PETER YOUNG. Speaking of Freedom: Human rights and mental health in detention.

Jul 31, 2016

Peter Young is a member of Doctors for Refugees who have launched a High Court challenge against the Secrecy Provisions in the Border Force Act which states that an ‘entrusted person’ who discloses protected information can face up to two years in prison. I am reposting below an earlier article that Peter Young contributed to this blog. This article was based on a speech he gave at a public meeting organised by the Asylum Seekers Centre.  John Menadue

In 2011, after many years working in public hospitals and community mental health services I came to work for the Commonwealth Government’s privately contracted immigration detention health provider.

This was a time when there had been much public and professional criticism of immigration detention. The harms to mental health of prolonged arbitrary detention were already being documented through the Palmer Inquiry; in reviews by the Australian Human Rights Commission; the Commonwealth Ombudsman and; in Coronial Inquiries relating to a number of deaths in detention.

The findings from these inquiries propelled a number of reforms within the immigration detention regime towards improving the standard of health services and introducing a degree of monitoring and oversight, particularly in the establishment of the independent Detention Health Advisory Group (DeHAG). I thought these changes held out the prospect that it was possible to work within the detention system to reduce harm and for positive change.

One of my first experiences of detention centres shortly after I started in 2011 was visiting Christmas Island. The first asylum seeker I met was a man the mental health staff were concerned had become very severely depressed and needed hospitalisation.

When I saw him he was housed in what was called the “visits” section at Christmas Island. It was a hot and dirty environment. More than 50 men were housed there – all sleeping on mattresses on the floor with no privacy, and with one shower and one toilet to share. The man was a survivor of torture and trauma and he had been in detention for a prolonged period – much longer than the administrative time needed for health, identity and other checks.

His mental health had been deteriorating and he had recently received news of other family members who had been killed by a bomb blast in his home country. When I saw him he was shaking and crying; he said he could see his dead family around him; and his speech made no sense.

It was clear from seeing this man and hearing from the staff – that he was severely traumatized and vulnerable. He had suffered torture and trauma; and the additional stress of prolonged detention in poor conditions – with no meaningful activities, little communication with the outside world, no capacity for making day-to-day decisions for himself, little and often conflicting information about his asylum claim, and with prolonged uncertainty as to it’s outcome. As a result of these factors his mental health had been damaged, and combined with the further personal loss he had suffered, he lost his sanity.

The health staff had done their best to support the man but counselling, psychological therapy, and medications can only do so much. It was obvious that he needed to be treated in a proper hospital environment and that action needed to be taken to address the issues that had led him to this point.

Anywhere else in Australia the decision to provide this treatment would be a medical matter and he would have been admitted to hospital immediately. However, in immigration detention I quickly learned that it was a much more complicated issue. It involved a process of briefings, justifications and written advice, that had to be escalated up through layers of bureaucracy; while being careful to maintain “stakeholder relationships”, meaning staying onside with immigration and security staff by leaving out the mention of contributions to his condition from delayed immigration processing and from the negative effects of detention conditions.

I was accustomed in public health services to dealing with people in extreme need and distress and of working within limited resources to assist; but this was quite different here, because the issue wasn’t one of rationing resources. Despite the knowledge and advice received from previous research and inquiries that showed damaging mental health effects, the State under its mandatory detention policy was deliberately expending resources to cause and to prolong suffering as a deterrent.

This experience framed the essential challenge of the professional and ethical conflicts of working as a health professional in the immigration detention system. How to carry out a medical duty of care to do no harm; to establish basic elements of a therapeutic relationship; trust, empathy and to be able to advocate for their interests; while working within and helping to support a system that was grinding them down and progressively destroying their mental health.

This situation represents a fundamental conflict of interest and for health staff, demanding the ability to constantly operate on two different and incompatible levels – walking a tightrope between professional and ethical responsibilities, and avoiding being labelled as “soft” or worse, an “advocate” which could quickly lead to your dismissal.

This dilemma was played out every day for every member of the mental health staff. It made for a stressful workplace with a high level of staff burnout. Some long-stay survivors had developed ingenious means to assist the most badly affected detainees, often by building relationships with more sympathetic security or immigration officials. Others, unfortunately, succumbed to the pressures of the environment, by distancing themselves and becoming hardened including through practices such as calling people by their boat numbers.

In my role I was a point of escalation for staff who were attempting to assist the most badly affected detainees and I was also the point of liaison with the senior decision making departmental staff in Canberra. This was a point of considerable friction but which enabled me to get a close view of the processes and politics as they played out over time.

Initially – the positive changes that had occurred in detention health policy and especially the support of DeHAG enabled recruitment of more mental health staff, including nurses, psychologists, counsellors and psychiatrists. We were able to introduce an “outreach” model of service to break down the barriers to mental health support and to improve mental health screening processes to identify people needing more support and treatment. In some cases, we were able to overcome other Immigration Department barriers to enable faster processing, or expedited community placement for individuals.

As the months passed, and in the wake of the failure of the “Malaysian solution”, arrivals continued to increase, and the number of people in detention and the length of detention both continued to escalate. This was a very worrying situation because all of the research and our data showed that when a person’s time in detention passes 6 months, their mental health steadily declines; the incidence of mental illness rises; and the risk of self-harm and suicide attempts increases rapidly.

It was evident that we were approaching a tipping point at which the numbers of people suffering negative mental health effects from prolonged detention was going to become unmanageable.

Planning what to do was difficult for the Immigration Department, because the Government’s policy was that arrivals of people by boat would stop, and so, to plan for greater numbers and length of stay would be seen as unsupportive of the Government. New places of detention were opened and capacity increased, but as the crisis continued to unfold there was a major change in policy – the decision to unblock the processing of asylum claims and the introduction of bridging visas.

Although such a temporary visa system has its own problems, at this time it provided a much-needed circuit breaker. As people were released on bridging visas the incidence of mental health problems, self-harm and suicide attempts fell substantially.

What was most striking from my perspective was that there was a dramatic change of atmosphere in the detention centres and also in the Immigration Department hierarchy. Now that people were no longer being treated as prisoners the immigration and security staff no longer needed to maintain negative attitudes towards them – and they started to treat the asylum seekers as normal human beings.

However – this did not apply to one group of detained asylum seekers – people from Sri Lanka who had been deemed to have adverse security risks and who, in some cases, had been in detention for many years. Several of this group were also involved in legal challenges to their indefinite detention labelling them as ‘trouble makers’ with the Department.

The Immigration Department had become convinced that this group of more than 50 individuals each carried cyanide capsules they had been hiding since they went into detention and that they were secretly planning a coordinated national mass suicide timed to occur on the anticipated failure of a prominent appeal case in the High Court.

Despite there being no evidence, and no historical precedent for such an event anywhere in the world – ever – this bizarre idea was firmly believed by people at high levels in the Immigration Department. Despite advice as to the futility of the plan the Department insisted that large quantities of cyanide antidote be kept at hand; that staff were specially trained in its use and; that extra staff be placed on duty for the event.

The Department’s plan did not include notifying NSW Ambulance and local hospitals; and they initially baulked at this suggestion. In typical fashion they wanted it all kept secret. We had to persuade the Department to agree to let us speak to the ambulance and local hospitals by convincing them of how bad it would look for them if their doomsday fantasy actually happened and they had not warned local services.

The mind truly boggles – it seems crazy – but this is just one of a number of similarly bizarre episodes that occurred while I was working within the system.

Of course, the predicted date came and went and nothing happened but this incident illustrated for me two of the underlying principles of immigration detention – the priority of secrecy above all; and the conception of asylum seekers as dangerous, inhuman and deceitful. This was a necessary view for those who devise and administer the policy of prolonged punitive detention to justify the need for their poor treatment of asylum seekers and is an example of the psychological defence mechanism we call “projection” – that is, attributing the feelings and motivations that you don’t want to admit in yourself onto others.

Meanwhile, the political crisis of continuing arrival in boats of people seeking asylum led first to the “rapid turnarounds” policy in which people denied the opportunity to make an asylum claim were “screened out” and returned to their home country. Presumably to aid in this process and to avoid an inconvenient paper trail showing that people returned were not simply ‘economic migrants’, the Immigration Department gave instructions that health staff should not ask people about torture and trauma experiences as part of their health screening assessment.

As we know, when ‘rapid turnarounds’ proved ineffective as a deterrent, the then Labor government turned to offshore detention. This was deemed necessary as an increased level of deterrence to asylum seekers, justified by the “saving lives at sea” or more correctly “no deaths on our doorstep” argument.

Both these policies co-opted health professionals to breach ethical obligations by handing over asylum seeker personal health information to the Immigration Department, without informed consent, in order for the person to be returned, or to be sent to an offshore facility. A fact which the Department is unable to acknowledge. Both these policies demanded that health professionals displace their ethical obligation to their individual patient in favour of the Government’s policy objective.

Opaque procedures; lack of information given to asylum seekers; obvious fictions such as pretending that the Nauruan and PNG governments were in charge of the centres; and that asylum seekers were not being detained – by calling them ‘transferees’, created an immediate environment of mistrust and unrest in the offshore centres.

These centres were by their design and intent, far more punitive and harmful places than even the harshest detention centres in Australia. The negative health effects on asylum seekers were immediately apparent from our mental health monitoring – showing that the people sent offshore fared much worse, and their mental health deteriorated much more quickly, than those who had remained in Australia.

These facts led to increasing conflict with the Department, especially when psychiatric hospital treatment was required. This was due to the work involved, the costs, and logistics – but most of all the politics of moving people from Manus or Nauru to Australia for treatment. We were expressly told by the Immigration Department that movement to Australia for medical reasons was to be a last resort because it undermined the Government’s policy that people detained offshore would never come to Australia. Furthermore, it opened up the possibility that asylum seekers could gain access to lawyers and it was important for the government to deny them legal representation.

The introduction of offshore detention also saw the progressive and systematic dismantling of the positive immigration health policies that had been put in place after the Palmer report. When the offshore centres were opened the independent health advisory group (DeHAG) was excluded from involvement. At the same time, the group’s terms of reference were changed, diluting its focus on health of asylum seekers in detention – and its representative membership was cut.

The group’s independent chair was ousted, replaced by the Department’s hand picked health advisor, a former military doctor with links to senior department officials. Further meetings of the advisory group were cancelled and finally, the independent group was disbanded altogether, leaving only the Department’s own trusted man who was then able to choose his own unrepresentative panel of favoured mates.

With the independent advisory group out of the way and compliant advice from its hand-picked “experts” assured, the Immigration Department was in an unopposed position to demand cuts to health staffing and the removal of interpretation and commentary from health reporting. When confronted with mental health statistics that did not support it’s position the Department simply axed the most important elements of the mental health screening procedures.

At this point one of the few remaining mechanisms of independent oversight was the Australian Human Rights Commission Inquiry into Children in Detention. Although Immigration Department officials said they intended to not make it easy for the Commission, and that health staff who made anonymous submissions to the Inquiry would be discovered and punished, they were not successful in thwarting the Inquiry.

In the hearings of the Inquiry the previous and the previous Minister under Labor and the then current Minister were subjected to detailed forensic examination. The former painfully tried to avoid responsibility while the latter went on the attack. Despite these attacks, the Commission by own investigations, and by its capacity to compel the Immigration Department against its resistance to release information, produced a landmark powerful and damning report that meticulously documented abuses in detention and the harms of prolonged detention on the mental health of children and families.

This episode marked the end of my involvement within the system as it was clear to me that dissent or disagreement within the system was not tolerated and independent oversight was not allowed. The beneficial changes had been unraveled and the system had returned to the position before the Palmer reforms. I believed that it was it was no longer possible to continue to work within the system without collusion, and contributing to further harm.

Since then, the Border Force Act came into being, with bipartisan support, further extending secrecy surrounding the immigration detention system. Staff reporting abuses in Nauru have been persecuted; and there have been a number of tragedies including self-immolations and the deaths of Hamid Kehazaei and others, in offshore detention due to poor medical care.

Australia’s policies have been condemned by the United Nations; multiple international humanitarian organisations; and the PNG court has found the detention of asylum seekers in Manus Island is illegal.

Men, women and children continue to be forced to suffer enforced misery to drain them of hope, and as a warning to others.

This is not an Australia of which we can be proud of:

We cannot support policies that defy international law.

We cannot support Governments that attack the institutions of civil society; Governments that enact laws that keep us in the dark and seek to silence dissent.

If we are to be free – we cannot continue to arbitrarily imprison and punish asylum seekers who have come to us seeking their own freedom.

Dr Peter Young is a Consultant Psychiatrist with experience of 20 years working in NSW Health. He took on the role responsible for oversight of mental health services to people in Australian and offshore detention centres. He held this position for three years from 2011 to 2014. Dr Young has given evidence to the Australian Human Rights Commission enquiry into children in detention and other public enquiries regarding mental health harms caused by detention.  

This speech was given at the Sydney Town Hall on 22 June 2016 for the Asylum Seekers Centre public meeting for Refugee Week 2016.

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