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Submission to the National Inquiry into Children in Immigration Detention from
Suicide Prevention Australia
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
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.
TABLE1: POSSIBLE SUICIDE DEATHS RELATED TO IMMIGRATION DETENTION
sex age DOD Method IDC nationality Story reported in media [source] 1 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 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
12Early 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
References
1. Cantor, C & Neulinger, K. The epidemiology of suicide and attempted suicide among young Australians. Australian and New Zealand Journal of Psychiatry 34 (3), 370-387.
2. Christopher H Cantor, Kerryn Neulinger, Diego De Leo. Australian suicide trends 1964-1997: youth and beyond? http://www.mja.com.au/public/issues/iprs2/cantor/cantorframe.html
3. M Dudley, N Kelk, Florio T, Howard J, Waters B. Suicide among young Australians: an interstate comparison of metropolitan and rural trends. Medical Journal of Australia 1998; 169: 77-80.
4. Sawyer MG, Arney FM, Baghurst PA, Clark JJ, Graetz BW, Kosky RJ, Nurcombe B, Patton GC, Prior MR, Raphael B, Rey JM, Whaites LC, Zubrick SR. The mental health of young people in Australia: key findings from the child and adolescent component of the national survey of mental health and well-being. Australian and New Zealand Journal of Psychiatry 2001: 806-814.
5. Eckersley R. (2002). Being young: never better or getting worse? Comment under 'Suicide Prevention' menu at http://auseinet.flinders.edu.au, accessed 3 May 2002
6. National Health and Medical Research Council. Depression in Young People: Clinical Practice Guidelines. Australian Government Publishing Service, 1997.
7. Hunter E. (2002) Aboriginal and Torres Strait Islander suicide. Comment under 'Suicide Prevention' menu at http://auseinet.flinders.edu.au, accessed 3 May 2002.
8. Commonwealth Department of Human Services and Health. Youth suicide in Australia: a background monograph. Australian Government Publishing Service, Canberra, 1995.
9. Commonwealth Department of Human Services and Health. Here for Life: a national plan for youth in distress. Australian Government Publishing Service, Canberra, 1995.
10. Australian Institute of Family Studies and Commonwealth of Australia. Valuing Young Lives: evaluation of the National Youth Suicide Prevention Strategy. Australian Institute of Family Studies, Melbourne, 2000.
11. Commonwealth Department of Health and Aged Care. LIFE (Living Is For Everyone): a framework for prevention of suicide and self-harm in Australia. Commonwealth of Australia, 2000.
12. Burke P. Suicide in Australia 1989-1999. Paper presented at Suicide Prevention Australia's 2001 conference, 4-6 April, Darling Harbour, Sydney.
13. Department of Immigration, Multicultural and Indigenous Affairs (DIMIA). http//www.immi.gov.au/facts/74unauthorised.htm, DIMIA Fact Sheet 74 (accessed 13 March 2002)
14. Mares P. Borderline: Australia's treatment of refugees and asylum seekers, 2nd edn. UNSW Press, 2001: 204.
15. Edmund Rice Centre for Justice and Community Education and School of Education, Australian Catholic University, Debunking More Myths about Asylum Seekers, Just Comment, Special Edn 2001; 9: 1-4.Also available at :http//www.erc.org.au/issues/text/se01htm
16. Refugee Council of Australia. Number of Children and Adults in Detention as at November 20, 2001, http//www.refugeecouncil.org.au/ngraphnoindetention.htm, (accessed 13 March 2002).
17.Pynoos RS, Nader K. Children's memory and proximity to violence, Journal of the American Academy of Child and Adolescent Psychiatry 1989; 28:501-504.
18. Pynoos RS, Eth S. Witnessing acts of personal violence. In: Eth S, Pynoos RS, eds. Post Traumatic Stress in Children, Washington DC : American Psychiatric Press, 1985; 17-43.
19. Kinzie JD, Sack W, Angell R, Clarke G. A three year followup of Cambodian young people traumatized as children, Journal of the American Academy of Child and Adolescent Psychiatry, 1989; 28: 501-504.
20. Pfefferbaum B. Post Traumatic stress disorder in children: A review of the past 10 years, Journal of the American Academy of Child and Adolescent Psychiatry, 1997: 36: 1503-1511.
21. Murray L, Cooper P. eds Postpartum Depression and Child Development, London , 1997.
22. Golpert M, Webster T, Seeman M. Parental Psychiatric Disorder: Distressed parents and their children. CUP, 1996
23. Blank AS. The longitudinal course of posttraumatic stress disorder. In: Davidson JRT & Foa EB eds, Post Traumatic Stress Disorder: DSM iv and Beyond, Washington DC: American Psychiatric Press, 1993; 3-22
24. Debellis MD. Developmental traumatology: The psychobiological development of maltreated children, Development and Psychopathology 2001; 539-564.
25. The Royal Australian and New Zealand College of Psychiatrists (RANZCP) position statement #46, Principles on the provision of mental health services to asylum seekers, adopted October 2000. Melbourne, RANZCP.
26. HREOC report, p218, cited in Steel Z, Silove D. The mental health implications of detaining asylum seekers. Medical Journal of Australia, in press.
27. Cohen S. States of denial: knowing about atrocities and suffering. Cambridge, UK: Polity/Blackwell, 2001.
Last Updated 9 January 2003.
