Aboriginal and Torres Strait Islander mental health: cultural considerations for risk assessment RANZCP webinar series for rural trainees Tuesday 25 August 2015
Acknowledgement of country
Webinar outline • Introduction & Housekeeping • Cultural discussion – Ms Kath Ryan – Pilbara Aboriginal Drug and Alcohol Program, Karratha, Western Australia and Member of the RANZCP Aboriginal and Torres Strait Islander committee • Content exploration – Dr Murray Chapman – Kimberley Mental Health and Drug Service, Broome, Western Australia and Member of the RANZCP Aboriginal and Torres Strait Islander committee • Exam focus – Dr Jason Lee – Townsville Hospital & Health Service, Queensland and Chair of the RANZCP Aboriginal and Torres Strait Islander committee • Questions and Answers – Participants (that’s you!) & presenters
Housekeeping • The presenters can’t see or hear you, so if you are experiencing technical problems please telephone 1800 733 416 for IT assistance. • Please dial in and listen via telephone Australia - Dial 1800 896 323 New Zealand – Dial 0800 441 984 then enter the pass code 31995035# • Use the chat box to ask for assistance
Audience participation • Let us know who’s participating • Send in your questions. Use the chat box! • Poll question
Cultural content Ms Kath Ryan RANZCP Aboriginal and Torres Strait Islander mental health committee member
Available at: http://www.indigenousinstyle.com.au/australian-aboriginal-map/ (accessed 24 August 2015).
Perspectives in risk management in indigenous mental health Dr Murray Chapman RANZCP Aboriginal and Torres Strait Islander mental health committee member
Focusing on what might be different in • Risk to self • Risk to others • Risk for family • Risk of vulnerability • Risk from a gender perspective • Risk of under/ over diagnosis • Risk of disengagement with community – individual – service • Risk of disengagement with services
Focusing on what might be different in • Country – association with the land • Confidentiality – much more family focused • Self disclosure – to help the process • ‘Seagulls’- why listen to you?
Primacy of cultural security • Utilising Resources • Role of Indigenous MH Professional • Awareness of History and Re-enacting it • Justifiable fear and mistrust • What is your role? • Advocate • Medical Expert • Manager/ recruiter of resources • Container of anxiety • Student
Risk to self • Direct – Suicide – Self-harm secondary to cultural shame/guilt • Indirect – Misadventure – Through aggravation of others
Jumping to conclusions
Indigenous context • Indigenous Risk is identified primarily at a community level • Awareness of history • Colonisation/invasion Process - Intergenerational Trauma - Denial of knowledge • Disempowerment/ Social Exclusion/ Racism • CSA, DV, Alcohol, unemployment, incarceration • Symbolism – Hanging
Indigenous suicide profile (Milroy & Hunter 2006) • Male, younger, unemployed or work for the dole, • May have family history of suicide, • Previous attempts, • Acute alcohol +/- Cannabis, • Recent altercation within family (can appear quite minor), • Impulsive act – piece of hose, in close proximity to home + • Female increasingly, • Clustering / contagion, • Petrol / gambling / (methyl amphetamine)
Possible tipping points • Transition from boy to man • Transition from girl to woman • The demise of ‘Kanyirninpa’ – capacity of ‘holding’ (Great Sandy Desert) - within the community
Risk to others • Gold Standard - HCR-20 - structured process - Static/ Dynamic/ Feasibility of plan • Intentional - specific persecutory delusions/ threats - cultural significance - alcohol, domestic violence • Unintentional - recklessness, MVAs, fire setting
Risk for family • Involving the family • Stress on family to contemplate help seeking • Family as a resource - containers of risk/ anxiety • Family understanding/ explanation/ integration/ flagging risk
Risk of misdiagnosis & vulnerability • Neglect - clinician’s expectations/ prejudice – invisibility - what are the cultural ‘norms’ - over emphasis on Cultural issues • Deterioration – (monitoring) - community tolerance - eventual community intolerance • Alienation from community • Weakening cultural identity – ‘sorry for country’ (SEWB) • Trauma Informed Care – involuntary admission (history repeating itself)
Risk from gender perspective • Gender issues tend to be very prominent culturally • Avoidance relationships • Inappropriate involvement • Men's’/ Women's’ Business • Guidance from IMHP
Risk of disengagement • Balancing short and longer term goals - Acute risk v ongoing engagement • Western treatment vs traditional healing - When you are not the expert - Adopting an ‘Enabling role’ • ‘Problem focused’ vs ‘well-being’ focused
Risk of disengagement • Balancing Cultural and Western risk reduction • Explanation – helping the community understand what has happened
Risk assessment done well Employ 2 nd order intelligence as to when to use risk assessment • • Perform ‘core’ activities to a high standard (overall accuracy is low) • Patient centered, collaborative, involve family, IMHP, community • Help patient/ family/ community/ clinic to hold their anxiety about risk (avoid system contagion) • Trust & therapeutic closeness – with community as well as individual • Seamlessly leads into appropriate balanced risk management
Exam content: risk formulation Dr Jason Lee RANZCP Aboriginal and Torres Strait Islander mental health committee chair
Risk formulation • Synthesise information and demonstrate an understanding of static and dynamic factors that inform an individual’s risks • Inform the development of a management plan that mitigates risks
Core principles • Specific • Meaning • Prioritisation • Cohesive
Example • At time point of scenario 2 • Thomas is a young Aboriginal man with strong cultural ties who resides in a remote community. He presents with aggression and recurrence of psychosis on a background of cannabis and alcohol use, and 2 previous diagnosed episodes of drug-induced psychosis. I am particularly concerned about his risk to others, although his risk of vulnerability is also significant.
• In regards to Thomas’ risk to others, significant static factors include his age, substance use history, history of violence and history of mental illness. • The status of his psychosis presents a significant dynamic factor, with his beliefs of being persecuted directly linked previously to intentional violence. • I anticipate that there may be 3 particular time frames at which this risk may be further elevated.
• Firstly, at the point of discussing possible admission, it is likely that he will feeling inappropriately victimised by the clinician as his perception is that he is being persecuted by others, and therefore perhaps the one on whom attention should be focussed. Given his strong sense of cultural identity and the spiritual themes incorporated into his past delusional beliefs, he may also feel that if treatment is warranted, this should take the form of cultural healing rather than ‘Western’ medicine.
• Secondly, when he arrives at the admitting service, he may be intubated, will likely be disoriented and will probably be in a physically restrictive environment. The experience of having an alien object within him may, in addition to being physically uncomfortable, hold special cultural meaning for him. As he comes from a remote community, being in a physically restrictive environment will not only be disconcerting and distressing, it will likely deprive him of the tools (open space) that he would normally utilise to calm himself.
• Finally, there will likely be a point during his admission when he expresses a pressing need to reconnect with land and family. Inability to access this would result in escalating agitation, which both poses a stressor on him and may be misinterpreted by the treating team as a deterioration in his mental state. The mismatch of understandings and the subsequent restrictions placed on Thomas would serve to compound his distress and heighten his risk of aggression.
• Thomas is a high risk of vulnerability, particularly in relation to being re-traumatised, his sense of self and of alienation from his community. • Every experience, from assessment through to discharge, has the potential to re-evoke personal and historical trauma for Thomas and his family, which, without culturally informed and sensitive intervention, can have a multitude of harmful consequences. • Thomas’ sense of self revolves around his cultural identity, which informs his aspiration to be a community leader. His community and family, through good intentions to him and inadequate understanding, may tolerate some of his psychosis-driven beliefs and behaviours, ultimately jeopardising both early intervention and continuing support.
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