20 MINUTE READ

From Luke’s Journal October 2023  |  Vol.28 No.3  |  Mental Health I

“Let justice roll on like a river” (Amos 5: 24)

“I was a stranger and you invited me in” (Matt 25:35)

“I want death, I need death.” Child on Nauru¹

Australia’s treatment of refugees remains broadly outside the imagination and knowledge of most Australian citizens, despite moments of media coverage. But as Christian health/helping professionals we are highly likely to meet refugees, and we are driven by both our codes of ethics and our Christian calling to enliven our care and to take their needs seriously. As medical and/or mental health professionals, we also research, document and advocate with vulnerable populations regarding their health and its social determinants. Few groups have needed our skills as healers and advocates more than asylum-seekers caught in Australia’s detention regime.

To understand the circumstances and mental health challenges that asylum-seekers and their health professionals confront, let’s imagine taking a journey with an asylum-seeker and the health professionals they encounter. It’s a journey that is grounded in Australia’s recent refugee history, and drawn from the personal experiences of this article’s authors. 

First however, some general observations. 

Faith, justice, human rights/needs and refugees

The tradition of giving asylum is central to the main monotheistic faith traditions: Abraham, Moses, Jesus and Mohammed were all forced migrants or refugees. These and other faith traditions acknowledge a duty to respond to asylum claims that is grounded in universal human need irrespective of the faith of the claimant.² 

For Jews and Christians specifically, the affirmation that humans are made in the image of God raises duties of compassion and justice towards all. The Bible provides extensive reference to treating foreigners and strangers equally (Ex 12:49; Lev 19:34; 24:22; Deut 27:9; Mal 3:5), providing for and supporting them (Lev 23:22; 25:35; Deut 10:18-19; 24: 19-22; 26:15; Ps 146:9; Matt 25:35; Heb 13:2) and not oppressing them (Lev 19: 33; Ex 22:21, 23:9; Jer 7:5-7; Ezek 22:17; Zech 7:9-10). Jewish and Christian faith-based organisations have a strong presence aiding and advocating for refugees. Moreover, the Christian churches have a long tradition of providing sanctuary. Opening St. John’s Cathedral Brisbane to desperate asylum-seekers in 2016, the Anglican Dean of Brisbane, the Reverend Dr. Peter Catt, noted:

“Many of us are at the end of our tether as a result of what seems like the Government’s intention to send children to Nauru. So we’re reinventing, or rediscovering, or reintroducing, the ancient concept of sanctuary as a last-ditch effort to offer some sense of hope to those who must be feeling incredibly hopeless.”³ 

Scholars of Islam have likewise emphasised pivotal Islamic texts and the role of foundational events such as the hijrah or migration of the first Muslim refugees for the moral and legal obligations of Islamic states, civil societies, individuals, and humanitarian and asylum policies, especially in Islamic countries.^4-6 Likewise, large scale Muslim organisations and local mosques assist refugees both in Muslim countries and internationally. These comments are also true for Hinduism and Buddhism.²

“Such universal moral duties that appeal to the principle of common humanity derive from religious revelation but also from moral philosophy.”

Such universal moral duties that appeal to the principle of common humanity derive from religious revelation but also from moral philosophy. In a defence of universal values, C. S. Lewis cites evidence from cultures widely separated in time and space, showing that the principles of mercy and magnanimity are ubiquitous in cultures in all ages.⁷ International human rights law mirrors this universal humanitarian concern. Asylum-seeking hinges upon such standards as the Universal Declaration of Human Rights (UDHR)⁸, clauses in the International Covenant on Civil and Political Rights⁹ and International Covenant on Economic Social and Cultural Rights¹⁰; the Refugee Convention¹¹;  the Convention against Torture^12;, the Convention on the Rights of the Child¹³ ; and the recent Global Compact on Refugees¹⁴. Signatory states are obliged to respect, protect and fulfil human rights including those of refugees, though commentators on health rights note this also requires the identification of duty bearers and the legislation of enforceable standards.^15-16

Unfortunately sometimes religions have produced human displacement and conflict, maintaining inhospitality via in- and out-group dynamics and fuelling ethnic or nationalist tensions and hostilities. A significant gulf sometimes exists between religious ideals and practice, suggesting that greater dialogue is needed within as well as between faith communities where interpretations of sacred texts lead to negative behaviours². 

However international researchers of migration and religion also describe religion’s importance in creating socially responsible cultures of reception and hospitality towards migrants and refugees, and in shaping and maintaining identity among migrant populations and their reception by host nations.¹⁷ Following on the formative role of religions in early humanitarian movements, and a post-WW2 phase during which the humanitarian sector secularised, the sector has reappraised the importance and expertise of faith-based organisations, local faith communities and faith leaders in forced displacement, and re-engaged with them (for a more thorough account of this complex history, see Sulewski²) . It remains true that the major world religions unite in the call to love the Other as oneself; and that practically speaking, religious agencies complement  secular agencies in providing vital services to asylum-seekers and refugees.

Refugees, mental health and border policies 

In the world’s largest refugee crisis since World War II, UNHCR recently registered 108 million forcibly internally displaced people (IDPs), including twenty-nine million refugees and five million asylum-seekers.¹⁸ This number has almost tripled in the ten years between 2013-2022. Only 114,300 refugees were resettled and six million IDPs returned.

The Refugee Convention, which Australia has signed, defines a refugee as “outside their country of origin and having a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion”.¹¹ Additionally, under Australian law asylum-seekers outside this definition facing removal that risks torture or their lives can claim Complementary Protection. Exceptions to asylum require grave proofs.¹⁹ Critically, climate change is expected to greatly increase both internally displaced communities and externally displaced people. 

Nevertheless, though international covenants proclaim human rights as universal, nations pre-eminently identify human rights with their citizens. Unlike other Western democracies, Australia lacks a human rights act and framework. Predictably therefore, Australia is not proactive regarding human rights.²⁰

Due to their need to travel in undocumented and unscheduled ways, asylum-seekers are marginal, enjoying little prospect of acceptance.^21-22 Post-9/11, the so-called “War on Terror” has featured arbitrary detention and torture, and exacerbated racism and animosity towards refugees.^23-24  Western countries, aiming to deter and force repatriation, detain asylum-seekers in below-subsistence conditions: harsh outlying places or islands where barbed wire and armed guards patrol borders.²² They are not considered rights-bearers. If refused asylum, they can endure forced labour and exploitation.²⁵

 “Asylum-seekers’ mental health problems exceed that of non-displaced community groups and they are weighted towards post-migration adversity, as growing evidence from reception countries shows.”

Asylum-seekers’ mental health problems exceed that of non-displaced community groups and they are weighted towards post-migration adversity, as growing evidence from reception countries shows. Imposed privation – including prolonged detention, insecure residency, burdensome determination procedures and restricted access to services, work and study – aggravates trauma, Post-Traumatic Stress Disorder (PTSD) and depression.²⁴ These problems lengthen with detention, markedly increasing after 12 months.²⁶ 

Unfortunately, such knowledge has not impacted official policy. Australia continues to detain irregular maritime arrivals (IMAs) vastly longer than elsewhere (more than 800 days in early 2023).²⁷ Since 1992-3, Australia has unremittingly championed global harsh border policies. Its bipartisan centrepiece for IMAs is indefinite mandatory detention. Assorted measures bolster this: temporary protection visas (1999-2008, 2013-2022), boat interceptions and turnbacks, excising offshore islands from the migration zone, and offshore detention (2001-2008, 2012-present). In February 2020, the International Criminal Court found: 

“These conditions of detention appear to have constituted cruel, inhuman, or degrading treatment (CIDT), and the gravity of the alleged conduct thus appears to have been such that it was in violation of fundamental rules of international law…”²⁸

Supplementary measures include fast-track processing, denial of independent reviews, official stigmatisation, and indiscriminate deportation. These rigours are not reserved for detained asylum-seekers: Sister Aileen Crowe searingly documents how they also affect those arriving by plane with valid entry visas who then claim asylum.²⁹ 

“This cruel treatment is no accident: indefinite immigration detention that callously isolates and forcibly separates families is deliberate and determined.”

This cruel treatment is no accident: indefinite immigration detention that callously isolates and forcibly separates families is deliberate and determined. The Australian Government shows it understands and allows detention’s risks and harms, justifying its abusive treatment of those who come seeking protection as allegedly stopping boats, deterring, and forcing repatriation. It has been compared to “‘a hanging in the public square’ designed to intimidate and deter future asylum-seekers”.³⁰ Eminent clinical authorities argue that it constitutes torture. In protest at this violence, Aboriginal social justice activists have asserted unceded Aboriginal sovereignty and conducted their own Passport Ceremonies for refugees.³¹ Although successive governments defy the UN and attempt to absolve their responsibility by outsourcing, the mental harms are not just the policy’s foreseen unavoidable consequence but its purpose.³² 

Finally, whatever the merits of Australia’s historical record on refugee resettlement, Australian politicians’ sporadic defence that Australia’s refugee programs are among the world’s most generous are refuted if the measure of generosity adds refugee recognition to resettlement.^18,33 

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Case Study and Commentary 

The following case closely reflects the clinical caseload of the first author, and the work of all three authors and their clinical and non-clinical colleagues who are involved in this area. All names used in the case are pseudonyms, excepting refugees Reza Barati and Hamid Kehazaei and former Australian Prime Minister (PM) Kevin Rudd. 

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Late 2013 

Farhad, a twenty-eight-year-old Iranian PhD student, humanities lecturer, fluent in Farsi (Persian) and English, and progressive nominal Muslim, receives death threats and is briefly imprisoned with his dissident father for political opposition to the government. His older brother is then murdered. His wife, two-year-old daughter and parents tearfully farewell him on his mission to prepare a safer life for them in Australia, believing that the country is strong on human rights. An agent organises a flight to Indonesia: Farhad believes UNHCR will facilitate his resettlement to Australia. In the large camp, UNHCR and Red Cross queues are enormous and people-smugglers come daily offering passage. Declining, he learns that almost no-one is leaving. Eventually the people smugglers prevail. Paying much of his savings, he rides by bus to a southern Javan village, where he is pushed onto an overcrowded small boat with limited food. The boat is not seaworthy and after three days begins to take water. 

Imagine being Farhad
People are panicking; you are panicking inside but outwardly you are trying to stay calm. The Australian navy intercepts the boat’s distress call and removes everyone to Christmas Island. The terrifying sea voyage is behind you, and you are relieved to be out of the sea. Australian Border Force (ABF) officials undertake checks. You are then woken at midnight and pressured to state you are voluntarily travelling to Papua New Guinea (PNG). Along with other single men under security guard and cameras, you board a flight to Manus Island.³⁴ The ABF are tight-lipped.

Comment
Under the so-called No Advantage principle, “to ensure no benefit is gained through circumventing regular migration arrangements”, the Australian Government in 2012 restored offshore refugee processing in former colonies Nauru and PNG (Manus Island). PM Kevin Rudd vowed no asylum-seeker would come to Australia from July 19, 2013. Processing was effectively suspended offshore and onshore till 2015.³⁵ In Indonesia also, 14,000 refugees remain stranded.³⁶

Risk factors for mental disorders occur before, during and after migration.^37-38 Pre-migration, refugees, asylum seekers and irregular migrants may tragically lose their families, witness horrors, survive dangerous escapes, and be separated from culture and country. Their long journeys hazard violence, disease, trafficking and drowning. Their asylum status at the border is uncertain, chancing possible restriction or detention. Post-migration, accepted or not, they may face family separation, discrimination, lack of social integration, accommodation and language barriers, and internal or intergenerational conflicts of cultural allegiance.³⁹ 

Farhad’s journey continues
The Regional Processing Centre (RPC) has cyclone fences topped with razor wire. Manus Island is tropical, colourful and very hot. The local Manusians shout outside the fence, clearly unhappy with the new arrivals. 

Comment
Tension across the island reflects the Manusians’ grievances: poverty, the centre’s consumption of resources, assurances the RPC would bring jobs and now uncertainty about that.

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Imagine now being Sue, an ABF nurse
You are assigned to administer Farhad’s mental health questionnaire, which reveals moderate anxiety. On inquiry he says he awaits news of his family and his case, but has made friends with fellow Iranians. He is feeling cautiously optimistic.

This is one of your first nursing jobs. You felt called to make a difference for refugees after a PNG Bishop’s Delegation addressed your church about their refugee work, and you then volunteered with them for a month.You finished your nursing training and were offered work with Immigration Health services (IHMS) on Manus Island. You’re a Christian, youthfully idealistic, and want to obtain experience. Your brief orientation, however, seems aimed at cooling your determination to show kindness, and includes a discussion about the best way to cut someone down who is attempting to hang themselves. You are told to avoid making friendships. 

Six months later it is early February 2014
There are now over 1,000 male refugees in four compounds. Gross overcrowding amplifies tensions between ethnic groups. With poor drinking water and sanitation, airless dorms like furnaces, food spoiling easily, and processing and pathways to resettlement stagnant, peaceful protests have been rising for weeks. On February 5th, a conference between the ABF, PNG and Australian immigration officials and detainee community leaders reaches an agreement to obtain clear answers within twelve days.⁴⁰

Sue, on February 15th you are told that Canberra authorises tomorrow’s planned meeting despite the volatile environment. For the last few weeks, you have managed men with profound withdrawal, despair, near-lethal suicide attempts and self-harm with inadequate nursing, medical and psychiatric staffing. Your senior colleagues appear disconnected (mentioning “manipulation” and “detention fatigue”), and the Australian bureaucrats are refusing to authorise patient evacuations. You overhear casual racism and then your co-worker shows you an ABF cartoon targeting would-be asylum-seekers, their families and people-smugglers; it depicts an asylum-seeker’s journey from departure to offshore detention, warning that processing will take years. You’re lonely. Your connectivity to family and friends is poor, and you regret being so unprepared: you are feeling inexperienced and helpless. You contact a female Salvation Army officer, the welfare service provider. But she is leaving when the Army’s contract ends on 17^th February with no clear replacement. Should you leave too? You are fervently praying for guidance. 

Comment
Sue’s noble reasons for joining the health service on Manus Island are coming under pressure. Her unfolding conflict of loyalties to her patients and employer highlights some dilemmas health professionals confront in these centres. They include: 

• Bureaucracies risking or inviting collusion in abuse or neglect
• Human rights violations making treatment and research impossible
• Growing distress and anxiety over these moral dilemmas.³² 

Neutrality is impossible. 

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Farhad, you represent asylum-seekers from one of the four compounds at the big meeting with the Centre Manager. The manager says that processing for third country settlement will be very slow but that repatriation is always an option. ABF officials will collect people’s preferences. 

This stalling escalates tensions. Thirty-five men escape one compound and are returned, but the guards violently invade another compound damaging property and causing injuries. Things are quiet the next day but that night, things worsen.  Mutual antagonism flares across the wire: coarse insults from some detainees and throat-cutting gestures and stone-throwing from locals. Most detainees are uninvolved, and many are hiding scared. You help them move to the oval or if injured to the wharf, where you hand them over to Sue for further medical treatment.

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Sue, you assist a doctor stitching a detainee whose throat was slashed: he was lucky to survive the assault. You receive no management, debriefing or psychological support plan. Guards from G4S (Group 4 Securicor, an international private security company) cannot prevent further disturbances, so the PNG mobile squad guarding the perimeter enters the compounds and, aided by locals and some maverick service providers, starts dragging detainees from their bedrooms and bashing them. Panic momentarily freezes you. At great risk to themselves, G4S guards and a male nurse step between guards and detainees, forming a cordon to evacuate them to the oval or a nearby wharf for further medical treatment. You run to join them. 

Comment
No-one knows how they will behave under the extreme pressure that these policies generate. Showing moral courage requires recognising injustice and using one’s strengths – one’s empathy, courage, discernment and openness – to respond proactively.  Though training may help, we never know if we will be bystanders, perpetrators or people of courage. Rescuers during the Holocaust (an incomparable yet frequently cited paradigm case) were devout people of all faiths, as well as atheists: male and female, young and old, rich and poor, peasants and intellectuals, Socialists and conservatives. Scholars note common threads: altruism, independent-mindedness, social marginality. Many acted spontaneously. The vast bystander population, religious and non-religious, neither aided nor hindered the Final Solution.^41-43

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Farhad, you are now among the evacuees. There is no safety, certainty, justice, or anywhere to hide. Late at night shots are fired. Fear overwhelms you: the years of terror at home, en route and now in Manus Island. It is at this time that you hear that a fellow Iranian, twenty-three-year-old Kurdish architecture student, Reza Barati, has been taken out, injured, in an ambulance.

The next day you hear that Reza Barati was murdered. Another man lost an eye. The Australian Minister of Immigration blames the detainees. You are awash with frustration and outrage at being blamed for the death of an innocent man, the carnage of the night before, and the terror you just survived.  Despite your fear, loneliness and exhaustion, you retain some small spark of hope. People turn to you because you keep it together. You have only been detained for some months, so you are not yet running out of hope.

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Sue, you continue to tend to wounded detainees late into the night. Secured in the staff compound with colleagues, you are exhausted and profoundly shaken by the ongoing battles, the murder of Reza Berati, and doubt about your own country’s government. You begin to understand there may be a strategy behind this suffering, that it might be all about forcing asylum-seekers to simply return to the persecution they fled.⁴⁴ You begin to wonder how this squares with your professional ethics and what options are available to you. 

Comment
Sue may be suffering vicarious trauma from exposure to abuse, trauma, horror, insoluble predicaments and invalidation. History teaches us that medicine can be co-opted for unethical political agendas.⁴⁵ Moral Injury involves spiritual-existential questioning about collusion with state priorities: feelings of betrayal, shame, contamination, grief, outrage, meaninglessness and being haunted about the banality of evil.³² Meanwhile, some of Sue’s peers seem insensible to this moral injury. 

Sue’s decision about whether to resign depends on many factors: her faith and values (including her search for God’s guidance and what she believes about that), her character (e.g. independence vs. obedience), professional ethical codes, her experience, training and exposure to Immigration Department culture, peer support and pressures, asylum-seekers’ appearance and behaviours and her relationships with them. Will she resign or challenge the culture, directly or indirectly? Some possible choices for Sue include compliance, mild subversion, active subversion or resigning.⁴⁶

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Fast forward to early 2019

Farhad, you have now been detained for five years. The UNHCR has long since decided that you are a refugee. But though children have been released from Nauru, any gladness for you on hearing this is bittersweet because your liberation and the prospect of family reunion are no closer. Phone and internet access to your family is fraught. Your daughter is now aged seven and you have missed her growing up milestones. 

As your burdens increase, so does the challenge of staying physically and mentally well. Despite your determination to stay in routine, your sleep cycle has become disrupted. The heat makes sleeping almost impossible. You have stomach pains and occasional bowel bleeding. The IHMS nurses just give you Panadol and it’s almost impossible to see a doctor. You don’t know what’s wrong – ulcer, tropical disease, something worse? You know your friend Hamid Kehazaei died in 2014 from a foot infection, evacuated too late due to ABF bureaucratic resistance. You know that various detainees have died by suicide. The Manus Island RPC closed in 2017. With many other male detainees you were transferred to the local town of Lorengau. There have been robberies and injuries there, so some fearfully remained behind in the RPC. Though the townsfolk are poor you find them kind. You hear that following an Australian Immigration departmental investigation regarding Reza Barati’s murder, two Papuans were gaoled and two involved Australians were flown off the island.⁴⁷ Most guards are standoffish, but one enjoys repeating, “Go home, Muslim terrorist, back where you came from.” The time pressure and endless days become an enormous burden. 

You have requested review by your case officer and wonder if the guards have conveyed the message or are creating obstacles. It has been extremely hard keeping your mood up, eating, and functioning socially. You request and receive the Qu’ran and read it, including when awake at night. It is comforting, controlling your episodic panic about whether you will die here or see your family again.

Comment: Mental Illness Rates
Currently, the best international evidence finds that among adult refugee and asylum seekers, the one-year period prevalence for clinical depression (that is, the number of people suffering clinical depression anytime during the past year)  is 30% (though some studies find lower rates).²⁴ The corresponding figure for PTSD is between approximately 15-30%. These latter rates persist over time and significantly exceed comparison rates for non-refugee populations. The conjunction of PTSD and clinical depression is common.  Psychosis occurs in 1.5%.^{24, 48} Detained children have shown attachment disorders, withdrawal and developmental delays.⁴⁹ But in offshore immigration detention, rates of mental and physical disorders are approximately 90%.⁵⁰ 

Moreover, there were at least thirty-seven suicides related to immigration detention in the ten years from November 2013 to October 2023.⁵¹ For a small population baseline, the equivalent suicide rates are several magnitudes higher than community rates. Yet the regulator Comcare has only once laid Work Health and Safety charges against Home Affairs, relating to a 2019 suicide.⁵² The policy has also harmed hundreds of Australian nurses, teachers, social workers, doctors and other staff who have served with service contractors. 

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Myths regarding asylum-seekers

Health professionals should recognise and challenge false narratives emanating from some politicians and sections of the media concerning refugees and asylum-seekers, that shape popular discourse. They include the idea that IMAs are ‘illegals’, ‘terrorists’ and security threats, ‘cashed up’,  ‘queue-jumpers’ taking Australian jobs, a ‘tsunami’, ‘invasion’, ‘undeserving’ welfare recipients and unwanted ethnicities: and that Australia is losing control of its borders. Mentally ill, traumatised  asylum-seekers are disparaged as manipulative extremists.³² It is asserted without evidence that detention (offshore or onshore) deters asylum-seekers or people-smugglers.⁵³ What is clear is the negative effects of racism on people’s mental health.⁵⁴

March 2019

Meanwhile in Australia some newly-elected politicians campaign to bypass non-medical bureaucracy and airlift the severely ill for medical help. Their Medevac bill passes parliament. Volunteer doctors work with legal firms working on refugee matters to coordinate these Medevac assessments.

Imagine being Bill, a volunteer doctor in the Medical Evaluation Response Group (MERG). You have worked as a Career Medical Officer in public health roles and community mental health previously. After becoming aware of repeated media reports of how these people remain indefinitely in limbo in terrible states, you wonder if the Australian Government fully understands what is happening, and then read the statements of outspoken doctors in key positions who highlight that such indefinite detention is torture.⁴⁴ You go with the ABF to Nauru, quietly intending to investigate this. In your post you challenge the ABF bureaucracy about non-evacuations of refugees with serious physical and mental problems. The ABF gives you notice. You then go public despite signing a confidentiality agreement about what is happening. 

You are assigned to assess Farhad, who is singled out for medical assessment. Like the vast body of asylum-seekers, Farhad is a very resilient person and hope has started to creep back in with the inception of Medevac. He presents with stomach cramps and bowel bleeding, and appears emaciated. On careful inquiry he has severe depression and continuing post-traumatic symptoms that have become quite chronic. He has survived as well as possible under extreme hardship, keeping himself sane by diarising, writing, and trying to pray regularly. The Minister publicly criticises ‘activist’ doctors, but you and another doctor strongly recommend urgent treatment. 

Farhad is airlifted to Australia and a detention hotel. The newly elected government rescinds Medevac and Farhad remains detained. You lose contact. 

Comment
Hotel detention involves a severe dearth of fresh air and sunlight, and COVID-19 worsens these conditions (a situation highlighted by tennis star Novak Djokovic’s detention in January 2022). MERG receives no information about the treatment of those they assessed despite rates of physical and mental disorders above 90%.⁵⁰ Reports show that most detainees are eventually released without the recommended treatment.⁵⁵

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Farhad’s journey continues 

Eventually, and unaccountably, Farhad is freed on a Bridging Visa. Released, he is joyful about getting to speak to his family, but his physical and mental conditions continue. Community organisations arrange health support. He volunteers with them but he doubts he will keep a job after such long detention. Moreover, various potential employers are all reluctant because of his visa’s precarity. 

Comment
Q: What are Farhad’s key needs and our roles as health professionals?
A: Farhad’s needs are those of all refugees as well as those who are severely ill. The ADAPT framework for understanding mental health and psychosocial needs in post-conflict settings identifies five pillars of wellbeing for stable societies and individuals damaged in mass conflict and needing repair for recovery. These are: 

1. Safety/Security
2. Bonds/Networks
3.  Justice
4. Roles and Identities
5. Existential Meaning.⁵⁶

These conditions are relevant for policy-makers and clinicians alike. Clinicians need to provide culturally sensitive and trauma-informed care, working with variations of language, culture and belief. As advocates they lobby for access and more attuned mental healthcare for individuals and groups.

Good practice includes promoting social integration to improve outcomes of Farhad’s illnesses/disorders and addressing his practical and social needs by engaging and coordinating mental healthcare, social care, outreach and volunteer activities. This could be housing, welfare, legal and voluntary support regarding his family, and employment, including reviewing qualifications, work readiness and employment options/programs. 

Farhad will need specific care for his depression and PTSD if this remains persistent after release. Evidence supports psychological treatments for refugees’ PTSD, depression and anxiety: cognitive-behavioural and trauma-enhanced approaches, including eye-movement desensitisation and reprocessing (EMDR) and Narrative Exposure Therapy.^57-58 Treatment is also important for parenting and children’s mental health.^59-60

Comment:
Help-seeking and barriers refugees face in obtaining (mental) health care:
Only a small proportion of refugees seek help.⁶¹ Formal mental health services, whether generic or specialized, cannot meet their mental health needs, the majority residing in low-income countries.²⁴

Barriers encountered by refugees, asylum seekers and irregular migrants in accessing mental healthcare include: poor host country language proficiency; belief systems and cultural expectations for healthcare diverging from the host country; cultural factors influencing identity, illness explanations, clinical relationships, and somatic symptoms as unrecognised communications of mental health concerns. Other factors include lack of familiarity with the host country’s healthcare entitlements and systems; mistrust of professionals and authorities, and finance, transport, and childcare needs.^61-62

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Sue, you have long left the ABF. You have retrained in mental health nursing and work with the NSW Service for the Treatment and Rehabilitation of Torture and Trauma Survivors (STARTTS). You meet Farhad again there. You recognise and acknowledge each other. There is warmth and sadness as he recounts his journey to release and that he is in contact with his family who are now safe. For you, the joy and sorrow are mixed with residual guilt feelings about your participation in immigration detention. You note Farhad looks physically much slower and worn.  You review Farhad’s complaints and undertake a cultural assessment. 

Comment
The NSW Transcultural Mental Health Centre has resources on cross-cultural assessment in mental health for GPs and health professionals, which include the American Psychiatric Association’s Interviews on cultural formulation, which encompasses sections on spirituality, religion and moral traditions, and coping including religious coping.⁶³

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Farhad, among your PTSD and depressive symptoms is residual anger about the continuing injustice.

Sue, in the closeness that your encounter generates, and the discomfort of Farhad’s anger, you share why you got out and apologise to him for your part in his suffering. 

Question 
What would be the role for apology in this situation? Can a clinician apologise for the failings of an institution, or at least for her part in that?

A possible response
An apology needs to be genuine, truthful, convincing (in terms of narrative), remorseful and committed to change (NB Sue has changed employers).⁶⁴ From the institution/government, though compensation has occurred (to buy silence), an apology has not. 

Farhad, you tell Sue that you don’t hold her responsible, and that you saw her as a helper not a manager or enforcer. 

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Sue, your “internal supervisor” tells you that you need to seek external supervision or obtain some therapy.

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Question
Farhad has also nominated his spiritual practice of prayer five times a day and reading the Qu’ran as being a source of safety and stability for him through this prolonged storm. As a health professional and a Christian, how do you respond to Farhad’s religious commitment and practice? 

A possible response
Taking into account Farhad’s severe ill-health and mental capacity, you may choose to:

1. Not comment
2. Acknowledge its value as a personally significant form of religious coping that promotes mental and physical health irrespective of faith tradition⁶⁵ 
3. Explore further how this works for and sustains Farhad. 

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Sue: Under what circumstances if any would you reveal your own (Christian) tradition and commitment in the context of his disclosure? What are the clinical/professional ethics here and is there any tension between them and your Christian commitment and your ethics? How do you understand the role of being a Christian nurse? 

A possible response
The encounter needs to remain strictly patient-focused (especially given Farhad’s depleted state) and non-proselytising. Remembering the patient’s need and the power differential are vital. Everything said needs to be true to that.

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For all of us

At the time of writing, this policy is thirty-one years old. We have all known, to a greater or lesser extent, just how destructive the immigration regime is for those caught up in it. At some point we will need to ask, or be asked: what did I do in face of this suffering? Our answers will be quiet, private reflections. But as Christians and health professionals we will eventually have to live with our answers.

Footnote regarding terminology. We use the terms ‘refugee’ and ‘asylum-seeker’ to refer to both certified refugees and asylum seekers, even though the latter enjoy considerably fewer rights and experience considerably more status insecurities. 

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Appendix: Some Resources/Services

1. Australian Institute of Family Studies⁶¹
2. Transcultural Mental Health Line – 1800 648 911  
3. Embrace Multicultural Mental Health 
4. Run by Mental Health Australia, it provides a national focus on mental health and suicide prevention for people from culturally and linguistically diverse (CALD) backgrounds 
5. Mental Health Community Living Supports for Refugees
   Community-based program in seven Local Health Districts (LHDs) supporting community living and participation for refugees and asylum seekers with mental health issues 
6. Multicultural Disability Advocacy Association
   The NSW peak body for CALD people with disability, their families and carers.
7. NSW Refugee Health Service
   The NSW Refugee Health Service (RHS) aims to protect and promote the health of refugees and people of refugee-like backgrounds via free weekly General Practice clinics and a Refugee Health Nurse Program
8. NSW Service for the Treatment and Rehabilitation of Torture and Trauma Survivors (STARTTS) provides treatment and rehabilitation to survivors of torture and trauma. 
9. Refugee Council of Australia – Services in NSW
   A searchable database of organisations providing services for refugees.
10. Settlement Services International
    Community-based, not-for-profit organisation providing services in relation to refugee settlement, migrant support, asylum-seeker assistance, housing, multicultural foster care, disability support, employment services and youth support in NSW
11. Australian Institute of Family Studies, 2022 (AIFS)

References

1. Farrell P. ‘I want death’: Nauru files chronicle despair of asylum seeker children. The Guardian 2016 Aug 10.
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