Aboriginal and Torres Strait Islander mental health: cultural considerations for risk assessment

Transcription

1 Aboriginal and Torres Strait Islander mental health: cultural considerations for risk assessment RANZCP webinar series for rural trainees Tuesday 25 August 2015

2 Acknowledgement of country

3 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

4 Housekeeping The presenters can t see or hear you, so if you are experiencing technical problems please telephone for IT assistance. Please dial in and listen via telephone Australia - Dial New Zealand Dial then enter the pass code # Use the chat box to ask for assistance

5 Audience participation Let us know who s participating Send in your questions. Use the chat box! Poll question

6 Cultural content Ms Kath Ryan RANZCP Aboriginal and Torres Strait Islander mental health committee member

7 Available at: (accessed 24 August 2015).

8 Perspectives in risk management in indigenous mental health Dr Murray Chapman RANZCP Aboriginal and Torres Strait Islander mental health committee member

9 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

10 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?

11 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

12 Risk to self Direct Suicide Self-harm secondary to cultural shame/guilt Indirect Misadventure Through aggravation of others

13 Jumping to conclusions

14 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

15 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)

16 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

17 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

18 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

19 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)

20 Risk from gender perspective Gender issues tend to be very prominent culturally Avoidance relationships Inappropriate involvement Men's / Women's Business Guidance from IMHP

21 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

22 Risk of disengagement Balancing Cultural and Western risk reduction Explanation helping the community understand what has happened

23 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

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25 Exam content: risk formulation Dr Jason Lee RANZCP Aboriginal and Torres Strait Islander mental health committee chair

26 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

27 Core principles Specific Meaning Prioritisation Cohesive

28 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.

29 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.

30 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.

31 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.

32 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.

33 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.

34 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.

35 Question and answer

36 Closing comments Thank you for your participation Help us by completing the exit survey for this webinar Continue the conversation on the College online forums Use your College membership details to login Agree to the Terms and Conditions Find our thread in the Clinical Practice issues section titled Aboriginal and Torres Strait Islander Webinar discussion