Intended for healthcare professionals


I witnessed the horrors of offshore detention and am appalled by the UK's Rwanda plans

BMJ 2022; 377 doi: (Published 17 June 2022) Cite this as: BMJ 2022;377:o1502
  1. Beth O’Connor, psychiatrist
  1. New Zealand

Australia's example provides a chilling lesson in how offshore detention harms people's mental health, writes Beth O’Connor

I spent almost a year working with the Médecins Sans Frontières (MSF) team on Nauru (a small Pacific island nation) when the government of Australia was indefinitely detaining asylum seekers and refugees on the island. Our team provided mental healthcare to asylum seekers, refugees, and local Nauruans. After witnessing first hand the impact of offshore detention on the asylum seekers and refugees I met on Nauru, I have grave concerns about the UK government’s planned policy to forcibly remove asylum seekers to Rwanda.

Over the 11 months I spent on Nauru, I witnessed high levels of depression, post-traumatic stress disorder (PTSD), anxiety, self-harm, suicidal thoughts, and suicide attempts among the 208 asylum seeker and refugee patients we treated. Among our asylum seeker and refugee patients, around 60% (124 patients) experienced suicidal thoughts and 30% (63 patients) attempted suicide during our time on Nauru from November 2017 until October 2018.1

During consultations with the men, women, and children seeking asylum and refuge, I began to gain an insight into the psychological damage inflicted on them by not knowing their future or feeling like they had any freedom or agency. One patient told me how they felt that if the Australian government could control their breathing, it’d be in charge of that too. We found that having a lack of control over their life was associated with patients experiencing PTSD, depression, anxiety, suicidal thoughts, and suicide attempts. I saw how people’s functioning steadily deteriorated, including their ability to care for themselves.

The severity and extent of mental illness among the people detained on the island was exemplified when a cluster of children developed a rare life threatening psychiatric condition known as resignation syndrome.1 Ten children presented to us with symptoms of depression and social withdrawal, before progressing to refusing food and fluids, becoming bed bound, mute, and unresponsive. When children reach this life threatening state, they require extended hospitalisation for supportive physical care, including nasogastric feeding, and psychiatric care. On Nauru this care was not available, and parents had to watch their child deteriorate while the slow process for seeking a transfer to Australia for care went through the court system. The parents’ mental health understandably often deteriorated in response to this distressing situation.

Asylum seekers and refugees have generally experienced multiple traumas, first in their home country and then often during their migration journey. The asylum seekers and refugees we treated in Nauru were no different, with 75% (155 patients) having experienced one or more traumatic events in their country of origin and/or during their migration journey.1 Unfortunately, the decision by Australia’s government to send these asylum seekers and refugees to offshore detention exposed them to further emotional distress and physical harm, with 23% of our patients (47 people) experiencing physical violence in Nauru.1

People need a safe environment to aid their recovery from past trauma, but this is impossible under such a system. Any detention setting—be it actual detention or “de-facto” detention where people are taken against their will and removed from their families and support networks with no certain future—is an environment that not only prevents people’s recovery from past traumas, but creates further anguish. We found that 37% of our patients (76 people) in Nauru were separated from a partner, child, or other close family member. Those who were separated expressed sadness, hopelessness, despair, and excessive guilt about their situation. I listened as fathers described how guilty they felt for not supporting their wife through the final trimester of her pregnancy and labour, and for not being there to witness their baby’s birth, first smile, first word, first step.

In Nauru, I saw how this detention system shattered people’s resilience, identity, and hope. It is unspeakably cruel to send asylum seekers who have struggled to reach a place of safety, such as Australia or the UK, to a third country. No pharmacological treatment or psychological therapy can help the people kept in these environments to fully recover. Although we sometimes supported people to develop coping mechanisms, ultimately, the environment in which they were trapped continued to cause their mental health to deteriorate.

Asylum seekers and refugees who have experienced trauma should be brought to a safe place, where they can begin the difficult process of recovery, regain hope for their future, and have a meaningful life with their family. I am horrified that this cruel chapter of history is repeating itself, with the UK having learnt nothing from Australia’s indefinite and inhumane forced detention of asylum seekers and refugees in a third country, except how to attempt to replicate it.


  • Competing interests: Beth O’Connor is on the Royal Australian and New Zealand College of Psychiatrists Asylum Seeker and Refugee Mental Health Network Committee.

  • Provenance and peer review: Not commissioned; not peer reviewed.