Abstract
In order to enforce the apartheid system, the South African governments of the time introduced draconian security legislation. Political expression was curtailed and the limited democratic process restricted along racial lines. Security laws such as detention without trial were in many ways an extension of a system that not only condoned, but also perpetrated organized violence against its own citizens. In contrast, Australia has a proud history of democracy, an independent judiciary and a system that, in the main, holds the individual rights of its citizens and non-citizens above the vested interests of the political leaders of the moment. Although the two political systems cannot be equated, the psychiatric and psychosocial issues raised by people detained under the migration regulations of the present Australian government, and those detained under the security legislation of the last apartheid government in South Africa, are similar in many aspects. There is, however, one fundamental difference. In South Africa, political detainees entered into the struggle expecting to face hardship and torture at the hands of the government of the time. Their incarceration had meaning and was seen as part of a legitimate struggle against tyranny. Asylum seekers flee to Australia expecting support from a democratic system and generally had not prepared themselves for further incarceration and yet another political struggle.
We present two cases scenarios. These case scenarios are representative of both the clinical experience of the first author (LFK) in his work with asylum seekers as part of his routine clinical practice in acute psychiatric units in Australia, and the experiences of psychiatrists who worked with political detainees as part of their routine clinical practice in acute psychiatric units in South Africa. While he did not directly work in the acute units to which political detainees in South Africa were admitted, the first author had many dealings with a fellow psychiatrist who did work in such a unit and is indebted to this colleague's willingness to share these experiences. The second author (ST) is a medical student, who has been exposed to this situation during her rotation through an acute psychiatric unit in Australia. Thus, although we will not be referring to two specific people, the case scenarios we describe will reflect the experiences of a number of people who have been subject to these conditions across the two countries.
Case scenario 1: the refugee detainee in Australia
Ms X was a 47-year-old woman. She escaped to Australia from a country ruled by a fundamentalist religious government. She had been religiously persecuted in her country for the last two decades because her particular religion was not classified as a holy religion by the government. This led to ruling religious fanatics believing that people of her faith were ‘sinners’ and ‘dirty’ and therefore it was justified to hurt, torture or kill them. They were also denied general rights, such as education or holding a job.
Prior to the change in government, Ms X had run her own small business. Shortly after the change in government, she was arrested while at work. Her shop was razed, and she was taken to court and given a substantial fine for refusing to adopt the mainstream religion. This led to her customers, neighbours and friends becoming aware of her religion, with many participating in her harassment, including throwing stones at her after her court case. Over the years, the secret service raided her house and beat her extensively. Over many years, her children were harassed at school, had their arms slashed for refusing to partake in religious rituals prior to prayer and were expelled from their schools.
Ms X eventually arranged for her two minor children and herself to be smuggled out of her country. She was told she was going to be taken to a country where she would be allowed to practise her religion and live without threat.
Ms X claims she was unaware of coming to Australia until she reached the borders and was taken to an urban detention centre.
She says her experiences in the detention centre have been dehumanizing and traumatic: ‘People treat their animals better than how we were treated.’ The riots in the detention centre and her exposure to riot police (and their uniforms) recreated her distressing experiences with the secret services in her country of origin. She witnessed people harm themselves and attempt suicide in public.
Amid these stressors, she learned after 3 months in the detention centre that her visa application had been refused. She and a number of other detainees organized a hunger strike. About 3 days into the strike their electricity and water were cut off. Ms X recalls being awoken by five security officers at 3 a.m. the following morning. Half an hour later she was escorted to a windowless cell. She was locked in: ‘Nothing… just four walls.’ By 5 a.m. she recalls feeling very cold. Other hunger strikers had been put into the cell with her until there were ‘six or eight women in a small room… they handcuffed us in such an awful way… like we were animals… and the officers kept swearing and spitting at us.’ Ms X recalls the guards removing a small covering blanket from her shoulder – her only protection from the cold.
When the detainees had been lined up, the guards wrote on their hands the letters ‘W’, ‘P’ and ‘S’. Guards would grab the hand of each detainee, and without a word, they wrote the letter on that person's hand. ‘Then they took us to the buses… back to the security people … with all their helmets… they cover themselves… they take us to another room… no-one knows where we are going… we're not allowed to talk to the officers.'
Ms X was transferred to a rural detention centre in another state. A few weeks later, her daughters joined her. Refusal of her second application a number of months later precipitated a serious suicide attempt. Once her daughters had left for school Ms X tried to hang herself with her bed sheet from a bar in the exercising quarters of the detention centre. Some detainees found her hanging and unconscious (after an unknown period of time) and cut her down. She was then resuscitated and flown to a hospital in the capital city of that state. After 2 days in intensive care she was admitted to the psychiatric ward of the hospital. ‘I tried to kill myself. There was no point to my life anymore… I wish they hadn't found me and pulled me down. I wish I had died.’
On admission to the psychiatric ward, it was clear that she was severely depressed, with anhedonia, insomnia, anergia, poor concentration, and feelings of worthlessness and excessive guilt toward leaving her extended family and adult children behind in her country of origin. She expressed ongoing suicidal ideation. She was also experiencing recurrent and intrusive distressing recollections, dreams, images and thoughts of the burning down of her shop and the assaults by the secret services. Prior to this she had tried to avoid situations where her recollections of the trauma were aroused, such as watching films that had police in them.
Although she was able to describe symptoms of major depression and posttraumatic stress disorder for many years, Ms X had not previously seen a psychiatrist. Over many years Ms X had suffered from chronic back pain. After the first refusal of her visa application, her back pain was exacerbated and led her to requiring a walkingframe. Ms X described herself as a law-abiding, strong, motivated, loving, friendly, sociable, polite and talented woman prior to coming to Australia.
Ms X was commenced on a course of antidepressants. Her back pain was stabilized with paracetamol and codeine, celecoxib and physiotherapy.
Very soon after her admission, the Department of Immigration and Multicultural and Indigenous Affairs (DIMIA) insisted that Ms X be independently examined by a psychiatrist of their choosing. This psychiatrist agreed with our assessment and management plan. DIMIA then indicated they would like another ‘independent’ psychiatrist to assess Ms X separately. Two months later no such psychiatrist had been sent to see Ms X.
For the first 2 weeks of her hospitalization, her daughters had been left behind in the detention centre. After they were brought to the city in which Ms X was hospitalized, they were placed into foster care by Family and Youth Services with a family who practised the state-sanctioned religion of her country of origin. Ms X was devastated: ‘Their beliefs are what we ran away from!’ However, because this meant that she could see her daughters daily and they would not be in the detention centre unaccompanied, she accepted this compromise. When Ms X learned that her daughters were being forced to follow the rituals and customs of that religion and barred from being able to participate in their usual recreational activities because these were regarded as sinful, she became very distraught. With the intervention of the treating team, her daughters were placed in a more suitable foster home.
In addition to concerns about the welfare of her daughters, the level of loneliness and social isolation also prevented Ms X's recovery and exacerbated her condition. The major reason for this was her inability to speak fluent English, which restricted her from establishing friendly relationships with the other patients. She was also unable to receive any visitors who could speak her native languages, as they had to obtain written permission for their visit from the DIMIA.
Ms X's level of depression and anxiety was also related to the news she would hear from her lawyer in terms of updates on the outcome of her visa application and on images of the detention centres on the television news. She was keenly aware that her prognosis was likely to be related to the status of her visa application. She was matter-of-fact when she stated that any return to the detention centre would result in her suicide.
These statements created considerable debate among the multidisciplinary team. There were those who felt that Ms X was not actually psychiatrically ill and that she was using the psychiatric system for her own political ends. A minority of the staff felt that she should be discharged back to the detention centre.
Two months after her admission Ms X was told that her and her daughters' visa application appeals had been refused by the Federal Court. Ms X was devastated, stating that she ‘could not take it anymore.’ She asked: ‘How much more do you expect me to wait? I know that I won't get a visa. Why should I wait to hear the devastating news?’ She reasoned that if she killed herself, her daughters would be granted visas as unaccompanied minors and that they would thus benefit from her death. Ms X also stated that if her visa application would be refused, upon deportation she would commit suicide, as she believed ‘it is a more respectful way to die in my own hands than to be taken to my home country and tortured.’
Case scenario 2: the political detainee in South Africa
Mr X was a 33-year-old man, the son of third generation migrants from India. After witnessing the shooting death of his then 16-year-old brother by riot police during a protest march, he became politically active. This resulted in his expulsion from his university course. Over the next 10 years Mr X became involved in the trade union movement, organizing a number of strikes and consumer boycotts. This brought him to the attention of the security police on a number of occasions. Under the security legislation at the time, he was repeatedly detained in security police custody. The longest period of detention was 6 months. Most of this time was spent in solitary confinement. At no stage was he brought to trial.
Two years prior to his psychiatric hospitalization, Mr X was served with a 5-year ‘banning order.’ Under the conditions of this order, he was confined to a magisterial district approximately 400 km from the major metropolitan area where he lived. He was not permitted to take part in any political activity. This included not mixing with anyone with whom he had previously been politically involved. As such, his girlfriend was not permitted to move with him. She remained with the trade union movement in the city. Mr X was unable to find work.
Six months into his banishment, Mr X was arrested for being outside his magisterial district. He had tried to travel back to the city to visit his girlfriend who had become depressed and suicidal. Two weeks after his arrest Mr X was told that his girlfriend had died in a motor vehicle accident. An hour after hearing this news, on a routine cell inspection, Mr X was found hanging from his trousers from the high bars in his cell. He was unconscious. After initial resuscitation, he spent 4 days in intensive care in one of the major city hospitals. During that time he was assessed by the psychiatric consultation-liaison team and transferred to the psychiatric ward once medically stable.
On admission to the psychiatric ward, it was clear that he was severely depressed, with anhedonia, insomnia, anergia, poor concentration, feelings of worthlessness and excessive guilt toward abandoning his girlfriend. He felt he should have been there to protect her. He had ongoing suicidal ideation. He was also experiencing recurrent and intrusive distressing recollections, dreams, images and thoughts of the shooting of his brother. He said he had not thought about it for many years, but since his detention these had resurfaced.
Mr X had not previously seen a psychiatrist. Over many years he had suffered from chronic back pain and headaches, related, he claimed, to assaults from the security police during his many periods in detention. Mr X described himself as a fun loving, laid back, friendly and sociable person prior to the death of his brother.
Mr X was commenced on a course of antidepressants. His back pain was stabilized with paracetamol and codeine, ibuprofen and physiotherapy.
Very soon after his admission, the security police insisted that Mr X be independently examined by a psychiatrist of their choosing. This psychiatrist felt that Mr X was not suffering from a psychiatric illness as such, but that he was using the psychiatric system for his own political ends. A significant minority of the multidisciplinary team agreed with this and suggested he should be discharged back to the security police. On more than one occasion, the consultant psychiatrist was issued with veiled threats by the security police that, by refusing to discharge Mr X, he was himself risking arrest.
Mr X was matter-of-fact when he stated that any return to detention would result in suicide. ‘This government is not going to change… I have no life… I have no future… perhaps my death will give others a future.’
Discussion
Were the detainees actually psychiatrically ill? With respect to refugees, Watters asked this pertinent question in a statement: ‘Rather than portraying refugees as “passive victims” suffering mental health problems, critics have argued that attention should be given to the resistance of refugees and the ways in which they interpret and respond to experiences, challenging the external forces bearing upon them’ [1].
While there was general consensus that the detention was associated with symptom manifestation and reexposure to detention would provoke continued symptom manifestation, attitudes and arguments among members of the multidisciplinary team, with regard to whether these symptoms represented genuine psychopathology or not, have been similar in both countries. On the one hand, there have been very sympathetic staff members who accepted that these patients were ill. They would generally fall into two camps, which were not mutually exclusive. There were those who saw the plight of the detained patients as an extension of their own political ideologies and were not shy to express their disgust with the government of the day. Others did not profess to hold strong political views, but clearly held strong humanitarian views and felt that, under these circumstances, a psychiatric diagnosis was not only appropriate but inevitable. There were also staff members who did not think these patients were psychiatrically ill. Once again they would generally fall into two camps, which were not mutually exclusive. There were those who had little doubt that these patients were malingering, and using the sympathy of the mental health system to further their own political ends. Others argued that, although the patients were not malingering, they could not be conceptualized as being mentally ill, as anyone would have been depressed under the circumstances. They felt it was not the role of the mental health system to protect these patients. These members of the multidisciplinary treating team, unlike Kendell [2], appeared to have very definite ideas about what constituted mental illness and of the boundaries of such a concept. Like their more sympathetic colleagues, they were often not shy to express their opinions. The role of psychopathology induced or exacerbated by the attitude of the treating team has become increasingly recognized [3–6]. It is extremely unlikely that patients do not pick up the tensions present in the multidisciplinary team.
Indeed, the arguments were, in both countries, not confined to the treating team. In both countries, politicians have questioned the clinical judgement of the treating psychiatrists, albeit in Australia not as directly or with the veiled threats that the security police in South Africa used. Also, in Australia the search for ‘independent’ psychiatrists by DIMIA has been notably less successful than the use of ‘independent’ psychiatrists by the apartheid security apparatus. As strictly regulated medical professionals, directly or indirectly reliant on the government of the day, for the effective practice of our chosen field, what role(s) can we be expected to take? With respect to the present situation regarding asylum-seeking detainees in Australia, Silove et al. state: ‘The medical profession has a legitimate role in commenting on the general and mental health risks of imposing restrictive and discriminatory measures on asylum seekers, especially when some of these administrative procedures threaten one of the fundamental principles underpinning the practice of medicine: primumnon-nocere’ [7]. They argue that when the asylumseeking detainee becomes a psychiatric patient, the role of the clinician is not straightforward, and confrontations may ensue (e.g. as to whether the patient is transported to a treatment facility in handcuffs). The ethical dilemmas such as being seen to cooperate with immigration officials in providing care for detained asylum seekers may be particularly problematic. With respect to the situation in apartheid South Africa and the medical management of political detainees, Strauss raised five questions related to these and similar issues: (i) What is the position of political detainees as opposed to those imprisoned under other legislation? (ii) Is the clinical independence of the treating practitioner guaranteed by law? (iii) What are the implications for the duty of confidentiality to the patient in regard to medical examination and treatment of detainees? (iv) How does the clinician deal with direct interference of treatment by government officials? (v) Should medical practitioners be involved in the treatment of detainees at all [8]?
In their important article, Steel and Silove [9] eloquently capture the damage the policy of mandatory detention of asylum seekers can inflict, not only on the individual but also on the society that appears to perpetuate and approve of such a policy. The medical and psychiatric profession, as a complex and integral part of that society, is frequently expected to take a leading role in managing the effects of such policies, and their representative bodies may find themselves condemned for not speaking out vociferously. Indeed, they may be viewed by future generations to have actively colluded in the discriminatory policies of the government of the day. Sashidaran and Platt, in their invited commentary on Domisse's criticism of the role of psychiatry in apartheid South Africa, went so far as to say: ‘any set of professionals who actively collaborate with a government whose policies in the health care field are racially discriminatory (by choice and not by ignorance or by default) are clearly in violation of all existing codes of medical ethics.’ Their argument was that by passively adopting the policy of separate development in health care, South African psychiatry was reinforcing the ‘prevailing political dogma’ of apartheid [10]. In the Australian context Steel and Silove pose the question as to whether we will be seen not to have examined closely enough policies that try to protect a ‘national way of life that requires, as its cornerstone, the exclusion, punishment and confinement of those fleeing persecution’ [9]?
Depression associated with detention is a particularly complex problem. Levin [11] and Sultan and O'sullivan [12] expand on the psychological aspects of the process of detention. With reference to South African political detainees during the apartheid era, Levin coined the ‘DDD syndrome’ of ‘debility, dependency and dread’ experienced by the detainee in response to the ‘uncontrollability, unpredictability and unaccountability (UUU)’ of the system that perpetrated the detention [11]. Sultan and O'sullivan, with reference to the experience of asylum seeking detainees in Australia, share a strikingly personal account of a ‘debilitating depressive reaction’ and an ‘overwhelming feeling of impending doom’ as the detainee's mental state progressives to the ‘tertiary depressive stage’ which is ‘dominated by hopelessness, passive acceptance and an overwhelming fear of being targeted or punished by the managing authorities’ [12]. The perpetuation of their sense of hopelessness and helplessness ensured that theirs were not depressions that would be amenable to treatment with antidepressants alone. The successful treatment of their depressions would almost entirely be dependent on the successful resolution of their visa applications or the gaining of their freedom.
Even in the absence of physical torture, detention can be seen as punishment and torture [11], [13]. McGorry is direct: ‘the ambient stress and trauma of the detention environment is not only non-therapeutic but frankly toxic’ [13]. Posttraumatic stress disorder (PTSD) has been well described in detainees and victims of torture [10],[14–20]. Many cases of PTSD were seen in both countries. There was one fundamental difference. In South Africa, political detainees entered into the struggle expecting to face hardship and torture at the hands of the government. Their incarceration had meaning and was seen as part of a legitimate struggle. Nevertheless, they frequently had a history of torture, solitary confinement and traumatic loss, even prior to the detention that resulted in the hospitalization. Although aware of hardships ahead, the latest detention was often seen as the event that triggered the symptoms of PTSD. Asylum seekers flee to Australia expecting support and were not prepared for further incarceration and another political struggle. Many had a history of torture and trauma in their country of origin. The circumstances of their migration were often traumatic. They experienced further traumas and losses following relocation. Their recollections of traumatic events were often triggered by their unexpected detentions and unforseen experiences in the detention centre. Did this provoke a qualitative or quantitative difference to their respective experiences of the symptoms of PTSD compared to their South African counterparts? This needs systematic research. Our anecdotal observations were that the learned helplessness provoked by the detention process was similar, regardless of whether the suffering was to be expected. However, the South African detainees did not appear to express the same sense of futility and incredulity as the Australian detainees.
Although many detainees in Australia have been found to be ‘genuine refugees’, their eligibility to receive permanent protection has not been recognized. While awaiting the outcome of their appeals, they are often granted ‘temporary protection visas.’ They fit into ‘… 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’ [17]. These detainees become ‘non-people’. Outside the protection of the hospital to which they have been admitted, they are denied privileges or rights. They become a de facto prisoner in the hospital. Many of the political detainees in South Africa were issued with ‘banning orders’ that confined them to certain magisterial districts. Their movements, ability to work and interaction with others were severely curtailed. Without the benefit of a trial, they were effectively barred from becoming productive members of society. These ‘banning orders’ were for a finite period, usually 5 years. In Australia the length of the refugees' ‘non-person’ status may remain undefined.
The resilience shown by Mr X, and people like him, was remarkable. Given their immense strength of character, as well as their commitment and courage, they had much to offer and teach the South African community also. The resilience shown by Ms X, and people like her, is remarkable. Given their immense strength of character, as well as their commitment and courage, they have much to offer and teach the Australian community.
Footnotes
Acknowledgements
We thank an anonymous colleague for the valuable descriptions of the experiences of detainees in South African hospital settings.