Suresh Sundram – Mental health in Refugees and Asylum Seekers
Professor Suresh Sundram is the head of adult psychiatry at Monash Medical Centre and is in the Department of Psychiatry School of Clinical Sciences at Monash University. He’s been involved for almost fifteen years in asylum seeker mental health and mental health service system development in low and middle-income countries and sits on the executive of the World Psychiatric Association section on developing countries. He chaired the health sub-committee of the joint advisory committee for the governments of Australia and Nauru on Nauruan regional processing of asylum seekers and now serves as an independent advisor to both governments. Also, he is an external expert advisor to the UNHRC and has provided expert advice to the Australian Human Rights Commission, the Australian Department of Home Affairs, and non-government organisations. He ran the psychiatry clinic at the asylum seeker resource centre for over a decade, providing pro-bono psychiatric services to asylum seekers. And in 2016 with Cabrini, established the Cabrini Asylum Seeker and Refugee Health Hub. He has published and presented widely nationally and internationally in this area.
Prof Sundram is interviewed by Dr James Shelly. James is a Child & Adolescent Psychiatrist from South Africa, currently working with Eastern Health’s Early Psychosis Team in Melbourne. He has published work on methamphetamine psychosis and schizophrenia as well as treatment guidelines on ADHD and has been involved in expert consensus conferences on ADHD and ASD with the WHO and the Karolinska Institute in Stockholm. His main clinical interests include work with younger children with ASD as well as psychotherapy for anxiety disorders in children.
James: Let’s dive right in! “Propaganda is the enemy of reason and truth” is a previous quote in the RANZCP essay exam and it references the asylum debacle in Australia as a challenge for Psychiatry, (Australian New Zealand Journal of Psychiatry 2002).
Now again, not to be prescriptive, and the intent is not that we answer that question while we’re here but that particular statement is very politically laden, and I think its hard to have a conversation around or about mental health in asylum seekers without ending up in some form of political discussion.
So, its inevitable and I guess we’ll get there towards the end. Initially, I would like to focus on mental health more specifically in this population. But perhaps to start with, if you might be able to give us, probably for people who aren’t familiar with this territory, just a bit of background in terms of some definitions around refugees, asylum seekers and perhaps some information in terms of numbers, movement patterns and just to get a sense of the land so to speak.
Sure, so the notion of the asylum seekers being a historically, very long history right from the very beginning of civilisation. There is, in-fact, some evidence that suggests some non-human primates would seek the protection from other social groups, would leave their social groups to seek the protection of another social group, and so throughout the whole of history, there’s the notion of the asylum seeker.
That reached a climax really in the aftermath of World War Two with tens of millions of displaced people throughout Europe, and those people weren’t able to return to their country of origin or were unwilling to return to their country of origin.
And so, the fledging of United Nations were built on the work of the league of nations which was the preceding organisation before World War Two, developed a convention for how the world should respond to the refugee crisis and the aftermath of World War 2. They formulated what became known as the 1951 convention, UN convention, on the status of refugees.
Now, in that document, they defined what a refugee was, and there was a number of key criteria to that definition. The first is that a refugee has to be somebody outside their usual country of residence, in other words, you can’t be a refugee in your own country; you have to have crossed a national boundary.
The second is you must be unable or unwilling to return to that country because you have a well-founded fear of being persecuted, for a range of reasons, and those reasons include reasons of race, nationality, religious, political, social opinion, belief.
The last criterion is you can’t be a war criminal, and that was because there was a whole lot of Nazi’s who sought protection of countries having fled from Germany after having lost the war, so that was a newly introduced criterion.
The difference between the asylum seeker and a refugee is that all refugees at one point in time were asylum seekers, that are you leave your country of usual residence and you then state that you are trying to claim the protection of another country or another place.
That claim for protection is then assessed, and that assessment can be done by an international agency such as UN high commission for refugees, or, it can be done by a delegated statutory authority within the country you are seeking protection.
So, in Australia for example, that would be what was the Department of Immigration and Border Protection but is now the Department of Home Affairs. You, as an asylum seeker, lodge an application of protection, the department assesses your protection claim, and if they determine that you meet the criteria of the Refugee Convention, then you will be identified as a refugee.
Now, there are a couple of important caveats and additions to that. The first is that back to the ’51 convention, it was known as the Geneva Convention, it was limited to Europe and the peoples of Europe. So, in 1967, recognises the fact that this is a global problem and the UN developed the ’67 protocol and simply expanded it to include the whole of the world.
The second important notion is countries, for example, Australia and New Zealand, are voluntary signatories to the convention. What that means, is that they seek to abide by the convention, that their obedience to the convention is purely voluntary.
So, at any point in time, they can withdraw from the convention; they don’t need to acknowledge or abide by the convention that is purely a voluntary action on the part of each government and each country. That’s not the case in countries where there are bills or charters of human rights such as the US or Canada or many countries in the European Union, where in-fact, those bills or charters of human rights compel those countries to legally abide by the convention or protocol.
The last point I’ll make about this is the definition of a refugee according to the ’51 convention. Although it sounds like it’s relatively broad, it is in-fact, comparatively narrow. So, for example, people who might be persecuted in their country of origin because, for example, their sexual preference or because they are being subjected to domestic violence or because they’ve been enslaved, cant claim refugee status.
That’s not covered by the refugee convention, and so, for those people to seek protection, they need to seek protection under what’s called complimentary protection and that is a range of other international conventions and treaties and protocols which countries, again, voluntarily sign on to but which recognises, for example, the rights of the child, recognises the rights of women for equality, it recognises the right to protection if you are going to be subjected to, for example, torture or slavery. So, those sorts of additional conventions and treaties.
And again, some of which Australia, for example, is a signatory to the treaties. If I now want to expand to the question of refugees in a global context, this is the worst it has ever been in global history.
There are in the order of recent data indicates about sixty-eight and a half million people are either refugees or displaced persons. If you put that in some sort of population context, it would make the population of displaced persons greater than the population of either France or the UK. It would be somewhere between number 20, 21, 22 regarding national population so, its a very severe problem.
That consists of two groups of people. It comprised of refugees in the way I’ve just described them but it also, and this is the greater number, about forty million are people who are termed internally displaced people. These are people that have been forced to flee from their home because of conflict or other troubles, but are still within the national boundaries of their country but are unable to return to their home.
They are people that are termed internally displaced, and they are not able to receive or are not considered refugees or asylum seekers within an international perspective.
James: “Okay, because they are not crossing any national borders?”
Prof Sundram: That’s right, they’re not crossing national boundary.
James: “Where are the biggest movements happening between one which countries or two which countries?
Prof Sundram: So, the primary source countries of refugees are the countries that are in the news where there is conflict. So, at the moment, five countries provide something like 68% of all the worlds’ refugees and they are Syria, Afghanistan, Somalia, Sudan and Burma.
I could be wrong, but those are the sorts of countries that provide the worlds’ refugees. The worlds’ refugees go not to the western industrialised side of the world, they go to the countries where they can first gain some degree of security and protection, so, most of those countries are the countries adjacent to the source countries of refugees.
So, for example, they would go to Turkey, Lebanon, Jordan in particular for Syria. They would go to countries like Uganda, the Democratic Republic of Congo, Pakistan for countries like Afghanistan and Somalia and Sudan.
About 85% of all the worlds’ refugees are hosted by the developing countries, and the western industrialised nations, really only host about 15% of the worlds’ refugees, which indicates the very significant disproportion between who is bearing the economic cost burden of the world refugees.
James: “That’s also quite significant in terms of the socio-economic impact that refugees might make on a country, for better or for worse, because a lot of refugees who want to move there, want to work there and want to contribute to society, can be a real asset. But, of course, if it’s a country that’s already struggling economically as well, that’s what one of the worries are.
Is there much data in terms of what kind of burden is placed on various countries according to their particular socio-economic standing or their GDP?”
Prof Sundram: Yes, so there are two really important measures of that. The first is the proportion of refugees in a host country. And again, recent data tells us that say, for example, in a country like Lebanon, about just over 16% of the population of Lebanon are in-fact refugees.
So, if we were to extrapolate that, for example, to Australia, that would be the equivalent to a city the size of Melbourne being completely filled with refugees. So, Lebanon, for example, has the highest number of refugees to proportion of its population.
Jordan has a proportion of about 7%, so what this is indicating, is that a very significant number of refugees are in countries which are not the wealthiest, in-fact, they are developing countries of the world. Another very important measure, is a relative measure, and this is a measure of the number of refugees as a function of the population and the GDP of the country.
It doesn’t have any absolute value, but it gives a relative measure of which countries are bearing the greatest cost burden as a function of their national wealth and a function of their national population. So, we don’t have any recent data, but data going back a few years, to about 2014 or so, stated that the Democratic Republic of Congo had a figure which was 471, Ethiopia was in the order of about 450.
The first western industrialised nation on that list was Russia, and that was a figure of 9. So, to give you some comparative idea, what that means is, that Ethiopia, or Democratic Republic of Congo, is carrying somewhere in the order of 50 times the economic cost burden of refugees compared to Russia, and that’s a western industrialised nation.
If we go to a country like the US or a country like Australia, that value or that figure is about 1, which means a country like Ethiopia or DRC, is carrying 450 times the economic cost burden compared to a country like Australia or a country like the US. So, that really gives you a very clear indication of where the burden for caring for the world’s refugees is falling.
James: “Thats quite astonishing. If we move then down to the individual or family and take a bit of narrative perspective; in the literature, they talk about stages of immigration, stages of asylum seeking and refugees, and the different kind of psychological and emotional burdens that comes along with each stage. So, perhaps before we get to the actual mental health diagnoses, I was wondering if you could talk us through a little bit about what psychological process that somebody might go through at each stage of ones journey.”
Prof Sundram: I think its important when you are thinking about the mental health of the asylum seekers and the refugees to think about the sorts of factors that might be operating from a psychological perspective in the individuals.
The way that I think about it, is to write them up into a number of different and discrete components. One needs to be aware that some of these are specific to the refugee and the asylum seeker, and some of these are more generic, in that they apply to everybody, but are very important in understanding mental health of asylum seekers and the refugees.
So, the refugee specific factors, I think, can be divided into the pre-migration experience; so what is it that the refugee experienced in their home country which may well be the reason why they then fled and sort the protection of somewhere else. So, the pre-migration experience is very important.
The migration experience is also very important. What I mean by that, is the journey the individual has made upon leaving their home, what sort of experiences they’ve had in transit to countries, what sort of experiences they’ve had in trying to get to their final destination, be that Australia or New Zealand, or the US or the EU or wherever it is. The third factor is the post-migration experience.
The post-migration experience is going to be relatively comparable, or share many features which are comparable, with the experience of migrants, for example, or experiences with other people who have moved into a different country.
So, that would be the issues of settling into a new place, that would be the issues of trying to understand how it is one lives, behaves and conducts ones self in a new environment, as well as the practicalities of daily living. But very importantly also, particularly in reference to refugees and asylum seekers, its about the reception from a social level of the refugee or asylum seeker.
So, this can be a very positive experience; so we can have communities that embrace and support refugees and asylum seekers, or, it can be an experience of hostility and discrimination and we can see that both in the political landscape but also in the media where people may be persecuted or subject to xenophobia or racism as a consequence of being a refugee or asylum seeker.
Now, they’re the three specific factors to this population, but there’s two additional factors that are mainstream for everybody that we would see from a psychological perspective. The first relates to peoples pre-existing conditions.
People may well have physical or psychiatric or psychological factors which they’ve had prior to their pre-migration traumas or pre-migration experiences, which will have an impact upon their post-migration psychological state. The other critically important element is the individuals own resiliences, strengths and vulnerabilities.
The charateristics of the individual mediate the response to stressors. Now, an interesting way of thinking about this is that coming to a country, for example Australia, which is really at the bottom of the world, like New Zealand, coming from a source country like Afghanistan, or Siberia, or Somalia, for example, requires a huge amount of resource, a huge amount of personal resource, a huge amount of potentially financial resource and very significant capability to be able to do that.
If you’re uneducated, if you’re poor, if you don’t have much in the way of resources, you will not make it to Australia, because Australia is so far away and so difficult to get to.
So, what we find in the refugee and asylum seeker populations, particularly the asylum seeker populations, are very high levels of personal resource and resilience which is able to mitigate a lot of the stressors that people are experiencing, those other refugee related factors that I mentioned before.
James: “If you’re suffering a particularly severe or major mental illness, it can be hard enough just to get out of bed in the morning, hard enough just to get out of the house to buy your groceries. So people moving from one country to the next, it really is quite a feat.”
Prof Sundram: So, in-fact, I see very much the pointy end of psychiatric problems in asylum seekers, so the most severe cases I end up seeing. I can count on the fingers of one hand the number of people who have got a major severe mental disorder, such as schizophrenia or bipolar disorder, which is difficult to control. It’s just because those individuals don’t have the resources to be able to, generally speaking, get to a country like Australia.
James: “In terms of the most prevalent diagnoses or mental health conditions that are most prevalent among these populations, are there particular conditions we see that occur with greater frequency than in the general population?”
Prof Sundam: Maybe if I can first come back to the second part of your question from before, which was about what might be the phases the refugee or asylum seeker might go through.
We can think about how those five elements that I mentioned previously impact upon their psychological state currently. Generally speaking, when asylum seekers refugees arrive in a country like Australia there is usually an overwhelming sense of relief that they finally come to somewhere which is safe, which is able to potentially provide a future for them, that’s able to be a suitable place for them to live safely and securely. So, there is a general sense of relief and happiness that people experience.
That experience is relatively quickly tempered by uncertainty particularly that you’re an asylum seeker, you don’t know what’s going to happen to you, you don’t know whether you’re going to be expected to or whether you going to be given refugee status or whether or not you might expect to be repatriated because you’re not recognised to be refugee.
Also, people when they arrive, are commonly plagued by doubt. And what I mean by that is, that they have always had the ability to exercise choice whether or not they stay or leave their country and in leaving the country, they’re aware that they’re leaving behind their identity, their national or ethnic religious identity, they may be compelled to leave behind their family, they may be compelled to leave behind all their resources and status and wealth, as well as their community and people who might be politically connected might feel as though there betraying their political colleagues who are staying behind, to continue the struggle or the fight.
That entry of doubt then creates anxiety and uncertainty in the individual and if that persists in particular when combined with other elements, such as, hostility, discrimination in the in the host community, in particular if it’s combined with psychosocial adversity such as not being able to find work, not being able to study, people not being able to resume their social status that they enjoyed in their home country. All of these social stressors in combination can then lead to the emergence of psychiatric disorder.
The disorders that we see very commonly in the asylum seeker and refugee cohort are major depression and post-traumatic stress disorder. Both of those disorders are many times higher in the asylum seeker and refugee population than they are in the mainstream population.
But, they also show different characteristics which distinguish that from the way that depression or PTSD might manifest in the mainstream population.
PTSD is a very interesting phenomenon, so maybe if I start with that. The first element, of course, is that the first question people should raise is: why are people manifesting PTSD now in the community given the fact that the communities are a safe, secure environment. But, I think the best way to think about this is, that the traumatic memories really relate to the past, so they relate their experiences, pre-migration experiences or migration experiences. Very occasionally they might relate to post-migration experiences, but generally speaking, pre-migration and migration.
However, the individual, because of the resilience and strength I talked about before have, generally speaking, been able to keep those traumatic memories under control, so that they’re not distressed by them to any great extent, that they’re able to function in a normal manner, even though they might have a memory that is traumatic.
However, with the intrusion of psychosocial adversity with the presence of stressors which are much greater than what they’ve been used to what they may have experienced the past, there is an erosion of their resilience, and the erosion of their resilience then leaves them more vulnerable to the effects of the traumatic memories.
So that what we see is the development of PTSD in people who previously weren’t experiencing PTSD, even though the memories are of times from a long time ago. That’s an interesting phenomenon that we see in this population. The other major disorder that I mentioned before was major depression and the major depression is much more the standard major depression in the context of the stressors that I talked about before, which overwhelm an individual and result in the manifestation of the depressive disorder. However, the interesting thing about depression is that the phenomenology can be quite distinct from the phenomenology of mainstream major depression.
So, for example, we tend not to see guilt as a major factor, we tend not to see worthlessness as a major factor. We see suicidality, but the prevalence and the severity and the incidence of suicidal ideation or suicidal intent, is a lot less than what you would predict for people with the same degree of severity from a mainstream population.
And the reasons for that are interesting to think about, but, I think relate to the fact that asylum seekers, in particular, don’t have depression in the sense that it’s a contradiction of who they are in terms of their identity. They see themselves as still being worthy, they still see themselves as people who can contribute and so even though they get depressed by the presence of the psychosocial stressors they can still maintain some degree of self-worth.
The other element of the asylum seeker and depression is that for many asylum seekers they are the Vanguard for their family, so, they are the individual who’s been sent by their family to try and establish a stronghold somewhere safe so that the rest of the family can join them and therefore be removed from the the persecution that they’re experiencing. Fo that individual despite the fact that they have been rejected by the refugee determination process, despite the fact that they’re unemployed, that they’re poverty stricken, that they are unable to establish any sense of their identity, self worth, they’re still required to maintain hope, because if they give up hope, then in a sense, they then are forsaking their family to the persecution of the families experiencing.
So what we see in asylum seekers, is a sense of maintaining hope even though they feel profoundly hopeless. And of the way that I’ve described this is that there’s an island of hope in a sea of hopelessness and for many asylum seekers that’s an extraordinarily difficult position to hold. But they need to hold it for their own identity and, if you like, their own self agency, but they also have to do it for your family.
James: “It’s kind of a greater onus on them to be resilient in the face of their adversity. There’s something about people who make these big journeys, there is some sort of resilient factor about them and perhaps almost as if when you’re faced with enough stress, the sense of self is the first thing to crumble, there are self-doubts, there are feelings of worthlessness, hopelessness, guilt that often come up in depression. There seems to be something that’s preserved in a lot of these people, their sense of self, and maybe part of that is because for the very fact that they’ve made this journey and have held on to their sense of identity because a lot of the journey is wrapped in that. It’s where I come from; it’s what I believe in, it’s what I’ve been subject to because of who I am and what I believe in. I heard there’s something called the prolonged asylum seeker syndrome.”
This is a very interesting phenomenon actually. This is something that I described with the Dr Samantha Loi quite a number of years ago, where we found that asylum seekers who was subjected to a prolonged refugee determination process developed a set of psychological and cognitive phenomena that seemed to differentiate them from anything that we could find and literature, or anything that we could easily hold onto in terms of disorder-specific diagnoses and so are we coined this term to describe that.
But actually, as the number of asylum seekers has increased significantly over the last 8 to 10 years, we found that the whole sort of clinical manifestation seems to have disappeared. It’s really interesting to think about why that might be the case, but it might well be that an important element is the solidarity of knowing that you know there are many thousands of people who are in a very similar situation to you. Whereas, when we first describe this syndrome, people felt very much isolated. So they really didn’t have any sense that anybody else was in the same predicament as they were.
So what we found was almost like a cognitive rigidity in a cognitive constriction so that the only things they ever thought about was their own personal situation and that they found it very hard to engage with the normal activities of daily living in a much more cognitively open and fixable manner. So I would say that generally speaking, with the prevalence of this this syndrome has decreased remarkably over last few years.
James: “I wonder if one of the factors in group psychotherapy that contributes towards it’s psychotherapeutic effect is the sense of universality, in other words, the sense that other people are experiencing the same thing that I am. I wonder if, as the numbers have increased, people have started to learn that I am not alone in this battle, and that perhaps it’s a little bit easier to sit with uncertainty when you’re sitting together with others with uncertainty.”
It’s interesting you use the term ‘sitting’ because most asylum seekers in their asylum seeking phase, avoid other asylum seekers and they avoid other people of their own ethnic background or religious background. It’s not just active avoidance but its generally a preference not to be associated.
Now that’s variable, and again, we see phases of this happening. So initially people tend to band together in the way that you’ve described, but then over time, they tend to drift apart. When you ask them why is it that you do this, what is it that drives you, they talk about an emerging sense of shame, these are my words, not the asylum seeker’s words, and emerging sense of shame that they have still not been accepted to be a refugee, that they’re still living in a life of limbo where their whole life is really in abeyance until they can get their refugee status. They tend to reduce contact with family overseas, they tend not to associate with other people of the same situation or people who are refugees, or even people who are citizens from their same ethnic background because of that sense of shame and the fact that they don’t want to be reminded of their, if you like, second class status in country.
James: “Immigration detention is obviously a very big contentious issue, what is that impact, as there already seems to be a very large mental health burden on people seeking asylum?”
Prof Sundram: So immigration detentions are a very special phenomenon. It was something that was introduced into Australia in the early 1990’s by a labour government, and the quality of the immigration detention in Australia contrasts with, up until very recently, most other types of Immigration detention anywhere else in the world and the difference is a very important difference. In most places in the world, people can still be subjected to immigration detention, but the immigration detention is for purposes of health and security checks. So it’s about ensuring that the person or asylum seeker doesn’t have a communicable disease and that the person or identities are able to be verified, and that they’re not a security risk for the host country. In those circumstances, the person or the family and individuals are very quickly then released into a community detention type environment or released into the community.
Australian immigration detention protocols and processes a very different. They were introduced principally to detain people who arrived in Australia but the quality of the detention here is that it’s indefinite and that it’s mandatory. What that means is that everybody that arrives in Australia in an unauthorised matter is placed in detention and they can be placed in detention for however long – the minister determines that they should be in detention which is indefinite.
What I mean by unauthorised arrival, is that I mean it’s an individual who has arrived in Australia without a valid visa. So you can come to Australia by aeroplane but if you get on an aeroplane you will only be allowed on aeroplane with the valid visa. That can be a work visa, student visa, a tourist visa, family reunification visa or any other type of visa. You can then arrive in Australia and then once you’ve arrived in Australia, you can then claim asylum and whilst your claim for asylum is being processed to determine if your’re a refugee or not, you can live in the community like anybody else.
However, if you’ve arrived in Australia without a valid visa, that is you’re an unauthorised arrival, this normally applies to the so called ‘boat people’, those people who are unauthorised will be placed in immigration detention by definition mandatorily and indefinitely. The reason for the indefinite mandatory detention is to act as a deterrent against people arriving in Australia in an unauthorised manner. So the intention was to stop boats leaving countries like Indonesia and Malaysia and coming to Australia. So the impact is a very different impact compared to immigration detention anywhere else in the world: the fact that it’s mandatory and the fact that it’s indefinite places a huge toll on people’s psychological status and functioning.
They are held in a prison-like environment, they have no sense of self-agency, they cannot engage in the sorts of activities that people who live in the community might engage with, and they’re not able to do anything that might be considered to be normal. So they’re not able to work, they’re not able to study, they’re not able to cook their food and to look after themselves. So in essence, they’re held in prison like an environment, and there’s no end date. So it’s those qualities which then have a very profound deleterious impact on people’s resilience and people’s psychological health.
James: “It’s a very traumatising experience. So torture and trauma is something that is highly prevalent in the life of a refugee and you spoke before about a specific phenomenology, particularly PTSD, does this require a specialised approach in terms of mental health and provision of mental health care? And in Australia, are we providing that?
The experience of torture is comparatively uncommon and I see the more severe end of asylum seekers and refugees. Of course the prevalence of torture in refugee asylum seeker populations is, I don’t want to say infinitely higher than in the mainstream population, but it’s much much much higher obviously.
The actual direct experience of torture is not that common however, every refugee and every asylum seeker has had a very significant experience of trauma and the trauma can be comparatively mild, right through to the most severe and distressing types of trauma that you could humanly imagine somebody being subjected to and experiencing.
That creates the types of psychiatric disorder that I’ve mentioned before, in particular post traumatic stress disorder, but also major depression and very occasionally psychotic type disorders. The general training experience for psychiatrists doesn’t have a very strong trauma focus, that’s not a particularly common type of presentation in Australia, and registrars aren’t really exposed to managing people with significant traumatic backgrounds.
There is an entire group of patients for example who might have been exposed to childhood traumas who then develop or a predisposed to develop disorders like borderline personality disorder for example, and we might come into contact in that context.
But in terms of adult traumas or trauma’s which have less impact upon the psychological development of the individual, but are existing in their rights as traumatic memories, we don’t have a lot of experience with them.
What we find is that, in particular, the mainstream mental health services don’t manage these people particularly well and that we’ve needed to develop more specialised services to be able to help these people with these types of disorders.
James: “So then what is access to care like for people , not only for people with these specific disorders, but in general for the asylum seeking and refugee population?”
So there are a number of organisations which deal with the people at the tip of the iceberg and in particular, people who have had significant torture and trauma experiences. For example, there’s a number of our services that deal with torture and trauma survivors and that’s both in Australia and New Zealand. They tend to deal with people in a long term perspective, so they are dealing with engaging them in an ongoing psychotherapy and using a whole range of modalities to try and deal with with that type of torture and trauma history.
However from what I’ve said, you can imagine that the vast majority of refugees and asylum seekers may have significant psychiatric and psychological morbidity, but may not quite have the requisite level of severity with regards to torture and trauma, and for many of those people, those disorders are either unrecognised, or if they are recognised, are not very well managed.
And mainstream services don’t manage them particularly well as I’ve mentioned before. For those people, there are very few services that are available. There are for example, for asylum seekers, a couple of services in Melbourne where asylum seekers are able to receive psychiatric and medical care.
But those services are not wide spread, and they’re oversubscribed in terms of being able to provide services. The other element, of course, is the recognition of the disorder, and this is a major problem in the sense that people come from countries where mental health literacy may be very low. People may not recognise symptoms in themselves as indicative of a psychological or psychiatric disorder, or there may be significant stigma and shame associated with identifying symptoms as a symptom of mental disorder.
What we’ve been able to do is to develop a screening tool for example that non-health clinicians or non-health workers can use to screen refugees and asylum seekers to identify those people who are more vulnerable or more likely to have major depression or post-traumatic stress disorder.
We’re hopeful that we can try and disseminate such a screening tool so that people in the sector can use that to identify and recognise vulnerable people before they manifest into a more severe disorder.
James: “It also brings us onto the next question which is around culture and language. Culture and language are critical considerations in any interaction around mental health concerns, but particularly for this population, in that often these people are forced out of their own culture, forced out of their own language, and may have never been educated and never been exposed before to other peoples cultures or languages, and so they presumably are the bigger divide.”
Language is very problematic in psychiatry, just even in normal interactions, but when you then introduce people who can’t speak English or don’t know English and you then have to introduce an interpreter, that adds a huge degree of complexity to the interaction. It becomes very difficult if someone comes from a language group where there’s very few interpreters available or maybe no face to face interpreters are possible, and that’s for a couple of reasons.
One is of course that many asylum seekers and refugees don’t want to talk with or engage with members of their ethnic or religious or national community, because they may feel that the interpreter’s might be passing information back, they may not trust them, it may be that there is actually an ethnic or religious division between the the interpreter and the patient and that can get in the way.
So it becomes a very challenging situation because you may not be able to use a face to face interpreter, you may only use a telephone interpreter because the patient doesn’t want the interpreter to see them. The other, and many of my patients wont allow me to use their name when I’m talking to the phone interpreter, they just want me to refer to them as him or her.
The other element of course is that you need the interpreter to be able to also culturally interpret for you or provide you with some sort of cultural frame of reference. Because the word that might be used for a feeling state or emotional state, for example psychosis, may be quite different from what you might be used to in an English language environment, and you might need to ask the interpreter how it is that you can ask about a persons mood because they don’t have a a simple straightforward word for feeling depressed or sad or happy.
Having said all of that, I think the important point is that ultimately though the phenomenology its not that different. There are some cultural shapings, there are some differences in particular, but the prevalence of shame and some cultures with less emphasis on guilt for example, so both types of differences are relevant. But on the whole, it’s not too challenging to work through those cultural issues and normally it becomes apparent that someone has a psychiatric disorder even though it might be influenced to some extent by cultural factors.
James: “And of course if you maintain a sensitive and honest approach then that’s an important way to transcend that cultural divide. You give of a sense that you care about this person, that you’re out for their best interests and i think it makes it easier to work with people who might not understand each others language or might come from different cultures.”
Prof Sundram: I would go further than that. I think what you just said is critical. Many asylum seekers and refugees who see you as the doctor will have the same status in Australia or New Zealand as you as the doctor would have in their home country which is usually an exalted status, and the other qualities that go with that status are also transferred, so the the the position of being trusted, of being able to hold a intimate and personal information, and are not to divulge that information to anybody else which are usually qualities that are associated in all health systems with doctors.
So you as the doctor maybe the only trusted individual in that person’s experience in Australia and New Zealand, and what I find repeatedly is, that the patient comes to me to see me because I am the person that they can tell everything to.
That therapeutic effect is frequently much more powerful than any therapy or pharmacology or anything else that I might do with individual.
James: “There are lots of issues around mental health and in psychiatry that interface with broader socio and political systems and structures. The question around immigration seems to be particularly, it feels like it’s reaching some sort of peak over the last decade or so, maybe that’s just the way its spoken about, but I guess my question is its critical to be able to both separate and incorporate one’s own social and political views from clinical interactions, so has psychiatrists found a balance between the individual needs of the person sitting in front of you, suffering with psychological distress or a mental illness from those of broader social and political groups that we can work within?”
Prof Sundram: The situation as I stated that the answer is now has most problematic as it’s ever been in global history and it’s interesting to try to think of what those currents are that did result of this situation. There’s no question that globalisation is a phenomenon has transformed the whole world as we know it and globalisation as a phenomenon has sought to minimise national boundaries and to create transnational structures.
So we can think of for example of technologies, we can think of multinational companies, we can think about the transfer of money and capital between countries. But what hasn’t been subjected to globalisation has been the movement of peoples and the movement of labour.
What we see instead is that nation-states have sought to do the reverse for people that they’ve done for trade and commerce, which is in fact to be more resistive and less porous to the movements of people. Whilst still showing, the for example the developing world, the successes and riches that exist in the developed world.
So what we get is a tough situation where people now will have expectations and desires and wishes which are being stifled because of these stringent nation-state type rules. So when we look at flows of people between countries or in this sort of situation, mass movements of people, it’s better to think of these mass movements as mixed flows of people, that is flows which incorporate both refugees and asylum seekers, but also people who might be moving for economic reasons or for reasons which might be about trying to find a better life.
For example and in particular, crossing from North Africa into Europe is a classic example where the flows are very mixed with both groups of people in that scenario.
The problem is, of course, it is that the person sitting in front of you may well be from such a mass movement of people, but the judgements that you might be thinking through in terms of your own understanding of what their situation is not particularly relevant to the clinical state in front of you.
It may be that the person has made a series of decisions about moving from country A to country B because they think they can get a better life in country B, but as a consequence of those decisions can now be destitute, can now be facing persecution, can now be facing extraordinary straightened circumstances and as a consequence of that, maybe experiencing very significant stress and a very significant disorder.
The decision as to whether or not that was a justifiable decision or a valid decision is not your decision as the clinician to make, that’s for the statutory authorities that I described before, so for example UNHCR or migration authorities in the country to make those decisions. But you as the clinician will be facing somebody with the same set of psychological and psychiatric factors irrespective of the motivations for them to leave the country.
James: “One death is a tragedy, a million deaths is a statistic. Depending on the intention of that statement, it made me think that whatever the motivations are, whatever the political structure is, when somebody sits down with you face to face, you have to approach them as an individual, you have to listen to their story and act in their best interest. I think that’s your responsibly as a clinician and as a psychiatrist.
So what do you see is the role of psychiatrists in advocating for the rights of asylum seekers refugees and for promoting and affecting positive change for this population?”
Prof Sundram: I think one needs to be very careful in this space because if there was a simple answer to the question then we would have arrived at that a long time ago, and in fact there isn’t a simple answer to this question.
The psychiatrist on the one hand needs to be an advocate for their patient, for their individual patient and to be able to ensure that their patient receives the best possible care that you as the treating doctor can ensure. It is however imperative upon us where we see factors operating to cause pain and suffering, where we see factors that act to reduce the access of an individual to healthcare, or reduce their access to other psychosocial support, that we take a more active stance in advocating for improved condition.
For example, there is now within our college a very strong position around immigration detention. There is no question that immigration detention in the way that I’ve described in the Australian context of being indefinite and mandatory has extraordinarily deleterious effects on people’s mental health, and we as a college have taken a position that we oppose indefinite mandatory immigration detention and then we are implacably opposed to children being placed in immigration detention for anything more than the absolute minimum period for basic health and security checks as I described to you before.
I think it is a very reasoned and rational response based upon our expertise and from what we’ve been able to observe from a clinical, psychiatric and psychological perspective. I think we can do the same as doctors for example, in advocating that asylum seekers should have access to healthcare, be it through the public health system, through the structure such as Medicare for example, or some other public health system access, so that all individuals have the right to basic health care and that shouldn’t exclude asylum seeker from that group of people. So I think those sorts of roles, we should be at the forefront in terms of advocating, because we really are the subject matter experts in those places and that we have a powerful voice that we should exercise.