Suicide Prevention in Aboriginal Australian populations

1. Suicide Prevention in Aboriginal Australian populations Reviewing current practice to determine ‘best practice’ in suicide prevention By Tracy Westerman, Managing Director Indigenous Psychological Services

2. 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

3. 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

4. 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?

5. 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

6. 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?

7. 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

8. 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.

9. 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

10. 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 delegate’s 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.

11. 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

12. 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

13. 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.

14. 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.

15. 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

16. 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.

17. 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.

18. 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.

19. 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 CBT’s 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)

20. 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

21. 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.

22. 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

23. 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”

24. 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

25. 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).

26. 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

27. 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.

28. Indigenous Psychological Services www.indigenouspsychservices.com.au email: tracyw@ips.iinet.net.au