The Nauru paradox: why help patients regain hope when it is dashed systematically?

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For the first time in my professional life I saw that rebuilding any sense of hope could potentially do more harm than good

Nauru public health centre, one of the locations where MSF provided mental health services to asylum seekers, refugees and Nauruan locals.
Nauru public health centre, one of the locations where MSF provided mental health services to asylum seekers, refugees and Nauruan locals. Photograph: AP

It’s almost been three weeks since Médecins Sans Frontières/Doctors Without Borders received the letter from the government of Nauru, informing us that we would have to cease our work in less than 24 hours.

We quickly realised that we were effectively being forced to abandon our patients, to instantly drop their mental health treatment, and to leave our highly vulnerable patients with no other independent provider on the island.

My position was mental health activities manager, responsible for the organisation, management, and strategic planning of the medical activities for the project. This was my fourth assignment with MSF. I had worked in two migration projects so I had a well-developed understanding of the effects of forced migration and the most common related mental health difficulties: anxiety, depression, post-traumatic stress, chronic pain, even psychotic symptoms.

High rates of torture and sexual violence, either from the countries of origin or the journey; and exposure to continuous, prolonged stress, insecurity, and loss of control.

I still believe I was well-prepared for the position. Despite that, nothing could have prepared me for sitting down with our patients and hearing their words:

Destroyed …”

There is no hope … all I think about is death, it is the only way to be free”

I wish I had drowned on the boat from Indonesia …”

Even if I leave this island, I no longer know who I am …”

Every asylum seeker and refugee patient, in virtually every session, reported such severe and ingrained symptoms of depression, anxiety, and hopelessness.

Virtually every patient expressed current intense suicidal thoughts, and many had recent self-harm or suicide attempts.

People described feeling that their sense of self, and any hope they have about living a meaningful future, had been irrevocably destroyed. I heard it in their words, and I saw it in their eyes.

I found myself at a loss: why try to help a person regain a sense of hope, only for them to spend their days sitting with nothing to do and almost nowhere to go.

The same place they were in last week, last month, last year … the past five years. We could help them manage their symptoms but for people whose hopes have been systematically and repeatedly dashed over five years, it seemed that rebuilding any sense of hope could potentially do more harm than good.

This is the first time I’ve encountered such a paradox in my professional life.

In his Pulitzer prize nominated book, The Noonday Demon, Andrew Solomon recorded the writing of a woman suffering from severe depression. She wrote in her journal about the state of her mental health: “Feeling hopeless and full of despair is just a slower way of being dead.”

The Australian policy of offshore detention has engendered deep hopelessness and despair in hundreds of people who have done nothing to deserve such treatment. Indeed, many repeated to me in private therapy sessions that they felt as if parts of them had already died, and they feared never being able to find themselves whole again. When faced with such thoughts day after day, it’s no wonder that the rates of self-harm, suicidal ideation, and suicide attempts are so alarmingly high.

So what are refugees and asylum seekers trapped on Nauru hoping for? Freedom. Autonomy. Safety and security. Opportunities to improve their lives and that of their children through work, education, and integration into a new culture. The same hopes that we all have for our own lives and the lives of people we love. The hopes that we take for granted as being essential human rights in our free, wealthy, and safe countries. For those born in countries where these tenets are neither guaranteed nor respected by the law or politics of the land, these basic rights become aspirational rather than fundamental. The asylum seekers and refugees who are now on Nauru embarked on a dangerous and frightening journey to Australia, seeking out even a chance at experiencing these rights that are so central to our concept of humanity. I’d like to think I would have the same perseverance, strength and courage to do the same.

Five years is too long, way too long. The devastating mental health conditions of the refugees on Nauru are worsening with time. They need hope in order to live. Hope can be restored, but only once the asylum seekers and refugees have been resettled in a place of safety. The onus is on the Australian government to restore the life of innocent people trapped on Nauru by immediately evacuating them to a place of safety where they can receive the care, resources, and opportunities they need to move beyond sliding towards death and instead progress towards life.


Dr Christine Rufener is an American clinical psychologist who has worked with MSF in Myanmar, Lesbos and Greece. She is asking Australians to add their voice to MSF’s call to immediately evacuate asylum seekers and refugees from Nauru