Getting out of (self-) harm's way: A study of factors associated with self-harm among asylum seekers in Australian immigration detention

Mental Health Consultations in Immigration Detention: What Can We Learn From Clinical Records?

Objectives: Knowledge on mental health consultations in immigration detention and characteristics of people receiving consultations is scarce. Based on a sample of 230 adult men in immigration detention in Switzerland, we aimed to: (1) Quantify the proportion of persons receiving mental health consultations during detention; and (2) Identify socio-demographic and clinical characteristics associated with mental health consultations. Methods: Retrospective observational study with a cross-sectional design. Prevalence estimates, logistic regressions, and contingency tables were used to analyse the data. Results: A total of 30% of the sample received mental health consultations during detention. Time spent in immigration detention, mental health problems during detention, use of psychotropic medication, and self-harm were associated with mental health consultations. Although mental health consultations are provided to people with more severe mental health problems, 41% of persons with assessed mental health needs during the initial screening and 26% of those who self-harmed during detention did not receive mental health consultations. Conclusion: Mental health resources and screening procedures could be improved to ensure that mental health consultations are matched to clinical need in immigration detention settings.

Self-harm in immigration detention: political, not (just) medical

Self-harm within immigration detention centres has been a widely documented phenomenon, occurring at far higher rates than the wider community. Evidence suggests that factors such as the conditions of detention and uncertainty about refugee status are among the most prominent precipitators of self-harm. While important in explaining self-harm, this is not the entire story. In this paper, we argue for a more overtly political interpretation of detainee self-harm as resistance and assess the ethical implications of this view, drawing on interviews with detainees from Australia's offshore system. Self-harm by detainees is not only a medical 'condition' arising in response to oppression but a form of political action to lessen or contest it. We first establish how self-harm could be conceptualised as resistance. We then discuss its political purpose, noting it serves at least three functions: intrinsic, instrumental and disruptive or coercive. Viewing detainee self-harm as political resistance is a supplement to (rather than a substitute for) a medical approach. However, conceptualising self-harm this way has several advantages, namely, moving away from the idea that such behaviour is 'maladaptive', recognising detainees as political agents, combatting government claims of 'manipulation' and 'blackmail' and clarifying the duties of healthcare workers who work in detention.

Prevalence, methods and characteristics of self-harm among asylum seekers in Australia: protocol for a systematic review

INTRODUCTION

Asylum seekers are at increased risk of self-harm compared with the general population, and the experience of detention may further exacerbate this risk. Despite this, evidence regarding the prevalence, methods and characteristics of self-harm among asylum seekers in Australia (including those detained in onshore and offshore immigration detention) has not been synthesised. Such information is necessary to inform evidence-based prevention initiatives, and effective clinical and governmental responses to self-harm. This review will synthesise findings from the literature regarding the prevalence, methods and characteristics of self-harm among asylum seekers in both detained and community-based settings in Australia.

METHODS AND ANALYSIS

We searched key electronic health, psychology and medical databases (PsycINFO, Scopus, PubMed and MEDLINE) for studies published in English between 1 January 1992 and 31 December 2021. Our primary outcome is self-harm among asylum seekers held in onshore and/or offshore immigration detention, community detention and/or in community-based arrangements in Australia. We will include all study designs (except single case studies) that examine the prevalence of self-harm in asylum seekers. Studies published between 1992-the commencement of Australia's policy of mandatory immigration detention-and 2021 will be included. We will not apply any age restrictions. The Methodological Standard for Epidemiological Research scale will be used to assess the quality of included studies. If there are sufficient studies, and homogeneity between them, we will conduct meta-analyses to calculate pooled estimates of self-harm rates and compare relevant subgroups. If studies report insufficient data, or there is substantial heterogeneity, findings will be provided in narrative form.

ETHICS AND DISSEMINATION

This review is exempt from ethics approval as it will synthesise findings from published studies with pre-existing ethics approval. Our findings will be disseminated through a peer-reviewed journal article and conference presentations.

PROSPERO REGISTRATION NUMBER

CRD42020203444.

Suicide and Suicide Attempts Among Asylum-Seekers in Denmark

OBJECTIVE

There are concerns that asylum-seekers are at increased risk of suicide attempt and suicide mortality. Yet, largescale nationwide studies are limited. Our aim was to examine whether asylum-seekers in Denmark had higher rates of suicide attempt and suicide when compared to the general population.

METHODS

A retrospective cohort design was used. Data on asylum-seekers and the general population living in Denmark during 2009-2019 were obtained from the Immigration services and national registers. Indirect standardization was applied to adjust for differences with respect to age group and sex and Incidence Rate Ratios (IRR) with 95% confidence intervals were calculated.

RESULTS

In a population of 78,666 asylum-seekers, a total of 601 suicide attempts and 9 suicides were recorded. The rate of suicide attempt was 842.0 per 100,000 person-years for asylum-seekers and 92.3 per 100,000 person-years for the general population. When adjusting for differences related to age group and sex, an IRR of 8.5 (95% CI: 7.6-9.5) was found for suicide attempt between 2014-2019. The IRR for suicide attempt unaccompanied minors between 2015 and 2019 was 5.8 (95% CI: 4.3-7.5) when adjusting for age group. We did not find an elevated rate of suicide among asylum-seekers (IRR: 1.6, 95% CI: 0.6-3.5).

CONCLUSIONS

Asylum-seekers were found to have higher rates of suicide attempt than the general population in Denmark. This also applied to unaccompanied minors. Our study emphasizes the need for awareness and preventive measures targeting mental health and suicidal behavior among asylum-seekers.HIGHLIGHTSAsylum-seekers had an 8-fold higher rate of suicide attempt than the general population.The suicide attempt rate for asylum-seekers reached its lowest levels during recent years.Unaccompanied minors had a 5-fold higher frequency of suicide attempt when compared to peers in the general population.We did not find elevated rates of death by suicide among asylum-seekers. No suicide deaths were recorded among unaccompanied minors.

Temporal variations in the distribution of self-harm episodes and methods across the Australian asylum seeker population: An observational study

BACKGROUND

Temporal patterns in the frequency and characteristics of self-harm episodes across the Australian asylum seeker population may have implications for self-harm prevention and public health policy. The aim of this study was to examine how the distribution of self-harm episodes and method(s) of self-harm used across the Australian asylum seeker population vary according to the 24-hour cycle, day, and month, and to establish a basis for further research.

METHODS AND FINDINGS

We conducted an observational study of all 949 self-harm incidents reported across the Australian asylum seeker population (representing a monthly average of 28,992 adults) between 1 August 2014 and 31 July 2015, obtained by Freedom of Information (FOI) from the Department of Immigration. Time of self-harm, day, and month of occurrence were investigated across all five Australian asylum seeker populations (i.e., community-based arrangements, community detention, onshore immigration detention, offshore immigration detention [Nauru], and offshore immigration detention [Manus Island]). Significant variations in distributions over the 24-hour cycle were observed by processing arrangements. Compared with the average distribution across all other processing arrangements, self-harm more commonly occurred among community-based asylum seekers (36.3%) between 12:00 AM and 3:59 AM (p < 0.001), in asylum seekers on Manus Island (36.4%) between 4:00 PM and 7:59 PM (p = 0.02), and among asylum seekers in onshore detention (20.4%) between 8:00 PM and 11:59 PM (p < 0.001). Compared with the average distribution across all other methods, self-poisoning (by medication) (25%) was significantly more likely to occur between 12:00 AM and 3:59 AM (p = 0.009), and self-battery (42%) between 8:00 AM and 11:59 AM (p < 0.001). The highest and lowest monthly self-harm episode rates for the whole asylum seeker population were in August (2014) (5 episodes per 1,000 asylum seekers; 95% confidence interval [CI] 1-11) and in both January and February (2015) (2.1 episodes per 1,000 asylum seekers; 95% CI 0.6-7.2), respectively; however, the overlapping CIs indicate no statistically significant differences across the months. When examining monthly trends by processing arrangements, we observed that self-harm was significantly more likely to occur in August (2014) than other months of the year among asylum seekers in onshore detention (19%) (p < 0.001), in January (2015) on Manus Island (18%) (p = 0.002), and in October (2014) on Nauru (15%) (p < 0.001). The main study limitations were that we could not investigate certain characteristics associated with self-harm (e.g., gender, country of origin), as the Department of Immigration did not routinely collect such data. There was also the potential risk of making a type 1 error, given the exploratory nature of the comparisons we undertook; we minimised this by lowering our significance threshold from 0.05 to 0.01.

CONCLUSIONS

Self-harm in the Australian asylum seeker population was found to vary according to time of day and month of the year, by processing arrangements. A series of procedure-related and detention-related factors were observed to be associated with the temporal variations in self-harm. These findings should form the basis for further investigation into temporal variations in self-harm among asylum seekers, which may in turn lead to effective self-harm prevention strategies.

An evaluation of the quality of self-harm incident reporting across the Australian asylum seeker population according to World Health Organization (WHO) guidelines

BACKGROUND

Asylum seekers are at elevated risk of self-harm, and the personal and public health costs of self-harm are high; yet the monitoring and reporting of self-harm has been limited and lacking in transparency. This study aims to evaluate the quality of self-harm incident reporting across the Australian asylum seeker population, including by processing arrangements (i.e. community-based, community detention, onshore detention, Nauru, and Manus Island).

METHODS

All self-harm incidents reported across the entire Australian asylum seeker population between 1 August 2014 and 31 July 2015 were obtained via the Freedom of Information Act. We assessed the quality of self-harm incident reporting according to the World Health Organization (WHO)'s self-harm reporting guidelines.

RESULTS

A total of 949 self-harm incident reports were assessed. Date, location (processing arrangement), and time of self-harm were routinely reported. Gender was recorded in less than two thirds (62.1%) of all incidents. Method(s) used to self-harm was reported in 81.5% of all incidents, though IDC-10 codes were not reported in any episodes. Psychological or psychiatric assessments were recorded after 4.0% of all incidents, most frequently on Manus Island (10.9%), and in Nauru (10.0%), and least frequently in community-based arrangements (1.7%) and in onshore detention (1.4%), and not at all in community detention. Ambulances were reported as attending 2.8% of all episodes. Hospital attendances were reported following 6.0% of all self-harm incidents, with attendances most commonly reported in incidents occurring in community detention (30.3%), and in community-based arrangements (19.4%). Medevac (air ambulances) were recorded as being utilised in 0.4% of all incidents (2.1% of episodes on Nauru, 1.8% on Manus Island).

CONCLUSIONS

The findings of our study indicate that the accessibility and quality of self-harm data is substandard and inconsistent with WHO self-harm reporting guidelines. Such variable reporting makes the identification of self-harm trends, the implementation of prevention strategies - including those at a policy level - and the clinical management of self-harm, extremely challenging. Improved self-harm reporting and monitoring is urgently needed for mitigating and responding to self-harm risk among asylum seekers.

Self-harm among asylum seekers in Australian onshore immigration detention: how incidence rates vary by held detention type

BACKGROUND

Detained asylum seekers are at increased risk of self-harm, and the type of detention in which they are held may further exacerbate this risk. In Australia, there are four types of closed (or held) immigration detention for people seeking asylum, with varying levels of security and supports: Immigration Detention Centres [IDCs], Immigration Transit Accommodation [ITAs], Immigration Residential Housing [IRH], and Alternative Places of Detention [APODs]. The objective of this study was to examine the variation in the incidence and method(s) of self-harm among asylum seekers in Australian onshore immigration detention, according to the type of detention in which they are held.

METHODS

We obtained data on all self-harm incidents reported among asylum seekers in Australian onshore immigration detention according to held detention type, as well as individual facility, between 1 August 2014 and 31 July 2015, by Freedom of Information. We calculated self-harm episode rates per 1000 asylum seekers using the average population figures for held detention type, as well as for each individual facility comprising the main types of held detention. Method(s) used to self-harm was also extracted for the main sub-populations.

RESULTS

The study included 560 episodes of self-harm. Individual facility rates of self-harm ranged from 91 per 1000 asylum seekers (95% CI 72-110) in Yongah Hill IDC to 533 per 1000 asylum seekers (95% CI 487-578) in Perth IDC. On average, calculated self-harm episode rates were highest among asylum seekers in: Immigration Transit Accommodation facilities, 452/1000 (95% CI 410-493); Alternative Places of Detention, 265/1000 (95% CI 233-296); and Immigration Detention Centres, 225/1000 (95% CI 195-254). The most frequently reported methods of self-harm across the main types of held detention were: cutting (35.2%), self-battery (34.8%), and attempted hanging (11.1%).

CONCLUSIONS

Self-harm rates for asylum seekers in all types of closed immigration detention were many times higher than rates found in the general population. Average rates were not lower in facilities with lower security features.

Self-harm in the Australian asylum seeker population: A national records-based study

Background

Systematic research into self-harm in the Australian asylum seeker population is scarce, largely due to the lack of accessible data. The aim of this study was to examine the incidence and characteristics of self-harm across the Australian asylum seeker population, and to ascertain whether self-harm rates and characteristics vary by processing arrangements (i.e. community-based arrangements, community detention, onshore detention, offshore detention (Nauru), and offshore detention (Manus Island)), and gender.

Methods

Data relating to the incidence of self-harm, method(s) used to self-harm, processing arrangements, and gender were extracted from all self-harm incidents recorded as occurring among the Australian asylum seeker population between 1st August 2014 and 31st July 2015. Self-harm episode rates were calculated using the average estimated adult population figures for the 12-month period for each asylum seeker population.

Results

949 self-harm episodes were included in the analyses. Rates ranged from 5 per 1000 asylum seekers in community-based arrangements to 260 per 1000 asylum seekers in offshore detention in Nauru. Rates were highest among asylum seekers in offshore and onshore detention facilities, and lowest among asylum seekers in community-based arrangements and community detention. The most common methods of self-harm were cutting (37%), self-battery (26%), and attempted hanging (11%), with asylum seekers in held detention using a wider variety of methods than those in community-based arrangements and community detention.

Conclusions

Our findings highlight the exceptionally high rates of self-harm among detained asylum seekers compared to rates observed in the general Australian population, and among asylum seekers in community-based settings. These findings point clearly to the deleterious impact of immigration detention, and warrant urgent attention.

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Rates of self-harm among asylum seekers were exceptionally high.

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Rates were highest in held detention, lowest in community-based settings.

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High rates of hanging were observed for both women and men.

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Asylum seekers in held detention used a wide variety of self-harm methods.

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Findings point to the deleterious impact of immigration detention.

The impact of immigration detention on mental health: a systematic review

BACKGROUND

The number of asylum seekers, refugees and internally displaced people worldwide has increased dramatically over the past 5 years. Many countries are continuing to resort to detaining asylum seekers and other migrants, despite concerns that this may be harmful. In light of the considerable body of recent research, this review aims to update and expand on a 2009 systematic review on the mental health consequences of detention on adult, adolescent and child immigration detainees, which found (on the basis on 9 studies) that there was consistent evidence that immigration detention had adverse effects on mental health.

METHODS

Three databases were searched using key terms relating to immigration detention and mental health. Electronic searches were supplemented by reference screening. Studies were included if they were quantitative, included individuals detained for immigration purposes, reported on mental health problems and were published in peer-reviewed journals. Two reviewers independently screened papers for eligibility, and a further two reviewers completed quality appraisals for included studies.

RESULTS

Twenty- six studies (21 of which were not included in the 2009 review) reporting on a total of 2099 participants were included in the review. Overall, these studies indicated that adults, adolescents and children experienced high levels of mental health problems. Anxiety, depression and post-traumatic stress disorder were most commonly reported both during and following detention. Higher symptom scores were found in detained compared to non-detained refugees. In addition (and more clearly than was evident in 2009), detention duration was positively associated with severity of mental symptoms. Greater trauma exposure prior to detention was also associated with symptom severity.

CONCLUSIONS

The literature base reviewed in this paper consistently demonstrated severe mental health consequences amongst detainees across a wide range of settings and jurisdictions. There is a pressing need for the proper consideration of mental health and consequent risk of detention-related harm in decisions surrounding detention as well as for improved care for individuals within detention facilities. Recommendations based on these findings are presented, including increased focus on the identification of vulnerability and on minimising the duration of detention.

Being Through Doing: The Self-Immolation of an Asylum Seeker in Switzerland

In April 2016, Armin, an asylum seeker in a village of Switzerland, set himself alight in the public square of the town, one of a few cases reported across Europe. He performed the act following a denied request for asylum and was saved by bystanders. We present the results of two qualitative interviews conducted with Armin, his translator and his roommate following the incident. The act is theorized through the lens of a dialogical analysis focusing on the concept of social recognition. The notion of trauma is considered as a key mediating mechanism, theorized as creating ruptures in time, memory, language, and social connections to an Other. We conclude this communicative act to represent both "being-toward-death" and a relational striving toward life; a "destruction as the cause of coming into being."