eMJA: Steel & Silove, The mental health implications of detaining asylum seekers

Asylum seekers and healthcare

The mental health implications of detaining asylum seekers

In the year when we should be celebrating the 50th anniversary of the United Nations Refugee Convention, we appear instead to be ignoring the lessons of history

Zachary Steel and Derrick M Silove

MJA 2001; 175: 596-599

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Abstract - Recent independent inquiries into detention - Research studies - Discussion - After September 11 - References - Authors' details

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Abstract

The possible mental health impact on asylum seekers of Australia's policy of mandatory detention is an issue of special relevance to health professionals and the public.

Independent commissions of inquiry in Australia have found varying degrees of mental distress to be common in detained asylum seekers.

Research studies in Australia and elsewhere suggest that detained asylum seekers may have suffered greater levels of past trauma than other refugees, and this may contribute to their mental health problems, with their detention providing a retraumatising environment.

Studies are urgently required to examine the mental health consequences of detention, and to determine the effect of detention on acculturation and adaptation for asylum seekers subsequently released into the community.

Australia is the only Western country that enforces a policy of mandatory detention for asylum seekers arriving without entry documents. This policy is noteworthy given the fact that Australia receives only a small number of asylum applications (12 700 in 1999-2000¹) compared with most European countries (Germany, 117 650; the Netherlands, 43 900; Belgium, 42 690; France, 39 780; Switzerland, 32 430 in 2000), the United Kingdom (75 680 in 2000), the United States (91 600 in 2000) and Canada (34 250 in 2000).² On a per capita basis, Australia was ranked 17th out of 21 industrialised countries in terms of the absolute number of asylum applications received during 1999.³ Because of Australia's policy, the possible mental health impact of mandatory detention on asylum seekers is an issue of special relevance to Australian health professionals and the wider public.

Sultan and O'Sullivan,⁴ provide a picture of the daily difficulties and mental reactions experienced by detained asylum seekers in Australia. Their documentation represents a unique convergence between the observations of an "insider" — a medical practitioner detained at Villawood Detention Centre, Sydney, since May 1999 — and those of a mental health professional who has worked in the same facility.

We focus here on several key areas raised by Sultan and O'Sullivan:

the mental health implications of detaining people who have previously been exposed to trauma including torture;
the patterns of mental and behavioural responses manifested by detainees; and
the possibility that conditions of detention may act to retraumatise those who are held for indeterminate periods.

In assessing these issues, we will draw on the findings of recent inquiries into the policy of detention and also on the small number of empirical studies investigating the mental status of detainees.

Recent independent inquiries into detention

A comprehensive inquiry undertaken by the Human Rights and Equal Opportunity Commission⁵ found that mental distress in varying degrees is a common manifestation in detained asylum seekers, with "a large number of detainees experiencing mental health problems". Factors regarded as increasing the risk of mental distress included prior experiences of torture or other forms of persecution in the country of origin, the stresses created by the length and conditions of detention, and the feelings of anxiety and desperation in those whose refugee claims are rejected. The report noted that suicide attempts by asylum seekers are not infrequent, with "numerous examples of detainees attempting suicide or serious self-harm" being cited in incident reports. This inquiry also found "evidence of violence between detainees, especially within families, as well as between detainees and custodial officers", and concluded that there was "considerable tension created by the regime of control necessary to implement the policy of mandatory detention". The evidence suggested that the indeterminate nature of the detention made it considerably more difficult to endure.

Of particular concern to the Commission was that there were no formal procedures to identify people who needed specialist care, such as survivors of torture and other forms of extreme trauma, or people at risk of suicide. In a subsequent report, the Commission concluded that the "balance between security and care is undermined by the contractual arrangements between DIMA [the Department of Immigration and Multicultural Affairs] and ACM [Australasian Correctional Management — the private contractor]", and the increasing emphasis on security ("multiple musters, night curfews") can be traced to this imbalance.⁶

An independent inquiry by the Commonwealth Ombudsman found evidence from credible witnesses about "the inappropriate use of force, unnecessary "trashing" of rooms for no apparent reason and the alleged harassment of detainees by some [ACM] staff".⁷ The report concluded that "long-term detention of immigration detainees is a source of frustration, despondency and depression often resulting in drastic action being taken by the detainees". Evidence of self-harm, damage to property, as well as fights and assaults, suggested "systematic deficiencies in the management of the detainees".⁷

A similar set of concerns emerged from a report by members of the Parliamentary Human Rights Sub-Committee.⁸ According to the report most committee members were shocked by what they saw during their visits to the centres: "the physical impact . . . the double fences, [the] barbed wire". Inside the centres, committee members were struck by the despair and depression of some of the detainees, and "their inability to understand why they were being kept in detention in isolated places, in harsh physical conditions with nothing to do". The Committee found that medical treatment was not always satisfactory, educational facilities were limited and the range of activities was inadequate for the number of detainees. The report also highlighted the negative psychological impact of prolonged detention, pointing out that "those who had been at Woomera [detention centre] for three or four weeks, for example, were notably less tense and depressed than those who had been at Curtin or Port Hedland [detention centres] for a year or more".⁸

Research studies

Several clinical observations have been published about the general plight of asylum seekers in detention in Australia,^9,10 with some focusing on specific issues such as hunger strikes.¹¹ More systematic studies are relatively scant, largely because of problems of access to the centres by researchers.

A survey in mid-1995 of 17 East Timorese held at the Curtin Detention Centre, in Victoria, for 1-3 months found substantial levels of premigration trauma, including random and unprovoked harassment, torture and physical assaults, and being arrested and/or detained under harsh conditions.¹² All 17 East Timorese were found to be suffering from posttraumatic stress disorder (PTSD), 16 were depressed and 11 suffered from severe anxiety.

Thompson and colleagues reported a survey of 25 detained Tamil asylum seekers held at Maribyrnong Detention Centre, Victoria, during 1997 and 1998.¹³ The results were compared with those of a parallel community-based study of Tamil asylum seekers, immigrants and resettled refugees living in New South Wales.¹⁴ Detained asylum seekers reported extensive trauma histories: 18 were victims of torture; 23 had witnessed the murder of family or friends; and 22 had been threatened with death at some time.

Detained asylum seekers reported exposure to an average of 12.4 (of a possible 16) major trauma categories, compared with 4.8 for asylum-seeker compatriots residing in the community. Compared with the community group, the detainees were more depressed, suicidal, and suffered more extreme post-traumatic panic and physical symptoms. Levels of past trauma exposure did not account entirely for the symptomatic differences across comparison groups, suggesting, albeit indirectly, that the immediate conditions of detention might be contributing to the mental health problems of detainees.

Although Australia is the only country that has adopted a policy of mandatory detention, a number of other countries, including the United States and the United Kingdom, detain asylum seekers considered at high risk of absconding or asylum seekers at various stages of the asylum-seeking process.¹⁵ In the United Kingdom, a group of 10 detained asylum seekers, six of whom had been tortured previously, were all found to be clinically depressed, manifesting appetite loss and multiple somatic complaints. Four were suicidal, with two having made suicide attempts while in detention.¹⁶ Another UK study found high levels of past trauma, including systematic torture, and ubiquitous depressive, posttraumatic stress, as well as suicidal symptoms, in 15 detained asylum seekers.¹⁷ The investigators observed that "a profound sense of injustice characterises detainees' views of their reception and treatment . . . detention is seen as punitive, hostile and unfair".

Discussion

In recording trauma histories, there is always a risk of retrospective bias, particularly when there is potential for gain, for example to advance a refugee claim. However, exposure to past trauma does not, in itself, provide grounds for claiming asylum. The key criterion is proving threat of future persecution. In addition, consistency in reports of trauma across various samples of asylum detainees, corroborated by the indepth investigations of successive commissions of inquiry, makes it difficult to avoid the conclusion that at least a portion of the detained population have been subjected to extreme forms of previous persecution, including incarceration in political prisons and torture. One study found that detainees may have suffered greater levels of threat and trauma than other refugees,¹³ suggesting that those under most threat tend to leave their home countries in haste, often without documents, thereby increasing the risk of being detained on arrival in Australia. (This conclusion is supported indirectly by statistics provided by the Department of Immigration and Multicultural Affairs which show that over 85% of recent detainees have been found to be genuine refugees fleeing from persecution, an endorsement rate that is higher than that for refugee applicants living in the community.¹⁸)

Sultan and O'Sullivan's account of past trauma among detainees thus appears to be credible.⁴ Their observations need to be considered in the light of conclusive evidence that extreme trauma associated with human rights violations constitutes a potent risk factor for a variety of mental disturbances, including PTSD, depression and anxiety.^19,20 A consistent dose-effect relationship has emerged from epidemiological studies of refugees, with greater levels of trauma exposure incrementally increasing the risk of mental disturbance.¹⁹ In refugees with comorbid disorders, particularly major depression and PTSD, the impact on psychosocial functioning is particularly severe.²¹ Furthermore, certain forms of trauma, particularly torture and incarceration in political prisons or concentration camps, appear to be particularly injurious to subsequent mental health.^20,21 Yet, according to successive commissions of inquiry into detention in Australia, there is no policy in place to systematically assess the psychological needs of detainees who have suffered trauma or to offer them special consideration in relation to early release.

The mental suffering of detainees identified by Sultan and O'Sullivan is not only consistent with the findings of recent research studies, but also paints a more complete picture of the way asylum seekers react at particular milestones in the asylum-seeking process.⁴ The close association between administrative procedures and psychological reactions is particularly worrisome, as it endorses the concern that these procedures, in themselves, act to undermine the psychological well-being of detainees. Although symptoms of depression and PTSD loom large in all recorded accounts, Sultan and O'Sullivan highlight additional features, such as extreme anger and resentment, self-destructive urges, profound social withdrawal, bitterness and alienation, and interpersonal conflict. These accounts of the wider adaptive difficulties triggered by conditions of threat, frustration, dehumanisation and confinement are reminiscent of those observed in survivors of concentration camps after World War II.²²

A critical issue is therefore the extent to which the detention environment itself is a direct contributor to psychological distress, either de novo or as a retraumatising influence. There is growing evidence that refugees rendered psychologically vulnerable by past trauma are at greater risk of PTSD if they are exposed to further trauma or adverse conditions.²³ For clinicians, there is little doubt that exacerbations of PTSD occur under stress, especially when people are exposed to salient triggers that remind them of the conditions of past trauma. Conversely, it is well accepted that the provision of a safe, supportive and predictable environment is instrumental to recovery for those suffering early psychological reactions to mass trauma.²⁴ Early recovery is important, as there is some evidence that the longer PTSD symptoms persist, the less potential there is for remission.²⁵These more general observations in the field of traumatology support the contention raised by Sultan and O'Sullivan⁴and others¹⁰ that environmental, procedural, and legal stressors associated with detention may converge to undermine the mental well-being of detainees, particularly those who have suffered past persecution and trauma.

Longitudinal studies are urgently needed to examine more definitively the possible mental health consequences of detention, an imperative supported by a recent public statement by the Australian Medical Association (for a summary of the AMA's statement, see Smith). Of particular concern is the possibility that detention may leave long term psychological scars that may impede the process of acculturation and adaptation when asylum seekers are released into the community — the outcome for a majority of cases.

After September 11

We have focused here on the mental health implications associated with the detention of asylum seekers. Elsewhere, we have considered some of the broader human rights concerns associated with detention, and the social and political implications of contemporary refugee policies.^26,27 The paradox of contemporary refugee policies has been thrown into stark relief by the world crisis precipitated by the terrorist attack on September 11. On the one hand, there is bipartisan political support in Australia for an international war against terrorism. At the same time, those fleeing from terrorist States are treated as criminals when they reach our shores. Also, in supporting war, we should not forget that one of the most certain outcomes is a large flow of refugees seeking asylum.

Yet, our leaders have gone to unprecedented lengths in recent times to deter asylum seekers by confining them in detention centres in economically poor island countries to our north, thereby incurring criticism from the United Nations and other international agencies.

Australia is a signatory to the Refugee Convention, a landmark international instrument committing ratifying countries to providing humane protection to persons fleeing persecution worldwide. In the year when we should be celebrating the 50th anniversary of the Convention, we appear instead to be ignoring the lessons of history. In so doing, we risk travelling full circle to the pre-Holocaust era. At an international meeting on the refugee crisis in Europe in 1938, Australia expressed its vociferous opposition to resettling Jews and others fleeing the Nazi terror — all in the name of defending our racial homogeneity and our "way of life". The outcome was the most destructive genocide of all time. Socrates once proclaimed that an unexamined life is not worth living. Are we examining closely enough a national "way of life" that requires, as its cornerstone, the exclusion, punishment and confinement of those fleeing persecution?

References

Department of Immigration and Multicultural Affairs. Humanitarian Program http://www.immi.gov.au/statistics/publications/popflows/c2_4.pdf (accessed November 2001).
United Nations High Commissioner for Refugees. 2000 global refugee trends: analysis of the 2000 provisional UNHCR population statistics. Geneva: UNHCR, 2001.
United Nations High Commissioner for Refugees The state of the world's refugees: fifty years of humanitarian protection. New York, NY: Oxford University Press, 2000.
Sultan A, O'Sullivan K. Psychological disturbances in asylum seekers held in long-term detention: a participant-observer account. Med J Aust 2001; 175: 593-596.
Human Rights and Equal Opportunity Commission. Those who've come across the seas: The report of the Commission's Inquiry into the detention of unauthorised arrivals. Canberra: HREOC, 1998: 167, 153, 154, 218. Available at: http://www.hreoc.gov.au/pdf/human_rights/asylum_seekers/h5_2_2.pdf (accessed November 2001).
Human Rights and Equal Opportunity Commission. 1998-99 Review of immigration detention centres. Canberra: HREOC, 1999: 12. Available at: http://www.hreoc.gov.au/pdf/human_rights/asylum_seekers/idc_review.pdf (accessed November 2001).
Commonwealth Ombudsman. Report of an own motion investigation into the Department of Immigration and Multicultural Affairs' immigration detention centres. Canberra: Commonwealth Ombudsman, 2001: 26, 20, 2. Available at: http://www.comb.gov.au/publications_information/Special_Reports/IDCMarch.pdf (accessed November 2001).
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Authors' details

School of Psychiatry, University of New South Wales, Sydney, NSW.
Zachary Steel, MPsychol, Adjunct Lecturer;
Derrick M Silove, MD, Professor.

Reprints will not be available from the authors.
Correspondence: Mr Zachary Steel, Psychiatry Research and Teaching Unit, School of Psychiatry,
University of New South Wales, Level 4, Health Services Building, Liverpool Hospital, Sydney, NSW. z.steelATunsw.edu.au