Abstract
Forced displacement is a phenomenon that is as old as history itself. Almost as universal has been the secondary abuse of refugees. People forced into exile have been exploited, misrepresented and periodically terrorized for political gain. In the fourth century, during the power struggles between the Roman Empire and the Barbarians, refugees were dragooned into military service, used as key informants, exchanged for political favours, and, when scapegoats were needed, targeted for attacks by both sides [1].
As late as the end of WWII, refugees continued to remain in an ambiguous position in terms of their international rights to protection. The UN Refugee Convention of 1951, forged in the ashes of the Holocaust, for the first time committed the international community to provide humane and dignified refuge to persons fleeing persecution. Initially applied to European refugees, the Convention was supplemented by the Protocol of 1967 which extended protection to displaced people worldwide. The key commitment is to provide protection to those with well-founded fears of persecution for reasons of race, religion, nationality or political and social affiliations. Signatory countries include all Western Nations such as Australia. The Convention prohibits forcible repatriation to situations where lives or freedom are threatened. Although imperfectly applied, these international provisions have acted as a restraining force and a moral guide, ensuring that human rights remain at the centre of deliberations and practices affecting refugees.
Why has the Convention and its spirit lost its moral imperative in Australia in recent times? From a position where Australia was regarded as a leading advocate for refugees, it is now regarded as a renegade state. Is this crisis of concern to psychiatry? Can psychiatrists engage in collective action that will alter the situation? The first task is to understand recent developments in refugee policy.
Categories of asylum
Migration legislation and policies relating to asylum seekers have become complex. Australia allows entry of 12 000 persons per annum under its humanitarian programme, with the largest category being reserved for persons who apply for refugee status while residing in other countries. Asylum seekers seek refugee status after arrival in Australia.
Those arriving without legal documents are held in immigration detention centres with Australia being the only Western country that mandates the detention of this group. The strength of a person's refugee claim does not influence that outcome and no provision exists for an independent judicial test of the appropriateness of detention. People entering Australia with valid entry documents, the majority of asylum seekers, are allowed to live in the community while they pursue their refugee claims. Legislation, passed in haste prior to the Federal election in 2001, has expanded other categories, particularly for people offered ‘temporary protection’. These provisions have in effect created a new underclass, persons found to be genuine refugees but who are allowed to remain for an extended period without any rights of citizenship, permanent resettlement or reunion with immediate family. The other newly created category, excluded even more radically from scrutiny, are groups forcibly directed to detention centres in neighbouring Pacific Island nations. Concerns about their wellbeing and health add to the dilemma facing mental health professionals.
Hardening of policy
Why have psychiatrists become increasingly concerned about the plight of asylum seekers? The proliferation of detention centres in remote and inaccessible places, and the conditions in these institutions, have drawn the most attention. The long-term detention of children, including unaccompanied minors, has provoked criticism by successive commissions of inquiry. Escapes, riots, hunger strikes, protests and outbreaks of violence have recurred, raising questions about the destabilizing psychological effects of confining persons who by any standards have not committed a crime. Yet, in spite of advocacy, the official response has been one of intransigence.
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In a climate in which asylum seekers have been publicly vilified, disastrous mishaps were inevitable. While
A psychosocial perspective on displacement
Although a complex phenomenon, forced migration is associated with universal realities. The commonalities in suffering experienced by displaced people are far greater than differences associated with cultural, religious or geographical factors. In consulting with refugees, it is evident that people do not forsake their livelihoods, families and possessions unless there are compelling reasons. If anything, the reverse is more common – even under severe threat, most choose to delay flight as long as possible in the hope that stability will return. Once wars and other forms of mass conflict reach a level of intensity that threatens survival, however, a substantial flow of refugees is inevitable.
Flight is a fundamental survival mechanism, a reality that our leaders attempt to obscure by differentiating between ‘good’ and ‘bad’ refugees. It makes sense for survival that people will go to great lengths to seek safety for themselves and their children, particularly when faced with torture, harassment, imprisonment and violence. It is also natural to strive for conditions of life in which human dignity is respected and fundamental freedoms nurtured. In that respect, it is no coincidence that Australia is a destination for asylum seekers. Those fleeing oppression search for the rights they have been denied – to health, opportunities, justice and participation in a free society. For psychiatrists working with asylum seekers, the interdependence of the principles of human rights, mental health and social development is self-evident [2], yet current policies threaten each of these domains. Instead of freedom, asylum seekers are locked up; instead of being accorded respect and dignity, they are rejected as interlopers; instead of receiving opportunities to regain their autonomy, they face restrictions, enforced dependency, discrimination and marginalization.
Politics and reality
Asylum flows are characterized by peaks and troughs, waves that mirror the flux in levels of conflict and oppression across the globe. We are warned that Australia faces a ‘tidal wave’ of refugees, but in reality, the country remains relatively inaccessible to asylum seekers. Boat people numbers diminished in the 1990s (to 300 in 1997–1998), with a peak only in recent times [3]. The number arriving by air declined between 1998 and 2000. Even during periods of larger flows, the numbers have been modest. Between 1998 and 2000, 8000 asylum seekers were apprehended and detained, most for over 3 months, and a substantial number for over 6 months. In 2000–2001, over 5000 asylum seekers were granted residency visas, most on a temporary basis, adding to the 7000 refugees accepted as part of the regular humanitarian programme.
In contrast, many poor countries of Africa, Asia and the Middle East host millions of displaced persons. Nations of Europe and North America receive many more asylum seekers than Australia, with Germany hosting over 1.9 million between 1989 and 1998. Australia is often compared to Canada as a country of migration, but the latter has received three times more asylum seekers during the past decade than has Australia. Overall, Australia ranked 17 of 21 industrialized countries in the number of asylum seekers received in 1999. No wonder that overseas colleagues express bewilderment that Australia considers the asylum seeker issue to be a national problem.
Yet misrepresentation about asylum seekers abound. They are portrayed as ‘illegal’ and as ‘unlawful noncitizens’ [4] although the Refugee Convention enshrines the right of the forcibly displaced to seek protection. They are referred to as queue jumpers although there are no Australian embassies to lodge refugee applications in several countries from which they flee. It is paradoxical that the absence of consular ties is given as the reason for the indefinite detention of some asylum seekers since they cannot be returned to their home countries. Also, those who have patiently lodged claims with the UN in Indonesia and have had their status upheld, have not in general been offered places, making a mockery of the queue jumping argument.
Political capital has also been made of people smuggling, ignoring the reality that even the most conscientious people will resort to desperate measures to escape persecution. Few would quibble with the use of bribes and intermediaries to rescue the renowned psychologist Bruno Bettelheim from a Nazi concentration camp. Desperation calls for creative solutions.
Detention is justified as a form of deterrence, yet it is not clear who it is that should be deterred. If it is directed at genuine refugees, then the policy violates the spirit of the Convention. Claims lodged by detainees usually prove legitimate as reflected in the statistics showing that more claims are endorsed for those held in detention than for the asylum group living in the community. Thus, detention can have only one meaning – punishment of the innocent as a blunt tool to discourage others from arriving.
Mass psychology
What might be the motivations behind the political attack on asylum seekers? Their public image is replete with contradictions, with communal responses oscillating rapidly between compassion and hostility. Psychiatrists are familiar with the way in which fear and insecurity can produce such polarities in the mental projections of others. At a communal level, the arrival of boats laden with desperate people can confront us with our most primitive anxieties. They remind us that none of us is invulnerable to cataclysmic events outside our control, and that fateful circumstances could force any of us to flee our homes and families to conditions of statelessness and helplessness.
Political leaders sense these insecurities. They can either grasp the responsibility of leadership by encouraging compassion and assuaging fears or they can inflame latent xenophobic tendencies. Distancing, denial and blaming are mass psychological defences that can be readily invoked by rhetoric and propaganda. Yet the pendulum can swing rapidly. Kosovars are embraced as ‘good’ refugees but the arrival of Afghan asylum seekers is depicted as a threat to the fabric of Australian society. The ease with which asylum seekers can be targeted is a gauge of how defenceless they are, a stateless minority without the protection conferred by citizenship, and with no capacity to react except in desperate ways.
Propaganda is the enemy of reason and truth. Irrational connections have been encouraged between international terrorists and boat people, with the insinuation being that the latter themselves are terrorists. To the contrary, asylum seekers are fleeing the very regimes that Australia condemns as ‘terrorist’. Other misrepresentations abound. Allegations have been made that boat people deliberately threw their children overboard and set boats alight, assertions unsupported by evidence.
Evidence of special mental health needs
Perhaps the strongest claim that psychiatrists have for making a special contribution to the asylum seeker debate resides in our knowledge about the effects of trauma and displacement on mental health. Serious concerns have been raised about the well-being of child asylum seekers, particularly those in detention. A range of reactions in children have been observed including conduct disturbances, separation anxiety, night terrors, and enuresis. To these concerns must be added the general impediments to social and educational development of children spending protracted periods in detention. A full test of the extent to which detention transgresses international covenants relating to the rights of the child is warranted.
The picture in adult asylum seekers is complex. Those with pre-existing mental illnesses face special difficulties. Many have fled war-torn countries where, because of their persecuted status, they were barred from seeking professional help. Mental illnesses predating migration are likely to have been inadequately treated, with the stress of flight exacerbating symptoms. Yet, in Australia, those without access to health care entitlements may be denied mental health attention (see Appendix 2).
Access of asylum seekers living in the community to health care, including mental health services and counselling, has been investigated [5–7] with serious difficulties reported in obtaining both medical and psychiatric treatment. Successive policy changes have clarified eligibility criteria but as seen in the patient in Appendix 2, access to health care remains difficult for certain categories, especially for those who appeal against an adverse decision in relation to a refugee claim.
Displaced people are at high risk of posttraumatic stress disorders [8, 9]. Exposure to genocide, torture, sexual violence and incarceration in concentration camps or political prisons all increase risk [8, 9]. Research focusing on the asylum subgroup, much undertaken in Australia, is made more difficult by issues of dispersal and understandable hesitancies among asylum seekers to participate in studies. Access to detention centres has presented an almost insurmountable challenge, with authorities failing to endorse studies by independent investigators. Notwithstanding these challenges, several studies have been completed with a substantial convergence in results [10–11].
High levels of exposure to trauma have emerged among asylum seekers but with some variation according to ethnicity and background as would be predicted [12–14]. For example, exposure to murder varied between 27 and 92%; to personal life threat, between 44 and 88%; and to torture, 26–72% [7, 12, 15]. Ill-health without access to medical care in the country of origin varied between 32 and 83%. Traumas reported are consistent in type and intensity with those found among refugees worldwide, reinforcing the observation that asylum seekers differ only from their authorized counterparts insofar as they have used unconventional methods to reach safety.
Rates of PTSD, depression and anxiety in asylum samples were uniformly high. In a study based on attenders at the Asylum Seekers Centre in Sydney [10], onethird exceeded threshold scores for depression, a quarter for anxiety and 40% for PTSD. In a study of Tamils from Sri Lanka [11], asylum seekers reported three to fourfold levels of anxiety, depression and PTSD compared to immigrants from the same ethnic background.
Symptom rates of those in detention are extraordinarily high. A detained Tamil group [13] had high scores on suicidity, panic, depression, PTSD, somatic distress and anxiety. These findings are supported by a Villawood study [15] in which all but one of 33 participants were judged to have had a psychiatric disturbance, most often depression, at some point during detention. Depression worsened with time, particularly in response to key milestones in refugee determination process.
These observations are consistent with findings of previous studies among asylum seekers in the community [14]. Instead of gradual adaptation, the usual trajectory for most refugees once they reach a place of safety, asylum seekers tend to show a deterioration in psychological functioning, substantially attributable to imposed restrictions. The implications for mental health prevention are grave. Instead of providing a secure environment to overcome the impact of trauma and displacement, we apply policies that undermine the potential for recovery.
A broader ecological model
The mental health perspective as outlined needs to be located in a broader ecological framework of survival. Asylum seekers are trapped in a continuum of threat, with conditions fostering a convergence and compounding of insecurities from the past, present and future. Memories of past dangers and humiliations intermingle with current feelings of uncertainty; this, in turn, magnifies fears of future persecution should detainees be repatriated. Recollections of past imprisonment merge with recurrent feelings of outrage at being confined behind razor wire in the country in which the asylum seeker has sought freedom. Loss of control over one's personal life, an inescapable reality when living under repressive governments, is compounded by the regime of control in the detention centre. The future is perceived as being entirely in the hands of an impersonal bureaucracy, intensifying feelings of helplessness.
The testing of refugee claims can provoke anxiety and, in those previously subjected to interrogation, torture and other abuse, dissociative reactions [16]. During the inquiry, memories can become incoherent, interfering with the capacity to provide a consistent account. Yet, inconsistency is often cited as the reason to dismiss a claim. Tragically, the long arm of torture reaches beyond the torture chamber jeopardizing the survivor's chances of securing protection.
Rage, withdrawal, passivity, and recourse to desperate acts like hunger strikes, suicide threats and violence reflect the exhaustion of strategies aimed at achieving safety in the country of origin, during flight, and in the country where the asylum seeker hopes to gain refuge. A key element that can modulate the process is the persisting faith in a benevolent protector, invested in this instance, in Australia's reputation as a humane society. What made the 1951 Refugee Convention such a landmark was precisely the centrality it gave to the principle that somewhere in the world, people fleeing persecution can feel assured of achieving refuge. When this faith is eroded, particularly in long-term detainees, psychological disintegration is likely. Although it is accurate to diagnose profound depression in such cases, understanding of the underlying forces is also necessary: a capitulation to hopelessness when the detainee confronts the reality that security and a life with dignity are beyond reach.
A role for psychiatrists
Over the last decade, psychiatrists collaborating with other agencies, particularly torture and trauma services, have been active in assessing and treating asylum seekers; initiating development projects with marginalized groups, for example, the East Timorese [7]; developing position statements and guidelines under the College of Psychiatrists and other medical bodies [15]; writing reports to support refugee claims; providing expert opinions in court; researching psychiatric morbidity and access to health care [6, 12]; and using research findings to highlight relevant mental health concerns. Courageous stands have also been taken, for example, a Fellow working in the navy publicised his concerns about the conditions in which asylum seekers were transported to Pacific Island detention centres.
By 2002, advocacy had achieved little to improve the plight of asylum seekers. This is a matter for serious reflection. In an advanced country in which health experts have repeatedly brought to attention the risks to asylum seekers of existing policies, not only have concerns been ignored, but policies have been put in place to worsen the situation.
Such intransigence makes it imperative to document the mental health effects of current policies. This will help psychiatrists to serve as expert witnesses in courts and at commissions of inquiry. Moreover, other countries may be deterred from adopting Australia's calamitous approach. Researchers must be allowed access to asylum seekers including those in detention. Openness to scrutiny and transparency in the workings of government departments or their proxies are principles that are fundamental to a democratic society. Given the contentiousness of the situation, only research undertaken independently of government is legitimate. Advocacy to allow this work to take place is a key strategy being pursued by the College in conjunction with other specialist medical bodies.
Providing expert mental health reports to assist refugee claims is another major task. Obtaining sufficient numbers of professionals to write reports is problematic since it often has to be undertaken pro bono. Yet the value to the asylum seeker is inestimable. A wellreasoned account which assists in understanding issues such as dissociation under pressure, and in which links are drawn between past abuse, current mental state, and fears of persecution, are critical.
Ethical and professional hurdles impede efforts to help individual asylum seekers, particularly those in detention [17]. Repeated concerns have been raised by detainees about the mental health care they have received, including the prescribing of psychotropics for non-medical reasons, for example, to restrain and transport detainees. The psychiatric presence in detention centres can be exploited politically, allowing a claim that ‘everything’ is being done to assist inmates. My own experience in the mid-1990s is that one is easily compromised. A paradox confronts the psychiatrist at every moment: trying to help people whose reactions are clearly exacerbated by the imposed conditions of confinement. Even when permitted external treatment, the person is routinely handcuffed en route, with guards remaining in the waiting room or ward. This is not an ideal basis for establishing a trusting relationship. In offering treatment, psychiatrists must maintain total independence. It would be appropriate for a body like the College to consider establishing a panel whose members have no links with government and who undertake the task of monitoring the mental health of detainees and the treatments offered.
Working groups of psychiatrists will be necessary to sustain initiatives in a struggle that is likely to be gruelling and prolonged, particularly in a climate where the profession may be criticized. Forming partnerships with torture and trauma services, groups in other areas of health, the legal profession and advocacy groups is essential for sustaining a cohesive strategy. Links with relevant international agencies also need strengthening since the problem of asylum is universal.
A sense of powerlessness will still be experienced, especially when faced with systemic intransigence. It is important to remember that the pendulum is bound to swing. Ultimately, an unjust system is bound to collapse under the weight of its internal contradictions. As a humanitistic profession, we have a role to highlight at least one key contradiction – pursuit of public policies that directly undermine the mental health of an already vulnerable group.