eMJA: Sultan & O'Sullivan, Psychological disturbances in asylum seekers held in long term detention: a participant-observer account

Asylum seekers and healthcare

Psychological disturbances in asylum seekers held in long term detention: a participant-observer account

Confinement in immigration detention centres for extended periods of time can have severe, psychologically disabling effects on asylum seekers. Aamer Sultan is a medical practitioner who fled persecution in Iraq after providing casualty medical care to Shiite Muslim rebels. He has been detained in the Villawood Detention Centre, Sydney, since May 1999, as his claim for protection under the United Nations Convention has not been endorsed by Australian authorities. He can not be returned to Iraq because Australia currently has no diplomatic ties with Iraq and no international flights go to Iraq. As a health professional and a bilingual Arabic/English speaker, he has acted as a confidant for many detainees. His observations are supplemented by those of clinical psychologist Kevin O'Sullivan, who provided psychological treatment for over 50 asylum seekers during a recent 12-month contract with the same detention centre.

Aamer Sultan and Kevin O'Sullivan

MJA 2001; 175: 593-596
For editorial comment, see Steel and Silove

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Abstract - The environment of detention - Refugee assessment process - Cumulative effects on the mental state of asylum seekers - Effect on children -
Survey of detainees at Villawood - Conclusions - Authors' details

Abstract

The process of applying for refugee status in Australia is complex, lengthy and often poorly understood by asylum seekers.
The psychological reaction patterns of detainees whose claims for asylum are unsuccessful are characterised by stages of increasing depression, punctuated by periods of protest, as feelings of injustice overwhelm them. These reactions have a marked secondary impact on their children in detention.
The prolonged detention of asylum seekers appears to cause serious psychological harm. Even if many of those who spend long periods of time are not deemed to have proven their refugee claims, this administrative decision should not be grounds for inflicting grave ongoing psychological injury on the applicants.

Most of the asylum seekers detained at Villawood Detention Centre come from developing countries ruled by oppressive regimes with poor human rights records. Many have been victims of State-organised violence, including torture and other forms of inhuman or degrading treatment or punishment, or have family members who have suffered such abuses. Thus, they are at high risk of the range of post-traumatic psychological reactions widely documented among victims of mass trauma and organised violence. These background issues are relevant to the understanding of the impact of detention on asylum seekers' psychological state.

The environment of detention

On arrival in Australia, most asylum seekers hold strongly to the belief that their applications for protection are legitimate and most are confident that a just society such as Australia will accept the veracity of their claims for refugee status. After transfer to a detention centre, several factors converge to undermine this faith and hence the psychological stability of the asylum seeker. The most threatening aspect is loss of liberty for an indeterminate period of time — detention without trial imposed on people fleeing injustice in a context where no crime has been committed.

The average length of detention in Villawood in February 2001 was six months, although the duration varies from individual to individual and, for some, may extend for longer periods of time, with no maximum limit on the period of detention. Lengthier detention is particularly common for detainees who appeal against adverse decisions about their refugee status, or those who are unable to be deported from Australia (because they are stateless or from countries with no diplomatic ties with Australia, particularly Afghanistan and Iraq).

The physical environment at Villawood is intimidating in a number of respects. Each compound is surrounded by multiple layers of high fencing topped and grounded by razor wire. All visitors must pass through high security checkpoints. Within the detention centre, there are multiple daily musters and nightly head counts, which may occur at 2 AM and 5.30 AM. The public address system, which operates almost continuously from 7 AM to 9 PM, is also disturbing. For most of the previous two years, there has been a general dearth of activities, resources, or educational materials, leaving detainees with long periods of unstructured time. Despite recent improvements, boredom, aimlessness and apathy are widespread, particularly among those who have been detained for longer periods of time.

At times, we have observed harsh and uncompassionate handling of asylum seekers by staff. Detainees are routinely handcuffed during transportation to and from the facility for medical or legal appointments. Access to medical services sometimes has to be negotiated through correctional centre staff, especially after hours or during security incidents. Detainees may then perceive medical practitioners as being aligned with the detaining authorities and are concerned that this may hinder them in acting in their best interests. Concerns have been raised about doctors authorising sedative medication for containment and removal of detainees rather than for genuine medical reasons. Multiple complaints have been lodged by detainees with the Commonwealth Ombudsman, the Human Rights and Equal Opportunity Commission, and the NSW Health Care Complaints Commission about inadequacies in medical and dental care. Apart from official hearings and interviews, interpreter services are not generally available, leaving detainees with poor English isolated and unable to communicate.

During crisis periods, such as when hunger strikes or breakouts occur, detainees have been confined for long periods in their rooms, and denied access to phones, faxes, postal services, and visitors. The rules governing daily life seem arbitrary, changing from time to time, and from one detention officer to another. Some detainees have suffered intimidation and reprisals after acts of advocacy, protest or revolt. Authorities have instituted room searches, confinement in solitary cells, restrictions in receiving visitors, and obstacles to accessing legal representation or medical care. During a hunger strike in July 2000, all electrical power and water supplies to the cell block where the hunger strikers were residing were cut-off, affecting uninvolved women and children. As a consequence of these inhumane actions, the atmosphere at Villawood leads to fear, despondency and frustration.

It is within this context that the refugee determination process is undertaken. It is soon apparent to all detainees that their future depends on the procedures established to test their refugee claims, but the complex mechanisms and the legal processes applied are poorly understood by most asylum seekers. Given the context and conditions of their detention, asylum seekers find it difficult to distinguish between the authority of the company managing the detention centre (Australasian Correctional Management) and that of the Department of Immigration and Multicultural Affairs in reaching decisions about their refugee claims. It is a widely held belief by detainees that every action within the detention centre may be observed and may critically influence the outcome of refugee claims. This belief appears to be covertly encouraged by those operating the facility to increase their control over the detainees.

Refugee assessment process

In their testimonies and at interviews, asylum seekers have to recount in detail the most distressing moments of their lives, testimony that may be treated with doubt, suspicion and incredulity. It is little wonder that memories for details become blurred under such pressure, yet inconsistencies in accounts are often cited as the reason for rejecting a claim. Those people whose claims are rejected at this primary (Department of Immigration and Multicultural Affairs — DIMA) stage can appeal to the Refugee Review Tribunal (RRT). If the claim is rejected by the Tribunal, recent legislation has removed any right of judicial review. The final resort is to appeal to the Minister for Immigration and Multicultural Affairs for humanitarian consideration. Few of these appeals receive compassionate outcomes. (For a summary of the stages of application for protection visas, see Smith.)

As the period of detention continues, life is increasingly punctuated by feelings of loss and grief arising from the release of compatriots who have been successful in their refugee claims or the forcible removal from Australia of those who have been unsuccessful. These stresses are combined with the ever-present anxiety about the wellbeing of family members left behind. Some may experience guilt for having left their family to secure their own survival and protection, for not yet being able to work and send money home to assist their family, and for not being able to sponsor them to the safety of Australia.

Cumulative effects on the mental state of asylum seekers

Our observations suggest that there may be some common themes in the psychological reaction patterns of detainees over time. Each successive stage is associated with increasing levels of distress and psychological disability.

Non-symptomatic stage: During the early months of detention, before the primary refugee determination decision, the detainee is shocked and dismayed at being detained, but these feelings are mitigated by an unwavering hope that confinement will be short-lived and that their claim will be upheld.

Primary depressive stage: This follows the receipt of a negative decision by DIMA and the realisation by detainees that they face a serious threat of forcible repatriation or detention for an indeterminate period, or both. The clinical presentation is consistent with a major depressive disorder, with the severity closely related to pre-existing risk factors, such as premigration exposure to trauma or personal predisposition to depression. There may also be a reactivation or exacerbation of any pre-existing post-traumatic stress reactions from past abuses (eg, torture, incarceration in political prisons and other forms of persecution). The sense of injustice overwhelms many detainees, who enter a "primary revolt stage" of non-compliance and non-conformity. The nature of the revolt varies: some become protesters (engaging in hunger strikes and other non-violent demonstrations); others become advocates (attempting to raise public awareness about the realities of detention); and some become aggressors (engaging in confrontations, riots, detainee-guard conflict and interdetainee violence).

Secondary depressive stage: This typically follows the rejection of the asylum seeker's application by the Refugee Review Tribunal, the ultimate administrative level. The timing of this final rejection may vary, but generally occurs between six and 18 months after first being detained. This stage is associated with a more severe and debilitating depressive reaction, with a greater level of psychomotor retardation and/or agitation. There is a marked narrowing of focus to issues of self-preservation and survival and an overwhelming feeling of impending doom. Whereas before most asylum seekers confided in others about their personal lives and their concerns for family left behind, communication about these issues ceases almost entirely. Some asylum seekers will also enter into a secondary revolt stage that is less aggressive and largely associated with passive, non-compliant resistance and attempts to escape. Many asylum seekers will remain in this secondary depressive stage for the duration of their detention, but a significant number appear to progress to an even more serious state of debilitation.

Tertiary depressive stage: At this stage the detainee's mental state is dominated by hopelessness, passive acceptance and an overwhelming fear of being targeted or punished by the managing authorities. Affected detainees become self-obsessed and trapped in their predicament. Ties to other detainees that were once strong become fragmentary and in some cases disintegrate. There is a significant and chronic impairment in concentration, with detainees being unable to perform even simple tasks. The detainee's life can become dominated by paranoid tendencies, leaving them in a chronic state of fear and apprehension and a feeling that no one, including other detainees, can be trusted. Long periods of time are spent alone and some develop frankly psychotic symptoms, such as delusions, ideas of reference and auditory hallucinations. Chronic rage and resentment are directed at the detaining country and the host government. The most disturbed engage in self-stimulatory, stereotypic behaviours, such as repetitive rocking or aimless wandering. Postures and facial expression are consistently downcast and affected detainees may appear to be disengaged or dissociated from their physical environment. Some engage in repeated acts of self-harm or self-mutilation leading to acute hospital admissions.

Effect on children

Between 10 and 50 children are held at Villawood at any one time. The detention environment, exposure to actions such as hunger strikes, demonstrations, episodes of self-harm and suicide attempts, and forcible-removal procedures, all impact on a child's sense of security and stability. A secondary effect is mediated via the parents, whose ability to provide a caring and nurturing environment is progressively undermined as they pass through the stages outlined above, with risk of neglect and physical abuse of dependent children increasing across the course of detention. Following allegations of child sexual abuse at the Woomera centre, detaining authorities have increased their monitoring of parents at Villawood for evidence of negligence and abuse, leading to parental fears of their children being removed, which has further increased family insecurity. At times, children have also become negotiating pawns in attempts to contain protests within the detention centre. For example, on a number of occasions, the authorities have separated children from their parents to pressure adults to cease their hunger strikes.

A wide range of psychological disturbances are commonly observed among children in the detention centre, including separation anxiety, disruptive conduct, nocturnal enuresis, sleep disturbances, nightmares and night terrors, sleepwalking, and impaired cognitive development. At the most severe end of the spectrum, a number of children have displayed profound symptoms of psychological distress, including mutism, stereotypic behaviours, and refusal to eat or drink. Children of parents who reach the tertiary depressive stage appear to be particularly vulnerable to developing a range of psychological disorders.

Survey of detainees at Villawood

To support some of our participant-observer accounts, in August 2001 one of us (A S) conducted a survey of detainees who had been held for over nine months. Of the 37 people meeting this criterion, 33 agreed verbally to participate in the survey and to allow the results to be reported.

The survey consisted of a semi-structured interview based on previous observations. As most of these detainees had been held in Villawood since their arrival in Australia, A S was able to corroborate much of the information from his own longitudinal observations of each participant.

The detainees originated from 10 countries, with most being from Afghanistan, Iraq, Iran and the former Yugoslavia. The average period of continuous detention was two years, with the longest period being three years and 10 months. Most were men (85%), and over half were married (55%), with most of these being separated from their spouses on fleeing to Australia. Despite rejection of their refugee claims, over half reported being victims of gross human rights violations before arriving in Australia, enduring abuses such as physical torture (58%) and the murder or disappearance of immediate family members (30%).

All but one of the detained asylum seekers displayed symptoms of psychological distress at some time. At the time of the survey, 85% acknowledged chronic depressive symptoms, with 65% having pronounced suicidal ideation. Close to half the group had reached the more severe tertiary depressive stage. Seven individuals exhibited signs of psychosis, including delusional beliefs of a persecutory nature, ideas of reference and auditory hallucinations. Due to the severity of their psychological symptoms, hospitalisation has been recommended for some of these people by the centre health staff, but authorities have not approved this, except in medical emergencies after incidents involving self-harm. A few have been deported without receiving any appropriate care.

Conclusions

In drawing conclusions, we acknowledge the limitations of our report. A S is faced with the same challenges that other detainees encounter and it might be claimed that he is motivated to advocate not only for others but also for himself. The only counterargument we can offer is our commitment to reporting our observations in what we consider to be as objective and truthful a manner as possible. The observations are broadly consistent with those of other health and mental health professionals who work with detainees, either within the detention environment or on their release from detention.

It is therefore difficult to avoid the conclusion that the policy of mandatory detention of asylum seekers is leading to serious psychological harm. Even if many of those who spend long periods of time in detention are not deemed by the strict criteria enforced to have proven their refugee claims, this administrative decision should not be grounds for inflicting grave ongoing psychological injury on the applicants.

Authors' details

Aamer Sultan, MB ChB, Immigration Detainee, Villawood Detention Centre.
Kevin O'Sullivan, BSc, PhL, DipClinPsychol, Former Visiting Clinical Psycologist, Villawood Detention Centre.

Reprints will not be available from the authors.
Correspondence: Dr A Sultan, Villawood Detention Centre, Villawood, NSW 2163.

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