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Seeking asylum in Australia: Immigration detention, human rights and

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DOI: 10.1177/1039856213491991 · Source: PubMed

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491991
2013
APY21410.1177/1039856213491991Australasian PsychiatryNewman et al.

AP
Dimensions of trauma

Australasian Psychiatry

Seeking asylum in Australia: 21(4) 315­–320

© The Royal Australian and
New Zealand College of Psychiatrists 2013

immigration detention, human Reprints and permissions:

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DOI: 10.1177/1039856213491991
rights and mental health care apy.sagepub.com

Louise Newman  Director, Centre for Developmental Psychiatry and Psychology, Monash University, Clayton, VIC, Australia
Nicholas Proctor  Chair, Mental Health Nursing, Division of Health Sciences, School of Nursing and Midwifery, University of
South Australia, Adelaide, SA, Australia
Michael Dudley  Senior lecturer, School of Psychiatry, University of New South Wales, Kensington, NSW, Australia

Abstract
Objective: The article aims to discuss the impact of mandatory detention and human rights violations on the men-
tal health of asylum seekers and the implications for psychiatrists and health professionals.
Conclusions: Advocacy for human rights and engagement in social debate are core ethical and professional respon-
sibilities. Clinicians need to maintain a focus on ethical obligations.

Keywords:  asylum seekers, Australia, detained children, detention, ethics, human rights, immigration policy,
mental health care, refugees, stress, trauma

M
andatory detention of asylum seekers arriv-
ing by boat in Australia continues to pro-
voke debate and concern. This is despite the
right to seek asylum being enshrined in the Universal
Declaration of Human Rights. This paper reviews
the mental health implications of current Australian
national policy. It posits the evolution of mental dis-
tress and despair as a clinical correlate to national pol-
icy, and how a series of high-profile cases prompted
reform in this area. The paper also raises key issues
pertaining to the intersection between human rights,
mental health and the ethics of clinical care in the
detention environment. Given the overwhelming con-
firmation of a system that is harmful to both detain-
ees and employees, closer scrutiny of clinical practice
within the detention setting and an overall re-thinking
of current policy is essential.
Policy, political and legislative context:
an overview
The United Nations (UN) estimates that 43.7 million peo-
ple are now displaced worldwide, of whom 15.4 million
are refugees and 837,500 are asylum seekers.1 Australia
currently accepts around 13,000 refugees per annum,
under the Refugee Humanitarian Program. Australia pro-
cesses only 2.2% of the asylum claims made to 44 indus-
trialised countries.1
Australia, as a signatory to the Refugee Convention
(1951), has the obligation to assess refugee claims; how-
ever, for over a decade public and political controversy
has surrounded the management of the asylum-seekers
arriving by boat. The current national policy is to auto-
matically detain asylum seekers who arrive by boat.
Applying to all the so-called unauthorised boat arrivals
since its introduction in 1992, the mandatory detention
policy has impacted more than 20,000 adults and chil-
dren. Under current immigration law, Australia detains
all asylum seekers (child and adult) arriving without
documentation in designated facilities, including off-
shore centres on Nauru and Manus islands. Both major
political parties have upheld this policy, asserting it has
significant deterrent value by communicating to unau-
thorised arrivals that seeking asylum by boat does not
automatically result in freedom nor entry to Australia.
In conjunction with mandatory detention, the govern-
ment initiated remote and/or offshore reception and
processing of asylum-seekers, excised offshore islands
from the migration zone and intercepted boats. Like
Correspondence:
Professor Louise Newman, Centre for Developmental
Psychiatry and Psychology, Monash University, C/- ELMHS,
Monash Medical Centre, 246 Clayton Road, Clayton VIC
3138, Australia.
Email: louise.newman@monash.edu

315
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mandatory detention, remote and offshore processing
aims at deterrence; however, processing in these loca-
tions makes effective health and mental health service
provision difficult and reduces visiting, public scrutiny
and external review.
What is clear is that the impact of mandatory detention
on vulnerable populations is central to current debates
and raises key issues concerning human rights and pro-
fessional ethics. The importance of documenting policy-
related harms again assumes high priority. Professional
bodies and clinicians face complex ethical dilemmas
while attempting to advise the government of the risks
of maintaining the policy and its long-term health con-
sequences for those whom are eventually released.
The context and setting of immigration detention is not
a therapeutic environment. Professional integrity of
clinical practice and policy advice in this context and
the challenge of maintaining a values-driven approach
to research and publication are critical.
Overview of immigration detention,
mental health and clinician
involvement
Mental health professionals have played a major part in
raising clinical and ethical concerns regarding the
impact of mandatory detention, including for children.
Asylum-seekers have often made a fraught decision to
leave home, culture and family. For unaccompanied
minors, there is the burden of sustaining their culture
and future alone. Disappointment about slow process-
ing times and release aggravates their feelings of power-
lessness and abandonment. For survivors of torture and
trauma, the un-empathic and intrusive responses of an
inflexible regime can revive traumatic memories, trig-
gering distress, anxiety and anger; which may be
expressed as interpersonal conflict with the staff in the
detention areas.
Researchers and clinicians became increasingly involved
in clinical practice and policy advocacy during the oper-
ation of remote facilities in Woomera and Baxter, in
South Australia, in the early 2000s. Behavioural distur-
bances, riots, self-harm and suicidal behaviour became
endemic, reflecting detainee distress, frustration and
despair at their powerlessness and the prevailing culture
of disbelief, blame and punishment.2 The psychological
impact on children, 3000 of whom were detained during
this period, prompted community concern and protest.3
Various official inquiries and publicised cases of children
with severe psychiatric disturbance and developmental
problems heightened concern.4,5
For many clinicians, the need to intervene and advocate
on behalf of detainees raised questions about the
boundaries of professional responsibility and the moral
duty to oppose damaging Australian Government pol-
icy, despite personal and professional risk. Gathering
evidence about the mental health impact of detention
316
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Australasian Psychiatry 21(4)
became strategically important. Several independent
studies find that mandatory detention is associated
with psychological harm.6–8 Researchers and clinicians
alike found themselves in a highly politicised environ-
ment. This raised issues of the ethics of researching
detained populations and the need to advocate for sys-
tems reform, on the basis of findings.
Research on detained populations is necessarily com-
plex, involving consideration of the appropriateness of
detention and the political system within which deten-
tion occurs. As a clinician and researcher, there is a moral
imperative to expose human rights violations and abuses
of vulnerable individuals and groups. Thus, research in
this context cannot be value-free: a strong argument
supports making explicit the values that underlie and
influence the research agenda. Researchers may strategi-
cally highlight the predicament of detained asylum
seekers by documenting mental health impacts of deten-
tion, while simultaneously critiquing detention policy
and practice.9 The ideal, therefore, is that such research
be conducted independently of the Australian
Government, with appropriate independent ethics com-
mittee scrutiny and approval.10 Findings must be pub-
lished after peer review is complete. While conducting
research in the face of resistance and sometimes more
blatant attempts at censorship remains difficult,11 the
integrity of this audit trail is vital for democratic and free
debate about policy reform and better practice.
Prolonged detention, non-resolution of refugee status
and uncertainty about the future emerge as major con-
tributing factors for persistent anxiety, depression,
increasing hopelessness and mental deterioration.12,13
Several reports noted high rates of self-harm amongst
detainees and forms of symbolic protest, such as mouth-
sewing. Self-harm may represent protest, frustration and
suicidal ideation, while suicidal intent is often difficult
to assess. The government and the detention system
have tended to label all such behaviour as ‘attention-
seeking and manipulative’, lacking in serious intent, and
denoting poor or ‘bad’ character.14 Several reports note
the damaging impact on children of witnessing such
behaviours and the mental deterioration of family mem-
bers. All such studies underscored the relationship
between the meaningless nature of prolonged deten-
tion, human rights and mental health. Given that man-
datory detention remains a key component of the
Migration Act, community detention for groups such as
children and unaccompanied minors has been a recom-
mendation of health and mental health groups.
The case of SB
The plight of detained children had often been
extreme. The case of SB, an Iranian child in detention
with his family, received considerable public attention
and raised community awareness.15 Details of this case
are noted in the 2004 Human Rights and Equal
Opportunities Commission (HREOC) inquiry.3 SB,
Newman et al.
aged 5 years, was held in Woomera for 11 months and
was exposed to riots, self-harming behaviours and sui-
cide attempts. He became withdrawn, anxious and had
nightmares. The family was transferred to the
Villawood centre in New South Wales (NSW), where he
witnessed a significant suicide attempt and became
withdrawn, mute and refused all oral intake. SB
required several admissions for rehydration and every
time after returning to detention, his condition dete-
riorated. Several child psychiatrists who assessed him
concluded that returning SB to such a traumatic envi-
ronment would cause relapse and they advised com-
munity release with his mother. Citing concerns about
setting a precedent, the then Minister for Immigration
declined. Predictably, SB’s condition deteriorated, so
he was placed in community foster care separated from
his mother. As he continued to deteriorate, his mother
was released from immigration detention 4 months
after separation and his father, 8 months later. SB was
found to be a genuine Convention refugee. He remains
distressed, with features of post-traumatic stress disor-
der, depression and adjustment difficulties and he
receives on-going treatment to this day. SB’s case exem-
plifies the harms to children resulting from an inflexi-
ble and rigid adherence to Australian Government
policy. Clinicians involved in the case of SB did not
distinguish public advocacy from their other clinician
roles; however, the then Immigration Minister queried
whether psychiatrists could advocate for children’s
rights and implied a conflict inherent in arguing for a
detained child’s release on medical grounds. The valid-
ity of medical and psychiatric recommendations about
treatment and placement of detainees was contested.
Clinicians sometimes argue that the environmental
contribution to disorder was so great, that release and
community placement provided the only possibility of
‘recovery’; while Government sometimes accused the
detainees of simulating psychiatric conditions, to gain
release.
The 2004 HREOC Report on children in detention, ‘A
Last Resort?’,3 notes the negative developmental effects
of detention on children and the failure of Australia to
respect its signatory obligations under international
human rights treaties. Informed by clinicians and child
workers, it notes the potential long-term effects of trau-
matic exposure, the risk of on-going mental disorder,
the difficulties that detained parents face, and the way
in which parental depression and despair affects chil-
dren. Children were also exposed to behavioural distur-
bance, violence and self-harm. Older children and
adolescents were involved in protest behaviour, and
younger children were inadequately protected wit-
nesses. Several clinical reports describe children with
attachment disorders, socially indiscriminate behaviour
and developmental delay. The lack of care, protection
and appropriate activities for play and education are
criticised. The detention of children is unacceptable
under several international conventions and child pro-
tection frameworks.
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The case of CR
The case of CR, an Australian permanent resident who
was found to have been held unlawfully in detention
for a period of 10 months, proved the predisposition
of the immigration detention system to mislabel psy-
chiatric disturbance as ‘misbehaviour’ or ‘simulation’.
The case was the subject of a Commonwealth Inquiry
and all details are on the public record. CR suffered
from a severe, chronic psychotic disorder and was
acutely unwell and speaking her native language
(German) when she was detained, initially placed in
prison and then in immigration detention, as it was
assumed that she was an ‘illegal’ person. As her condi-
tion deteriorated, she was largely isolated in a behav-
ioural management unit for up to 21 hours a day. She
became incoherent, smeared faeces on the wall and
removed her clothes, yet the system did not recognise
this as possible mental illness and she did not receive
adequate psychiatric assessment nor any treatment.
CR was in need of an urgent psychiatric treatment, yet
was treated as ‘badly behaved’ and disruptive. She was
only released from detention into the public sector
mental health care when she was recognised by family
members in a media article. Ironically, fellow detain-
ees recognised that CR was mentally unwell, and had
asked that she be assessed and cared for in a psychiat-
ric facility. This case raised serious issues about a
detention culture which focuses on behavioural con-
trol and assumes detainees are manipulative and
deceitful. The ensuing Palmer report16 addresses the
provision of mental health services and support in
detention, and recommends on-going independent
monitoring of service standards and provision of
appropriate levels of care. This report prompted the
establishment of an independent advisory body, com-
prising representatives of medical and health profes-
sional bodies (Detention Expert Health Advisory
Group, 2005), which continues to advise the
Department of Immigration and Citizenship regard-
ing the health and mental health needs of asylum-
seekers and detainees’ suicidal ideation.
Consequently, a Detention Health Framework was
developed and the provision of psychological support
and mental health services instituted. The negative
impact of detention itself on mental and physical
health has been acknowledged. The value of designat-
ing detainees as ‘clients’, appointing case managers and
describing the ‘journey’ of detainees cannot obscure
their involuntary status and the significant risk of men-
tal deterioration. Increasing the length of time in
detention, slowing of the processing of asylum claims
and detaining of those with histories of torture and
trauma has again produced a high-risk and volatile sit-
uation, with increasing rates of self-harm and clusters
of suicidal behaviour and completed suicides. Earlier
research noting the clear relationship between deten-
tion and mental disorder has re-surfaced in political
discussion.
317

Clinical research
Many studies have examined the mental health of refu-
gees and asylum seekers.1–9,17 A recent systematic review
of the studies investigating the impact of immigration
detention on the mental health of children, adolescents
and adults identifies high levels of mental health prob-
lems in detainees.18 This review reflects a considerable
body of scientific research that has consistently demon-
strated high rates of mental disorder in detained asylum
seekers. In their study exploring the health of those in
Australian detention centres, Green and Eagar19 find
that those detained for unauthorised boat arrival or
unauthorised air arrival have the highest rates of self-
harm (17.7% and 14.4%, respectively), rates that were
well above that of the illegal foreign fishers (2.1%), those
who overstayed their visas (3.6%) and the average of all
the groups in detention (6.2%).
Research has focussed on the impact of experiences in
detention on vulnerable groups of asylum seekers, and
also on modelling the factors contributing to better or
worse outcomes.20 Factors such as length of time in
detention, negative experiences and traumatic expo-
sure, inability to communicate freely in a language
most familiar to the detainee and the process of estab-
lishing refugee claims, all compound the asylum-
seeking experience. Time in detention correlated with
severity of distress. The conditions of anxiety, depres-
sion, post-traumatic stress symptoms, self-harm and
suicidal ideation were commonly reported. Mental
health may initially improve shortly after release,
although the mental health effects post-release may
also be prolonged. The role of pre-existing trauma and
the impact of persecution, displacement and loss also
contribute to the overall mental health risk and medi-
ate outcome. The specific needs of children, and their
vulnerability in the face of trauma and detention, were
also examined. The overall results point to high levels
of psychiatric morbidity, particularly of Post-Traumatic
Stress Disorder (PTSD), arising from the detention expe-
riences, and these have been used to counter the pre-
vailing systemic tendency to deny or minimise the
negative impact of detention.
Initial descriptive studies found high rates of depression,
PTSD and suicidal ideation. A study of Cambodian
detainees, held for a period of 32–55 months, notes
strong feelings of anger and frustration, a sense of loss of
control over their lives and a sense of profound bore-
dom. The situation of detention and prolonged uncer-
tainty contributed to mental distress.21 A study of East
Timorese asylum-seekers reports that 45% had suicidal
ideation. Other reports note that relative to those in the
community, detained asylum-seekers experience higher
levels of depression, PTSD and physical symptoms,
despite both groups having experienced similar rates of
persecution and trauma in their country of origin.22
These findings point to the negative impact of detention
and its direct contribution to the development of men-
tal disorder.
318
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Australasian Psychiatry 21(4)
Steel and colleagues studied 10 of 11 families in a remote
centre, using standardized instruments for diagnostic
assessment13. Every adult was found to have major
depression and most reported suicidal ideation. All chil-
dren were diagnosed with at least one psychiatric disor-
der and most had more than one disorder. Half the
children had PTSD and separation anxiety disorder, and
more than half expressed suicidal ideation, while a quar-
ter had engaged in self-harm. A low level of pre-existing
(lifetime) psychiatric symptoms or disorder support the
view that detention causes mental disorder. A striking
feature is the high reporting of negative experiences
within detention itself, including abusive and harsh
treatment, and witnessing others’ self-harm and suicidal
behaviour. This paper supports advocacy for the removal
of vulnerable children and individuals from detention
and it calls for the abolition of mandatory detention. In
the current environment of ongoing detention, length-
ening detention and increasing behavioural breakdown
and suicidal behaviour, these results remain important.
A study of children in a remote facility found high levels
of trauma-related symptoms and developmental com-
promise amongst 20 children, aged 11 months to 17
years.23 Some children under 5 years of age had spent
most of their lives in detention (7 children). All the
younger children showed delayed cognitive develop-
ment, related to neglect and deprivation. All children
aged 7 to 17 years met diagnostic criteria for PTSD and
major depression with suicidal ideation. The children’s
trauma related to events that they experienced whilst in
detention.
As noted, length in detention emerged as a major con-
tributing factor to mental deterioration, physical symp-
toms and hopelessness. While asylum-seekers arrive
with pre-existing high levels of traumatic exposure and
loss, which impact their rates of distress, research sug-
gests that the experience of detention itself is most sig-
nificant. An early study by a detained medical
practitioner in Villawood detention centre12 finds that
the severity of depressive symptoms increases with the
length of time in detention and finally results in a state
of cognitive deficit, pervasive mistrust and psychotic
symptoms. Recent work reviewing medical records of
detainees again relates length of detention to health
problems and particularly notes complex physical health
presentations, medical service utilisation and mental
health diagnoses increasing at the 12-month period.
Rates of disorder are low in the early periods of deten-
tion and extremely high after 18 months in detention.19
Whilst the Australian government now accepts this rela-
tionship and risk, detaining people for only brief periods
(current policy of 90 days) and facilitating community
processing of vulnerable groups, such as survivors of tor-
ture and children, this remains difficult. Community
alternatives to detention, if based on a model of personal
autonomy and participation, may be the only way to
prevent deterioration, increasing distress and rates of
self-harm. The occurrence of five suicides across the
Newman et al.
detention system, from September 2010 to July 2011, is
clearly extremely concerning and requires rethinking of
the policy of mandatory detention.24
The questionable value of clinical
care in the immigration context
The above body of research contributes to the ‘asylum
seeker’ debate and calls for reform of immigration law in
Australia. The findings raise questions about the mean-
ing of individual diagnosis, when the detention envi-
ronment and the refugee determination process
themselves are major factors in producing distress.
Labelling self-harm and behavioural disturbance as
politically-motivated ‘bad behaviour’ contributes to
under-recognition of serious mental distress and disor-
der, amplifies the distress and disorder, and compounds
the difficulty in creating a psychologically-supportive
environment.
Similarly, the capacity to treat psychiatric conditions
within the immigration detention setting is limited.
Treating professionals have little control over the length
of detention, lack of status resolution and detainees’
deterioration. The example of a psychologist teaching
‘anger management’ following a protest action by dis-
tressed detainees illustrates how psychological interven-
tions that ignore context may misunderstand the
healthy role of political protest and ultimately, exacer-
bate the feelings associated with being misunderstood
and humiliated. For mental health clinicians, the deten-
tion context challenges the traditional model of trauma
and recovery. The conventional individual model of
PTSD, applied to individuals, has less utility when we are
talking about trauma across a collective culture, across a
whole community or group. Cultural variations in the
expression of distress, when the how and why for being
held is sought and their experience of trauma prompts
exploration in frameworks which are broader than
Western diagnostic approaches. Socio-political interven-
tions potentially transcend the individualistic psycho-
logical models of Western Psychology.
The prescription of anti-depressant, anti-psychotic and
analgesic drugs is also of questionable value and utility.
It is unclear to what extent such practices are regulated.
Consequently, in dealing with detained populations,
many clinicians describe feelings of disempowerment
and even experience vicarious traumatisation and have
been unable to continue.25 Constraints on the tradi-
tional clinical role pose ethical dilemmas, including the
age-old question of whether to work ‘within the system’,
trying to mollify its harmful effects, or ‘to oppose it from
without’. Clinicians working within the system, noting
how difficult it can be to resist taking up simplistic
approaches, have raised the need for external supervi-
sion and support. Supporting non-professional advo-
cates and volunteers has also been necessary: many are
not experienced in dealing with the high levels of com-
plex distress and suicidality.26
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Advocacy, therefore, becomes important as it is poten-
tially therapeutic for detainees. This includes stating
that the treatment is of limited value within an environ-
ment known to be harmful to the people who are living
and working within it. Clinicians have documented
development and deepening of mental and physical
health issues over time, and they often put the argument
for community release forward, when concerned about a
detainee’s well-being. For the health professions, this is
part of clinical practice.
Conclusion
Immigration detention has once again become a key
political issue, following a period of relative calm within
the system. Increasing numbers of irregular maritime
arrivals to Australia have prompted a political debate
about the factors influencing asylum seeking and those
which might deter it. Both sides of politics have argued
for the regulation of unauthorised arrivals and for manda-
tory detention. In the face of increasing numbers of
detainees, many with a history of torture and trauma, and
significant numbers of unaccompanied minors, concerns
have once again been raised about the serious harmful
effects of immigration detention and the impact on chil-
dren – now and in the future. The overwhelming strength
of international evidence appears not to guide current
planning. Attempts to provide psychological support and
increase mental health services confront the problems of
treatment efficacy in a damaging environment. Increasing
numbers of so-called ‘failed’ asylum seekers and long-stay
cases will have a major impact on the operation of deten-
tion centres and the rates of protest, disturbance and
mental disorder. There is anecdotal evidence that the
attempted suicides and suicidal behaviour is on the rise. It
is clinically and ethically ill-informed to say that such
actions are ‘bad behaviour’ or ‘playing-up’ and that asy-
lum-seekers should face criminal charges. The challenge
appears to be one of re-creating some level of psychologi-
cal and empathic understanding for the plight of the asy-
lum-seeker, and of the impact of mandatory detention. A
trauma-informed model of care is essential and should
underlie policy reform and service provision. The sense of
déjà vu is strong, for those who have been involved in
these issues over the last decade or more.
Disclosure
The authors report no conflict of interest. The authors alone are responsible for the content
and writing of the paper.
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