Introduction by Croakey: New guidelines launched today aim to ensure better, culturally safer care for Aboriginal and Torres Strait Islander people who present to hospital services when at risk of self-harm and suicide.
The Best practice guidelines for psychosocial assessment of Aboriginal and Torres Strait Islander people presenting to hospital with self-harm and suicidal thoughts recommend that services and practitioners move beyond a narrowly clinical focus, and take a strengths-based approach to engaging with the social and emotional wellbeing (SEWB) of patients.
They also suggest that practitioners become familiar with the local and surrounding Aboriginal and Torres Strait Islander communities, languages and cultures where they work to ensure their assessments and recommendations for care are informed by what is locally relevant and available.
The guidelines, developed by The Menzies School of Health Research and commissioned by the Centre for Best Practice in Aboriginal and Torres Strait Islander Suicide Prevention (CBPATSISP), make 227 evidence-based recommendations.
These have been endorsed by an expert panel of Aboriginal and Torres Strait Islander and non-Indigenous professionals and those with lived experience.
The guidelines are aimed at all clinical staff in hospitals responsible for providing mental health assessments, especially mental health nurses, clinical psychologists, psychiatrists, and Aboriginal mental health workers, where available.
Read more about the guidelines and their development from some of those involved – Tanja Hirvonen, a clinical psychologist based in Darwin, who holds an Adjunct position with Flinders University, Bernard Leckning, a Research Officer and PhD candidate with the Menzies School of Health Research in Darwin, and Professor Gary Robinson, Director of the Centre for Child Development and Education at the Menzies.
Tanja Hirvonen, Bernard Leckning and Gary Robinson write:
Aboriginal and Torres Strait Islander people have higher rates of hospitalisation involving self-harm in comparison with non-Indigenous Australians. When we have concerns about risk of harm for ourselves or we are concerned about others, the message provided to the community and health professionals is to contact 000 or attend the Emergency Department of the nearest hospital.
When admitted to hospital we hope that the care provided can keep people safe; however, it is known that admission to hospital doesn’t always end with a positive outcome.
Other layers of complexity include whether there is timely access to mental health services within the hospital system, if culturally appropriate mental health care is provided and trust that the hospital will provide adequate treatment.
The opportunity to identify needs and support the process of recovery for Aboriginal and Torres Strait Islander people experiencing suicidal thoughts is compromised when the care is culturally unsafe.
This is a significant concern because self-harm is one of the strongest predictors of suicide, and we are uncertain how useful admissions to hospitals are in helping Aboriginal and Torres Strait Islander people.
Holistic approaches advised
A common criticism of mainstream services is a neglect of cultural and social considerations for the social and emotional wellbeing (SEWB) of Aboriginal and Torres Strait Islander people.
SEWB refers to the inter-related connections to the domains of body, mind and emotions, family and kinship, community, culture, Country, and spirituality that sustain collective and self-identity, health, wellbeing, meaning and purpose for Aboriginal and Torres Strait Islander people.
The ongoing history of colonisation, intergenerational trauma, contemporary disadvantage and exclusion and institutionalised racism negatively impacts on a person’s health and wellbeing. It is imperative that hospital staff provide culturally safe health care and provide a culturally safe environment when Aboriginal and Torres Strait Islander people present to hospital.
Despite this, the evidence-based guidelines used in emergency departments and hospitals, to which many Aboriginal and Torres Strait Islander people present when experiencing these problems, are organised around assessments of acuity and risk for which patient safety is the goal. The need for cultural safety and understanding can often be overlooked.
A research project was established to develop guidelines for assessing self-harm and suicidal thoughts for Aboriginal and Torres Strait Islander people presenting to hospital.
The aim of the study was to establish a standard of practice in which cultural safety encompassing social and emotional wellbeing was central to the assessment of self-harm and suicidal thoughts by Aboriginal and Torres Strait Islander people.
A Delphi study was designed to build upon the available practice-based evidence and the expertise of clinicians, suicide prevention workers and those with lived experience.
The results of this research have culminated in the Best practice guidelines for psychosocial assessment of Aboriginal and Torres Strait Islander people presenting to hospital with self-harm and suicidal thoughts.
The guidelines encourage the development of clinical interviewing skills that will give practitioners further considerations to appropriately and effectively interact and engage with Aboriginal and Torres Strait Islander people in ways that are culturally safe and empowering.
Most recent mental health assessments are including strength-based questions that can support recovery for people who self-harm, rather than narrowly focusing on only identifying risk.
With a strong grounding in the concept of social and emotional wellbeing and cultural safety, the guidelines have adopted a strength-based framework.
The guidelines do not only contain recommendations for evaluating factors that negatively impact SEWB. They also encourage practitioners to identify the social and cultural resources that are sources of strength and resilience that can support healing and recovery from the underlying issues that are related to suicidal thoughts or self-harming behaviour to begin with.
Recognising the diversity of Aboriginal and Torres Strait Islander people and communities is important for provision of appropriate care. Self-harm and suicide by young Aboriginal and Torres Strait Islander people are occurring at a tragic rate. Therefore, culturally appropriate recommendations for assessment of young Aboriginal and Torres Strait Islander people have been provided.
The guidelines point to the need to recognise that within this diversity, other groups, such as LGBTQI Aboriginal and Torres Strait Islander people, will also have specific requirements that are not met by general recommendations.
Ultimately, our focus is to improve patient outcomes by enriching the information health practitioners have available.
These guidelines recommend that practitioners become familiar with the local and surrounding Aboriginal and Torres Strait Islander communities, languages and cultures where they work to ensure their assessments and recommendations for care are informed by what is locally relevant and available.
Where possible, this is best facilitated by ensuring Aboriginal and Torres Strait Islander practitioners are leading or involved in these assessments, or that cultural liaison or other Aboriginal and Torres Strait Islander health workers are available to support non-Indigenous health practitioners.
Self-harm and suicide typically result from the complex interplay of multiple individual, contextual and historical influences. Diagnosis alone and only providing clinical mental health care would not be the only recommended solution.
The strategic focus of prevention should be to enhance support Aboriginal and Torres Strait Islander communities and families, who must also contend with ongoing social and political determinants of health.
Regardless, mainstream hospital services are vital as part of the solution going forward, for medical treatment and specialised psychiatric care to treat known mental illnesses.
If hospitals are to contribute to this preventive effort, then the social and emotional wellbeing of Aboriginal and Torres Strait Islander people presenting with self-harm and suicidal thoughts needs to be central to the assessments that informs decisions about ongoing care in the community that best supports healing and recovery.
• The authors:
Tanja Hirvonen is a clinical psychologist based in Darwin and holds an Adjunct position with Flinders University.
Bernard Leckning is a Research Officer and PhD candidate with the Menzies School of Health Research in Darwin.
Gary Robinson is the Director of Centre for Child Development and Education at the Menzies School of Health Research in Darwin.
If you or someone you know needs help or support, contact:
Your local Aboriginal Community-Controlled Organisation
Lifeline 13 11 14
Beyondblue 1300 22 46 36
Kids Helpline 1800 551 800
Mensline 1300 78 99 78
Q Life 1800 18 45 27
Open Arms Veterans & Families Counselling 1800 01 10 46
The National Indigenous Critical Response Service 1800 80 58 01.