Editorial

Mental health implications of the Christmas Island boat crash tragedy

Nicholas G Procter
Professor and Chair: Mental Health Nursing, School of Nursing and Midwifery, Division of Health Sciences, University of South Australia, Adelaide SA

PP: 111 - 114

Article Text

At approximately 6.30 am local time on Wednesday, December 15, 2010, Australian Federal Police officers on the remote location of Christmas Island witnessed a wooden vessel overloaded with passengers, crash onto the shoreline of Rocky Point. Media reports of the incident highlighted that the geography of Rocky Point and the intensity of the waves made it extremely difficult for assistance to be rendered from the shoreline. In the hours and days that followed the true extent of the tragedy become clear: At least 30 people died and 42 survived. There is little doubt that the people who survived the crash thought they were going to die on that particular day.

Prime Minister Julia Gillard, and Minister for Immigration and Citizenship Chris Bowen, were once again facing critical decisions regarding the management of asylum seekers to Australia. Where should the asylum seekers be located? How could assistance be given to the survivors? And, of equal importance, how best to support the people who frantically tried to help from the shoreline?

The first of these questions continued to dramatically play out almost three months later when in February this year, the decision was made to return Seena (pictured), a nine-year-old Iranian boy made orphan by the tragedy, to detention on Christmas Island with 21 other boat crash survivors after they had attended the funerals in Sydney of those who had died. After days of heated debate and passionate pleas from some of Australia's leading mental health professionals, current and former politicians and human rights lawyers (Guest, 2011; Needham, 2011), the federal government took steps to release 11 detainees, including members of the orphan child's family, into the community.

My view is that the federal government was right to ensure that the boat crash survivors be part of the funeral proceedings. The young orphan boy, Seena, and his family should have been brought to the mainland weeks ago. Simply put, it was wrong to continue to detain him and the other survivors of major trauma on Christmas Island. Australia's Fourth National Mental Health Plan (Commonwealth of Australia, 2009) argues that continuity of care and early intervention requires sustained and multipronged activity across sectors and disciplines. The plan advocates for improved linkages and care coordination to ensure information about, into and through care are highly visible, readily accessible and culturally relevant. This can be best found on the mainland where mental health professionals and child trauma experts can be leaders in improved care coordination. Working with the Department of Immigration and Citizenship, with migration lawyers and asylum seekers awaiting outcomes, the mental health professionals and child trauma experts can facilitate not only positive mental health outcomes and early intervention, but, where necessary 'wrap around' and 'joined-up' service provision (Procter, 2011). This is particularly important in terms of co-ordination and continuity of care, as well as ensuring that mental health needs are considered jointly rather than separately by more than one provider.

I also believe that any extension of time for traumatised people on Christmas Island is likely to lead to an increase in behavioural disturbance, depression, post-traumatic panic and anxiety for the people concerned. There is also good evidence to suggest that the longer people are held in detention, the less likely they are to trust others and the more likely they are to suffer mental and physical deterioration. The distress of the boat crash survivors has shed light on the plight on the estimated 6000 people who currently remain in immigration detention. Living in restrictive limbo can manifest in feelings of fear, anxiety, sleep disturbance and self-harm, along with hopelessness, irritability and frustration. The overcrowded conditions of detention and the inability to communicate freely and spontaneously in a language most familiar to the detainee will further compound and contribute to the mental health difficulties they experience.

Overcrowding within immigration detention is a major concern and is causally related to mental health through factors such as tense patterns of interaction and an inability to establish buffers against stressful events or uncomfortable physical factors such as heat. Long waiting time for use of telephones, the internet, recreational and washing facilities add additional layers of frustration and delay to an already stressful environment.

Overcrowding is also associated within an increased number of sound exposures both day and night, contributing to the adoption of inverted sleep patterns, with detainees sleeping during the day. This has a flow-on effect where detainees may miss meals, social interaction, group activities and access to morning legal and/or medical appointments. The frequency of waking increases with the number and level of noise stimuli in the night. Sleep disturbance leads to chronic physiological change compounding their anxiety and depression.

The cumulative mental health effect of sleep disturbance is associated with people being unable to cope with everyday stress, unable to effectively problem-solve and may contribute to physical health complaints.

Processing asylum seekers quickly is vital in ensuring that as a nation, we do no further harm to people who have already suffered. In addition, there is a strong body of evidence to suggest that the health status of people in immigration detention deteriorates, with a clear association between time in detention and rates of mental and physical ill health (Green & Eagar, 2010). A recent systematic review of studies investigating the impact of immigration detention on the mental health of children, adolescents and adults identified high levels of mental health problems in detainees (Robjant, Hassan, & Katona, 2009). Anxiety, depression and post-traumatic stress disorder were commonly reported, as were self-harm and suicidal ideation. Time in detention was found to be associated with severity of distress. There is evidence for an initial improvement in mental health shortly after release, although longitudinal results have shown that the negative impact of detention can be ongoing.

I am deeply concerned by media reports of self-harm being on the rise inside Australian detention centres. In my view the Prime Minister should, as a matter of urgency, commission a study examining the prevalence and profile of people who self-harm in relation to numerous demographic, diagnostic and needs-related variables across the immigration detention system using a standard methodology.

The self-harm data obtained should consist of sections on age; sex; marital status; ethnicity; clinical history; history of self-harm; history of violence; history of substance misuse; recent (<1 month) adverse life events; the type, dosage and frequency of medications prescribed and administered; adherence/non-adherence to medication; details of current or previous self-harm management care plan; details of the means of previous and current self-harm (e.g. by starvation, lip stitching, burning, skin cutting, scratching, self-poisoning, attempted hanging, attempted electrocution, banging or hitting body parts, hair pulling); details of incidence of self-harm by index case and by repeat case; details on whether person who self-harms is a survivor of torture and trauma; history of attending or missing medical, legal or nursing appointments while in detention; and length of time in detention.

In making decisions on how to move forward on this important issue, the Prime Minister should be mindful that indefinite or lengthy forms of detention are clearly destructive to mental health. There needs to be informed leadership on the treatment of asylum seekers and the detention process must again be scrutinised.

At the same time no compassionate answers can be found in policies of the alternative Australian government. The announcements prior to the last election by the Federal Opposition of their intention to reintroduce temporary protection visas (TPV) should they win government is nothing short of cruel and reckless.

If the policy is reintroduced it will go a long way to ensuring traumatised refugees almost never have an opportunity to re-build their lives. It is now well known and documented that these policies caused great suffering, re-traumatisation and family dislocation for people who had already experienced a level of suffering most of us cannot imagine (Procter, 2005). To consciously and deliberately reintroduce such a policy would be state-sanctioned cruelty.

To palm this off as a deterrent, and therefore justifiable, is not only cruel; it shows a lack of leadership and humanity. Fear, uncertainty and a legal impediment to getting on with life form a toxic stew that impacts upon a persons' ability to re-build their life. TPVs harm people who have already arrived - it is not something that operates to deter desperate people from hoping for the chance of a better life by seeking asylum.

I have spent many hours visiting immigration detention centres across Australia and on Christmas Island. And many more hours with people of refugee background who were kept on TPVs, and what they experienced was an inability to see a future for themselves, and a sense of abiding depression, sadness and fear.

The temporal nature of their circumstances is an added trauma for people who generally have fled their homeland in dire circumstances - people who have seen death, torture and persecution in very personal ways.

Most people of refugee background want to start afresh, to make a valuable contribution to a new life. Asylum seekers are no different. They also have a strong ambition to contribute to this country because they have a strong sense of what Australia represents. For refugees, the reintroduction of the TPV is a kind of time torture sentencing them to months and years of living on a knife's edge.

Ironically, it runs counter to values such as individualism, independence, self-reliance, and tolerance: values which are supposedly at the heart of the Liberal Conservative philosophy. Considering the facts - that most people who suffered under the TPV system were eventually made permanent residents in Australia - surely the Federal Opposition can think of more constructive and compassionate ways to nurture them along the path to citizenship.

So what sort of investment is required and by whom? In many instances changing the culture of how we view refugees and asylum seekers is required. Freedom, stability and the sense of belonging in a permanent home have a strong role to play in the psychological healing process for people of refugee background and are core to civil societies.

They are the combined antidote to factors such as post-traumatic stress, depression, worry and fears of persecution, imprisonment, torture or even death, and the chaos and disorder these stressors engender.

Permanent protection is the key to helping people to succeed. By providing stability, acceptance and understanding, refugees will then have the opportunity to prove themselves through work, education and community involvement, escape the stigma associated with their arrival here, and go on to live fruitful lives.

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