- Email: [email protected]
Mental health crisis intervention for asylum seekers in the emergency department
Australasian Emergency Nursing Journal (2006) 9, 113—117
DISCUSSION
Mental health crisis intervention for asylum seekers in the emergency department Nicholas G. Procter, RN, PhD ∗ School of Nursing and Midwifery, University of South Australia, City East Campus, Adelaide, SA 5000, Australia KEYWORDS Asylum seekers; Emergency nursing; Refugees; Self harm; Suicide risk
Summary Emergency nurses worldwide have seen and will continue to see asylum seekers in mental distress in their professional work. This paper is intended to support nurses in their practice should they encounter an adult asylum seeker needing assistance in the emergency department. Beginning with the exemplar of a 31-year-old asylum seeker found wandering the street in the early morning hours, a preliminary interview with the emergency department nurse reveals an emerging picture of depression, hopelessness, and self-mutilation. Practical strategies are highlighted to help emergency nurses assess, care, and comfort asylum seekers in this and similar predicaments by working closely with community-based services and an accredited interpreter to prevent isolating the asylum seeker from appropriate services. To help strengthen continuity and integration of mental health supports for refugees and asylum seekers, care must be actioned in a culturally appropriate and sensitive fashion. © 2006 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights reserved.
Introduction Suicide by people born overseas but living in Australia represents 25% of all suicides in Australia.1 Of this 25%, more than half (approximately 60%) of suicides are by people from non-English speaking backgrounds.2 While suicide is not a mental illness — it is a behaviour — it is strongly associated with mental illness and, therefore, risk factors pertinent to both are overlapping and interrelated for migrants and refugees. This is especially the case for asylum seekers, many of whom are Temporary Protection Visa (TPV) holders, a class of visa grant∗
Tel.: +8 8302 2148; fax: +8 8302 2579. E-mail address: [email protected].
ing temporary entry to Australia and humanitarian protection for 3 years.3 In Australia around 9500 TPVs are granted to people who are recognised as refugees but who have travelled to Australia without valid documentation. Access to social security and education services is limited under this class of visa and holders do not have access to a class of legal entry to Australia, known as the family reunion visa. This means that they cannot legally bring family, including spouse and children, into the country. Each person granted a TPV must have this reviewed by Immigration Officials and this usually occurs at approximately 30 months after it was issued. This is known anecdotally as the ‘‘30month interview’’, where asylum seekers must re-
1574-6267/$ — see front matter © 2006 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.aenj.2006.04.001
114 tell their story of why they have previously sought and will continue to require protection in Australia. If successful in this interview then asylum seekers will be granted a Permanent Protection Visa (PPV), which allows for them to have increased social security benefits and be re-united with their families. The recent onset of TPV review interviews for PPVs in Australia has revealed new information about the way some asylum seekers experience their current existence, and the impact previous trauma has upon everyday life.4 The uncertainty of their existence — living in a state of limbo — and strongly held belief of many that it is unsafe to return to their homeland, has had an enormous physical and psychological toll on many adult asylum seekers. Those who have been in immigration detention display a threefold increase in mental illness subsequent to their release.5 Exposure to trauma within detention was commonplace as were frequent upsetting memories about detention, intrusive images of events that had occurred, and feelings of sadness and hopelessness. It is for this reason that the separateness of mental illness and suicide, and the association between the two become entwined. Frequently TPV holders have fled their birthplace to save their lives—–their will to live is strong but the prospect of not being able to cope in Australia and a fear that they will be killed if returned to their homeland remains ever present. The knowledge that their TPV may soon expire, and with it their hopes of remaining in Australia, contributes to a state of unbearable mental distress. They are often convinced they will be killed if forced to return to their homeland. If they are to die, most would prefer it to be at their own hands.6 So fragile is their ability to cope with problems of living brought about by their situation, some see no point in acquiring the usual accoutrements of life; they use disposable tableware such as paper tablecloths, paper plates, plastic cutlery.5 At the expiration of their 3-year visa, people holding TPVs must reapply for refugee status, approval is not assured. As seen in the next section of this paper this uncertainty can take an enormous physical and psychological toll.7
Emergency department scenario Ali1 is a 31-year-old TPV holder, his wife and two children remain in Afghanistan. He was found wandering a Sydney street at 3.30 a.m. and taken by police to a Sydney hospital. He was tearful, frightened, and appeared very upset in police 1
Not his real name.
N.G. Procter custody. Through an accredited interpreter, the admissions nurse began with an introduction of who she was and relied upon the keywords ‘I am not here to hurt you, I am hear to listen to your story’. Although initially picking at his shirt buttons with his fingers, limiting eye contact, shaking and speaking in a soft almost inaudible voice, Ali relaxed as the conversation developed between himself and the emergency nurse: For a few months after I arrived here I felt that I was free. Now I feel I am again the victim of fundamentalism and I have suffered in the past and will again in the future. I feel that my being here has meant that I have been penalised twice as I was not trusted or liked in Afghanistan and I am not trusted or liked here in this country — Australia. And this is the thing we are being penalised twice and here they don’t trust us as the Government thinks we might endanger this country in some way. And so we are the victim of fundamentalism twice. I have been away from my family for about 4 years now and it is very hard for a human being, it is hard for me to be the sort of human being I want to be. . . I cannot speak the language here, I feel stupid here, and I feel I don’t have respect from anyone here. I don’t have any family or friends here. My life is in limbo like I am floating2 . I have been waiting 39 months for a letter about my fate. As the interview between Ali and the nurse progressed it was possible to develop a general picture of Ali’s suicidality and mental state assessment. Questions pertaining to risk and protective factors for suicide were asked by the nurse (with the assistance of an interpreter) in an indirect rather than direct way. This is the preferred mode to help asylum seekers avoid feeling shame or becoming reticent in openly discussing their situation. Ali arrived in our region 4 months ago to work at the local chicken farm. He did not speak English on arrival in Australia but learnt basic language skills from some of the people he had been living with at various times since being released from immigration detention. During the previous 7—14 days he had been missing his family terribly, fearful of the outcome of his application for permanent protection, living in limbo, and this had kept him awake at night. He would go to bed at night around 11 or 2
This word was explained using the Dari word ‘‘Mualagh’’ in the following way, ‘‘It comes from a feeling of being suspended. Either you are on the ground or in the air. When you are neither on the ground or in the air, you are ‘floating’. It is like your feet are not walking on the ground or in the air at either time. It is like ‘‘being and not being somewhere’’ at the same time.
Mental health crisis intervention for asylum seekers in the emergency department 12 p.m., initially falling asleep and then waking at around 1—1.30 a.m. He described having difficulty in concentration and suicidal thoughts. After removing his jumper, the emergency nurse noticed between 8 and 12 burn marks on Ali’s right arm. These were self inflicted using a lit cigarette. He said he had done this at night, felt no pain nor any discomfort or distraction from the smell of his burning flesh. He would sometimes walk the streets at night immediately prior to burning his body. He also talked of feeling as if all people hated him: ‘‘all his Australian and non-Australian (Afghan) friends did not like him here . . .Nobody wants us here . . . it is all politics’’, Ali told the nurse. At this point in the interview he produced medication he was given by a local General Practitioner (Fluvoxamine 150 mg nocte). He said he was trying to trust others. He also said that he wanted to believe that his life was worth living.
Challenges for emergency nursing practice While asylum seekers like Ali frequently face periods of suffering and periods of calm, individual suffering has become increasingly intolerable when being reinterviewed and when immigration authorities reject refugee claims. When people seek asylum their application is considered in light of the information they can supply and any facts known about the country they are fleeing. Some people in mandatory detention and when reapplying for permanent protection, suffer a denial of credibility because of inconsistencies in their story. This can lead to claims being dismissed on the grounds of minor discrepancies. At times this appears to have a flow-on effect whereby it is difficult for therapeutic trust to be developed between mental health providers and persons in or released from immigration detention.8 Asylum seekers to Australia like Ali must remain alert to the possibility of being called to interview with Immigration Officials at any time. There is no way of knowing well in advance the date and time of interviews to re-assess claims, when invitations to interview or rejection letters will arrive, what questions will be asked or what will be the primary data source used to determine whether a homeland country is safe to return to. Mental distress and emotional disorders can and will impact upon the quality of information people can recall and the way this is communicated to others during interview.9 Where the experience is highly traumatic — for example, a situation involving serious injury to the person — the situation is considered
115
even more complex. There may be important differences between traumatic and non-traumatic memories. For example, initial recall of traumatic events by people with post-traumatic stress disorder typically does not involve normal narrative memory. In other words, the way the story unfolds may appear fragmented or disconnected from previous events and therefore appearing unreliable and inconsistent. This research also found that asylum seekers with post-traumatic stress at the time of their interview are more likely to have their claim rejected the longer their application is in the system.9 Knowledge of these and other stressors impacting upon TPV holders like Ali are important for emergency nurses because assessment of mental health problems, mental illness and suicide for asylum seekers should incorporate an understanding of the factors that heighten the risk of these occurring and those factors that protect against them.10 Emergency nurses working in acute and crises intervention services should know as much as possible about how to access groups and individuals who could potentially benefit from targeted clinical interventions.
Emergency nursing interventions for asylum seekers who self harm Anecdotal evidence is emerging showing that self harm and suicide attempts are likely to occur when an asylum seeker’s application for permanent protection has been rejected and they are asked to return to their county of origin.4,6,11 Gathering evidence of previous actions and behaviour may help to indicate if the impact on individuals or families will be negative and place them at increased risk. This should be done with the fundamental belief that trust is a core requirement for promoting mental stability. The emergency nurse’s choice of intervention should be guided by the twin processes of developing therapeutic trust in the context of the nurse—patient relationship, as well as data gathering for clinical decision making. Mental health interventions in emergency nursing care should acknowledge that social interventions can have secondary mental health effects and that mental health interventions can have social effects—–as the term psychosocial suggests.12 Social interventions are actions that primarily aim to have positive social effects, a mental health intervention is an intervention that primarily aims to have positive mental health effects.13 Preparation by nurses in settings where asylum seekers are likely to present should involve: (a) the
116 development of a system of coordination with a specific focal person responsible for linking the nurse and other health and human service professionals to persons seeking help; (b) a design of detailed plans to prepare for adequate social and mental health responses; and (c) education and training of relevant personnel in indicated social and psychological interventions. 1. Assessment and planning for the local context, for example cultural beliefs, setting, history and nature of mental health problems, family perceptions of distress and illness, ways of coping, resources within community network. It should include quantitative assessment of disability and/or daily functioning as well as qualitative and psychosocial dimensions. If initial assessments uncover a broad range of needs that are unlikely to be met, nursing assessment reports should specify urgency of needs, local community resources and potential external resources. 2. Collaborative interventions involving consultations and engagement between the TPV holder’s family and friendship network, migration lawyer and/or agent, mental health workers, non-government organisations and trusted community supporters working in the area. A multitude of individuals and agencies who demonstrate innovative ways of operating in a synchronised fashion, will prevent wastage of valuable resources and help bring health benefit to the asylum seeker and their family. Networking and information gathering by the emergency nurse are fundamental to the delivery of clinically relevant integrated emergency services. The therapeutic interaction between asylum seeker and emergency nurse is supported by understanding the ‘explanatory model’ of cultural awareness in mental health. Based on the work of Kleinman and Seeman,14 this means emergency nurses learning from asylum seekers about the way in which symptoms of mental distress are understood and presented, the way help is sought and the way care is evaluated by those who receive it. Such actions by the nurse are also consistent with Australia’s National Mental Health Plan.10
Data gathering in the acute phase of self harm Using World Health Organisation protocols12 as a guide, data gathering must be in partnership with significant others and, in what is described here as the ‘acute emergency phase’, the crude morbid-
N.G. Procter ity rate is elevated and the risk of self-injurious behaviour or harm to others is extreme. This period can be followed by a ‘reconsolidation phase’ when fundamental needs are again at a level comparable to that prior to the emergency.
Acute emergency phase Valuable early mental health interventions for emergency nurses to employ may include: • Establishing and maintaining contact with interpreters and emergency mental health workers to manage urgent psychiatric crises and to undertake suicide risk assessment using existing protocols as a guide (i.e. level of dangerousness to self or others, psychoses, severe depression, agitation). If an individual has any pre-existing mental illness, the sudden discontinuation of medication should be avoided. • Acute interventions may be best managed without medication by following the principals of mental and physical health first aid: (a) to preserve life where a person may be a danger to themselves and/or others; (b) to prevent major or permanent damage to a person’s emotional health and wellbeing; and (c) to prevent deterioration and promote recovery. The clinical skills necessary to apply these principles include: listening without interruption; speaking in a measured way without providing too much information for the interpreter to translate; conveying compassion; assessing physical and safety needs; ensuring basic physical and spiritual needs are met; not forcing, rather gently encouraging talking; providing or mobilising company from significant trusted others (especially a volunteer community supporter, a Community Health worker); encouraging but not forcing social support; and protecting from further harm. • Speaking in a calm voice identifying what the nurse can do. Consider using words such as, ‘‘I can see you need help. I am here to help you. I am not here to hurt you. I am here to understand you, to listen to your story and see what I can do, with others, to help you’’. Ask yourself, ‘‘Am I in immediate danger?’’ ‘‘Is the person in any immediate danger?’’ (e.g. standing near a road or a dangerous object). ‘‘Is anyone else in immediate danger, especially children or other vulnerable people?’’ ‘‘Can you safely remove a third person from danger?’’ ‘‘Can you safely communicate with this person in their preferred language?’’ Valuable early social interventions may include: • Establishing and distributing a flow of written and verbal information to asylum seekers (using
Mental health crisis intervention for asylum seekers in the emergency department an interpreter) on: (a) the application or visa appeal process; (b) efforts to establish physical safety of self and family (if in a family situation); and (c) efforts being made by each organisation/individual to help and support asylum seekers. This information should be as simple as possible and in a language most familiar to the individual and their family — for example, understandable to a local 12-year-old — and empathic (showing understanding of the situation of the family member). Given the nexus between mental health need and generating trust in community supports, migration advocacy is an increasing feature of a coordinated response to assist TPV holders. For this reason it is recommended that, where possible, TPV holders who are given individual mental health outpatient assistance have this provided in consultation with a community mental health worker and their migration agent/lawyer. This framework can provide an important backdrop to prevent misunderstandings as well as appropriately engage with the legal context within which emotional suffering can be understood and lives revealed. Partnership strategies of this kind also serve to help asylum seekers build resilience, and to continue moving forward through combined legal and psychosocial processes.15
Summary With the increased trend for mental health presentations to be assessed in general hospital emergency environments rather than psychiatric hospitals and the need for interdisciplinary management of mental health issues, the skills required for emergency nursing must be deliberately and convincingly practical and applied in nature. Emergency mental health care for asylum seekers is best achieved by bridging discrete elements in the asylum seeker journey of preparing for visa appeals and rejections—–in the context of different episodes, interventions by different providers, and changes in mental distress. The craft of the emergency nursing is to elicit information in a psychological atmosphere that is not adversarial to enable a whole of service, region and inter-disciplinary approach which brings together a range of sectors and indi-
117
viduals working within them that impact on the mental health of asylum seekers. Emergency nurses through their proximity and skill can be influential in this process.
References 1. Hassan R. Suicide explained: the Australian experience. Melbourne: Melbourne University Press; 1995. 2. Cantor C, Neulinger K, Roth J, Spinks D. The epidemiology of suicide and attempted suicide among young Australians. In: Commonwealth Department of Health and Aged Care. Setting the Evidence Based Research Agenda for Australia: A literature Review. National Youth Suicide Prevention Strategy. Canberra: Commonwealth Department of Health and Aged Care; 2000. 3. Visa opportunities for TPV holders in Regional Australia. Media Release VPS101.04, Wednesday 14 July 2004. Available at http://www.vanstone.com.au/default.asp? Menu=VPS101.04,. Accessed July 14 2004. 4. Procter NG. Paper plates and throwaway cutlery: aspects of generating trust during mental health initiatives with asylum seekers released from Australian immigration detention centres. Synergy 2004;(Spring):8—9. 5. Steel Z, Momartin S, Bateman C, Hafshejani A, Silove D, Everson N, Roy K, Dudley M, Newman L, Blick B, Mares S. Psychiatric status of asylum seeker families held for a protracted period in a remote detention centre in Australia. Aust N Z J Public Health 2004;28(3):527—36. 6. Ashford K. Seeking trust in asylum. Adelaide Rev 2003;November:2—3. 7. Kelbie P. The life and death of an asylum seeker. Independent 2004;May:1—2. 8. Procter NG. Speaking of sadness and the heart of acceptance: reciprocity in education. Parramatta: Multicultural Mental Health Australia; 2003. 9. Herlihy J, Scragg P, Turner S. Discrepancies in autobiographical memory—implications for the assessment of asylum seekers: repeated interviews study. BMJ 2004;324:324—7. 10. Australian Health Ministers. National mental health plan 2003—2008. Canberra: Australian Government; 2003. 11. Joint Standing Committee on Foreign Affairs Defence & Trade. Human Rights Sub-Committee Report. Canberra: Australian Government; 2001. 12. Department of Mental Health Substance Dependence. Mental Health in Emergencies: Mental and Social Aspects of Mental Health of Populations Exposed to Extreme Stressors. Geneva: World Health Organisation; 2003. 13. Procter NG. Emergency mental health nursing for refugees and asylum seekers. Aust Nurses J 2004;12:21—3. 14. Kleinman A, Seeman D. Personal experience of illness. In: Albrecht GL, Fitzpatrick R, Scrimshaw SC, editors. Handbook of social studies in health and medicine. London: Sage; 2000. p. 230—42. 15. Procter NG. Support for temporary protection visa holders: partnering individual mental health support and migration law consultation. Psychiatry Psychol Law 2004;11:110—2.
DISCUSSION
Mental health crisis intervention for asylum seekers in the emergency department Nicholas G. Procter, RN, PhD ∗ School of Nursing and Midwifery, University of South Australia, City East Campus, Adelaide, SA 5000, Australia KEYWORDS Asylum seekers; Emergency nursing; Refugees; Self harm; Suicide risk
Summary Emergency nurses worldwide have seen and will continue to see asylum seekers in mental distress in their professional work. This paper is intended to support nurses in their practice should they encounter an adult asylum seeker needing assistance in the emergency department. Beginning with the exemplar of a 31-year-old asylum seeker found wandering the street in the early morning hours, a preliminary interview with the emergency department nurse reveals an emerging picture of depression, hopelessness, and self-mutilation. Practical strategies are highlighted to help emergency nurses assess, care, and comfort asylum seekers in this and similar predicaments by working closely with community-based services and an accredited interpreter to prevent isolating the asylum seeker from appropriate services. To help strengthen continuity and integration of mental health supports for refugees and asylum seekers, care must be actioned in a culturally appropriate and sensitive fashion. © 2006 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights reserved.
Introduction Suicide by people born overseas but living in Australia represents 25% of all suicides in Australia.1 Of this 25%, more than half (approximately 60%) of suicides are by people from non-English speaking backgrounds.2 While suicide is not a mental illness — it is a behaviour — it is strongly associated with mental illness and, therefore, risk factors pertinent to both are overlapping and interrelated for migrants and refugees. This is especially the case for asylum seekers, many of whom are Temporary Protection Visa (TPV) holders, a class of visa grant∗
Tel.: +8 8302 2148; fax: +8 8302 2579. E-mail address: [email protected].
ing temporary entry to Australia and humanitarian protection for 3 years.3 In Australia around 9500 TPVs are granted to people who are recognised as refugees but who have travelled to Australia without valid documentation. Access to social security and education services is limited under this class of visa and holders do not have access to a class of legal entry to Australia, known as the family reunion visa. This means that they cannot legally bring family, including spouse and children, into the country. Each person granted a TPV must have this reviewed by Immigration Officials and this usually occurs at approximately 30 months after it was issued. This is known anecdotally as the ‘‘30month interview’’, where asylum seekers must re-
1574-6267/$ — see front matter © 2006 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.aenj.2006.04.001
114 tell their story of why they have previously sought and will continue to require protection in Australia. If successful in this interview then asylum seekers will be granted a Permanent Protection Visa (PPV), which allows for them to have increased social security benefits and be re-united with their families. The recent onset of TPV review interviews for PPVs in Australia has revealed new information about the way some asylum seekers experience their current existence, and the impact previous trauma has upon everyday life.4 The uncertainty of their existence — living in a state of limbo — and strongly held belief of many that it is unsafe to return to their homeland, has had an enormous physical and psychological toll on many adult asylum seekers. Those who have been in immigration detention display a threefold increase in mental illness subsequent to their release.5 Exposure to trauma within detention was commonplace as were frequent upsetting memories about detention, intrusive images of events that had occurred, and feelings of sadness and hopelessness. It is for this reason that the separateness of mental illness and suicide, and the association between the two become entwined. Frequently TPV holders have fled their birthplace to save their lives—–their will to live is strong but the prospect of not being able to cope in Australia and a fear that they will be killed if returned to their homeland remains ever present. The knowledge that their TPV may soon expire, and with it their hopes of remaining in Australia, contributes to a state of unbearable mental distress. They are often convinced they will be killed if forced to return to their homeland. If they are to die, most would prefer it to be at their own hands.6 So fragile is their ability to cope with problems of living brought about by their situation, some see no point in acquiring the usual accoutrements of life; they use disposable tableware such as paper tablecloths, paper plates, plastic cutlery.5 At the expiration of their 3-year visa, people holding TPVs must reapply for refugee status, approval is not assured. As seen in the next section of this paper this uncertainty can take an enormous physical and psychological toll.7
Emergency department scenario Ali1 is a 31-year-old TPV holder, his wife and two children remain in Afghanistan. He was found wandering a Sydney street at 3.30 a.m. and taken by police to a Sydney hospital. He was tearful, frightened, and appeared very upset in police 1
Not his real name.
N.G. Procter custody. Through an accredited interpreter, the admissions nurse began with an introduction of who she was and relied upon the keywords ‘I am not here to hurt you, I am hear to listen to your story’. Although initially picking at his shirt buttons with his fingers, limiting eye contact, shaking and speaking in a soft almost inaudible voice, Ali relaxed as the conversation developed between himself and the emergency nurse: For a few months after I arrived here I felt that I was free. Now I feel I am again the victim of fundamentalism and I have suffered in the past and will again in the future. I feel that my being here has meant that I have been penalised twice as I was not trusted or liked in Afghanistan and I am not trusted or liked here in this country — Australia. And this is the thing we are being penalised twice and here they don’t trust us as the Government thinks we might endanger this country in some way. And so we are the victim of fundamentalism twice. I have been away from my family for about 4 years now and it is very hard for a human being, it is hard for me to be the sort of human being I want to be. . . I cannot speak the language here, I feel stupid here, and I feel I don’t have respect from anyone here. I don’t have any family or friends here. My life is in limbo like I am floating2 . I have been waiting 39 months for a letter about my fate. As the interview between Ali and the nurse progressed it was possible to develop a general picture of Ali’s suicidality and mental state assessment. Questions pertaining to risk and protective factors for suicide were asked by the nurse (with the assistance of an interpreter) in an indirect rather than direct way. This is the preferred mode to help asylum seekers avoid feeling shame or becoming reticent in openly discussing their situation. Ali arrived in our region 4 months ago to work at the local chicken farm. He did not speak English on arrival in Australia but learnt basic language skills from some of the people he had been living with at various times since being released from immigration detention. During the previous 7—14 days he had been missing his family terribly, fearful of the outcome of his application for permanent protection, living in limbo, and this had kept him awake at night. He would go to bed at night around 11 or 2
This word was explained using the Dari word ‘‘Mualagh’’ in the following way, ‘‘It comes from a feeling of being suspended. Either you are on the ground or in the air. When you are neither on the ground or in the air, you are ‘floating’. It is like your feet are not walking on the ground or in the air at either time. It is like ‘‘being and not being somewhere’’ at the same time.
Mental health crisis intervention for asylum seekers in the emergency department 12 p.m., initially falling asleep and then waking at around 1—1.30 a.m. He described having difficulty in concentration and suicidal thoughts. After removing his jumper, the emergency nurse noticed between 8 and 12 burn marks on Ali’s right arm. These were self inflicted using a lit cigarette. He said he had done this at night, felt no pain nor any discomfort or distraction from the smell of his burning flesh. He would sometimes walk the streets at night immediately prior to burning his body. He also talked of feeling as if all people hated him: ‘‘all his Australian and non-Australian (Afghan) friends did not like him here . . .Nobody wants us here . . . it is all politics’’, Ali told the nurse. At this point in the interview he produced medication he was given by a local General Practitioner (Fluvoxamine 150 mg nocte). He said he was trying to trust others. He also said that he wanted to believe that his life was worth living.
Challenges for emergency nursing practice While asylum seekers like Ali frequently face periods of suffering and periods of calm, individual suffering has become increasingly intolerable when being reinterviewed and when immigration authorities reject refugee claims. When people seek asylum their application is considered in light of the information they can supply and any facts known about the country they are fleeing. Some people in mandatory detention and when reapplying for permanent protection, suffer a denial of credibility because of inconsistencies in their story. This can lead to claims being dismissed on the grounds of minor discrepancies. At times this appears to have a flow-on effect whereby it is difficult for therapeutic trust to be developed between mental health providers and persons in or released from immigration detention.8 Asylum seekers to Australia like Ali must remain alert to the possibility of being called to interview with Immigration Officials at any time. There is no way of knowing well in advance the date and time of interviews to re-assess claims, when invitations to interview or rejection letters will arrive, what questions will be asked or what will be the primary data source used to determine whether a homeland country is safe to return to. Mental distress and emotional disorders can and will impact upon the quality of information people can recall and the way this is communicated to others during interview.9 Where the experience is highly traumatic — for example, a situation involving serious injury to the person — the situation is considered
115
even more complex. There may be important differences between traumatic and non-traumatic memories. For example, initial recall of traumatic events by people with post-traumatic stress disorder typically does not involve normal narrative memory. In other words, the way the story unfolds may appear fragmented or disconnected from previous events and therefore appearing unreliable and inconsistent. This research also found that asylum seekers with post-traumatic stress at the time of their interview are more likely to have their claim rejected the longer their application is in the system.9 Knowledge of these and other stressors impacting upon TPV holders like Ali are important for emergency nurses because assessment of mental health problems, mental illness and suicide for asylum seekers should incorporate an understanding of the factors that heighten the risk of these occurring and those factors that protect against them.10 Emergency nurses working in acute and crises intervention services should know as much as possible about how to access groups and individuals who could potentially benefit from targeted clinical interventions.
Emergency nursing interventions for asylum seekers who self harm Anecdotal evidence is emerging showing that self harm and suicide attempts are likely to occur when an asylum seeker’s application for permanent protection has been rejected and they are asked to return to their county of origin.4,6,11 Gathering evidence of previous actions and behaviour may help to indicate if the impact on individuals or families will be negative and place them at increased risk. This should be done with the fundamental belief that trust is a core requirement for promoting mental stability. The emergency nurse’s choice of intervention should be guided by the twin processes of developing therapeutic trust in the context of the nurse—patient relationship, as well as data gathering for clinical decision making. Mental health interventions in emergency nursing care should acknowledge that social interventions can have secondary mental health effects and that mental health interventions can have social effects—–as the term psychosocial suggests.12 Social interventions are actions that primarily aim to have positive social effects, a mental health intervention is an intervention that primarily aims to have positive mental health effects.13 Preparation by nurses in settings where asylum seekers are likely to present should involve: (a) the
116 development of a system of coordination with a specific focal person responsible for linking the nurse and other health and human service professionals to persons seeking help; (b) a design of detailed plans to prepare for adequate social and mental health responses; and (c) education and training of relevant personnel in indicated social and psychological interventions. 1. Assessment and planning for the local context, for example cultural beliefs, setting, history and nature of mental health problems, family perceptions of distress and illness, ways of coping, resources within community network. It should include quantitative assessment of disability and/or daily functioning as well as qualitative and psychosocial dimensions. If initial assessments uncover a broad range of needs that are unlikely to be met, nursing assessment reports should specify urgency of needs, local community resources and potential external resources. 2. Collaborative interventions involving consultations and engagement between the TPV holder’s family and friendship network, migration lawyer and/or agent, mental health workers, non-government organisations and trusted community supporters working in the area. A multitude of individuals and agencies who demonstrate innovative ways of operating in a synchronised fashion, will prevent wastage of valuable resources and help bring health benefit to the asylum seeker and their family. Networking and information gathering by the emergency nurse are fundamental to the delivery of clinically relevant integrated emergency services. The therapeutic interaction between asylum seeker and emergency nurse is supported by understanding the ‘explanatory model’ of cultural awareness in mental health. Based on the work of Kleinman and Seeman,14 this means emergency nurses learning from asylum seekers about the way in which symptoms of mental distress are understood and presented, the way help is sought and the way care is evaluated by those who receive it. Such actions by the nurse are also consistent with Australia’s National Mental Health Plan.10
Data gathering in the acute phase of self harm Using World Health Organisation protocols12 as a guide, data gathering must be in partnership with significant others and, in what is described here as the ‘acute emergency phase’, the crude morbid-
N.G. Procter ity rate is elevated and the risk of self-injurious behaviour or harm to others is extreme. This period can be followed by a ‘reconsolidation phase’ when fundamental needs are again at a level comparable to that prior to the emergency.
Acute emergency phase Valuable early mental health interventions for emergency nurses to employ may include: • Establishing and maintaining contact with interpreters and emergency mental health workers to manage urgent psychiatric crises and to undertake suicide risk assessment using existing protocols as a guide (i.e. level of dangerousness to self or others, psychoses, severe depression, agitation). If an individual has any pre-existing mental illness, the sudden discontinuation of medication should be avoided. • Acute interventions may be best managed without medication by following the principals of mental and physical health first aid: (a) to preserve life where a person may be a danger to themselves and/or others; (b) to prevent major or permanent damage to a person’s emotional health and wellbeing; and (c) to prevent deterioration and promote recovery. The clinical skills necessary to apply these principles include: listening without interruption; speaking in a measured way without providing too much information for the interpreter to translate; conveying compassion; assessing physical and safety needs; ensuring basic physical and spiritual needs are met; not forcing, rather gently encouraging talking; providing or mobilising company from significant trusted others (especially a volunteer community supporter, a Community Health worker); encouraging but not forcing social support; and protecting from further harm. • Speaking in a calm voice identifying what the nurse can do. Consider using words such as, ‘‘I can see you need help. I am here to help you. I am not here to hurt you. I am here to understand you, to listen to your story and see what I can do, with others, to help you’’. Ask yourself, ‘‘Am I in immediate danger?’’ ‘‘Is the person in any immediate danger?’’ (e.g. standing near a road or a dangerous object). ‘‘Is anyone else in immediate danger, especially children or other vulnerable people?’’ ‘‘Can you safely remove a third person from danger?’’ ‘‘Can you safely communicate with this person in their preferred language?’’ Valuable early social interventions may include: • Establishing and distributing a flow of written and verbal information to asylum seekers (using
Mental health crisis intervention for asylum seekers in the emergency department an interpreter) on: (a) the application or visa appeal process; (b) efforts to establish physical safety of self and family (if in a family situation); and (c) efforts being made by each organisation/individual to help and support asylum seekers. This information should be as simple as possible and in a language most familiar to the individual and their family — for example, understandable to a local 12-year-old — and empathic (showing understanding of the situation of the family member). Given the nexus between mental health need and generating trust in community supports, migration advocacy is an increasing feature of a coordinated response to assist TPV holders. For this reason it is recommended that, where possible, TPV holders who are given individual mental health outpatient assistance have this provided in consultation with a community mental health worker and their migration agent/lawyer. This framework can provide an important backdrop to prevent misunderstandings as well as appropriately engage with the legal context within which emotional suffering can be understood and lives revealed. Partnership strategies of this kind also serve to help asylum seekers build resilience, and to continue moving forward through combined legal and psychosocial processes.15
Summary With the increased trend for mental health presentations to be assessed in general hospital emergency environments rather than psychiatric hospitals and the need for interdisciplinary management of mental health issues, the skills required for emergency nursing must be deliberately and convincingly practical and applied in nature. Emergency mental health care for asylum seekers is best achieved by bridging discrete elements in the asylum seeker journey of preparing for visa appeals and rejections—–in the context of different episodes, interventions by different providers, and changes in mental distress. The craft of the emergency nursing is to elicit information in a psychological atmosphere that is not adversarial to enable a whole of service, region and inter-disciplinary approach which brings together a range of sectors and indi-
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viduals working within them that impact on the mental health of asylum seekers. Emergency nurses through their proximity and skill can be influential in this process.
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