The provision of mental health services for asylum seekers and refugees

Key messages

• Asylum seekers should be screened, assessed and granted conditional community release wherever possible.
• Asylum seeker applications should be processed as fast as possible and while they are residing in the community, to minimise risks to mental health and well-being.
• Detention should be a measure of last resort and, if unavoidable, should be independently and strictly regulated and monitored, in a similar manner to other institutional settings.
• Prolonged and indefinite detention violates the rights of asylum seekers and refugees to liberty and freedom from cruel and degrading treatment, as well as their rights to seek asylum without punishment on account of their method of entry into a territory.
• Certain high-risk groups should not be detained in immigration detention facilities, including children, pregnant women, people with mental illness/disability, and survivors of torture and traumatic experiences.
• If people must be held in immigration detention facilities, they should be held for the shortest possible period to enable health, security and identity checks.
• Detention facilities should be located in onshore areas with good access to high-quality mental health, trauma and physical health services and facilities, and not in remote or offshore locations.
• Initiatives should be developed to provide support to asylum seekers and refugees to address existing, and prevent further, psychiatric and other health and developmental problems. This includes trauma-informed care – an approach that acknowledges trauma, its prevalence, impacts and dynamics and that requires recognition of lived experience of trauma and awareness of ‘triggers’ that can lead to retraumatisation.
• Immigration detention should not be used coercively, as a punishment or for deterrence.
• Immigration detention facilities should be open to independent scrutiny and reporting in the same manner as other institutional settings.

Purpose

The Royal Australian and New Zealand College of Psychiatrists (RANZCP) presents this position statement to reflect its concerns about the inadequate provision of mental health services to asylum seekers and refugees, and to call for policy change to improve mental health outcomes.

RANZCP position statements aim to influence issues of relevance to psychiatric practice, service delivery, education, research and mental health outcomes for the community. The RANZCP is guided on policy matters by a range of expert committees including the RANZCP Asylum Seeker and Refugee Mental Health Working Group, which was established to consider issues faced by psychiatrists working with asylum seekers and refugees.

Definitions

• An asylum seeker is a person who has fled their own country and applied for protection as a refugee.
• A refugee is a person whose claim for asylum has been granted. This is generally on the basis of a person being found to be outside their own country and unable or unwilling to return due to a well-founded fear of being persecuted due to their race, religion, nationality, membership of a particular social group or political opinion (UN, 1951; UN, 1967). Refugee status may also be conferred on those entitled to protection under laws of armed conflict, international humanitarian law, and other international covenants and conventions, including those pertaining to civil and political rights, torture and genocide (so-called ‘complementary protection’) (Maley, 2016; McAdam and Chong, 2014).

Overview

The RANZCP has ongoing concerns about the mental health of asylum seekers and refugees, and recognises the importance of working with other organisations to ensure that a coordinated approach to health-care provision is achieved, involving government and non-government agencies.

Asylum seekers have a high prevalence of mental and physical health problems related to their experiences. Despite this, they often have inadequate access to necessary supports and services. The provision of appropriate mental health services for asylum seekers and refugees is essential to improve quality of life and well-being, and to enable recovery from experiences of trauma. Child asylum seekers and refugees are particularly vulnerable to the impacts of trauma, negative detention environments and other post-arrival adversities including family separations and exposure to violence (Fazel et al., 2012; Mares, 2016).

The RANZCP opposes the mandatory detention of asylum seekers who arrive in Australia by boat and holds that screening, assessment and community release (with conditions as required) should be preferred wherever possible. If all other options have been shown to be inadequate, detention may be necessary, but should be independently and strictly regulated and monitored for its grounds, length, conditions, avenues for release, treatment including behavioural management, and access to information and the outside world (Sampson et al., 2015). The RANZCP supports the implementation of more humane and efficient access to mental health services, particularly for people held in Australian immigration detention centres, both onshore and offshore.

Mental health of asylum seekers and refugees

Asylum seekers and refugees are among the most vulnerable and marginalised people in our community, many having experienced torture, trauma and other catastrophic events prior to displacement and flight. Of all migrant groups, asylum seekers and refugees are the most vulnerable to mental and physical ill health with common mental health disorders twice as high in refugee populations in comparison with economic migrants. Asylum seekers and refugees are at particular risk of developing a range of comorbid psychological disorders including post-traumatic stress disorder (PTSD), anxiety, depression and psychosomatic disorders. Contributing factors include previous traumatic experiences including torture, persecution, displacement and loss as well as life-risking journeys involving forced migration, cultural bereavement, culture shock, discrepancies between expectations and achievements, and/or non-acceptance by a new nation (Bhugra et al., 2011).

Many mental illnesses, including PTSD, are complex to treat and often unresponsive to primary interventions. They require specialist therapeutic interventions, resources and independent treatment settings which are not available in Australian immigration detention centres (Ashcroft, 2005). Young and Gordon (2016) found that approximately one-half of the detained refugee group who completed the Harvard Trauma Questionnaire reported PTSD symptoms and that, on clinician-rated measures, one-third of children, adolescents and adults suffered with clinical symptoms requiring tertiary outpatient assessment.

Furthermore, prolonged or indefinite detention itself is known to contribute to adverse mental health outcomes as a result of prolonged exposure to factors including uncertainty, lack of autonomy, deprivation of liberty, dehumanisation, isolation and lack of social support (UNCAT, 2014). The prolonged uncertainty created by a system of indefinite detention is a major factor in increasing hopelessness, mental deterioration and the persistence of mental disorder (Newman et al., 2013). Self-harm and suicidal behaviour have become endemic in detention facilities amid well-documented allegations of the exposure of asylum seekers and refugees in detention to sexual and physical assault and abuse, and conditions which are tantamount to cruel and degrading treatment (AHRC, 2013; AHRC, 2015; Amnesty International, 2016). An international systematic review from Campbell Collaboration confirmed the deleterious effects of detention on the mental health of asylum seekers and refugees (Filges et al., 2015).

Harms to well-being accumulate during detention and the longer a person is held in detention, the higher their risk of developing or worsening mental ill health (Méndez, 2015; AHRC, 2014). Mental health conditions are unlikely to respond to treatment until key stressors are removed from the patient’s life. While people continue to be held in difficult, often (re-)traumatising conditions and with an uncertain future, mental disorders are likely to persist or worsen.

The continuing negative impacts of immigration detention on asylum-seeking children’s health and development are particularly worrying. Though research with detained populations is ethically and practically difficult, for detained child asylum-seekers, there are consistent findings of high rates of psychiatric disorders, worsening over time, worse than for those who were not detained, and intimately connected to injurious or hazardous aspects of the environment, including trauma and violence, from which parents also suffer and are unable to protect their children (Mares, 2016).

Successive Australian governments persist with mandatory offshore detention policies because of a continuing belief in the value of deterrence (AHRC, 2014d, 7 & 40–1). This is despite the various arms of government having access to detailed information about the conditions and attendant risks and harms associated with current immigration detention policies (AHRC, 2014b, 12; AHRC, 2014d, 40). Recent clinical commentary expresses the view that detention is intended to make asylum seekers suffer, the end being held to justify the means with suffering the purpose, not an unintended consequence, of the policy (Marr and Laughland, 2014; Young, 2015; Isaacs, 2016; Dudley, 2016) and that this ‘corresponds to torture’ (Dudley, 2016: 15; Sanggaran and Zion, 2016; Essex, 2016; Isaacs, 2016). Commentators have also highlighted the critical ethical dilemmas that face health practitioners working in immigration detention centres such as the potential to impact on clinical independence (Sanggaran and Zion, 2016; Iasacs, 2016).

Asylum seekers and refugees residing in the community are not immune to the negative impacts of prolonged uncertainty (Steel et al., 2011). Experiences of discrimination and marginalisation, along with insecurity of tenure, residency status and policies that prevent family reunion, can significantly affect well-being, so access to adequate supports and services, avenues for social inclusion, and acknowledgement of cultural identities are essential. Appropriate treatment requires a recognition of, and sensitivity to, trauma and torture histories, as well as an understanding of an individual’s cultural background and experiences – for example, expressions of distress or impacts of community and cultural loss – and appreciating that the meaning one gives to violence and trauma can vary depending on culture (Creamer et al., 2001).

For the above reasons, and because there are effective, documented, community alternatives to detention for asylum-seekers (Sampson et al., 2015), the RANZCP opposes the use of detention, except as a measure of last resort, and categorically opposes prolonged indefinite detention. Claims for asylum should be processed as quickly as is practical with efforts made to minimise risks to mental health and well-being, until claims have been resolved. Detention of children should only ever occur as a last resort, with the child’s best interests in mind and for the shortest possible length of time (RANZCP, 2015).

Service delivery to asylum seekers and refugees

Asylum seekers and refugees should have access to health care at a level comparable to the general populations of Australia and New Zealand, taking into account the higher prevalence of mental disorders among these groups. This should apply whether they are living in the community, or held in detention centres either onshore or offshore. However, there are clear difficulties in providing an appropriate and independent level of care to asylum seekers and refugees detained in remote offshore locations, and medical practitioners working in these settings have consistently raised clinical and ethical concerns.

Robust standards and protocols regarding the provision of, and access to, quality mental health care for all refugees and asylum seekers are required, along with support and training for those who provide the care. Independent research into the mental health of asylum seekers and refugees is essential in order to inform the design of standards, service delivery and treatments. Standards should be complemented by appropriate governance and oversight mechanisms, including independent scrutiny and reporting, at least equivalent to that of health and forensic services, which ensure transparency and accountability. Information regarding how to access health care should be easily available in languages understood by asylum seekers and refugees, and properly trained interpreters should be provided when needed.

Recommendations

In recognition of the United Nations Universal Declaration of Human Rights 1948 and the Convention Relating to the Status of Refugees 1951, the RANZCP takes the following positions:

• Asylum seekers should be screened, assessed and granted conditional community release wherever possible.
• Asylum seeker applications should be processed as fast as possible and while they are residing in the community, to minimise risks to mental health and well-being.
• Detention should be a measure of last resort and, if unavoidable, should be independently and strictly regulated and monitored, in a similar manner to other institutional settings.
• Prolonged and indefinite detention of asylum seekers violates the rights of asylum seekers and refugees to liberty and freedom from cruel and degrading treatment, as well as their rights to seek asylum without punishment on account of their illegal entry into a territory.
• Certain high-risk groups should not be detained in immigration detention facilities, including children, pregnant women, people living with mental illness or disability, and survivors of torture and other traumatic experiences.
• If people must be held in immigration detention facilities, they should be held for the shortest possible period to enable health, security and identity checks.
• Detention facilities should be located in onshore areas where there is good access to high-quality mental health, trauma and physical health services and facilities, and not in remote or offshore locations.
• Initiatives should be developed to provide support to asylum seekers and refugees to address existing, and prevent further, psychiatric and other health and developmental problems including those associated with trauma. Such initiatives may include:
  • community accommodation wherein families are kept together to better support their emotional and mental health adjustment and recovery
  • greater support and training for those who provide care to asylum seekers; the RANZCP calls on its members to take positive steps to update their knowledge and skills regarding refugee and asylum seeker health
  • better training to ensure that clinicians and health-care workers to act in accordance with international ethical guidelines for medical practitioners (e.g. World Psychiatric Association’s Madrid Declaration on Ethical Standards for Psychiatric Practice) in a way that advocates for the human rights of asylum seekers and refugees
  • the provision of adequate and independent health and mental health services to asylum seekers and refugees, including access to interpreters
  • reviews of existing and development of new standards and protocols regarding the provision and access of quality mental health care to all refugees and asylum seekers in the community and detention centres
  • robust research into the mental health of asylum seekers and refugees, to illustrate their plight and inform service delivery needs
  • support for psychiatrists and other health and non-health professionals working with asylum seekers and refugees, including processes to facilitate the establishment of peer review groups to assist with peer support and consultation
  • building on the existing expertise and skills within mental health and related community services for trauma informed work with refugees, humanitarian entrants and community based asylum seekers as existing torture and trauma services are limited. Psychiatrists have a role in supporting community based workers and NGOs who assist people awaiting resettlement, outcomes of asylum claims as well as in community detention.
• Immigration detention should not be used coercively, as a punishment or for deterrence purposes.
• Immigration detention facilities should be open to independent scrutiny and reporting in the same manner as other institutional settings.

Additional resources

• RANZCP Position Statement 52: Children in immigration detention (Royal Australian and New Zealand College of Psychiatrists, 2015).
• RANZCP Professional Practice Guideline 12: Guidance for psychiatrists working in Australian immigration detention centres (Royal Australian and New Zealand College of Psychiatrists, 2016).
• Refugee and Asylum Seeker Health Position Statement (Royal Australasian College of Physicians, 2015).
• Madrid Declaration on Ethical Standards for Psychiatric Practice (World Psychiatric Association, 2011).