manuwa and her children are currently living in Brampton, Ontario. Ms. Manuwa’s children are attending
school/daycare and Ms. Manuwa recently started school to be certified as a Personal Support Worker. Ms.
Manuwa’s sister Linda also lives in Toronto. It is my impression that Ms. Manuwa has been significantly
traumatized by the fear, harassment, threats, and domestic abuse she has experienced. She is terrified of being
forced to return to Nigeria where she believes she and her children will be in danger.

Behaviour and Presentation

Ms. Manuwa cooperated fully during the interview. She responded to the questions asked, as well as
established eye contact throughout. The interview was stressful for Ms. Manuwa as she experienced painful
memories, threat, and vulnerability throughout causing her to suffer from aversive physiological arousal (e.g.
crying, agitation, heart palpitations, hot flashes, and abdominal cramps). Ms. Manuwa’s emotional display and
nonverbal behaviour were congruent with the themes presented in response to the questions and seemed to
correspond with the experiences that Ms. Manuwa has described. The fear, harassment, threats, and domestic
abuse that Ms. Manuwa has described enduring have clearly been traumatic and it is evident that damaging
psychological and emotional after-effects persist.

Psychological and Emotional Functioning

Ms. Manuwa reports to having ongoing and prominent sleep disturbances. She wakes up frequently throughout
the night and the sleep she does get is restless and non-restorative. Ms. Manuwa reports to having distressing and
recurrent nightmares. Although she does not remember the images from her dreams, Ms. Manuwa stated that she
often wakes up in a state of anxiety.
Ms. Manuwa reports to suffering from persistent re-experiencing of traumatic events. She describes having
frequent and painful memories, thoughts, and flashbacks traumatic events that have occurred. Intrusive ideation
(i.e. memories of traumatic events or worries that erupt spontaneously into consciousness) occurs frequently,
followed by surges of threat and vulnerability. The response is accompanied by feelings of fear, anxiety, and
sadness.

Ms. Manuwa reports to be experiencing many symptoms of hyperarousal. She is hypervigilant of her
surroundings and often experiences paranoia where she feels as if she is being followed or watched. Ms.
Manuwa stated that she prefers to stay indoors. Ms. Manuwa has a high startle response to loud and sudden
noises. She feels alone in crowds of people. Due to her experiences, Ms. Manuwa has difficulty trusting people
which hinders her ability to socialize.

Ms. Manuwa often feels distracted by negative and scary thoughts, which causes her to experience cognitive
issues. She reports to be having problems with concentration and focus which interferes with fluidity of thought,
learning, and daily tasks. Ms. Manuwa also reports to having impaired short-term recall (i.e. short-term memory
loss) which causes her to have difficulty retaining or recalling information. It is important to note that
concentration and memory problems are very common among people who have been exposed to trauma and
high levels of stress. The pressure that is inherent to the high-stakes context of immigration proceedings can
easily exacerbate or amplify this stress causing a person to have difficulty understanding questions, retrieving
specific details of the past or formulating a coherent response. The person may request for questions to be
repeated or rephrased, and these stress-related cognitive problems can lead to difficulties in providing clear and
consistent testimony. Should such problems arise, it will be important to understand that the person is likely
responding to the disorganizing effects of traumatic stress rather than being dishonest or evasive.

Ms. Manuwa reports to be experiencing such depressive symptoms as over/stress-eating (resulting in weight
gain), low energy, sadness, hopelessness, despair, fear, worry, frequent crying, low self-esteem, social
withdrawal, difficulty getting out of bed or maintaining self-care, low motivation, discouragement about the future,
increased irritability, and anhedonia (i.e. an inability to experience pleasure or interest from activities usually
found enjoyable). Ms. Manuwa denies having any suicidal ideations, interest or intent.

Ms. Manuwa is intensely worried about the possibility of having to return to Nigeria. This fear, as well as the
trauma she has endured, causes Ms. Manuwa to experience acute and frequent anxiety and panic symptoms
that manifest themselves physically and are accompanied by autonomic arousal. These symptoms include light-
headedness, heart palpitations, chest tightening, dyspnea (i.e. difficulty breathing), trembling, hot
flashes/excessive sweating, blurred vision, dry mouth/throat, numbing/tingling in extremities, abdominal pain,
diarrhea, and dissociation (i.e. detachment from one’s immediate surroundings and/or from one’s physical and
emotional experience).

Psychodiagnostic Testing

As part of the assessment, I administered two highly-regarded and widely-used self-report psychological tests
used to measure the severity of anxiety and depression. The Beck Anxiety Inventory (BAI) includes cognitive
and somatic subscales, providing measurement of fearful thoughts and impaired cognitive functioning, as well
as symptoms of physiological arousal. Ms. Manuwa obtained a raw score of 45 reflecting “severe” anxiety. The
Beck Depression Inventory (BDI) includes questions relating to symptoms of depression such as hopelessness
and irritability, cognitions such as guilt or feelings of being punished, as well as physical symptoms such as
fatigue, appetite, guilt, and sexual interest. Ms. Manuwa obtained a raw score of 21 reflecting “moderate”
depression.
Clinical Impression

Based on my observations, evaluations, and test scores, it is my clinical impression that Ms. Manuwa is
exhibiting symptoms consistent with post-traumatic stress. Post-traumatic stress is a condition created by
exposure to one or more psychologically distressing events outside the range of usual human experience,
which would be markedly distressing to almost anyone. These events tend to cause intense fear, terror, and
helplessness and symptoms fall under the categories of hyperarousal/anxiety, re-experiencing, and
numbing/depression. Ms. Manuwa exhibits symptoms from all of these categories. Ms. Manuwa is also
exhibiting symptoms consistent with generalized anxiety and depression. It is my clinical impression that that
Ms. Manuwa presented in a manner consistent with the symptomatology of a person living with trauma, and in
particular a person facing retraumatization due to an anticipated return to a prior traumatic situation. From Ms.
Manuwa’s account of her experiences, as well as the symptoms that she exhibits, I believe that Ms. Manuwa is
displaying the traumatic psychological symptoms of someone who has experienced harassment, threats,
domestic abuse, and significant fear. Ms. Manuwa is very concerned about her state of mind and eager to heal
psychologically and emotionally; however, I believe she cannot begin to work through the past events and
trauma she has experienced as long as there is an imminent threat of being sent back to Nigeria. Given her
current state, I believe Ms. Manuwa’s symptoms will increase considerably should she be forced to return to
Nigeria. Being exposed to intense stress, re-traumatization, and/or dangerous circumstances would likely cause
Ms. Manuwa’s psychological and emotional state to deteriorate, for her engagement and involvement in society to
lessen, and for her level of child/self-care, motivation, and confidence to decrease significantly. Studies show that
depression can destroy the very essence of an adult’s personality, causing an overwhelming sense of sadness,
despair, or anger. This can lead to drug and alcohol abuse, self-loathing and self-mutilation, violence, and
suicide. Prolonged anxiety can cause such problems as substance abuse, academic problems, strained
interpersonal relationships, insomnia, physical ailments, and further depression. A woman, such as Ms.
Manuwa, who has suffered from fear, harassment, threats, domestic abuse, and trauma requires appropriate
counselling and a strong supportive network in order to rebuild a sense of security and self-worth.

The trauma, anxiety, and depressive symptoms that Ms. Manuwa is experiencing are not only harmful to her but
also to her three young children. Studies have shown that children living with an anxious or depressive parent
may not understand what is happening or why, and they may start to worry about their parent's well-being.
Children may also worry that their parent cannot properly care for them. Children may feel that their parent does
not care about them when the reality is that the parent is simply unable to emotionally or mentally engage in a
healthy way. People suffering from anxiety and depression often struggle with experiencing positive emotions
and may feel "cut off" from other people, including their own children. When a parent withdraws and has trouble
feeling positive emotions, children can inaccurately interpret this as the parent not being interested in them or
loving them, even though the parent may try to indicate otherwise. Irritability and low frustration tolerance can
make a parent seem hostile or distant, again making children question the parent's love for them.

I believe that Ms. Manuwa’s children are likely to experience significant stress and trauma if they are forced to
return to Nigeria, essentially removing them from the safety, stability, community, and sources of support they
now have in Canada. Extensive studies have shown that there are serious psycho-social ramifications of
uprooting young children from stable environments and moving them into a chaotic or insecure situation. The
research suggests that a breakdown of connections with peers, discontinuation of group activities, distress, and
worries related to the chaotic environment are potentially psychologically distressing events for children.
Frequent exposures to these events can be stressful and confusing and may affect their psycho-social well-
being. In an article written by Heather Sandstrom and Sandra Huerta in September 2013 titled The Negative
Effects of Instability on Child Development: A Research Synthesis, the authors state that “Children thrive in
stable and nurturing environments where they have a routine and know what to expect. Although some change in
children’s lives is normal and anticipated, sudden and dramatic disruptions can be extremely stressful and affect
children’s feeling of security”. The authors go on to say that “’Unbuffered’ stress that escalates to extreme levels
can be detrimental to children’s mental health and cognitive functioning”. Many variations of uncertainty can be
brought on by a young child’s sudden and extreme displacement from his or her home, uncertainties such as
economic, residential or family/childcare instabilities. The result is poor academic performance, a lack of social
competence, and an inability to regulate emotions. Even adult cognitive abilities have been shown to be impaired
in part by elevated chronic stress during childhood”.
If Ms. Manuwa and her children were to remain in Canada, a plan of medical and therapeutic care could be
implemented for Ms. Manuwa involving medication, proper counselling, and strategies which could help her
work through the depression, anxiety, and trauma she currently feels, which in turn would be very beneficial for
her children. Treatments such as Cognitive Behavioural Therapy (CBT), Psychological First Aid, Eye Movement
Desensitization and Reprocessing (EMDR), Interpersonal Psychotherapy, and specialized interventions have
proven to be very effective in treating people with trauma, anxiety, and depression. During our session, I gave
Ms. Manuwa psycho-education and feedback. I taught Ms. Manuwa a breathing technique to help her cope with
her anxiety and panic, as well as referred her to the Riverdale Immigrant Women’s Centre for ongoing therapy.

I hope this report will assist you in determining the best possible outcome for Kevwe Manuwa and her
children.
Sincerely,

Natalie Riback, RP, CTP Dipl, BA

Registered Psychotherapist
Registration #: 001193