Aborigines,colonizers and newcomers: The landscape of transcultural psychiatry research in Australia

Introduction

The promotion of appropriate responses to the mental health needs of culturally diverse populations, including indigenous people, immigrants, and refugees, is considered one of the cornerstones of transcultural psychiatry (Kirmayer & Minas, 2000). In a diverse country such as Australia, special attention must be given to the cultural dimensions of mental disorders; and to the suitability of mental health services for its population (Minas, Lambert, Boranga, & Kostov, 1996).

In this review the authors present a synopsis of transcultural psychiatry in relation to three main population groups in Australia: Aboriginal Australians, immigrants, and refugees. An exploratory literature search was conducted on Pubmed using “transcultural,” “psychiatry,” and “Australia” as keywords. This search produced 61 entries, although many of these were unrelated to the themes under investigation. On the basis of citations and references of the preselected scientific articles, a snowballing method was used to locate other relevant articles and to determine the key researchers in the field.

We note at the outset that this paper has intentionally set out to cover a broad landscape of transcultural psychiatry in Australia—both in terms of the breadth of its historical sweep and key areas of research. As a result, one of the limitations of this paper is the shortage of detailed critique of particular studies. The aim is to give the reader an overview of transcultural psychiatry in Australia.

Historical context of transcultural psychiatry in Australia

“Aboriginal Australians” is a term used to denote more than 200 Australian Aboriginal tribes in addition to the Austronesian population of the Torres Strait. Archaeological evidence suggests these were the first people to arrive in Australia, via the Indonesian archipelago, around 50,000 years ago. They established one of the longest surviving civilizations in human history.

In 1606 Willem Janszoon, a Dutch explorer, was the first European to land in Australia and to document its existence (Sheehan, 2008). Other European voyagers followed until James Cook, sailing along the East coast of Australia, claimed the land as a British possession in 1770. The ensuing colonization took place after Britain’s loss in the American War of Independence in 1783, which caused the British to seek new territory for a penal colony (West & Murphy, 2010). The British First Fleet arrived in Botany Bay, Sydney, in 1788. Of note, it was comprised not only of convicts from English and Scottish backgrounds, but also of several other nationalities, including Germans and Norwegians, as well as both Black and White Americans. The first years of settlement took place in an inhospitable land and were marked by droughts, heat, lack of food and fresh water, and conflicts with Indigenous Australians (West & Murphy, 2010).

On the 26th day of January 1788, Britain’s newest colony was established. Each year this date is celebrated as “Australia Day,” although for many Aboriginal communities, the date is labelled “Invasion Day” or “Survival Day,” to mark “the beginning of the disease, violence, and invasive government policies that destroyed life as they knew it” (West & Murphy, 2010, p. 42). After a referendum (at the end of the 19th century) held by the six Australian colonies—New South Wales, South Australia, Tasmania, Queensland, Victoria, and Western Australia—a united federation was established. In July 1900, Queen Victoria signed the Commonwealth of Australia Constitution Act in London, and the date of enactment was set for January 1, 1901 (West & Murphy, 2010).

During the first year of the establishment of the federation the initial action of the new federal government was to establish legal parameters for one to become a member of the Australian community. The most important yardstick was whiteness, meaning light-skinned people of northern European descent (Andreoni, 2003; West & Murphy, 2010). The Constitution of 1901 dealt fundamentally with the country’s Aboriginal people and migrants. The constitution expressly stated that Aboriginal people were not to be counted in either state or federal censuses. This restriction was only removed in 1967, when full citizenship rights were given to Aboriginal individuals (Cameron, 2000). With regard to migrants, three separate bills were passed to establish the legal foundations to promote the importance of whiteness in Australian identity. The third of these acts, the Immigration Restriction Act, restricted immigration to Whites, thereby formalizing the White Australian policy and setting the requirements for Australian citizenship (National Archives of Australia, 2005).

Aboriginal children—under the pretext of providing education, Christianity, or a tradesman’s skills —were removed from their families and placed under the “protection” of the government or church-sponsored missions from the early days of European occupation until the 1970s. Today these Aboriginal people are known as the “Stolen Generation” (Welsh, 2004). The obliterating effect of the “Stolen Generation” on Aboriginal Australians has been officially recognized through a formal apology given by the former Prime Minister Kevin Rudd on behalf of the government of Australia (Rudd, 2008). The apology recognized that many of those affected by these interventions still face numerous issues including mental and physical illness, homelessness, substance abuse, educational and family relationship difficulties as a consequence of the removal from their families (Commonwealth of Australia, 2010).

Every nation is characterized by key historical events that define its past and shape its present. This national self-perception impacts in all spheres of life including the treatment of migrants to that nation. For Australia the two world wars were instrumental in the creation of its national self-view. Australia fought alongside the allied forces during the two world wars. In 1915, the Anzacs (Australia and New Zealand Army Corps) spent 8 months in Gallipoli, Turkey, where more than 8,000 Australian soldiers died. Gallipoli became an important unifying symbol for Australians, creating a “new consciousness of nationality,” and contributing significantly to Australians’ nationalistic pride (Welsh, 2004).There were two aspects to the Gallipoli campaign that were vital in developing an Australian self-view. World War I was the first time Australians participated on the world stage as a unified nation. Secondly, Australians saw in this Gallipoli campaign—fighting alongside the British against a common enemy—an affirmation of their English colonial roots. This campaign continues to have strong resonance for many modern Australians as to how they see themselves and their nation.

Australia entered World War II along with the allied forces in September 1939. In 1942 the Japanese air force bombed Darwin’s harbour on the north coast of Australia, killing 243 people (National Archives of Australia, 2009). By the end of WWII, Australians—feeling vulnerable to external forces—reviewed their global position (West & Murphy, 2010). Given the loss of a significant proportion of Australia’s population during the two world wars, future political leaderships developed the policy of “populate or perish,” which continued until the global economic crisis of the 1970s.

Between 1947 and 1970, a period mostly under Prime Minister Robert Menzies’ government, more than 2.5 million immigrants came to Australia (West & Murphy, 2010). Arthur Augustus Calwell, Australia’s first Minister for Immigration, was the main proponent of the immigration process. Based on the conviction that “they are simply not wanted and are permanently undesirable,” Calwell was determined to maintain the “White Australia” policy; to the point of expelling “non-White” residents in 1948, despite the country’s desperate need for labour (Kunz, 1988).

In 1947 Australia became a signatory to the International Refugee Organization (IRO). Australia accepted “White” displaced refugees in the aftermath of the Second World War. The first of these migrants, from the Baltic countries of Lithuania, Latvia, and Estonia, arrived in Western Australia in November 1947 and were transferred to Victoria.

The restrictions imposed by the White Australia policy were progressively attenuated. The Migration Act 1966 increased access to people other than those from Europe, including refugees from Vietnam (National Communications Branch Department of Immigration and Citizenship, 2007). Immigration from the Asia-Pacific region expanded progressively and by the 1990s, about 50% of all immigrants originated from Asian countries (West & Murphy, 2010). In 1967, the Aboriginal people were recognized as citizens via a referendum.

Finally, in 1975, the Racial Discrimination Act was passed, making racially based immigration policies illegal. Yet, the resulting demographic effect of the “White Australia” policy allowed for the formation of a population of European descent, predominantly of Anglo-Celtic ethnicity and Christian religion. By 2006, 24% of the total Australian population were foreign-born (Australian Bureau of Statistics, 2006). The most commonly reported ancestries—people are not classified according to race—were Australian (31.13%), English (29.65%), Irish (9.08%) and Scottish (7.16%), whereas 2.3% of the population reported Aboriginal and/or Torres Strait Islander origin (Commonwealth of Australia, 2008).

Current immigration policies admit two main groups into the country: those with specific occupational skills and family members of current immigrants. Additional immigration schemes include the Refugee and the Special Humanitarian Program, as well as the Special Assistance Category (Refugee Council of Australia, 2011). However, asylum seekers who arrive on the north coast of Australia are still detained for health and security checks and may remain in detention for prolonged periods. The number of asylum seekers arriving by boat has increased significantly from about 2,750 in 2009, to approximately 6,800 in 2010 (Phillips, 2011), which is comparatively small when contrasted with the number of unauthorized people arriving by boat on the coasts of Italy, Spain, Greece, and Malta (over 72,000 in 2006) (Østergaard, 2008). This phenomenon remains an unresolved and controversial human rights issue, which has generated significant political debate and criticism.

Aboriginal psychiatry in Australia

Duke (2007) reviewed the writings of several anthropologists from the first half of the 20th century, finding limited reference to Aboriginal Australians within the Western psychiatric perspective. In fact there was “little interest” in the health of Aboriginal and Torres Strait Islander peoples in the Australian medical literature before 1950 (Christophers, 2004). Early reports portrayed Aborigines as an inferior race, doomed to extinction. Aboriginal patients, described by Bostock in the context of purported psychiatric disorders, were characterized as suffering from “mixed breeding and general racial decay” (Bostock, 1924b). In a report on “insanity in the Australian aborigine,” Dr. Bostock mentioned that dementia praecox and manic-depressive disorders occurred among Aborigines, but epilepsy was “more frequent in those in contact with civilization” which could be “a factor in race extinction.” He also observed Aboriginal individuals had “not reached the evolutionary stage where the neuroses and certain of the psychoses, hysteria, and the phobias exist” (Bostock, 1924a, p. 203).

Decades later, the pioneering studies by John Cawte focused on the detribalizing process suffered by Aborigines, who were under great pressure to alter their traditions and life-style to conform to the dominant urbanizing and industrializing European-type Australian social order. Cawte produced a series of analyses in 1963 (Cawte, 1963) and 1964 (Cawte, 1964; Cawte & Kidson, 1964), in which he referred to the psychiatric repercussions of the plight faced by Aboriginal people.

Cawte and Kidson also conducted studies with the Walbiri Aborigines at Yuendumu, Central Australia, with the purpose of understanding the role of indigenous healing methods utilized by the so-called “medicine men” or “Aboriginal doctors” (Cawte & Kidson, 1964). The authors observed that although Western and Aboriginal medical systems were contemporaries during a period of cultural transition, many Aborigines remained “tradition-oriented.” Cawte predicted that the Walbiri healers would continue to practise “because the people will turn to them in times of stress” (Cawte & Kidson, 1964, p. 983).

In a subsequent study with the Walbiri people, Cawte and Kidson observed that “the march of assimilation” had prompted an upsurge of “a number of disciplines,” including psychiatry, which would bring to light “the importance of cultural factors” in explaining the challenges faced by Aboriginal people (Cawte & Kidson, 1965, p. 1079). The authors described three phases of adaptation to rapid culture change: an initial phase characterized by reactions to contacts with the White settlers; a second phase, marked by gross physical deterioration in response to disruption of traditional ways of life; and a third phase characterized by “shyness, withdrawal and regression” (1965, p. 1084) and limited involvement with White society. The authors also reported a more recent phase pertaining to efforts by White Australians to promote assimilation of Aboriginal people into the dominant society (Cawte & Kidson, 1965).

Cawte also conducted studies on the Yowera Aboriginal people of Central Australia, since there were reports of an unusual incidence of mental instability in that Aboriginal community. South Australian mental hospital records revealed that many Aborigines of that region had been referred because of “unusual psychoses.” Cawte described two patterns of psychopathological presentation: The traditional illnesses, on the basis of Aboriginal beliefs, manifested often by states of animal “possession” which represented “a vicissitude of totemism”; and the transitional illnesses, associated with assimilatory pressures from the dominant culture, characterized by hostility to the White culture as well as increased adherence to traditional Aboriginal beliefs.

Kidson conducted a survey of psychiatric disorders in Australian Aboriginal people living at Yuendumu, Central Australia. The author expressed “little doubt that a group of disorders resembling the functional psychoses of Western societies [did] exist among the Walbiri” (Kidson, 1967, p. 20). Yet, he cautioned that additional studies would be required in order to fully establish “the occurrence of schizophrenia or manic depressive psychosis” (1967, p. 20). Kidson also observed “a clinical syndrome of dementia with memory loss and disorientation,” (1967, p. 20) and suggested that histological studies would be needed in order to determine if this should be considered as one of the senile disorders. He also cautioned that the diagnosis of personality disorders presented “special problems,” in that this diagnostic entity depended upon comparative analyses of compliance with expected social norms.

Kidson and Jones subsequently reported findings from an investigation of psychiatric disorders among Western Desert Aborigines, which at that time were encamped at the Warburton Ranges Mission in the Great Victoria Desert of Western Australia. The frequency of all psychiatric disorders occurring among this group of Aborigines was 6.8%, compared with 5.4% as had been previously determined for the Walbiri in Central Australia (Cawte & Kidson, 1965). Although the authors detected affective psychoses occurring among desert Aborigines, syndromes resembling Western forms of neurosis, including anxiety, phobic, or obsessive-compulsive states were not observed. No suicidal behaviour, including suicide attempts, was observed (Kidson & Jones, 1968).

Subsequently, a survey was conducted with 959 Australian Western Desert and Kimberley Aborigines to investigate the prevalence of psychiatric disorders. The authors observed that, although the prevalence of psychiatric disorders was “somewhat lower” than figures obtained from studies in Western communities, the nature of the psychiatric disorders encountered was similar. The authors detected “cases of dementia, schizophrenia, puerperal psychosis, depression, hysterical states, personality disorders, organic brain syndromes, mental deficiency and childhood behavioural disorders” (Jones & Horne, 1973, p. 219). The authors cautioned that “no cases of suicide or homosexuality” had been found in that group although these “two forms of behaviour” had been found “among Aborigines who have lost a great part of their indigenous culture” (Jones & Horne, 1973, p. 219). In addition, based on evidence collected during “visits to isolated Western Australian missions to examine psychiatric behaviour among full-blood Aborigines,” Jones and de La Horne reported that depression and schizophrenia could be treated with antidepressants and antipsychotics “precisely as one would do with Europeans” (Jones & Horne, 1972, p. 345).

Eastwell examined a community of 350 people at Numbulwar Mission in the Gulf of Carpentaria in northern Australia. The investigated Aborigines were living in conditions far removed from their traditional indigenous lifestyle. The author observed around 25 cases of mental disorders, of which nine were admitted to inpatient care (Eastwell, 1977). The author noted that the disorganization of traditional Aboriginal societal elements led to a series of psychiatric effects, especially via a radical change from a nomadic life to a settled lifestyle in which many traditional roles related to subsistence hunting and gathering had been undermined or lost.

In order to explore the nosological applicability of personality disorders in Aboriginal people, an investigation was conducted with the Pintupi people, Australian Aborigines who speak a dialect of the Western Desert language (Morice, 1979). The results revealed that this group of Aboriginal people was able to linguistically differentiate appropriate behaviour from inappropriate patterns of aggressive behaviour, which would be identified as explosive or antisocial personality disorders according to Western psychiatric tenets. Accordingly, the authors suggest that “it should be possible” for psychiatrists to differentiate between culturally appropriate behaviour, transient situational behavioural reactions, and personality disorders of Aboriginal people (Morice, 1979).

By the beginning of the 1970s, studies expanded to focus on additional age groups—initially adolescents and later children—as well as to encompass urbanized groups of Aborigines. A study conducted with 172 Aboriginal adolescents in the state of Victoria in 1970, revealed that the majority (51.2%) of the adolescents interviewed presented “psychological and psychosocial disturbances” (Gault, Krupinski, & Stoller, 1970), an observation which was similar to the findings of the study conducted by Gault (45%) in 1968 (Gault, 1968). The results of that study revealed no difference in the prevalence of psychosocial disturbances between adolescents from tribal reserves and those brought up in an urban environment. The authors interpreted this finding as evidence that “tribal norms and values are not decisive,” but cautioned that “this has yet to be proven” (Gault et al., 1970, p. 32). The authors also concluded that socioeconomic deprivation could be considered as an explanatory factor to account for the high rates of “almost all disorders in those living in poorer economic and housing conditions” (Gault et al., 1970, p. 32).

A survey of health problems experienced by Aborigines living in Sydney revealed that many children presented with disturbances of behaviour (Eastwell, 1977). The author emphasized that treatment plans to assist these children should take into account aspects of “life style and culture” as well as factors related to “adjustment to the environment” considering the “rapidly changing cultural milieu” (Eastwell, 1977). Another survey with urban Aboriginal patients attending a general practitioner in the Victorian Aboriginal Health Service revealed that the majority of respondents presented a psychiatric disorder according to evidence obtained via standardized psychiatric interviews (McKendrick, Cutter, Mackenzie, & Chiu, 1992). Despite the high rates of psychiatric morbidity, the authors pointed out that Aboriginal people were “effectively denied access to mainstream mental health services” provided by public hospital and community centres, due to the fact that those services were “culturally inappropriate for Aboriginal people” (McKendrick et al., 1990, p. 350). In view of these findings, a dedicated Aboriginal mental health program was established in Melbourne. This led to a marked increase in service utilization by Aboriginal people. The authors underscored the fact that the addition of Aboriginal mental health workers produced a “highly positive impact” on the functioning of the mental health program (McKendrick et al., 1990).

The importance of involving Indigenous people in the process of developing effective partnerships in the context of mental health care and research procedures has been emphasized elsewhere (Eley et al., 2007). In fact, results from a needs analysis study revealed that productive partnerships between the Indigenous people and mental health professionals are essential in the process of promoting culturally appropriate and effective mental health services for Aboriginal people (Eley et al., 2007).

Aboriginal people were also particularly vulnerable to abuse of psychoactive substances (Edwards & Madden, 2001). A study in which 105 Aboriginal people aged 8 to 17 years were assessed in Western Australia revealed that the most commonly used drugs were tobacco, alcohol, and cannabis and, among those aged 15 to 17 years, 48% were frequent poly-drug users (Dunne, Yeo, Keane, & Elkins, 2000). Additional evidence confirmed that Aboriginal and Torres Strait Islander youth were more susceptible to substance use than non-indigenous youth (Gray, Morfitt, Ryan, & Williams, 1997). A series of sociodemographic variables such as poor school performance and low parental supervision were found to be significantly associated with substance abuse (Gray et al., 1997).

The need for a sustained effort to examine alcohol abuse and dependence among Aborigines has been advocated, with a special emphasis on the burden experienced by Aborigines due to imposed cultural norms and the ensuing socioeconomic deprivation (Kahn, Hunter, Heather, & Tebbutt, 1991). A recent clinical review of 170 patients with diagnoses of a psychotic disorder in Cape York and the Torres Strait revealed high comorbid rates of substance abuse (E. M. Hunter et al., 2011).

In addition, concerns had been raised that cannabis use was facilitating subsequent addiction to nicotine among Aborigines (Burns, Ivers, Lindorff, & Clough, 2000). The initial impressions were corroborated in a survey conducted in three eastern Arnhem Land communities in the Northern Territory, which revealed that cannabis had influenced the continued use of tobacco in that sample (Clough, 2005). Additional reports demonstrated concern with the escalating proportion of the population using cannabis in indigenous communities and the persisting nature of such use (Clough, Cairney, Maruff, & Parker, 2002; Lee, Clough, & Conigrave, 2007). A cross-sectional study conducted in the Northern Territory revealed that cannabis users were more likely than nonusers to have used alcohol as well as tobacco, and to have sniffed petrol (Clough et al., 2004). Additional evidence obtained from Aboriginal communities in the Northern Territory also revealed that heavy cannabis use was significantly associated with moderate to severe depressive symptoms (Lee, Clough, Jaragba, Conigrave, & Patton, 2008). Finally, a 5-year longitudinal study revealed that those who reported cannabis use at baseline remained using the same substance at follow-up (Lee, Conigrave, Clough, et al., 2009), which highlighted the need for preventive and therapeutic strategies to curb what was characterized as a problem of epidemic dimensions among Aboriginal youth (Lee, Conigrave, Patton, & Clough, 2009). Recently, symptoms of depression or anxiety have been described among Aboriginal Australians seeking treatment for substance use problems (Dingwall & Cairney, 2011).

A qualitative study conducted with Aboriginal health services in Sydney revealed that issues related to the extended Aboriginal family were pivotal in the mental health assessment of Aboriginal Australians. A review of qualitative findings related to Aboriginal mental health indicated that culture, family, social factors, and loss, along with fear, were the five central topics regarding the understanding of mental health maintenance and psychiatric disorders among Aboriginal Australians (Ypinazar, Margolis, Haswell-Elkins, & Tsey, 2007). Aboriginal and Torres Strait Islander mental health workers are particularly adept at dealing with indigenous mental disorders in Aboriginal Australians, considering their holistic understanding of Aboriginals in the context of their cultural and spiritual needs (Parker, 2003).

Evidence indicates that suicide is particularly prevalent in younger Aboriginal populations (E. M. Hunter, 1997). Furthermore, an increasing number of Aborigines commit suicide while in custody (E. M. Hunter, 1988, 1989). It has been hypothesized that historical determinants may also exert an influence on determining specific patterns of disorders, including suicide and self-harming behaviour (E. M. Hunter, 1990). Findings from a formal investigation of Aboriginal suicide conducted in Western Australia (E. M. Hunter, 1991a) revealed that major environmental and cultural changes may have had detrimental effects on the lives of Aboriginal people, particularly during childhood and youth (E. M. Hunter, 1991b).

Although many authors have pondered over the destructive impact of European colonization on the mental health of Aboriginal people, the measurement of the fallout and setbacks that have come out of colonialism is difficult to achieve with empirical methods. Nonetheless, plausible correlations between colonization and specific outcomes are implicitly or explicitly expressed in contemporary studies. In a comprehensive review of Aboriginal mental health, Parker refers to “the destruction of Aboriginal culture and the emergence of an epidemic of mental illness” (Parker, 2010, p. 4). The author argues that the British colonization of Australia produced a deleterious impact on the physical and mental health of the Aboriginal population, leading to “psychological distress and spiritual despair” (Parker, 2010, p. 4). Additional governmental interventions and/or policies such as the infamous “Stolen Generation” (from the 1930s to the 1960s), which authorized the removal of Aboriginal children from their families and their subsequent institutionalization in boarding schools and foster family settings, dismantled emotional and family bonds of numerous Aboriginal families, and undermined the self-esteem of Aboriginal children and youth.

Immigrants: From White Australia to multiculturalism

In Australia, the initial studies on psychiatric morbidity of immigrants focused on high rates of admissions for psychosis among Eastern European immigrants (Cade & Krupinski, 1962; Krupinski, Stoller, & Wallace, 1973). A series of factors were explored to explain this phenomenon, including migration selection circumstances (Williams, Krupinski, & Stoller, 1965), previous history of mental disorder (Schaechter, 1965) and migration-related stress (Schaechter, 1962).

During the 1970s, the Australian Parliament began to articulate policies that recognized the reality of Australia as a multicultural society. The Report of Migrant Services and Programmes, listing services for immigrants, was tabled in the Australian Parliament in nine languages. Malcom Fraser, the Prime Minister at that time (1975–1983), acknowledged that “few Australians face the difficulties many migrants … are confronted with” (Fraser, 1978; see also Cawte, 1980). At that time, the Galbally Report had identified that the Australian health system was not prepared to effectively treat patients from a diversity of cultural backgrounds (Galbally, 1978). In 1988 an official document entitled “Health for All Australians” recommended health promotion for every Australian (Australia Health Targets and Implementation [Health for All] Committee, 1988). Yet, the ethnic and cultural aspects of health care remained unaddressed (Eisenbruch, 1989). The document, entitled “Health Policy for Multicultural Australia,” commissioned by the Australian Office of Multicultural Affairs, highlighted the need for specific policies to address health inequalities affecting immigrants in Australia (Mitchell, 1988).

Cawte later warned that there was a dearth of “theory and practice sufficiently developed to call multicultural medicine” (Cawte, 1980, p. 491). Additional authors cautioned that medical education was not keeping pace with crucial social and cultural changes in Australian society and that medical students were not being trained to assess and treat patients from multicultural backgrounds (Eisenbruch, 1989). Eisenbruch argued that much “cross-cultural” thinking in Australia used ethnocentric criteria of physical and emotional disorders based on Western formulations of health and illness. As a result, immigrant patients were dissatisfied when doctors did not take into consideration patients’ perceptions of their symptoms and disorders (Eisenbruch, 1989).

In light of these deficiencies, Cawte pointed to the “omission of transcultural psychiatry from the fabric of Australian medicine” (Cawte, 1980, p. 492) and proposed the creation of “a Department of Transcultural Psychiatry in Australia, at least equal to those existing in Canada” (1980, p. 495). Later, the discipline of multicultural medicine started to be offered as an elective course in medical schools in Sydney. In addition to apprehension regarding the unpreparedness of the medical establishment to effectively deal with an “important cultural gap” and differences “in explaining the causes of health and ill-health” (Eisenbruch, 1989, p. 575), concerns were raised in relation to xenophobia, which manifested itself collectively as “racism, discrimination and prejudice” (Cawte, 1980, p. 494).

Although the concept of “ethnic minorities” can vary in different countries (Minas, 1996), in Australia this definition is based on a dichotomy between people born in an English-speaking nation and those born in countries where English is not the main language. Research evidence indicates that individuals from minority ethnic groups in Australia who have limited fluency in English tend to utilize mental health services proportionally less than the mainstream population (Stuart, Minas, Klimidis, & O’Connell, 1996). It was hypothesized that differential access to mental health services may be related to a series of factors such as limited knowledge about the availability and means of access to mental health services (Fan, 1999), variable impact of stigma on the experience of having a mental disorder across cultures (Ng, 1997), and inadequate outreach by mental health services due to clinically insensitive practices and service orientation (Minas, Stuart, & Klimidis, 1994).

Preliminary evidence demonstrated that matching the ethnic background of patients and clinicians may produce better health service outcomes in Australia (Ziguras, Klimidis, Lewis, & Stuart, 2003). Patients from ethnic minorities who were matched with bilingual clinicians remained in treatment longer than those who were not matched linguistically. In the case of Vietnamese immigrant patients, shorter and less frequent stays in hospital were attained by those who were followed up by bilingual health professionals (Ziguras et al., 2003). A more recent study conducted with Vietnamese immigrants who were receiving psychiatric care in Sydney revealed that the unsatisfactory quality of assessment and referrals at the primary care level constituted one of the main obstacles to effective mental health care in this group (Wagner, Manicavasagar, Silove, Marnane, & Tran, 2006). It has been hypothesized that underrepresentation of immigrants in psychiatric services and their disengagement from psychiatric services could be better explained on the basis of limited access to psychiatric services in general (Klimidis, McKenzie, Lewis, & Minas, 2000). Initiatives have been taken to reduce the obstacles for members of minority groups to access culturally sensitive mental health care, which include the development of specific policies to address this issue, prioritized funding mechanisms, and recruitment of bilingual clinical staff (Ziguras, Stankovska, & Minas, 1999).

A study in Western Australia in which the rates of hospital admissions were analysed for country of birth revealed variable patterns among different migrant groups (Burvill, Reymond, Stampfer, & Carlson, 1982). Eastern European immigrants had the highest hospitalization rates and presented significantly high rates of schizophrenia, while southern European immigrant women presented significantly elevated rates of neurosis and personality disorder. Further studies confirmed the different rates of psychiatric morbidity among diverse minority groups in Australia. Yet, a later study conducted in the same region revealed that immigrants and Australian-born patients had similar rates of psychiatric admissions (Bruxner, Burvill, Fazio, & Febbo, 1997). Immigrants from Southeast Asia presented rather low rates, which was interpreted as an indication of undiagnosed and untreated psychiatric morbidity in this group (Bruxner et al., 1997).

As previously hypothesized, it is probable that limited command of English could explain limited access to treatment, as well as prolonged admissions in psychiatric facilities. In one study, immigrants from the United Kingdom presented rates similar to Australian-born patients in terms of diagnosis and frequency of hospital admissions (Burvill et al., 1982). Additional evidence demonstrated that patients whose primary language is not English tend to have longer stays in psychiatric inpatient facilities, in comparison with Australian-born patients (Trauer, 1995). A retrospective analysis of psychiatric admissions to a public inpatient facility in Melbourne in the preceding year revealed a higher proportion of involuntary admissions among elderly patients from a non-English-speaking background compared to a similar group of patients from an English-speaking background (Hassett, George, & Harrigan, 1999). In another study in which patients from non-English-speaking countries were compared with their Australian-born counterparts, no difference was observed in the proportion of patients receiving depot medications, (in conjunction or not with an oral agent) despite a statistical “trend” towards foreign-born patients being more likely to receive a depot medication (p = .08; Ziguras, Lambert, McKenzie, & Pennella, 1999).

Recent Australian studies have focused on community-based analyses of mental disorders in specific ethnic groups of immigrants. A study was conducted in Victoria, in which samples of Australian-born adolescents whose parents were also born in Australia, Australian-born children of immigrant parents, and refugee adolescents were compared. The study did not produce conclusive findings in relation to hypothesized correlations between immigrant status and psychological morbidity. The authors did not identify a significant effect of immigration on four measures of psychopathology, including anxiety and depressive state (Klimidis, Stuart, Minas, & Ata, 1994). On the other hand, a study conducted with 126 Bosnian immigrants with comorbid posttraumatic stress disorder (PTSD) revealed potential correlations between traumatic experiences and presenting mental disorders (Momartin, Silove, Manicavasagar, & Steel, 2004). The authors observed that life-threatening experiences and traumatic losses were significantly associated with psychiatric comorbidity, particularly PTSD and depression (Momartin et al., 2004). Despite the complexities and heterogeneity of personal migration experiences, it is probable that forced migratory movements of displaced people in the context of traumatic experiences and violence at any stage of their migration to a host country is a contributing factor in their subsequent development of mental disorders.

More recent evidence indicates that even highly qualified immigrants may face burdensome resettlement processes in Australia. Since the mid-1990s Australia’s immigration program has focused on encouraging skilled migration. Data obtained from longitudinal surveys conducted between 1994 and 2006 revealed that a significant number of migrants were not using their original professional skills, despite the fact that many had proper command of English (Reid, 2012). Migrants who did not use their job qualifications had worse mental health as indicated by scores on the GHQ-12, a measure of psychological distress (Reid, 2012). Furthermore, research evidence indicates that skilled migrants have experienced discrimination in the workplace as well as unduly restrictive measures towards their visa status and professional registration in Australia, which have been associated with anxiety and low self-esteem (Anonymous, 2008; Omeri, 2006; Zubaran, 2011).

Refugees: Still struggling for shelter and dignity

In recent years, there has been criticism of Australia’s treatment of asylum seekers, especially the mandatory detention of unauthorized migrants who arrive by boat (Steel & Silove, 2001). It has been shown that their imposed prolonged detention has harmful effects on the mental health of detainees (Becker & Silove, 1993). There is a consensus of medical opinion that prolonged detention, as mandated by these policies, is causing harm to the mental health and social development of children, adolescents, and families (Mares, Newman, Dudley, & Gale, 2002; Royal Australasian College of Physicians, 2008; Steel et al., 2004).

Although many countries detain asylum seekers, Australia has been unusually strict in establishing a policy of mandatory, indefinite detention (Silove, Austin, & Steel, 2007). It has been advocated that places of detention created outside the customary “legal, ethical and social systems of nations,” constitute “a major threat to international human rights” (Kirmayer, Rousseau, & Crépeau, 2004, p. 85). Societal factors such as unwelcoming and hostile environments in host countries, and unaccommodating refugee policies are known obstacles to effective and functional resettlement (Murray & Skull, 2005; Stanaway et al., 2011). There is a growing body of research evidence on the psychological impact of pre- and trans-migration experiences of refugees (United Nations High Commissioner for Refugees [UNHCR], 2004). The official criteria for the right to asylum were defined by the United Nations Geneva Convention Relating to the Status of Refugees (United Nations High Commissioner for Refugees [UNHCR], 2010). The personal journeys of refugees often involve a wide range of traumatic experiences—including physical, psychological, and sexual abuse. Mental health problems commonly arise from these traumatic experiences, including anxiety and depressive disorders, grief reactions and somatization (Mares & Jureidini, 2004). Over the last two decades, most of the refugees relocated to Australia have come from South West Asia, the Middle East, Africa, and the former Yugoslavia (Australia Department of Immigration and Citizenship, 2007).

There is mounting evidence that Australian asylum policies have disproportionately burdened the health and wellbeing of asylum seekers (Johnston, 2009). The confinement of asylum seekers in detention centres is considered one of the most controversial initiatives countries use to deter the influx of undocumented migrants (Loff, 2002). Although Australia maintains an off-shore humanitarian programme—an annual quota of refugees are offered residency in Australia—until recently, Australia was one of the only Western countries supporting the indefinite mandatory detention of asylum seekers (Millbank, 2004). It has been stated that “Australia has taken the toughest line of all Western countries” in dealing with asylum seekers (Millbank, 2004, p. 29). Initially—the legislation on mandatory detention of all unauthorized arrivals was passed in 1992—asylum seekers could be detained up to 1 year, but subsequently detentions were reclassified as indefinite, and some detainees, including children, were held in detention for several years (Silove et al., 2007). The detention centres reportedly resemble and function in the style of correctional facilities, with buildings surrounded by razor wire and electrified perimeters, and inmates are referred to by numbers rather than by their names (Australia Human Rights Commission, 2002; Silove et al., 2007; Sultan & O’Sullivan, 2001). A series of protests, hunger strikes, self-harming behaviour, and riots have taken place in different detention centres (Silove, Steel, & Watters, 2000). Cases of detainees who present with marked deterioration in their mental health status have been documented after the introduction of the detention policy (Silove, McIntosh, & Becker, 1993).

Research evidence from Australia and elsewhere indicates that many detained asylum seekers have been exposed to a level of trauma and distress that exceeds the trauma experienced by other refugees, and that these tribulations tend to recur in the “retraumatizing environment” of detention centres (Silove et al., 1993). However, in one study, the long-term effects of trauma on mental health of Vietnamese refugees resettled in Australia revealed that risk of mental disorders decreased over time, although those who had been exposed to more than three traumatic events still experienced an increased risk of mental disorder after 10 years—as compared with their untraumatized counterparts (Steel, Silove, Phan, & Bauman, 2002).

The majority of Sudanese refugees who have relocated to Australia are from South Sudan of Christian background and, apart from tribal dialects, also speak Arabic (Tempany, 2009). A qualitative investigation of the experiences of Sudanese refugees during premigration, transit, and postmigration periods revealed a series of traumatic experiences (Khawaja, White, Schweitzer, & Greenslade, 2008). Racism and inadequate treatment were identified as major difficulties, manifesting as obstacles to attaining employment, disproportionate scrutiny from the police, and experiences of verbal abuse (Khawaja et al., 2008). Additional findings from an Australian study on the premigratory experiences of Sudanese refugees include a high rate of exposure to traumatic events; including torture, rape, and other forms of abuse, as well as witnessing the assassination of family members and friends (Schweitzer, Melville, Steel, & Lacherez, 2006).

There is a growing concern that sanctions and uncertainties imposed on asylum seekers may aggravate previous mental health problems or contribute to the onset of other disorders in this group (Harris & Telfer, 2001; Smith, 2001). Recent evidence indicates that the consequences of mandatory detention on mental health can continue for sustained periods of time after release into the community (Silove et al., 2007). Despite the limited refugee-specific research in the areas of help-seeking and mental health service utilization, the underutilization of mental health services is patent for children of ethnic minorities (de Anstiss, Ziaian, Procter, Warland, & Baghurst, 2009). One of the few studies to investigate the prevalence of psychiatric disorders among refugee children in Australia revealed comparable morbidity rates to Western Australia’s general population, which was explained on the basis of their limited exposure to traumatic events and the long period of time that these children had already lived in Australia (McKelvey et al., 2002).

A common thread

There are points of similarity and difference in the research into the three population groups covered in this paper. One common thread is that of social exclusion. The concept of social exclusion has been used to understand forms of social disadvantage. It refers to the processes by which individuals and population groups are denied the rights, resources, and opportunities required to integrate effectively into society (Burchardt, Le Grand, & Piachud, 2002). Although poverty is an essential aspect of social exclusion, additional forms of disadvantage can be experienced at economic, political, cultural, and social levels (Popay et al., 2008). Furthermore, individuals with mental disorders may experience social exclusion as a result of societal stigma, independently of material wealth (Morgan, Burns, Fitzpatrick, Pinfold, & Priebe, 2007).

It has been noted that in Australia social exclusion is “experienced by newly arrived migrants as well as refugees and some by some long-term residents including the Aboriginal population” (Taylor, 2004, p. 16). Immigrants experience social exclusion via inferior command of English, limited network of social support, and regular exposure to manifestations of racism and discrimination. Refugees, on the other hand, face aspects of social exclusion that “are not generally experienced by the rest of the community,” including the removal from Australian society with the alleged purpose of “border protection” as well as deprivation of basic human rights (Taylor, 2004, p. 5). Similarly, indigenous people are considered one of the most socially excluded peoples in Australia (B. Hunter, 2000). The exclusion experienced by Aboriginal Australians is “complex and multi-generational and cannot be reduced into a simple static notion of Indigenous poverty” (B. Hunter, 2008, p. 4). Although social exclusion commonly affects indigenous people, immigrants and asylum seekers in Australia, each of these vulnerable groups faces a distinct range of setbacks.

Conclusion

Australia is both an old and young civilization: home to an Aboriginal population that stretches back as one of the longest continuing lines of human culture, alongside an inflow of migrants over the past several decades from countries around the world. In many ways this diversification of cultures and peoples in Australia has been an extraordinary societal success. Nonetheless the legacy of the destruction of Aboriginal culture and belated attempts to understand and redress complex social issues represent a moral and political issue that pervades all dimensions of Australian life. Aboriginal mental health research, sluggish to begin with, has increased substantially in recent decades and will, no doubt, continue to diversify. Aboriginal mental health is now very much on the agenda of psychiatric training and is part of a broader public awareness of Aboriginal rights and historic abuses. The continued urbanization of Aboriginal populations, the destructiveness of substance abuse, and efforts by Aboriginal people to reclaim some of their traditional belief systems will make stringent demands upon a mental health system that has struggled to keep pace.

The remarkable influx of immigrant groups into Australia over the second half of the 20th century was initially shaped by the White Australia Policy. However, since the 1970s, with a change in political will, the development of Australia as a multicultural country has influenced recent mental health approaches. Whilst older immigrant groups, largely from a European background, have integrated into the broader community with little acculturative stress, the newer mental health challenges come from immigrant groups that are more culturally diverse. These latter groups of people—from the Middle East, Asia, and Africa—often have a history of trauma.

The way forward for psychiatric research in this area will be most interesting as the political context continues to heavily shape the quality of the debate, particularly about those seeking refuge in Australia. Research on these new migrants to Australia, including the most vulnerable ones affected by multiple traumatic experiences, such as asylum seekers and their families, will require significant clinical, scientific, and educational leadership, in order to instigate prompt advocacy action and policy advancements in this arena. In addition, the impact of poverty and discrimination, as well as other forms of economic and social disadvantages, on the mental and physical health of Aborigines and immigrants will need to be incorporated as priority topics in the contemporary research agenda in Australia.

In a political landscape driven by divisiveness and short-term political advantage, mental health clinicians and researchers have a moral responsibility to conduct research and rekindle discussion about the psychological adversities experienced by underprivileged people left aside by the economic growth in Australia.