Aboriginal and Torres Strait Islander mental health: cultural - - PowerPoint PPT Presentation

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

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Audience participation

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• 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

• 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

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 2nd 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

• f 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

• ne 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

• bject 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.

• Alienation from his community and family would have a devastating

impact on Thomas, with subsequent loss of meaning, potential existential despair and high emotional distress. In that scenario, he may attempt suicide, or alternately to self-treat through escalating substance abuse, further perpetuating the cycle of psychosis and loss of connection from his culture.

• Appropriate management of these 2 core areas of risk will not only

influence his progress in treatment and longitudinal prognosis, but also mitigate his risks of harm to self and of disengagement from community and services.

Question and answer

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