Indigenous Knowledge Approach to Successful Psychotherapies with Aboriginal Suicide Attempters

Abstract

Introduction:

Suicide is disproportionately common among Aboriginal people in Canada.

Methods:

Life stories were collected from 54 Aboriginal suicide attempters in northern Saskatchewan. Constant comparison techniques and modified grounded theory identified common themes expressed.

Results:

Three common plots/themes preceded suicide attempts: 1) relationship breakup, usually sudden, unanticipated, involving a third person; 2) being publicly humiliated by another person(s), accompanied by high levels of shame; and 3) high levels of unremitting, chronic life stress (including poverty) with relative isolation. We found 5 common purposes for suicide attempts: 1) to “show” someone how badly they had hurt the attempter, 2) to stop the pain, 3) to save face in a difficult social situation, 4) to get revenge, and 5) don’t know/don’t remember/made sense at the time, all stated by people who were under the influence of alcohol and/or drugs at the time of their suicide attempt. We found 5 common beliefs about death: 1) you just cease to exist, and everything just disappears; 2) you go into the spirit world and can see and hear everything that is happening in this world; 3) you go to heaven or hell; 4) you go to a better place; and 5) don’t know/didn’t think about it.

Discussion:

The idea of personal and cultural continuity is essential to understanding suicide among First Nations youth. Interventions targeted to the individual’s beliefs about death, purpose for suicide, and consistent with the life story (plot) in which they find themselves may be more successful than one-size-fits-all programs developed outside of aboriginal communities.

Suicide disproportionately affects indigenous peoples.¹ Suicide and self-inflicted injuries are the leading causes of death for First Nations youth and adults up to 44 years of age.² In Canada, a simple variable measuring the knowledge community members have of their own Native language had greater predictive power than 6 other cultural continuity factors identified in previous research.³ Youth suicide rates effectively dropped to zero in those communities in which at least half the band members reported a conversational knowledge of their own Native language. In the rest of Canada, communities where there is a strong sense of culture, community ownership, and other protective factors have lower rates of suicide and sometimes none at all.⁴ These cultural continuity factors included self-government; land control; control over education, police, fire services, and health services; and control of cultural activities.^3,5 The usual risk factors for suicide consist of depression and other mental illnesses, alcohol and drug dependency, hopelessness, low self-esteem, sexual abuse and violence, parental loss, and homelessness.⁶ Aboriginal elders asserted that mental health workers for indigenous people should develop and maintain strong social networks; are well informed about local sociocultural factors and taught how to work with local elders, traditional healers, and community members; and are well supported in their roles to ensure longevity of service and good relationships with community.⁷ Mehl-Madrona⁸ showed that Aboriginal elders hold similar beliefs about what mental health workers should know and how they should be trained and supported. With suicide attempters, I was especially interested in their theories about death and what happens after death, as well as their beliefs (stories) about how their death would affect others whom they knew. If suicide is a strategy, then what need is it meant to fulfill? What is the purpose of this behaviour within the social hierarchy in which the attempter finds himself or herself?

Methods

As part of a research protocol on spirituality and health approved by the University of Saskatchewan Institution Review Board, life stories were collected for a number of patients from 2006 to 2009. From those life story interviews, case records were prospectively identified for Aboriginal suicide attempters. Data from individual cases were collected in a process similar to that described by Peterson.⁹ Fishman¹⁰ has summarized this process in which we begin with a focus on the client and his or her presenting problem. We select a guiding concept with accompanying clinical experience and research support. We then conduct a comprehensive assessment. Applying the guiding conception to the assessment results in a customized formulation and treatment plan. The plan is implemented during the course of therapy. The clinical process is continually subjected to an evaluation/feedback process with modifications being made as needed. Building upon Peterson’s original conceptualization, we have included all stakeholders in these components whenever possible. The process is decidedly dialogical and conversational. With clients who attempted suicide, I included as part of the assessment component a modification of the Northwestern University Life Story Interview.¹¹

Fishman described how Peterson’s model can be used to build theory in psychotherapy, exemplified by him in the work of Stiles,¹² Gray and Stiles,¹³ and Schielke et al.¹⁴: “A central tenet of theory building case study research is that observations about rich material from individual cases—both the commonalities and differences—can be combined to inform and support theories about complex underlying psychological phenomena.”¹³ This is also compatible with indigenous knowledge methodologies.

Modified grounded theory¹⁵ was used to review the life stories of Aboriginal suicide attempters, using constant comparison methodology to find the common themes stated by respondents in the areas of interest.¹⁶

All Aboriginal suicide attempters were offered psychotherapy immediately after their life story was obtained. Case notes from these suicide attempters were reviewed using the constant comparative method¹⁷ to iteratively review the material to select what was common and to delete what was not. This was applied to the psychotherapy case notes.

Results

A total of 54 patients were interviewed in depth at 3 clinics in northern Saskatchewan. Twenty-three were male and 31 were female. The mean age was 21 years, with a standard deviation of 6.1 years. Psychotherapy proceeded with 27 patients of this group. Twenty-four of them made no further suicide attempts. No patients completed suicide. Psychotherapy lasted an average of 9 sessions, the range being 1 to 16. Sessions frequency ranged from weekly to monthly. Of the patients who did not engage in psychotherapy, 21 attempted suicide again, at least once. Average length of follow-up was 15 months, while the range was from 5 to 19 months. Medication was available to these patients, if desired. Typically, medication was less desired among Aboriginal populations compared with mainstream Canadians. Twelve patients chose to take medication (primarily selective serotonin reuptake inhibitors), 5 from the group who did not choose psychotherapy and 7 from the group who did. Of those who started medication, 2 were still taking medication at the completion of psychotherapy. The author was the psychotherapist and is also Aboriginal.

Review of the life story interviews revealed 3 common plots/themes preceding suicide attempts:

1. Relationship breakup, usually sudden, unanticipated, involving a third person

2. Being publicly humiliated by another person(s), accompanied by high levels of shame

3. High levels of unremitting, chronic life stress (including poverty) with relative isolation

Alcohol was involved in 30 of the attempts, with other drugs involved in another 23, meaning that almost all persons were in a state of altered judgement at the time of the attempt.

Review of the life story interviews resulted in 5 common purposes for suicide attempts:

1. To “show” someone how badly they had hurt the attempter

2. To stop the pain

3. To save face in a difficult social situation

4. To get revenge

5. Don’t know/don’t remember/made sense at the time, all stated by people who were under the influence of alcohol and/or drugs at the time of their suicide attempt

Five common beliefs about death were found:

1. You just cease to exist; everything just disappears.

2. You go into the spirit world and can see and hear everything that is happening in this world.

3. You go to heaven or hell.

4. You go to a better place.

5. Don’t know/didn’t think about it.

Review of the interview records revealed the following reasons for not attempting psychotherapy:

1. Distances to travel for appointments too great¹²

2. Previous bad experience with psychotherapy⁹

3. Patient convinced that there really was not any problem that needed to be addressed⁴

4. Belief that talking does not do anything³

Review of the case notes revealed 5 common strategies that were successful in psychotherapy with Aboriginal suicide attempters:

1. Create delays and alternative pathways from the habitual thinking that occurs before a suicide attempt.

2. Among these alternative pathways, create a sense of narrative agency of being a person with other options for revenge and other ways to show people how much the hurt has been.

3. Build narrative competence by assisting the Aboriginal suicide attempter to build and rehearse stories of positive futures, face-saving when necessary.

4. Find islands of humor, when possible.

5. Engage culture and elders to every possible extent.

To summarize, in a review of successful psychotherapeutic strategies with Aboriginal suicide attempters, a narrative-oriented approach appears to be successful. In this approach, counternarratives are introduced about ideas of death, what happens after death, how suicide affects the living, how revenge can be achieved, and how a positive future can be imagined. The term counternarrative refers to stories, which present a message opposite to those of prevailing or previous incorporated stories. Narrative competency is fostered, especially the idea of recognizing feelings and motives in characters (including ourselves). Basic dialectical behavior therapy (DBT) techniques for recognizing and describing feelings were helpful, as was instruction in nonviolent communication techniques for interacting with others about these feelings.

Discussion

The analysis of interviews and case notes from successful psychotherapies (as defined by no further suicide attempts) can help us to understand some basic principles for working with Aboriginal suicide attempters. A narrative approach may be more acceptable to Aboriginal people, since Aboriginal culture is organized around storytelling, and elders perform most of their interventions through stories’ use. The purpose of psychotherapy was to change the stories people held about death, about what happens when people die, about the effect of completed suicide on the people who are left alive, and about how one can best communicate hurt and achieve revenge. Counternarratives were introduced and participants were assisted to develop more rich stories on these topics that led to different, more positive outcomes. The idea of personal and cultural continuity is essential to understanding suicide among First Nations youth. Identity narratives resolve the question of what it means to have or be a self and to consider oneself as continuous in time. Those whose identity narratives are undermined by radical personal and cultural change are at risk for suicide related to loss of a sense of continuity and a future with commitments that are necessary to guarantee appropriate care and concern for one’s well-being.