Submission from the Forum of Australian Services for Survivors of Torture and Trauma to the National Mental Health Review 2014

  1. Background

 

FASSTT is a network of eight not-for-profit agencies – one in each State and mainland Territory – that respond to the needs of survivors of torture and trauma who have come to Australia from overseas (the majority through the Federal Government’s Refugee and Humanitarian Programme). During the last decade, Australia has settled over 127,000 people through its Refugee and Humanitarian Program.

 

Member agencies seek to address the impact of torture on the individual, the family and the community through counselling and advocacy, health assessment and referral, information provision, training of other service providers, research and service innovation. The names and contact details of FASSTT member agencies are contained in Appendix 1.

 

FASSTT agencies receive funding through the Department of Health (DoH) Program of Assistance to Survivors of Torture and Trauma (PASTT) to provide services to survivors from the time of first arrival in Australia through to the long-term period of their settlement. Most FASSTT member agencies receive additional funding through other Commonwealth and State programs and also through various philanthropies and fundraising.

 

In the twelve month period 2012 – 2013, FASSTT member agencies provided psychological support (under the PASTT program) to nearly 7500 people who had arrived in Australia under the Refugee and Humanitarian Program. Services to a further 4000 people from refugee backgrounds was provided by FASSTT member agencies with complementary sources of funding. Thus, in 2012 – 2013 FASSTT services assisted more than 11,000 individuals who came to Australia from more than 72 countries. More than 70% of people using FASSTT services require the support of an interpreter.

 

PASTT funding is also used to build the capacity of other service providers to respond to the needs of survivors of torture.

 

  1. The unique context of FASSTT

 

Torture[1] has a specific definition and methods of torture are well documented[2].   It is estimated that world-wide up to 35% of refugees have been physically tortured or psychologically violated[3].   Many refugees have experienced other traumatic events in countries of origin, during flight and in transit countries. Research suggests survivors of torture are a particularly vulnerable group for health disorders of different kinds[4]. FASSTT member agencies provide a specialist service response to refugee survivors of torture and trauma. The rationale for a specialist service is not only the prevalence of mental health concerns associated with the legacy of the refugee experience but also their enduring vulnerability in the course of settlement at an individual family and community level.

 

The majority of FASSTT clients have physical and mental health problems related directly to torture experiences or trauma associated with their refugee experience. For example, the most recent report to the Department of Health from FASSTT indicated that 70% of clients assessed by FASSTT services (with PASTT funding) exhibited psychological sequaleae of trauma to a significant degree. International clinical studies support the finding that refugees have high prevalence rates of mental health problems, significantly greater than the rates among the general population.[5][6]. In other words, FASSTT member agencies provide bio-psychosocial support to refugees and asylum seekers who are profoundly traumatised and whose recovery must develop essentially in a place of exile where systems, language, culture and identity all need to be renegotiated.

 

  1. Client profiles

 

Refugee and humanitarian entrants, particularly survivors of torture and trauma, have particular needs and are accordingly appropriately treated as a special needs group within the mental health service context. These needs arise from the fact that their circumstances are commonly characterised by the following:

  • extreme adverse life circumstances such as experience of war, persecution, torture, displacement and prolonged periods in refugee camps or countries of asylum prior to arrival
  • limited or disrupted schooling
  • family dislocation
  • limited health care before arrival in Australia
  • stressful nature of settlement demands
  • limited employment opportunities for new arrivals
  • limited social support and networks because of the small size of refugee communities and fragmentation within those communities
  • cultural and language barriers to accessing mainstream health services for asylum seekers and people on temporary and bridging visas, uncertainty about their future status and ability to remain in Australia

 

The well-being of children and young people can be particularly affected because disruptions to schooling and family integrity are major risk factors for poor health.

 

The profile of the refugee and humanitarian population is constantly changing and will continue to change because the make- up of this group reflects conflict situations around the world and decisions by government about regions from which refugees will be selected for resettlement. The top refugee producing countries in 2011 were Afghanistan, Iraq, Somalia, Sudan the Democratic Republic of Congo and Myanmar. It is essential therefore to maintain specialist torture and trauma services so that we can continue to develop new service approaches based on an understanding of the broad impacts of torture and trauma.

 

  1. What makes FASSTT unique

 

FASSTT member agencies have been delivering services for between 18 and 26 years. Throughout this period FASSTT members have remained focussed in their agreed mission – that is – to provide psycho-social support to refugee survivors of torture and trauma. The scope of support has broadened during this time to include – counselling and clinical support, advocacy, community development, training and support to mainstream mental and primary health services, research and service innovation. The emphasis is on early intervention (i.e. soon after arrival) but support is also offered across the lifespan.

 

FASSTT member agencies share a strong commitment to working in collaborative partnerships and to developing clear protocols and “mission” for these partnerships. Partnerships are formed in order to provide wrap around support services for vulnerable people. Thus partnerships have been developed with children, family and youth, housing, education, health, settlement and community services.

 

There is also a clear commitment to working in partnership with government. For example, the Victorian Refugee Health and Well Being Plan was developed by the Victorian Foundation for Survivors of Torture in partnership with the Victorian State Government and has led to a significant policy commitment including creation of 18 Refugee Health nurse positions working across the state.

 

The PASTT funding models allows for flexibility in how each FASSTT agency can use its allocation to meet its particular State/Territory circumstances. For example, it not only provides high need clients with access to counselling and case advocacy, it can also be used to support resource development and infrastructure costs. PASTT also supports a national infrastructure, through FASSTT, that provides a forum for sharing resources and expertise to maintain and increase service standards and minimise duplication.

 

During this past 26 years, FASSTT has developed a unique international reputation for cooperation, collaboration, clinical expertise, quality assurance, resource sharing and skill development. It is represented on a number of UN and international bodies addressing the issues for refugee related torture and trauma.

 

  1. Innovative responses to meeting the needs of the population

 

FASSTT member agencies have built an innovative model of service delivery that is based on a profound appreciation of the social and clinical impacts of trauma; how this applies to the refugee experience; a capacity to work cross culturally; and a focus on building capacity (at an individual community and systems level) to maximize an individual’s full participation in their new society.

 

Several FASSTT member agencies have developed specialised clinical tools, in particular the Multicasi multilingual assessment platform developed at STARTTS with international partners, the Goal Tree outcomes measurement tool developed by VFST and the client feedback protocol developed by QPASTT.

 

The FASSTT model of service recognizes the fundamental importance of the social determinants of health and the importance of linkages to other supports. Links to innovative employment support options, community development, family relationship support, and work with health and education systems are key to the recovery model within which we work.  FASSTT member agencies have implemented a number of programs that address linkages to a broad range of partner services. Descriptions of of three such projects which have been independently evaluated are in Appendix 2. They are :

 

  1. Ucan2 – Ucan2 is a sophisticated early intervention for young people of refugee background. Ucan2 creates learning and employment pathways that help connect young refugees into the Australian community. It has been evaluated by the McCaughey Centre of the University of Melbourne.
  2. Nexus – The NEXUS program aims to reduce risk factors for suicide and self-harm and to promote protective factors in young people from a refugee background living in Brisbane. It has been evaluated by Latrobe University.
  3. CCDP – The Creative Communities Partnership Initiative aims to Increase bonding and bridging social capital and wellbeing of small and emerging refugee communities through arts and non-arts partnerships. It has been evaluated by the University of New South Wales.

FASSTT agencies are engaged in the development of research projects and service innovations to address emerging needs. In this way, it has been possible to develop services that help to prevent people from needing to access the acute mental health system – e.g. development of culturally appropriate psycho-educational strategies, outreach clinics, parenting programs, work in rural and regional areas and work around older people who are refugee survivors of torture and trauma. Through the collaborative structure and FASSTT it is possible to share expertise across the network and build national quality.

 

  1. The broader role of FASSTT

 

An important achievement for FASSTT (through the PASTT funding platform) is its capacity to attract additional resources to fund projects and activities that add considerable value to its services and program objectives. Presently, the opportunity for this to occur is enhanced by the fact that current PASTT providers, the member agencies of the FASSTT network, are widely recognised as specialists in the field. A range of different programs within FASSTT agencies, some funded through philanthropic organisations and fundraising, add value to and support the delivery of PASTT services.

 

For example, the clients of FASSTT services are brought to the attention of public community mental health services. Historically, public mental health services for adults funded by state governments have focused on those with serious mental illness, with responsibility for the care of those with high prevalence and non-psychotic disorders such as depression and anxiety being seen to lie with GPs and psychiatrists and funded through Medicare.

 

Recently there has been increasing recognition that non-psychotic disorders are more common and account for a greater – and increasing – proportion of the burden of disease than was previously thought (CDH&AC 2000a).[7] There is also growing evidence that these disorders have their origins at least in part in negative social and environmental influences. Research by Whiteford et al also highlights the social cost of mental health distress.[8] The FASSTT model of support is based in a recovery model that aims to work with clients to build a contributing life and enables full participation in social and economic life. FASSTT services are actively engaged with public mental health services in all states, to facilitate referral assessment and treatment of those a serious mental illness and to work in partnership with the public system to build recovery options in the community and sub-acute phase.

 

In all States and Territories there is now a significant proportion of the population who have particular needs as a result of trauma impacts from their refugee or refugee-like experience. FASSTT has been able to work in partnership with government and non government services to build a broad system response to manage some of the issues facing this population. For example, through the development of creative and sustainable partnerships FASSTT has been able to

 

  • Provide training to mainstream mental health services so that acute mental health services can adequately identify and assess people from refugee backgrounds who are acutely unwell
  • Build capacity in schools such that significant levels of support can be leveraged through school channels such as school based nurses and school counsellors
  • Developed creative partnerships with employment services so build support for job seeking
  • Developed long term sustained partnerships – some funded and some not – to build new primary care health responses to recently arrived refugee and asylum seekers. This includes developing referral protocols, training of primary care workers, supporting consumer participation in service development and building capacity in refugee and asylum seeker communities to enable effective access.
  • Impact on health and education policy at State government level
  • Provide clinical and policy advice to Commonwealth portfolios of health and immigration on refugee and asylum mental health needs

 

  1. Conclusion

 

FASSTT members have enjoyed a long and productive partnership with the Department of Health and through this working relationship have been able to feed back to government some of the specific client needs and program concerns.

 

FASSTT believes that the following key principles should continue to underpin the delivery of mental health services to survivors of torture and trauma:

  • The Commonwealth should continue to place emphasis on recognising and responding to the particular health needs of refugee and humanitarian entrants who have experienced torture and trauma.
  • The Commonwealth should continue to acknowledge that torture and trauma related service delivery requires a professional, flexible and rigorous approach based on demonstrated expertise that is commensurate with the complexity of the nature of the work in this field.
  • Specialist torture and trauma services should continue to augment the capacity of mainstream service providers to respond to health needs of humanitarian arrivals, with emphasis by FASSTT services on complex case management, capacity building and sector development focused within the health, community and education sectors.
  • Specialist torture and trauma services should continue to develop and implement culturally appropriate support strategies (including community development) for newly arrived refugee and humanitarian entrants.
  • Specialist torture and trauma services should continue to develop the recovery model with flexible application in each state/territory context in service delivery models and strategies for integration with mainstream health providers.
  • Services in rural and regional areas require a higher level of resourcing than those in metropolitan centres. The recovery model is more difficult to realise in rural and regional areas and funding should reflect this greater complexity.

 

 

APPENDIX 1

FASSTT Member Agencies

 

ASeTTS: Association of Services to Torture and Trauma Survivors

Address: 286 Beaufort St,

Perth, WA 6000

Telephone: 08 9325 6272

 

Companion House

Address: 41 Templeton Street, Cook, ACT 2614

Telephone: 02 6251 4550

 

Melaleuca Refugee Centre: Torture and Trauma Survivors Service of

the Northern Territory

Address: 24 McLachlan Street, Darwin NT 0800

Telephone: 08 8985 3311

 

Phoenix Centre

Address: 1/116 Bathurst St, Hobart, TAS 7000

Telephone: 03 6234 9138

 

QPASTT: Queensland Program of Assistance to Survivors of Torture

and Trauma

Address: 28 Dibley, Street, Woolloongabba, QLD 4102

Telephone: 07 3391 6677

 

STARTTS: Service for the Treatment and Rehabilitation of Torture and Trauma Survivors

Address: 152 The Horsley Drive, Carramar, NSW 2163

Telephone: 02 9794 1900

 

STTARS: Survivors of Torture and Trauma Assistance and Rehabilitation Service

Address: 81 Angas Street, Adelaide, SA 5000

Telephone: 08 8346 5433

 

VFST: Victorian Foundation for Survivors of Torture

Address: 6 Gardiner St, Brunswick, VIC 3056

Telephone: 03 9388 0022

 

Correspondence to:

FASSTT: P.O. 6254, Fairfield, Brisbane. 4103

 

APPENDIX 2 – Examples of project evaluations.

 

 

 

Ucan2 – Recognizing the Potential in Young People From Refugee Backgrounds

 

The Ucan2 program is a program developed by Foundation House in Victoria. The program currently runs in both Victoria and Queensland and is an example of a program run in collaborative partnership. In Victoria, Ucan2 is delivered in partnership by Foundation House, the Adult Multicultural Education Services (AMES) and the Centre for Multicultural Youth. In Queensland, Ucan2 is run in partnership with TAFE Queensland.

 

Developed progressively since 2006, Ucan2 is a sophisticated early intervention for young people of refugee background. Ucan2 creates learning and employment pathways that help connect young refugees into the Australian community. Through a combination of education, work experience and mentors from major Australian employers, Ucan2 makes learning for young refugees highly relevant, builds their social capital and increases their access to mainstream jobs. Ucan2 is a practical demonstration of how to integrate young refugees into the Australian community.

 

Ucan2 is as inclusive as the refugee population is diverse. The program targets young refugees aged 16 to 24 years from a diversity of backgrounds.

 

How Ucan2 Works:

  • Eligible refugees enrol in an English language program. Ucan2 is integrated into these programs.
  • Phase 1 of Ucan2 runs over 16 consecutive weeks (or two terms) for one day each week. Ucan2 has three core components:

1. Work skills curriculum

2. Psychosocial support to assist with recovery from trauma and resettlement

3. Development of social connections and networks through contact with trained peer volunteers and work experience placements.

  • Ucan2 participants can complete six shifts of part time work experience over three weeks.
  • Some participants gain ongoing casual part time work after work experience placements.
  • Work experience puts Ucan2 participants in touch with the common experience of their Australian counterparts.

Outcomes for participants

Ucan2 starts from a simple proposition: for any young person, successful transition to responsible adulthood and active citizenship relies on self-confidence, self-awareness and social capital.

 

Ucan2 is successful precisely because it is integrated with existing services and avails itself of opportunities readily available in the broader community.

 

A formal evaluation of Ucan2 was undertaken between 2008 and 2010 by The University of Melbourne’s McCaughey Centre. A second evaluation was undertaken in 2011. A copy of this evaluation is attached. The evaluation reveals numerous positive

  • outcomes for young people of refugee background who participate in Ucan2 including:
  • improved personal well-being
  • improved help-seeking strategies;
  • understanding community values and expectations;
  • enhanced self confidence
  • establishment and maintenance of social networks that reach beyond the refugee community
  • increased work readiness
  • substantive employment outcomes.

 

 

 

Community Cultural Development Project

In 2011 STARTTS received 2 years funding from the Australia Council for the Arts under their Creative Communities Partnership Initiative (CCDPI). This funding was supplemented by funding from the Westpac Foundation for the same period. It aimed to:

“Increase bonding and bridging social capital and wellbeing of small and emerging refugee communities through arts and non-arts partnerships”

An independent evaluation was undertaken by the Centre for Refugee Research of UNSW in 2013/14. The focus of the evaluation was on both the short and long outcomes of program activities. It utilised the Social Capital Evaluation Tool to assess these outcomes. The designing of this tool was a project commissioned by STARTTS, and designed in conjunction with the Centre for Refugee Research and various refugee communities and leaders. STARTTS had a long standing interest in the concept of Social Capital as available research indicates that high level of Social Capital is a strong protective factor for good mental health and wellbeing. Additionally, refugee trauma occurs in the context of organised violence which specifically aims to destroy relationships of trust and mutuality amongst the population. These relationships form the basis of Social Capital, and it is highly likely that an increase in Social Capital will address the impact of communal trauma directly. The evaluation also provided recommendations to inform future community cultural arts programs within STARTTS, as well as can be used as a guide for mainstream organisations or others who intend to undertake similar projects with refugee individuals and communities. The full evaluation report is available upon request.

Key Evaluation Findings

The evaluation reported that the CCDP engaged over 1,400 participants/performers and over 30,000 audience members across a range of arts activities including dance, visual art, music, song, theatre, film, creative writing/literature, Capoeira Angola, circus skills, workshops, excursions, competitions and youth camps. Men, women and children were engaged, aged 5 to 70, from a diverse range of ethnic and cultural backgrounds including Ethiopian, Sierra Leonean, Ghanaian, South Sudanese, Burundian, Liberian, Congolese, Eritrean, Ivoirian, Afghan (Hazara), Iraqi (Assyrian, Chaldean, Mandaean), Iranian, Sri Lankan (Tamil), Kurdish, Burmese (Karen), Vietnamese, Bhutanese, Tibetan, East Timorese, Native Fijian, Ukrainian, Coptic Egyptian, Chilean, Venezuelan, Cuban, Peruvian and Argentinean.

The evaluation indicated that STARTTS has made excellent progress toward achieving its long-term outcomes. The CCDP increased bonding and bridging social capital, through the strengthening of social capital enablers, leading to the enhanced wellbeing of participants. The evaluation identified that the CCDP has made a significant impact on participants, benefiting them socially and emotionally, whilst increasing their skills. The Evaluation provided evidence of increased social capital through a boost in self-confidence and abilities, the expansion of friendships and networks and the strengthening of connection to the wider Australian society. The Evaluation also found that the CCDP has provided opportunities for people to process and express their thoughts and feelings through different artistic mediums outside of a traditional therapeutic framework.

The evaluation put the success of the project to the following factors:

  • The ability and capacity of STARTTS to draw on staff from other roles in the organisation and utilise their connections and skills to engage and retain refugee individuals and groups in these projects, especially important is the access to counsellors to support and facilitate arts creation processes
  • STARTTS reputation within the wider community and the established links and networks with other communities and organisations upon which connections and resources can be drawn upon
  • The positive working relationships and rapport that STARTTS has built with refugee communities over long periods of time (which can lead to sustainability in projects that involve them)
  • The value that participants place on STARTTS, acknowledging and appreciating the dedication of staff in assisting them through arts process and caring for their general wellbeing.

The project effectively enabled participants to strengthen their bonding and bridging social capital through providing them with a safe and open space where people could take risks and learn new skills, form new friendships and social supports, and extend their broader networks, improving settlement outcomes including education and employment opportunities and feelings of connectedness.

The full text of this evaluation can be downloaded at

https://www.dropbox.com/sh/sjbj7a0f923kvum/AABuwwT7AE43-uDgttQ-SQc3a/STARTTS%20CCDP%20Evaluation%20FINAL.pdf

(Please advise if there are difficulties in downloading from this link and the full text will be posted to you.)

NEXUS – A Suicide Prevention Program for Young People from Refugee Backgrounds

The NEXUS program is a strategy developed by the Queensland Program of Assistance to Survivors of Torture and Trauma (QPASTT) that aims to reduce risk factors for suicide and self-harm and to promote protective factors in young people from a refugee background living in Brisbane. NEXUS is currently funded by the National Suicide Prevention Strategy but leverages off and compliments the Program of Assistance to Survivors of Torture and Trauma (PASTT). The project has been externally evaluated twice by Dr Ignacio Correa-Velez, with assistance from Purity Chelangat Goj, La Trobe Refugee Research Centre, La Trobe University. A copy of the evaluation is attached.

The following analysis has been taken from the latest Evaluation.

The objectives of the NEXUS program are to:

  • Increase the number and quality of connections of young people from refugee backgrounds to people, place and culture thereby promoting wellbeing and social connectedness;
  • Increase the proportion of young people from refugee backgrounds with internal locus of control thereby building resilience;
  • Decrease the impact of high academic and employment expectations on the suicide risk of young people from refugee backgrounds thereby building resilience;
  • Decrease suicide risk in those young people who have attempted suicide or are at high risk of attempting suicide; and
  • Improve community attitudes, understanding and awareness to better identify and help youth from refugee backgrounds at risk of suicide.

The evaluation showed high levels of satisfaction with the program. NEXUS has had a positive impact in increasing young people’s connection to other people, place and culture, and enhancing their sense of belonging. It improves youth’s sense of control over their lives through providing culturally appropriate access to advice and information, facilitating the acquisition of new skills, and increasing their networks. The program reduces the impact of high academic and employment expectations by helping young people do better at school and work, and providing them with information and skills that increase their chances to gain further education and employment. The homework club, the Ucan2 program, and the Creative Community Computing Workshops in particular were seen by young people as supportive strategies that helped them to improve their language and computer skills and cope better with the academic and employment challenges. Importantly, some of the employment-related activities offered by NEXUS have led a number of young people to find employment.

NEXUS participants reported that the program activities have made their lives better and enhanced their subjective wellbeing. This positive impact of the program in particular, may contribute to decrease the risk among those refugee youth at high risk of attempting suicide. Importantly, QPASTT has taken positive steps towards addressing the knowledge gap about suicidal behaviour and risk and protective factors for suicide and self-harm among youth from refugee backgrounds by embarking on two research projects. First, a digital story-telling activity with youth from the Karen and Liberian communities and second, a survey of suicide and self-harm among 120 youth from refugee background living in Brisbane. The findings of these two projects will contribute to a greater understanding of suicide and self-harm among refugee youth, and assist QPASTT and the NEXUS program in decreasing the risk of suicide and self-harm among this population group.

 

[1] Torture is the intentional infliction of severe mental or physical pain or suffering by or with the consent of the state authorities for a specific purpose. It is often used to punish, to obtain information or a confession, to take revenge on a person or persons or create terror and fear within a population. Some of the most common methods of physical torture include beating, electric shocks, stretching, submersion, suffocation, burns, rape and sexual assault. Psychological forms of torture and ill-treatment, which very often have the most long-lasting consequences for victims, commonly include: isolation, threats, humiliation, mock executions, mock amputations, and witnessing the torture of

[2] IRCT http://www.irct.org/what-is-torture/defining-torture.aspx

[3] R Baker, ‘Psychosocial consequences of tortured refugees seeking asylum and refugee status in Europe’, in M Basaglu (ed), Torture and its consequences: current treatment approaches, Cambridge University Press, Glasgow, 1992, p85.

[4] UNHCR, Refugee resettlement: an international handbook to guide reception and integration, UNHCR and VFST, Melbourne, 2002, p233.

[5] K Allden, Paper presented to the International Conference for the Reception and Integration of Resettled Refugees, Sweden, 2001.

[6] C Gorst-Unsworth and E Goldenberg, ‘Psychological sequelae of torture and organised violence suffered by refugees from Iraq: trauma related factors compared with social factors in exile’, British Journal of Psychiatry, vol. 172, 1998, pp90-94; MA Simpson, ‘Traumatic stress and the bruising of the soul’ in J P Wilson and B Raphael (eds), International Handbook of Traumatic Stress Syndromes, Plenum Press, New York, 1993, pp667-684.

[7] Commonwealth Department of Health and Aged Care (2000a) National Action Plan for Promotion, Prevention and Early Intervention for Mental Health. Canberra, Mental Health and Special Programs Branch.

[8] H A Whiteford et al ‘Global burden of disease attributable to mental and substance use disorders: findings from the Global Burden of Disease Study’ in The Lancet Volume 382, Issue 9904, 9–15 November 2013, pp 1575–1586

 

 

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