Suicide Prevention in Aboriginal Australian populations

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Suicide Prevention in Aboriginal Australian
populations

• Reviewing current practice to determine
• best practice in suicide prevention
• By
• Tracy Westerman, Managing Director
• Indigenous Psychological Services

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And in the words of Midnight Oil - Music Legends

• The time has come to say fairs fair
• To pay the rent now, to pay our share
• The time has come
• A facts a fact
• It belongs to them
• Lets give it back
• How can we dance when our earth is turning
• How do we sleep while our beds are burning

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Suicide Prevention in Australia - how do we
define best practice

• Project Need
• Rates of suicide in Australia - Aboriginal versus
  non-Aboriginal rates
• 2.3 the rate of non-indigenous Australians
• Accounted for by
• 1. Problems with diagnosis and assessment
• Can the higher rates of suicide be accounted for
  by the existence of mainstream factors at a
  higher rate, or the existence of unique risk
  factors that create a heightened risk.
• What is the role of culture in suicide risk
• Cultural triggers and maintaining factors
• Phenomenology differences
• 2. Problems with intervention
• lack of access by Aboriginal people
• cultural appropriateness of existing intervention
  and training programs
• 3. Prognosis
• Comorbidity

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Addressing problems in suicide prevention

• PHASE ONE Developing culturally valid methods
  of assessment to understand the nature of
  Aboriginal suicides
• Methods of assessment currently used
• unreliable
• different methods used within and across studies
• Problems with equity in service delivery.
• Culturally biased assessment considered as a
  barrier to determining effective outcomes and
  interventions
• Has the assessment identified all possible
  factors associated with the development and
  maintenance of disorder?
• Are assessments a valid indication of the clients
  true functioning (cultural impairment)?
• Does the assessment provide information of
  cultural relevance that impacts upon
  interventions with indigenous clients?

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The development of the Westerman Aboriginal
Symptom Checklist for Youth (WASC-Y) as a
consumer rated measure

• Developed to account for differences in the
  conceptualisation of mental ill health amongst
  Indigenous communities
• Measure already culturally-validated for use in
  Indigenous populations
• 5 clear factors (accounting for between 34-88 of
  variance)
• High levels of validity and reliability,
  demonstrated through Factor Analytic studies and
  calculations of internal reliability (Cronbachs
  alpha levels of .85 - .90)
• Kappa statistic of .84

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Results - What places these Aboriginal kids at
risk?

• Impulsivity
• The role of depression
• lack of appropriate methods of coping and
  reinforcement of this
• The Cluster evidence - grief - the local
  experience
• respect suicides
• Method
• 68 by hanging (compared to 42) 88 for
  females
• location
• anecdotal evidence of intent
• Rescue?

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Purpose Of Cultural Validation

• To ascertain if behaviour is culture-bound or
  clearly related to mental ill health
• Range of culture-bound syndromes (Westerman,
  2000 Vicary, 2001)
• Psychosis
• Being sung by an aggrieved party
• Sorry time -
• pathological grief and hysteria
• self harm
• Longing for and being sick for country
• Rituals - obsessional and compulsive behaviours
• Payback - external attribution belief system

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Stage Two Development of a culturally
appropriate suicide prevention program

• Stage Two Development of a culturally
  appropriate suicide intervention package
• Access to existing suicide prevention training
  packages
• no indigenous specific content
• lack of research information regarding the
  particular phenomenology of indigenous suicide
• suicide training packages do not incorporate
  specific risk factors but also culturally
  appropriate methods of resolving mental health
  issues.
• IPS training and popularity of this - training of
  1,230 service providers over two years.
  Evaluations indicated significant benefits with
  knowledge shifts, skills increase, intentions to
  help behaviours.
• Content addresses indigenous specific suicide
  risk and protective factors as well as culturally
  appropriate interventions with suicidal
  Aboriginal people.

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Program Philosophy

• Community Development approach - training of
  youth, community and service providers (Neill,
  2002)
• Increasing the cultural competence of
  practitioners
• Uniqueness of such an approach to intervention
• The role of IPS
• Focus on high risk areas in the Kimberley,
  Goldfields and Northwest
• Community members to define content of training

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Suicide Forums

• Forum Philosophy
• To discuss the issue of Aboriginal Youth Suicide
  in an open, candid and non-threatening manner. It
  was envisaged that information gained through
  Forum delegates participation would provide a
  greater understanding of both the issue's and
  potential gaps in service. It was also
  anticipated that Forum delegates might also make
  recommendations for potential interventions for
  the target cohort.
• For youth and community the training aimed to
  validate the vital role they were both currently
  playing in suicide prevention
• For youth the focus was also on the provision of
  clinical intervention.

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Stage Three Delivery of Introductory Suicide
Training

• Program
• 2 days with Service Providers
• Evenings - Counselling / debriefing provided
• Weekend - counselling / debriefing to families
  and individuals
• 2 days training with Community Members
• 2 days training with a psychoeducational focus
  with Youth (aged 12 - 25)
• 2 days of counselling provided to families

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Training Content

• Adaptation was made to the content to address the
  wider issues of skills facilitation and
  development with community and youth
• suicide myths within Aboriginal communities
• the nature of Aboriginal suicide - how does this
  look in Aboriginal people?
• What am I looking for? Conducting culturally
  relevant risk assessments with suicidal youth
• Developing concrete community strategies to
  address issues of immediate risk when help is not
  available
• understanding our rights within the community -
  the Mental Health Act and its relevance to
  Aboriginal people
• Interventions to prevent contagion in my
  community - what can I do?
• Self-care and understanding my limitations
• A debriefing process occurred at the commencement
  and completion of each group
• Facilitators were also available for one one
  counselling following the group

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A community development approach

• Major Aims of the Forum
• To identify services already providing programs
  to the Aboriginal community.
• To understand the nature of the services provided
  (e.g., perceived strengths and limitations due to
  funding, distance, lack of staff etc).
• To identify the gaps in suicide prevention
  services offered in the West Kimberley.
• To identify collaborative strategies that might
  be employed to offer a more holistic services to
  suicidal Aboriginal people.
• To identify new strategies for suicide
  prevention.
• To provide current and relevant research and
  practice information to aid Forum processes.

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Service Providers Forum

• A Brief Overview
• Two introductory Suicide Prevention Forums have
  been held since July, 2002 at two primary
  locations Derby in the West Kimberley and
  Roebourne in the North West.
• Forums have been well attended with
• 54 delegates from the two locations over two
  days.
• All participants either worked with suicidal
  clients, had personal experience of a family or
  friend who had engaged in suicidal behaviours or
  expressed a desire to assist in preventing the
  high levels of Aboriginal youth suicide.

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Needs Analysis

• Gaps In Services (the service shortfalls
  identified and listed here do not necessary
  represent all of the delegates opinions are
  indicative of opinions expressed by the group).
• Pre-Case Management (Nil).
• Multiple agencies unable to provide a service
  (e.g., hand-balling clients).
• Remote Communities have a paucity of services.
• Lack of money to provide services to clients in
  towns and remote communities.
• Lack of support to suicidal clients, families and
  workers at the coal face.
• Train the Trainer (Culturally appropriate Suicide
  Prevention Course). Local people need to be
  trained, especially those permanent residents.
  The community and staff from Agencies need
  ongoing support debriefing

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Needs Analysis

• GAPS IN SERVICE (CONT)
• Lack of 24 hour service
• Downgrading of Derby Health Service
• For suicidal youth/families no one stop shop re
  primary through to tertiary services
• Poor accessibility to services
• The stigma of accessing mental health services
• Limited of collaboration between service
  providers
• Lack of funds being targeted properly for this
  specialist area. Need a specialist service.
• Clients concerned about their confidentiality
• Suicide awareness should be commenced in school
• There is no 24 hour crisis response for suicidal
  clients.
• The families and the victims left after a suicide
  completion require a support service. This
  service would address building resilience in the
  other siblings and extended family.

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Community Forums

• A Brief Overview
• The Community Forums have been held in two
  primary locations - Derby and Roebourne.
• The Forum have been well attended with 77
  participants from the two locations over the two
  days of training.
• Participants were from a range of family groups
  within the region who were concerned about the
  escalating rates of youth suicide in the region.

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Youth Forum

• A Brief Overview
• The Forums were well attended with 71 youth
  attending the two days from the two locations.
• All youth had experiences of suicide making the
  program a clinical intervention program.

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Youth Forum

• THE FORUM INTERVENTION
• The Youth forum was developed specifically for
  Aboriginal Youth
• All youth were prettested using the WASC-Y
• Based upon existing research and clinically
  validated therapeutic interventions developed by
  IPS.
• Culturally appropriate psychotherapeutic
  techniques including adaptation of CBTs for use
  with Aboriginal youth developed by IPS
• The content of this training was presented in the
  most efficient and appropriate cultural
  methodologies, including
• Group work
• role plays based upon real life scenarios and
  difficult situations
• development of a range of concrete strategies
  based upon identifiable risk factors for
  Aboriginal people (eg. Impulsivity and contagion
  suicides)

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Youth Forum

• THE FINAL PROGRAM
• The Youth forum included
• Suicide myths that youth and others have about
  those who have suicided
• depression and what it looks like - how do I tell
  when someone is depressed?
• Impulsivity - how to pick who is most likely to
  harm themselves
• Developing a plan for reducing the risk in
  friends and community
• How to prevent contagion suicides in my community
• recognising my limitations - where can I go for
  help
• Managing my emotions - recognising what
  impulsivity looks like and developing strategies
  to reduce the negative impact of my impulsivity
• anger management - why do I get angry, and what
  can I do about it?
• Development of disputational strategies for
  negative thought processes
• Conflict - its role in suicidal behaviours - how
  can I handle conflict in my community
• Payback and its implications
• cultural conflicts - why do I get involved - my
  behaviour and what I do to contribute to
  escalating conflicts
• Assertive and effective communication strategies
• Techniques for diffusing conflict
• Development of a range of recommendations to
  address youth suicide

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Brief Analysis

• there was poor integration and communication
  exchange between services working with suicidal
  youth. This has the potential for clients to
  fall through the gaps.
• Some services were not aware of the work of other
  agencies.
• Poor understanding of the role delineation
  between agencies.
• There is no one group (Committee) dealing with
  and co-ordinating interventions for Youth Suicide
  in the West Kimberley. This committee would
  facilitate information exchange and co-ordinate
  joint training etc.
• No Suicide Prevention Officer for the West
  Kimberley.
• Lack of/or poor community consultation to
  identify appropriate interventions.
• Lack of specific and realistic funding for
  specialised suicide prevention interventions.
• Lack of funding (including access to resources in
  program development) in agencies to deliver
  specialised services in an ongoing, aggressive
  and intensive manner.
• Culturally appropriate suicide prevention
  workshops would increase the understanding of the
  suicide dynamic and possibly assist in suicide
  prevention in the townsite and communities.

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Outcomes of Introductory Forums

• OUTCOMES
• Employment of a Suicide Prevention Coordinator -
  100,000 pledged.
• Establishment of local Aboriginal Youth Suicide
  Prevention Committee - 10,000 provided by the
  Health Department for running costs.
• Role of local Committees
• to provide advocacy to suicidal individuals or
  those who have experienced death through suicide
  of loved ones
• to plan ongoing suicide workshops
• to ensure community participation in workshops
  particularly in defining content of training and
  timing of training.
• Indigenous Psychological Services training
  extended to other regions and made available to
  more community people, and that the relevant
  services/departments undertake this training as
  part of their core business
• Research Grant to pilot and validate a clinical
  intervention suicide program for Aboriginal youth

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Results

• The Introductory forums have been well-attended
  with over 212 community, service providers and
  youth attending the two forums.
• Qualitative Evaluation
• High reports of satisfaction with the training
  including comments such as
• I have been to other workshops on suicide, but
  doing this one I felt free to be involved.
• Being here over these few days, I feel I can
  finally stop blaming myself
• Actually able to talk and felt comfortable
  asking questions
• This course is easy to understand, not too high
  English like other courses. I found them too
  hard to understand. This course should be
  available to all Aboriginal people

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Results

• IPS field approximately two calls per week
  regarding suicidal behaviours from community
  members and service providers.
• Since July there has been one suicide death in
  the Kimberley region. No further attempts or
  completions have been reported.
• Reports from community regarding the ability to
  mobilise local resources to address suicide risk
  in individuals

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Results

• QUANTITATIVE ANALYSIS - OUTCOME EVALUATION
• A. Service Providers
• Prettest and Posttest analysis
• Questionnaire developed specifically for Youth
  Suicide Forums, focusing on
• Aboriginal specific suicide myths
• Beliefs about suicide (that it is preventable)
• Barriers to help seeking behaviours
• Intentions to help seeking behaviours
• Skill acquisition
• Suicide Myths
• From True answers to False Answers - mean group
  shifts of 2.8 to 7/8
• Suicide Beliefs, Barriers, Intentions to Help and
  Knowledge
• Shift from Not at all (Mean 1.3) that suicide
  is preventable to 6.8/9 Most of the time that
  suicide is preventable.
• Shift from Lots of Barriers (Mean 2.3) to
  Moderate Number of Barriers (Mean 5.2)
• Shift from Intentions to help (Mean 1.2) No
  confidence that they could help a suicidal
  person to Moderate Confidence (Mean 5.4) that
  they could help.
• Knowledge shifts from Little knowledge (Mean
  2.2) to Good Knowledge (Mean 6.4/9).

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Results

• QUANTITATIVE ANALYSIS - Community
• Prettest and Posttest analysis
• Suicide Myths
• From True answers to False Answers - mean group
  shifts of 2.8 to 7/8
• Suicide Beliefs, Barriers, Intentions to Help and
  Knowledge
• Shift from Not at all (Mean 1.3) that suicide
  is preventable to 7.3/9 Most of the time that
  suicide is preventable.
• Shift from Lots of Barriers (Mean 2.3) to
  Moderate Number of Barriers (Mean 6.2)
• Shift from Intentions to help (Mean 2.2) No
  confidence that they could help a suicidal
  person to Fairly Confident (Mean 6.7) that
  they could help.
• Knowledge shifts from Little knowledge (Mean
  1.4) to Good Knowledge (Mean 7.5/9).
• Three Month follow-up and Advanced Skills
  Training
• Beliefs - shift of .34
• Retention of Knowledge (Mean shift of 0.84)
• Barriers to Help (Shift of 1.56)
• Skills increase of 1.12

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Community Forums

• FOLLOW-UP
• To provide Training to community members who were
  not able to attend the last training workshop.
• To provide greater levels of access to remote
  communities who requested that the training be
  delivered on a community wide basis (e.g., the
  whole community undertake the training)
• To provide advanced skill training to Community
  Members and incorporate debriefing stress
  management and managing crisis modules (including
  development of a local crisis management
  strategy)
• To evaluate participant skill retention in core
  competencies of suicide knowledge, skills
  application, intentions to help behaviours and
  barriers to help seeking behaviours and assisting
  suicidal Aboriginal people
• To undertake individual and family work when
  required.

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Indigenous Psychological Services

• www.indigenouspsychservices.com.au
• email tracyw_at_ips.iinet.net.au