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Submission to the National

Inquiry into Children in Immigration Detention from

Suicide Prevention Australia

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TWO AUSTRALIAN NATIONAL POLICIES

ON SELF-INJURY AND SUICIDE: A SUBMISSION TO THE HUMAN RIGHTS COMMISSION

ON CHILDREN IN DETENTION

Michael Dudley

Conjoint Senior

Lecturer, School of Psychiatry, University of New South Wales and Sydney

Children's Hospital, and Chair, Suicide Prevention Australia

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Suicide and self-harm

among the young in Australia

For over a decade

and until fairly recently, expert reports and news stories made Australians

aware of rising Australian male youth suicide rates. Suicide rates for

Australian males aged 15-24 years rose from 9.6/100,000 in 1964-1968 to

28.6/100,000 in 1994-1998. Such trends also have affected young adults

aged 25-34 years, who have shared the highest rates with males over 75

years, though the latter have been falling. One 1999 report indicated

that from 1990-1994, Australia had fourth highest recorded male youth

rate and eighth highest female youth rate in the world [1-3].

These trends are

the tip of the iceberg. For every male suicide there are 30-50 attempts

and for every female suicide there are 150-300 attempts. Fifteen percent

of adolescents have a psychiatric illness at any point, up to 25% of young

people may have suicidal behaviour at any time, and up to 25% of adolescents

have had an episode of depression in the last 12 months [4-6].

Australian male youth

share various risk factors for youth suicide with other Western countries

that have also seen this trend, but some Australian populations are experiencing

elevated rates and may have also more specific risks. Aboriginal and Torres

Strait Islanders (ATSI) have historically had very low rates, but now

young male rates are double that of non-Aboriginal groups [7]. Male youth

suicide rates also rose tenfold in small rural towns over the 35 years

to 1998, compared with metropolitan rises one quarter that amount [3].

ATSI and rural populations, among others, have been the focus of national

suicide prevention strategies.

The Australian

government's response to community concern about suicide

The Australian government

responded to wide-ranging community concern about suicide with the National

Youth Suicide Prevention Strategy (NYSPS) (1995-1999, $31 million) [8-10]

& Living is for Everyone (LIFE) program (all ages, 2000-, $66 million)[11].

These programs are umbrellas for national, state and local prevention

initiatives. They are Government, non-government and volunteer based,

and linked with other strategies e.g. violence & crime, drugs, mental

health, homelessness, child & youth health, ATSI well-being. NYSPS

and LIFE have adopted a biopsychosocial model, and a progressive and innovative

public health approach. They aspire to evidence-based practice (or practice-based

evidence), are population-based & individual in scope, and involve

national, state and local interventions with community, consumers and

youth. Partnerships, intersectoral collaboration and sensitivity to cultural

diversity are key philosophical tenets. They heavily emphasise prevention

and early intervention, and work directly with target populations or indirectly

at a community or system level. Their outcome measures may be suicidal

behaviour or mental health & other risk factors for suicide. The programs

are comprehensive and proactive. Very few other countries have promoted

and funded suicide prevention to this degree.

Moreover, tentative

evidence has accumulated from evaluation that significant gains were made

by NYSPS, despite the short time since initiation of the Strategy, problems

with using suicide rates as outcome measure, the absence of measurable

intermediate objectives and lack of baseline and population data, and

confounding factors. A substantial minority of projects demonstrated positive

impacts on individual and environmental risk and protective factors. Significant

reductions in disability occurred for youth attending mental health services.

Access, engagement & capacity-building emerged as major themes [10].

Male suicide rates for the year 2000 fell in all age groups, except 25-34

years [12]. While it is impossible to prove that this was due to the strategy,

lower rates for two years in succession may signify that the strategy

is working. Thus, this is a story about working together, with some indications

about success.

Self-harm among

young asylum-seekers in immigration detention centres (IDC's)

A uniquely Australian

group that has not been the focus of the LIFE program is that of asylum-seekers

in immigration detention centres. For decades post-World War II, Australia

willingly accepted immigrants & refugees, but as large movements of

refugees continued, it and many other western governments increasingly

interpreted the UN Refugee Convention (1951) more strictly. Since 1991,

Australia has had a policy of mandatory detention of asylum seekers while

applications for refugee status are processed. From 1997, it toughened

refugee review and appeal processes, abolished family reunion and permanent

visas, and severely restricted access to work, education, social security

and health services for ex-detainees. In the last 18 months, the government

deemed certain offshore islands and reefs to be outside Australia for

arriving boat people, and established certain Pacific nations as holding

points. Recent statistics show that the majority of asylum seekers who

enter Australia's immigration detention system will be found to be refugees

under the 1951 Convention [13-15].

Detainees include

families and unaccompanied children, and processing can take many months

or even years [16]. In November 2001 a total of 521 children under the

age of 18 were in immigration detention and 53 of these were unaccompanied

minors. Ninety four percent of children and families were in remote Immigration

Detention Centres (IDC's), far from family, services & scrutiny [16].

IDCs are run by Australian Correctional Management (ACM), a subsidiary

of the American company Wackenhut Corporation, for the Department of Immigration,

Multicultural and Indigenous Affairs (DIMIA). ACM also runs a number of

Australian and overseas (US) prisons.

Media and public

interest in asylum-seekers was sporadic before mid-January 2002, when

explicit suicide threats by adults and children to DIMIA and Australian

media, a 16-day hunger strike at Woomera and other sites, and lip sewing

by hundreds of asylum seekers, captured sustained national attention.

Attempted hangings and poisonings were reported, and one detainee jumped

into razor wire on the Woomera camp perimeter. After negotiation with

the Government's Immigration Detention Centre Advisory Council, the asylum

seekers agreed to end their self harm. Explicit drawings of self harm

and psychological distress were widely reported by media to Australian

community [Sydney Morning Herald, 14th January 2002, and thereafter daily].

At least five suicides

or undetermined deaths due to external causes have apparently occurred

in the last 18 months in the IDC population of about 3,500, making a suicide

rate of somewhere between 100 and 200 per 100,000 per year. These deaths

all occurred among adults (see Table 1). Self-harm remains endemic in

IDC's. There is at least one serious suicide attempt per day in Woomera

IDC, and at the time of writing 60 out of 500 were on suicide watches.

Many adults have made suicide attempts which have almost been fatal. Many

children are suicidal, and have engaged in a range of seriously life-threatening

actions (see Table 2).

Studies of adult

asylum seekers, especially (ex-)detainees, show high levels of depression,

anxiety and post-traumatic stress disorder (PTSD). There is little available

systematic information concerning the mental health of detained children

& adolescents. However, much literature documents the impacts of trauma

and violence [17-20], parental mental illness [21-22] and institutionalisation

and incarceration on children's social and emotional development, and

the long term developmental consequences of such impacts [23-24].

At time of writing,

except in South Australia, no arrangements exist between DIMIA & state

Departments of Health and Family and Community Services for guaranteeing

mental health assessment and treatment for families in need. This is at

odds with the Royal Australian and New Zealand College of Psychiatrists

(RANZCP) Position Statement on Provision of Mental Health Services to

Asylum Seekers [25], which states that all asylum seekers should be given

full access to mental health services. The Position Statement is committed

to promoting and researching the mental health needs of this population,

and expresses concern about detention of children. Australia ratified

the United Nations Convention on the Rights of the Child in 1990. Its

policy of detaining accompanied and unaccompanied children has been identified

by Amnesty International as breaching our obligations under this Convention:

to provide for children's developmental needs, to protect them from harm,

and to enable them to participate in decision-making about their future.

Access by mental

health professionals to Australia's immigration centres is extremely limited.

Repeated offers from the Faculty of Child and Adolescent Psychiatry and

the Committee of Presidents of the Combined Medical Colleges to assess

need and provide mental health services, have met with inconclusive responses

from DIMIA.

Knowledge about the

problem of self-harm in detention, its management and prevention derives

from convergent multi-source testimony, scientific literatures in related

areas and from the experience of many who have reported on this issue.

Dr Sarah Mares, Dr Louise Newman, Dr Fran Gale and the author undertook

a series of visits to 2 IDC's between October 2001 and April 2002. Visits

to the centres occurred with the lawyers representing the families interviewed

and we were involved in preparation of medicolegal reports on their behalf.

We were not given permission to interview unaccompanied children, or to

sit in on the interviews conducted by the lawyers representing these children.

Individual family members were announced to us by number not name. Interviews

were held with the assistance of interpreters. In order to protect the

families, family details were altered.

A case example

A aged 17 and R aged

15 are brothers, detained with their mother and younger two sisters in

an IDC. The family is known to authorities for their role in IDC riots,

and have been willing for their case to be widely discussed in the media

and elsewhere. They have been in various IDC's for 21 months. When both

escaped in a riot 2 years ago, police returned them, allegedly beating

and kicking them. A was handcuffed in a poorly lit small room for a week,

with no toilet or washing facilities, only a thin blanket and freezing

air-conditioning (which guards refused to turn off). He witnessed a prolonged

beating in which he thought the victim might be killed. Further hunger

strikes and lip-sewing occurred over the progress of visa applications:

A,R and their father were separated from the rest of the family.

In August 2000, 20-25

riot staff allegedly burst in on the family at 5 a.m., and handcuffed

the older members. Different family members were put in separate cells

(one for mother and 2 youngest children, one for father and R, and one

each for A and older brother). The family spent 15 days in cell block.

There were no working showers, no toilet facilities in cells. The younger

children and mother had to use a plastic bag which they found in the cell.

Their mother found this unhygienic and humiliating, and went on a hunger

strike for two days before guards would allow them to use the toilet.

A said that because

the guards didn't allow him to go to the toilet, he started banging the

door. They forced him to the floor, caught him by the throat, and broke

his nose. The family lodged a complaint, but the outcome is unknown. R

in his cell tried to electrocute himself by breaking a light globe, then

went on 4-day hunger strike. He was so weak that he lay on floor, banging

his head against wall and desperately wanted to die. In December 2000,

his mother was worried about R's social withdrawal and death preoccupation.

R had wedged his bedroom door shut so he could cut without detection.

His mother discovered him, guards broke in door, and he had a 2 week psychiatric

admission in Perth where he was diagnosed as depressed and traumatised.

The family's refugee claims were rejected at this time. In March 2001,

R took rope from washing line, and found a place under stairs where he

could hang himself while his parents went to dinner. He was found by chance

by another detainee. He remains a significant ongoing risk of suicide.

A and R's mother

and father both served prison terms for role in riot. Their father has

been in a WA jail for several months on people smuggling charges, which

have been recently dropped. The family was frequently split up, the younger

children sometimes cared for by A, sometimes without any carers. Their

sister cried till 2 a.m. because she had been separated from her mother.

The younger children

have witnessed many episodes of deliberate self-harm and suicide attempts

by other inmates. They suffer from nightmares and panic attacks, tension,

anger, social withdrawal, loss of interest (e.g. in school) and sadness.

They also show extreme emotional distress at any suggestion of threat,

manifesting for example as screaming or running and hiding. They demonstrate

hypervigilance, fears of loud noise and shouting. They are unable to laugh

and play.

Why immigration

detention predisposes to youth mental disorder, violence and self-harm

A series of factors

account for youth mental health problems, suicidal behaviour and violence

in IDC's. Families are held behind razor wire indefinitely. This, and

the consuming, legalistic, adversarial nature of the refugee determination

process, makes detention considerably more difficult to endure [26]. Traumatised

children and youth witness ongoing violence, such as suicide attempts

and riots. Their parents often cannot comfort or protect them from these

events, and their own intense hopelessness and depression may at times

be a source of the child's trauma and anxiety.

As institutions,

IDC's are harsh, dehumanising environments. They lack adequate educational

and play facilities, stimulation and organised activities. There is a

lack of autonomy and bureaucratic impediments e.g. parents cannot prepare

their own food and meal times for young children are inflexible. Phones

often do not work, and calls are expensive. Appropriate facilities for

women and children are lacking. Families are isolated from society, children

are separated from parents, and families from relatives and friends. Protest

is punished by coercive disciplinary strategies; there have been reports

of solitary confinement for 'troublemakers' for extended periods (Lateline,

23/04/02). Refugees are often referred to by number rather than name,

and may be stigmatised by demeaning names, such as 'little terrorists'

or 'queue jumpers'. Children are exposed to violence including shock raids,

room searches (often at night), body searches, tear gas and water cannon,

and handcuffs which leave abrasions. In some centres, there are multiple

daily musters and nightly head counts, and a continuous public address

system from 0700 to 2100 hours. Access to lawyers, medical care and visitors

may be arbitrarily restricted.

Despair and protest

are both important as motivations for self-harm in IDC's. Lip-sewing signifies

hunger (and hunger strike), protest that grievances are not heard, and

the symbolism of being 'silenced'. The detainees have few resources to

make their point, other than using their bodies.

For those desperate

enough to engage in self-harm or suicide attempts, there is a high risk

of their being caught in a process of malignant alienation from any support.

Despite the LIFE strategy, negative community perceptions of self-harm

are still widespread: those engaging in it, and attending hospital casualty

departments, for example, are often regarded as 'just attention-seeking,

manipulative' etc.

The community stereotype

about self-harm is linked with the community's negative perception of

asylum-seekers by the Minister, his spokespeople and ACM staff, who generally

adopt a disciplinary policy towards self-harm and a negative attitude

to those engaging in it. For instance, 18 people on a hunger strike at

Port Hedland IDC were allegedly restrained and handcuffed, placed in isolation

after slashing their wrists with razor blades, and chemically restrained

by intramuscular injections [Age, 9/5/98, and HREOC report 'Those who've

come across the seas']. A 27 year old Palestinian man on a hunger strike

was placed in solitary confinement for 3 months in Woomera IDC, and then

because of repetitive self-harm, spent 5 months in isolation at Maribyrnong

[SMH, 27/03/01]. A man who tried to hang himself at the Curtin detention

centre was cut down and beaten for hours by ACM, according to allegations

in a draft confidential report prepared by HREOC [SMH, 5/4/01]. After

a man in his 20's tried to immolate himself in Woomera IDC in April, he

was charged with destroying property, and this precipitated a further

overdose (Lyn Bender, personal communication). Eleven unaccompanied Afghani

children aged 14 to 17 who threatened mass suicide and passed notes to

the media were allegedly punished by having their English classes withdrawn

[Australian Financial Review, 29/1/02]. The Minister apparently equates

self-harm with crime and manipulation or terrorism, requiring counter-terrorist

tactics. He allegedly asserted in the recent Woomera action that parents

helped children to sew their lips, despite lack of evidence for this [SMH,

07/02/02, p6]. He was quoted as saying that the Government might be judged

in future as having been too soft on asylum-seekers [SMH, 25/01/02].

Community stereotypes

about suicidal people and about refugees dovetail with the present Australian

government's on-shore asylum-seeker policy, which expressly aims to deter

would-be 'boat people' and people-smugglers, by denying access to mainland

Australia and punishing those who actually arrive by keeping them in prolonged

detention. Thus, it can be plausibly argued that the Australian state

knowingly and wilfully re-traumatises stateless and traumatised people,

in furtherance of this policy. The official position that government won't

be influenced by suicidal behaviour and it is a manipulation, is also

of concern. It gives a dangerous message to suicidal people in the general

community, about official perception and response to their needs.

The goals of the

LIFE program include enhancing resilience and protective factors and reducing

risk factors for suicide, supporting those affected by suicide, ensuring

'Whole of community' approaches and 'Partnerships', addressing stigma,

implementing effective parenting skills and support programs, and providing

timely access to accurate and up-to-date data. IDC's represent the antithesis

of those goals. Approaches to managing self-harm in IDC's typically focus

on end point interventions and/or treatments, rather than prevention.

Individual but not systemic problems are addressed. Components of government

do not communicate with each other. This is a situation where no amount

of individual 'anger management', 'cognitive behavioural therapy', and

antidepressants, can undo the extreme effects of the environment. Thus,

these centres attack their inmates by denuding them of their culture,

identity and humanity.

What must be done

Suicide Prevention

Australia and the Alliance of Professionals concerned about the Health

of Asylum-Seekers and their Children, have recommended that children should

be removed from detention centres with their families, and unaccompanied

children to the care of appropriate foster carers as soon as possible.

Children should not be separated from their parents if at all possible.

They have called on the Australian Government to revoke the policy of

detaining asylum seekers, as international experience shows it is unnecessary

for processing refugee status claims and because psychological harms associated

with detention are unacceptable. They have also called for an external

group of child and adolescent mental health consultants to independently

review the needs of these groups, and advise the ministers of immigration,

health and community services.

Those attempting

suicide and engaging in self-harm should be treated as people. Their behaviour

should be taken seriously and as communications of distress rather than

regarding them as behaving badly or as simply manipulative. Suicidal threats

require humane, empathic responses and amelioration of immediate environmental

stresses. As suicidality & mass self-harm in detention centres is

unprecedented in Australia, the prevention of future self harm should

also be addressed expertly and collectively to ensure the safety of those

involved. Links need to be forged between the Immigration Detention Centre

Advisory Group, the National Suicide Prevention Advisory Council and other

national mental health advisory bodies, to ensure the best expert advice

is available in handling this unprecedented situation.

Conclusion

Suicidality &

mass self-harm in detention centres is unprecedented in Australia, and

represents a convergence of (child) health, protection and human rights

concerns. The problem, management and prevention of self-harm in refugee

detention is intimately related to the extremity of detention environment

& to the politics of detention. Federal government (and until very

recently, federal opposition) policy regarding mandatory detention of

on-shore asylum-seekers is the antithesis of the Australian government's

LIFE program for the reduction of youth suicide. This is a contradiction

to the 'whole of government' approach announced in the LIFE document.

It is argued in this paper that the Australian government, to further

its deterrence policy, is engaging in state-sponsored trauma. Community

stereotypes, negative attitudes and ignorance, together with lack of community

and professional leadership have made this possible. Violence and self-harm

flourish when we see fellow humans as 'the Other', as objects rather than

subjects, and we regard our own responses to mutually socially challenging

situations as more reasonable than theirs [27]. The situation of children

and families in detention is one such example.

Acknowledgements:

I thank Ms Lyn Bender for input concerning self-harm in Woomera IDC, Ms

Jonine-Penrose-Wall for work concerning SPA's position on this issue,

and Drs Sarah Mares, Louise Newman and Fran Gale for discussions concerning

children's attachment relationships in detention centres.

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TABLE1: POSSIBLE

SUICIDE DEATHS RELATED TO IMMIGRATION DETENTION

	sex	age	DOD	Method	IDC	nationality	Story reported in media [source]
1	M	52	21/12/00	Jumping	2	Tonga	Worked 17 yrs illegally to provide for family in Tonga. Detained August 2000. Climbed basketball pole in IDC, in bid to avert threat of deportation. Taunted by guards. [Age, 2/1/01; 30/12/00]
2	M	?	28/07/01	hanging	1	Nigeria, on Sth African passport	At Sydney airport, had visa cancelled immediately, transferred to IDC. Bewildered, asking why he'd been detained. Hung self from bedsheets [SMH, 27/7/01].
3	F	20's	26/09/01	?over-dose	1	Thailand or Vietnam	Taken from work in a brothel to IDC. Alleged heroin addict in withdrawal, locked up for 2 days. Asking where she was, and why she was in IDC. Made suicide threats when released for an hour. Found dead in a pool of vomit 6 hours later [SMH, 29/9/01].
4	F	30's	13/01/02	Jumping	1	Vietnam	Overstayed student visa. Sent to psychiatric ward for wrist slashing, escaped and was returned to IDC. Shouting and crying on balcony, 'send me back to my country' [SMH 15/01/02]
5	M	47	2/04/01	Burns	N/A	Pakistan	Set self alight outside Parliament House, Canberra, over delay bringing family to Australia [The Age, 30/05/01]

DOD = date of death

IDC code. 1 = Villawood,

2 = Maribyrnong

TABLE 2: EXAMPLES

OF MEDICALLY SERIOUS SUICIDE ATTEMPTS BY CHILDREN AND YOUTH IN IDC'S

sex	age	when	method	IDC	Country	Story reported [source]
M	17	06/01/01	Throat-slashing	2	Iraqi	Occurred when ACM refused to let his father attend a dentist without handcuffs [Age, 8/01/01, Illawarra Mercury 09/01/01]
M	15	March 2001	Hanging	5	Iraqi	Major depression, conflict with ACM guards, hospitalised in Perth [PK, SMH 29/05/01]
		Prior to 29/01/02	Hunger-strike			11 unaccompanied children, demanding to be released into foster care [SMH, 29/01/02]
M	14	07/02/02	Lip-sewing, forearm-slashing	3	?	Occurred during recent Woomera hunger strike [SMH 07/02/02]
M	?		Hanging	3	?	Occurred during recent Woomera hunger strike [SMH 07/02/02]
M	13	Early April	Drank shampoo	3	Iranian	Unaccompanied minor, previously 'compliant' [PC]
M	12 12	Early April	Hanging	3	Both Afghani	Suicide pact? [PC]
M	13	Early April	Hanging	3	Iranian	[PC]
M	18		Hanging (multiple attempts) & cutting	1	Afghani	PTSD and psychotic depression [SMH 17/04/02]
F	10	8/04/02	Hanging	2	Iranian	PTSD and severe depression. Successful hanging narrowly averted by sister alerting parents [PK]. Hospitalised.

IDC

code. 1 = Villawood, 2 = Maribyrnong, 3 = Woomera, 4 = Curtin, 5 = Port

Hedland

PC = personal communication

[Ms Lyn Bender]

PK = author's personal

knowledge of case

PTSD = post-traumatic

stress disorder

---

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