Understanding Deliberate Self-Harm in Pacific Populations of New Zealand

1. Deliberate Self-Harm as it occurs within the context of Pacific Populations living in New Zealand: Perspectives of key informants Synthia Mairikura Dash Dr. Teuila Percival Dr. Malakai Ofanoa

2. PRESENTATION OUTLINE • Study Context • Objectives • Methodology • Findings • Recommendations • Conclusion

3. DSH in New Zealand & among PI populations • A major Public Health concern in New Zealand (MoH, 2014) • 7267 intentional self-harm hospitalisations in NZ in 2013 – 54.2%(3939) Short-stayed ED events, (3328) ward admissions (MoH, 2016) • Precursor to suicide • DSH hospitalisation increased with deprivation (MoH, 2014)

4. Defining “Self Harm” • Problematic defining of DSH in literature • General understanding of DSH DSH is generally considered: a sub-type of self-destructive behaviors that are self-initiated, intentional and causes direct and immediate damage to body tissue with non-fatal outcomes. It does not include self-destructive behaviors that are considered habitual, indirect and cause physical harm over a longer duration of time such as eating disorder and substances, and those associated with mental retardations and episodes of psychosis (Latimer et al., 2013; Lundh et al., 2007).

5. DSH Paradigms DSH-irrespective of Suicidal Intent (Self-harm) DSH without suicidal intent (Non-suicidal self-injury) USA Excludes all acts with suicidal intentions (e.g. overdoses and methods of high lethality) Differs in intent, correlates, lethality, methods, cognition, response to therapy & prevalence • UK, Australia/NZ • Broad spectrum of non-fatal self-injury and self-poisoning behaviours • Includes suicide attempts/overdose. • Intention-difficult to determine

6. Research Aims & Objectives This study aimed to explore Pacific peoples (PI) in NZ’s understandings and experiences of DSH as it occurs within the PI context. Objectives: • To review national and international literature on definitions, perspectives and understanding of DSH. • To explore understandings’ and experiences of DSH of Pacific Peoples living in NZ based on key informant interviews. • To identify a PI-specific definition and concept of DSH based on PI perspectives, experiences and understandings.

7. Why a Pacific Island concept of DSH? • Cultural differences in defining suicidal & self-harm • Present gap in literature – no PI perspective of DSH • Holistic view of health • PI understandings of DSH will help clinician/researcher formulate issues and understand needs of patients

8. Why perspective of PI Mental Health Professionals? • Ethical considerations –PI mental health professionals most appropriate cohort to address research questions. • General perspective based on seeing many cases • A perspective based on cultural understandings, professional training and experiences in the field • A perspective based encounters with PI patients, families and communities

9. Methodology • Qualitative Methodological Framework – Talanoa • Recruitment: Key informants = Pacific mental health alcohol & drug services (Auckland) “snowballing sampling procedure” • Interviews 18 face-to-face semi- structured in-depth interviews + 1 focus group • Data Analysis Nvivo qualitative software

10. Demographics Table

11. Study Findings Five central themes emerged from the analysis • Informants general understanding of DSH based on professional experiences and cultural perspectives • Perceived prevalence of DSH among PI in NZ • Risk factors associated with DSH of PI clients’ • Current interventions, services and assistant for Pacific DSH clients • Suggestions for action and strategies to effectively tackle DSH among PI people in NZ

12. Key Informants Understanding of DSH Most of the participants defined DSH as the “intentional” or “deliberate’ attempt to inflict physical injury, harm, hurt or pain to the self. “Deliberate self-harm is when someone actually hurts themselves in whatever form they can think of. It’s deliberate, they just want to hurt themselves”… (P1)  “I guess it’s the process of someone hurting themselves for many different reasons in a way that’s intentional” (P2)

13. Methods of DSH and superficial injuries Superficial injuries “Self-harm is when I hurt or do damage to my own body by cutting it with a needle, stabbing it with a knife, or slice it with a razorblade, I damage my body deliberately” (P20) Hidden Injuries “I couldn’t tell my parents that I had hurt myself, so I’d cover up. It’s too embarrassing…You want to ask for help, but then you cut yourself and then you hide it” (P4)

14. DSH intentions and functions No intention to die rather an outlet “It’s just someone wanting to harm themselves without any intent, not really wanting to die but just…wanting to self-harm themselves but then not really wanting to die…they are two different, deliberate one is just doing it without thinking that I want to die. But the other one intent, I want to die no second thought about it, I want to die” (P16) To cope and relief distressful emotions “What I find is that self-harm can be understood in terms of relieving that stress…Some are very clear that cutting serves a purpose for them around just relieving that tension and they do it quite often to relieve that tension, but with no, most of the time, with no intentions to die” (P6)

15. DSH intentions and functions To seek attention and/or to influence others • “…some do it for attention, like no one is listening to them, no one is hearing them out. And they just got all this emotional pain, that cutting they don’t feel it, they are generally not wanting to end their life… But within the discussion, some have said that, ‘they want it to so that their parents can feel sorry for them” (P17) A cry for help “I think DSH is a cry for, it’s like that ‘please help me’ before some people are actually succeeding to harming myself” (P8)

16. DSH intentions and functions To feel alive “Sometimes they just do it…to let them know that ‘I’m still alive’… it’s a form of saying yeah that I’m alive…I’m not invisible I can still feel. Coz I think that some people come to a point where they are so numb, I’m just here…I can’t feel myself. Yeah, it’s a sense of saying ‘Ok I’m alive’ it’s one expression of it” (P10) To stop suicidal thoughts and plan “The self-harm, the deliberate harming of themselves in cutting, is a way of relieving themselves…I mean from what they’re telling me is that while they’re cutting themselves, it is taking away their thoughts away from the actual suicide plan…yeah, they’re cutting themselves to relieve themselves from the suicidal thoughts and the plan that they are initiating…” (P12)

17. DSH intentions and functions Influenced by others “…I have sat in front of a young lady, who was trying to overcome that self-harm. And when you approach her with it, how do you learn, How do you learn this behaviour and why do you think it helps you to get rid of the pain? ‘Well, this is what my friends do, this is what we talked about, this is what will help me, so I tried it’… She learnt it from the friends…” (P12). To Punish Self “…That was the whole thing around I want to hurt myself, by harming my, the way that I look…I need to change my appearance as a way to not only change the feelings but I’m going to make sure that I tattoo myself so I can hurt who I used to look like, who I don’t want to look like anymore.” (P11)

18. Other understandings of DSH behaviours Emotional, psychological and spiritual self-harm “They actually harm themselves emotionally, you know, because harming it can be, it is not only physical but emotional, that’s the definition that I want you to know that it is not only physical, harming physically but it can be emotional too…ithat person won’t have a self-esteem, he just have a negative perspective of everything, you push her to do things, no, nah, nah, nah, but then that is the first stage. The second stage is physical” (P13). Deliberate disconnection of spirituality and faith “…I would look at it from a Pacific way, from my upbringing also…I would look at self-harm from a spiritual sense, a cultural sense, I look at it from a holistic view…” (P7)

19. Other understandings of DSH behaviours Social behaviours “Yes, of course and if you do not obey to what the doctor is saying, so that means that you are harming yourself…Yes, because you put yourself in risk…In danger, at risk…That is self-harm…”(P18 & P19). Risk taking behaviours “I consider drug taking as a deliberate form of self-harm, and drinking and driving as a deliberate form of self-harm…if you’re getting in a car and your drunk and you’re behind the wheels, what are the chances of you crashing into a pole…” (P8).

20. Other understandings of DSH behaviours Substance abuse (particularly alcohol) “But I think that Pacific Island families, we are there for the Pacific people. I think that is the main, harm for our PI families, gambling, smoking, and drinking alcohol...Yeah that is the main harm for our people” (P18 & P19). “Well there is other ways too…drinking alcohol, taking drugs….Yeah over the top I would say. Taking drugs I guess to numb whatever’s going on for them, the emotional stress, they can’t cope so…” (P1)

21. Self-harm and Suicide as behaviours on a continuum. “Well, there are those on one end that would just self-harm, then those who have self-harm who have fleeting thoughts of like maybe not waking up one day, then there is those who have thought about killing themselves but no plan, and then there are those who have self-harm and have thoughts of suicide and have a plan but never make that plan, but then there are those who have self-harm and have attempted. So, in that way you can see that it is a continuum” (P3) “Suicide attempt and self-harm, I think that they are the same thing, when you talk about self-harm your putting yourself in, and suicide is probably the end of self-harm, it’s probably the workings towards suicide I think. They’re the signs I think self-harm is, someone starts cutting themselves, hurting themselves, talking about hurting themselves is,I think that the difference is that suicide would be the final straw…” (P10).

22. Discussion Supports Literature • Informant’s understanding of DSH mostly consistent with general definition of DSH in literature • Informants definition of DSH largely aligns with NSSI paradigm of DSH (to cope, relieve emotional distress not to end life) • Informants view aligns evidence suggest self-mutilating on self-harm behaviour continuum Unique Perspectives • DSH can involve spiritual and emotional self-harm not just physical self-harm • Habitual behaviors cause harm over time are forms of DSH behaviours particularly (alcohol consumption and misuse) • Gambling, smoking, running away from home, not obeying doctors orders as main form of DSH for PI peoples.

23. FutureDirections • To explore PI clients, families & community elders and leaders perspective of DSH to gain a direct understanding of their views and experiences of DSH • More clinical and population based studies is needed to investigate DSH behaviours of PI • Findings from this study will inform recommendations to address policy and legislations, clinical and research settings and to inform community and Pacific leaders

24. Acknowledgements Thank you  To all the key informants and their respective organisations and communities To my supervisors and mentors To HRC, PHWA(MoH), Le Va To my husband and children To family and friends

25. References Clark, T. C., Fleming, T., Bullen, P., Denny, S., Crengle, S., Dyson, B., Fortune, S., Lucassen, M., Peiris-John, R., Robinson, E., Rossen, F., Sheridan, J., Teevale, T., Utter, J. (2013). Youth’12 Overview: The health and wellbeing of New Zealand secondary school students in 2012. Auckland, New Zealand: The University of Auckland De Leo, D ., & Heller, T. S (2004) Who are the kids who self-harm? An Australian self-report school survey, Medical Journal of Australia, 181 (3), 140-144 Gratz, K L., Latzman, R D., Young, J., Heiden, L J. (2012)Deliberate self-harm among underserved adolescents: The moderating roles of gender,m race and school-level and association with borderline personality features. Personality Disorders: Theory, Research and Treatment, 3 (1), 39-54. Hatcher, S., Sharon, C., Collins, N. (2009) Epidemiology of intentional self-harm presenting to four district health boards in NZ over 12 months, and comparison with official data.Australian Psychiatry, 43 (7), 659-655. Helu, S., Robinson, E., Grant, S., Herd, R., Denny, S. (2009). Youth’07: The health and wellbeing of secondary school students in New Zealand: Results for Pacific young people. Latimer, S.,Meade, T., Tennant, A. (2013). Measuring engagement in deliberate self-harm behaviours: psychometric evaluation of six scales. BMC Psychiatry, 13:4  Ministry of Health. (2014). Suicide Facts:Deaths and intentional self-harm hospitalisations, Wellington, Ministry of Health.