Emergency-room logic and asylum seekers

We are all alarmed that asylum seekers are destroying documents, sabotaging their boats and threatening to kill themselves if their demands are not met. Even when in detention awaiting processing, we hear that some go on hunger strikes and sew their lips together to protest the slow pace of processing and other grievances. The symbolism is certainly powerful, if not bizarre, considering  that those same people must have escaped famine and regimes where the freedom to open your mouth and speak freely is severely restricted.

Most of us cannot imagine how terrible one must feel in order to do such things, but at the same time it makes us angry because we know that it is blackmail by another name. It violates an unspoken contract that we have with each other, a contract that goes something like: You are allowed to depend on me for a while, but only if you are badly in need, are grateful, don’t deliberately make yourself worse and try to get better.

People who claim that their level of desperation is so unutterably extreme that any behavior up to and including killing themselves and others is justified are not only to be found amongst asylum seekers fleeing foreign perils. They are also everyday occurrences in our hospitals’ emergency departments.

It seems to be well known that societies like our own, tjhose whose identity is inextricably tethered to the recognition that a sense of compassion for others as the highest individual and collective virtue, will become paralysed in the face of suicide threats. Asylum seekers — whether they be refugees from war, economic migrants, or citizens of our own country requesting sanctuary at an emergency department — correctly understand there is nothing that cannot be excused, no behaviour too terrible, that it will deprive them of the right to have their demands met if they threaten to kill themselves.

Most people would not be aware that on any night of the week in any given hospital in any city in Australia, desperate people throw themselves on the mercy of public hospitals. The triage note to the staff charged with assessing these claims will often record the simple notation that they are “suicidal”. Often, these people say they will kill themselves if not admitted. A threaten to kill others is  the province of law enforcement. Threatening to kill yourself becomes the responsibility of the healthcare industry.

In the mind of desperate patients (for patients he or she now is), the collective altruism of the State guarantees, amongst other things, some tension-reducing medication, a meal, a bed and asylum from the pressures of having to look after themselves.

To lay people “suicide” is indistinguishable from “depression”, which we have all been led to believe is in itself inseparable from being “sick”. After all, no one can help being sick or desperate, can they? The end result is that the real problem, no matter how complex, is dumbed-down to an insistence that the person is sick and has no more control over his or her problem than, say, a person with HIV has over an intercurrent infection.

In a similar way, arriving on a leaky boat because you will be tortured and killed in your country of origin is indistinguishable from saying ‘whatever it takes to get a better life.’ All responsibility is transferred from the supplicant to the institution or the State. After all, the resources of the State are so great that it would be immoral not to offer succor by admitting the patient to the hospital — or the asylum seeker to the Australian mainland. It is no business of the patient that the hospital is always full, that there are budgets, that there are competing needs, or that resources and patience are each finite commodities. Nor is it the business or concern of the asylum seeker that there are quotas and acceptable channels for admission and subsequent residency.

In the case of emergency department patients, they are correct not to be seduced or fobbed off by offers of appointments in a few days’ time (and the waiting lists for more appointments, plus therapy of dubious effectiveness). They want their needs met tonight. Some of these patients, will, if denied admission, proceed to injure themselves, submit themselves to all manner of depredations or degradation, and escalate their outrageous, self-directed behavior in order to force the clinician to prioritise them over someone else in order to attain the goal of immediate institutional care. That this care is often of the sort that would horrify most people makes no difference. Incorrectly, they associate institutional care with genuine interpersonal care of the sort that most of us understand and take for granted.

Only several years ago these people could come into hospital and stay for months, even years, by continuing to insist they would kill themselves if discharged. Most felt better after a while and, bored with hospital, would agree to move on if offered a post-discharge life-line to a counselor or doctor.

Somewhere along the line things got tougher, no thanks to the pusillanimity of senior clinicians, policy makers and managers, but due to the desperation of front-line staff, who realized this ritualised business of threat-and-reward  was pointless. These patients didn’t get better; they just grew more demanding.

Risks had to be taken. Finally, the courage was found to say, “Yes, we care, but not as much as you want, and not in the way that you want.” It was then that changes were implemented. They were offered slightly more sophisticated outpatient-based programs, with access to hospital-based care was kept very brief, if offered at all.

The current situation whereby front-line mental health services are overrun with problems related to psychosocial chaos is, of course, not really any better. How could it be? These patients have what we call Borderline Personality Disorder, often coupled with alcohol and other substance abuse. A better way of saying it is that they suffer the adult-life consequences of complex psychological traumas that are usually rooted in childhood. These horrendous psychological problems are the results of years of abuse, assault, neglect and privation. Hospitals can’t re-write the past or fix its scars. They can certainly make things much worse — something it took clinicians a long time to understand. Agents of the State (public hospital staff) pretending to provide care on behalf of the State for problems they could not fix was never going to represent a solution.

The point is that, while reducing the frequency and duration of hospital admissions for some chronically suicidal patients did not help them, it did not make things worse. There was no great spike in suicides.

There is a parallel here with international asylum seekers, and it is our moral vanity that prevents us from seeing it. The self-deception and self-congratulatory attitude to our faux compassion is the problem.

One prominent and compassionate commentator challenged the Prime Minister to state that, with the rate of asylum seeker arrivals then much lower, it would take 20 years to fill the MCG. We could all live with that, couldn’t we? But what if it takes only 20 weeks, or just 20 days, to fill the MCG? At some point the cheer squad starts to thin out. The cruelest amongst us thought every 20 years was still a bit rich; the kindest, presumably, are still rolling out the Rudd carpet as what began as a trickle of boat people became first a stream and now a deluge which, on 2013’s figures, would fill the MCG in less than three years. Would another 1% tax levy be enough to care for the arrivals? Or what about a 5% levy if arrivals see a further increase? At some point real priorities must be faced, along with budgetary and logistical limitations and, eventually, the pressing need to say “No!”

Saying “no” is very difficult — just ask any parent. It is never popular. But it is the only thing that breaks the moral paralysis and can turn back the boats. The vanity in the argument for endlessly saying “yes” is even starting to wear thin with the self-proclaimed compassionate side of politics. Foreign Minister Bob Carr, for example, is only just discovering that desperate people sometimes tell lies while others lie about being desperate. This is unpalatable stuff, but why should it surprise? We shouldn’t be unkind, we all have our limits.

Turning back the boats won’t fix anything beyond our immediate but laudable goal of deciding “who comes to this country and the circumstances in which they come,” as John Howard memorably put it.  But neither will allowing them all in. This policy has already made things worse.

In the end, our asylum seeker policy, such as it stands, will do nothing to mitigate poverty, starvation or persecution, just as hospital policies of admitting desperate and suicidal people did nothing for cruelty and neglect in our own society.

Dr Murray Walters is a Brisbane pyschiatrist