Live chat with Professor Ernest Hunter - May 2010
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Above: Professor Ernest Hunter.
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Below is a transcript of a live chat session held on the LIFE website in May 2010 with Professor Ernest Hunter, author and Principle Investigator of Health Interactive Technology Network (HITnet). The topic was 'suicide prevention in Indigenous communities.'
Q: What are your thoughts on highly recommended resources and narrative therapy as a ‘new’ opportunity for engaging self-help and strength?
A: I think narrative therapy has shown itself over the last decade to be a major contribution to our resources in working with Indigenous clients. In our service based in Cairns all of the child practitioners (Indigenous and non-Indigenous) have been trained in narrative therapy. So I think that it is important and useful and needs to be included as part of a broader set of strategies to foster self-help and strength.
Q: Are there any postvention/bereavement programs running successfully in Indigenous communities? I understand Indigenous culture has a very specific way of dealing with death and I am interested to find out about any programs that work effectively in this area.
A: There has been a range of bereavement kits made available for use in wider society. A number of years ago the Edward Koch Foundation in Cairns was involved in attempting to adapt those resources for use in Indigenous communities. More recently there has been a similar kit that has been made available through the Commonwealth (I think through the Mental Health Branch) which was also adapted for use in Indigenous settings. However, my experience working as a clinician in remote communities is that we always need to be very mindful of local practice and local strengths in this matter. Sadly, we have had a number of traumatic deaths in Cape York over the years, and while it is important to have strategies and resources available and at hand, it is critical that the first step is to ensure that whatever is done is done in partnership with local players. To that end, my approach is to make contact early, to ensure that it is clear that the resources we have - our time, personnel and other materials - is available. Sometimes it is sufficient to give those on the ground to proceed at their own pace. My belief is that we need to try and support local responses, not only because they are appropriate and informed by local experience but also because it is about supporting development of capacity locally. Having said all of the above, sometimes it is critical to be there and help. For instance I have been involved in the aftermath of several airplane crashes. Even in such tragic circumstances my approach was to be there but to be as much behind the scenes as possible, rather than presuming to stand centre stage.
Q: How can people working to prevent suicide in Indigenous communities be sensitive to the cultural needs of individual Indigenous tribes?
A: This is a complex area. From the perspective of services and organisations it would be great to be able to send out the CD and leave it there. However, this is not just about 'knowledge' but also about attitudes and skills. To that end one of the things I recommend to registrars in psychiatry who are working in Indigenous settings is to develop a capacity for informed listening. What I mean by that is that it is important to be able to convey to those with whom we are working that we have some (perhaps not great) understanding of the circumstances and issues that are at play locally. That means becoming aware of local history and issues; it does not require developing an anthropological understanding. That would be difficult anyway because of the vast diversity of Indigenous communities. Having that local knowledge allows people to tell their own stories rather than to feel that they have to educate you about basic matters of Indigenous history and circumstances. That being the case, one can then move to developing relationships, and I think it is through developing relationships that real cultural sensitivity develops. In fact, that has become a central support of the National Health and Medical Research Council’s (NHMRC) guidelines for research in Indigenous communities, which has moved from the dos and don’ts of research practice to whether researchers are able to develop ethical relationships. I suggest that you access that report (first author Ian Anderson) through the NHMRC website.
The following two questions are related to Indigenous children, which Professor Hunter will answer in one response.
Q: What do you see as important issues to bear in mind in prevention with Indigenous children and young people? I am especially concerned about impulsivity.
Q: I work with kinship and foster carers, some of whom are caring for Aboriginal kids. Are there some specific things that carers can do to help improve the resilience of kids in their care?
A: This is an area of incredible complexity. I believe that the major issues in relation not only to Indigenous mental health, but the larger projects of addressing the disempowerment and marginalisation of many Indigenous peoples and communities starts with healthy beginnings to life. In terms of developing resilience, we have research evidence (some of which I have been involved with) that shows the profound benefits of ensuring educational outcomes. That is, not just retention in school, but having realisable outcomes. I recall many years ago being with the Minister for Health and the American Surgeon General in Central Australia looking at desperate settings and very disadvantaged children. He turned to Michael Wooldridge and said ‘you don't have a health problem here, you have an education problem.’
What he was saying was that it is facile to think that you can address those huge issues through the health sector alone and that only by giving people control and capacity can they move forward as a group. Schooling, however, also presupposes that kids can get to school and that they have the inherent (biological) and contextual (social, family) strengths to support that. So, I am very firmly of the belief that the area which demands major input from government, and where we should all direct some attention, is early childhood. To come back to your question in relation to what we do to support kids with difficulties in terms of impulsivity etcetera I think we need to operate in a manner that supports families in providing structure, to ensure that families recognise the importance of children's requirements to be well enough to get to school, and to get them there. At the moment there are trial programs of the Family Home Visiting program developed in the United States by David Olds, which are being piloted around Australia. The aim of that initiative is to work very closely with vulnerable first pregnancies and support those families through the first years of that child's life. The goal is to provide skills at a family level which will be continued with subsequent births. The data from the US is very promising and I recommend finding out if there are local pilot programs and how one might be able to support those initiatives. My sense is that the issues around early childhood are so important we need to try and add value to what is happening - and that means coordination.
Q: As you have recognised in the introduction you wrote recently for the rural and remote edition of LIFE News, there is large enthusiasm for digital technologies among Indigenous communities. What types of technical opportunities are currently being taken advantage of to improve the effectiveness of suicide prevention in remote Indigenous Australia?
A: You can think of this in a number of ways. First, there are adaptations of resources that are available in the wider society through e-Health type approaches, such as what (the live chat session) we are now all engaged with. There are also adaptations of helplines that have got both digital access and culturally informed approaches, for examples Kids Helpline. Then there are the IT accessible websites that have undertaken to provide access to resources and probably the best of those in relation to Indigenous issues is the Indigenous HealthInfoNet which is generated through Edith Cowan University in WA. I recommend accessing that. Then there are a set of interventions which aim to develop specific resources. I have been involved in one - HITnet - which has developed resources that sit on touch screens. There are now about 75 in communities around Australia. The important issue in relation to this approach is developing materials locally, thus utilising engagement, performance and representation as motivators. One of the models created - buluru yealaumucka: healing spirit - was created with the Yarrabah community and addresses suicide prevention from a community recovery perspective. That is now deployed on most of those kiosks. We have recently created a module for corrective services in Queensland (we have a kiosk in every jail in Queensland) called Free the Warrior. We are now producing an interactive DVD package with both of the above modules and instructions for use in group mediated sessions. So, there are lots of avenues and I would put a plug in for our conference in Cairns in September. Creating Futures occurs every two years and will have a stream on creativity and digital processes. It’s in September, be there!
Q: Macquarie University has students (aged 22-50) from remote communities enrolled. They come to Sydney campus as a group four times per year for two weeks at a time. We also have groups of Year 10 students visit for residential programs. We offer a health program to assist with access to primary care, also a mental health service. Is it appropriate to talk about suicide or other means of self-harm during such a short interaction? Our academic staff travel to remote communities to live and talk, sometimes up to six months. How can I best assist them to support those experiencing such distress?
A: The issue of whether one talks about suicide - be it with children or adults - is raised a lot. From experience in the remote communities that I work in my feeling is that it is (appropriate to talk about suicide and self-harm during short interactions) but there are caveats. First, I think that there is an age issue. At least in the communities I visit, everyone has been exposed to acts of self-harm or people talking about it. So I think the idea that we might be planting ideas is false. However, I think we need to be mindful of the age of the people we are talking to. By the time a young person is in Year 10 (as you mention) I would hope that, generally, the developmental progression should be such that these issues could be raised. However, one also needs to be mindful of process and ready for difficult issues. So, considering what I mentioned earlier about exposure, it should not be a surprise if the group has people within it who have been exposed in some way. With that in mind, before I proceed in such settings, I try to make sure that I have a local person with me who knows that I am going to talk about these matters. I make it very clear at the outset that this is what I am about to do, that I recognise there may be people in the group who have been affected in some way, and that people should feel free to step out of the room. Then, of course, you need to be attentive to the emotional responses, and I try to stay behind at the end because I have had the experience time and time again that some people want to speak. If it is a matter of the bell ringing and then rushing off, that is compromised. So, in short, these are important issues that need to be talked about and it is not a matter of if but of how.
Q: As a suicide bereavement support group how can we offer support to Indigenous families when we cannot speak of the dead?
A: Not speaking the name of a deceased person is common in many Indigenous settings. However, I would not presume that it is universal and when I am in such a situation I tread carefully, often talk about the person who has ‘passed' and with some people acknowledge my naiveté in such matters and ask their guidance. Indigenous people are very forgiving as long as one is not barging in and is conveying an intent to help. So again it is not if you can talk of the dead but how one goes about the process. I also think it is critical for mental health practitioners and bereavement counsellors to be comfortable with silence. Every patient I see in a remote community I make a cup of tea for. I think we can do much to change the ambience of the settings in which we work. That also allows me to have periods in which there is simply silence or listening - sometimes we feel that we need to fill up those spaces with sound (our own) and that, I think, is a problem. If you want I will post an article I wrote about tea and listening on this website. So, ask guidance, talk about the one who passed, show concern and take time.
Q: One of the difficulties in applying suicide prevention models to Indigenous communities involves making culturally specific programs. But with so many different Indigenous dialects and variations of Indigenous culture, how is this in general terms best achieved? It is such an ongoing challenge...What advice can you give?
A: The diversity of Indigenous settings makes most of the 'ready made' approaches problematic. So, if you can develop resources and programs locally that is great. However, it may not always be the case. It was raised with us by Canadian colleagues that there was a problem with the standard approach which seemed to be to go to a community somewhere in Indigenous Canada where suicide was rampant and to develop a resource of some kind that was then taken back to Ottawa, packaged for national distribution, and sent to very different cultural settings, some of which had never had a suicide. In fact, it would probably have been better to do the reverse, learn from places where suicides had not occurred. However, a lesson that we attempted to take on board was that of horizontal experience transfer. But we meant that instead of having outsiders (often non-Indigenous) going into communities with messages and directives we should be facilitating a dialogue. What we attempted to do was to work with the community of Yarrabah which had moved through a period of terrible loss some fifteen years ago. We sought to try and distil lessons that they had learned from their experience, and then to provide the means for them to meet with colleagues from other settings. In those meetings the message was not this is what you do; rather, the message was this is what we did, you might find something in this of use, then you have to figure out what is relevant to you and what is not. So then the meeting would move to thinking locally. That was the basis of a National Suicide Prevention Strategy project that ran in Queensland called ‘Learning From the Experts.’ A flow on program is now proceeding.