Panel Session: Supporting People At Risk
TRANSCRIPT
PANEL DISCUSSION: Supporting People At Risk
How to support people at risk of suicide through family, work, community, cultural and other settings.
FEATURING:
Simon Hatcher (Associate Professor, Psychological Medicine, University of Auckland)
David Codyre (Clinical Director, Consultant Psychiatrist, ProCare Psychological Services)
Irene Walker (Kia Piki te Ora, Western Bays)
Karlo Mila-Schaaf (Writer and Researcher)
Det Insp Mark Benefield (Acting Area Commander, West Auckland, NZ Police)
Sarah Gordon (Consumer Advocate)
Simon Hatcher: My name’s Simon Hatcher, I’m an Associate Professor of Psychiatry at the University of Auckland. As you can probably tell from my accent, I’m originally from England, but I’ve worked in New Zealand now since 1994.
One part of my job is working clinically as a Psychiatrist in a General Hospital, and if you work as a Psychiatrist in a General Hospital, one of the places you do a lot of work is in the Emergency Department which is where you see a lot of people who present with self-harm.
I work at Waitemata DHB, and we see somewhere between six and seven hundred people a year who present to the hospital with self-harm.
The other part of my job is as an Academic, as Researcher. For the last six years I’ve been the Principle Investigator in three large trials of various interventions in people with self-harm to see if we can improve outcomes in that group of people.
Irene Walker: My name is Irene Walker, and I hail from a beautiful place that they call the Centre of the Universe, and big mihi out to the Bay of Plenty.
I’m from a place called Tauranga Moana, and I am one of the Kia Piki Te Ora Regional Coordinators. I have two people in crime with me – not this guy! – Emma Kutia and myself. I do the Western Bay of Plenty, and my colleague does the Eastern Bay of Plenty.
We have a public health portfolio around suicide prevention. Kiaora tatou. And I just want to mihi to you that you’re the best looking group in the complex, and the most intelligent looking one too. Kia ora.
Mark Benefield: Kia ora. Good morning all. My name is Mark Benefield, I’m a Detective Inspector from the Auckland City Police District for Auckland. I’ve been twenty-two years in the New Zealand Police, both in the General Duties branch and the Criminal Investigation branch.
I have a background in negotiation – I was a Police Negotiator for eleven and a half years, and I’m also a District Trainer for custodial suicide prevention.
I’ve experienced suicide both in my role as a Police Officer, and also in a personal situation with colleagues and friends that have death by suicide.
The Police, as you are well aware, are involved deeply with suicide; it’s a major part of our business or our work. We have calls for service both for intervention and also, sadly, where people have died through suicide, or attempts to suicide.
Additionally we have intervention through negotiation, and also we have a staff welfare issue in the same area.
Just to give you some figures around our calls for service, nationally, and these are not official, but they’re roughly – calls for service around suicide and the intervention of it range nationally somewhere between seven and a half thousand to eight thousand nine hundred a year, which you can tell that’s a large amount of work and people at risk.
In the District aspect around Auckland Metropolitan-wise, deaths by suicide number around a hundred and fifty per year, and if you put that in perspective, you look at the current national road toll, that’s only a hundred and thirty. So in Auckland alone – and that’s all Auckland from the Bombays up to the... past Orewa, that’s a hundred and fifty deaths through the mortuary that the Police have to deal with.
David Codyre: Kia ora koutou. I am a Psychiatrist who works in primary care, so I guess my kind of... this is a big topic, I must say I feel very nervous up here, sitting up here talking about it.
Professionally it’s the worst thing that can ever happen when you’re trying to support and help someone through dark times, and like I guess everyone, I have also had personal connection with people who’ve both attempted and succeeded at suicide, so it’s a big topic we’re here to talk about.
Sarah Gordon: Approximately this time three years ago, a thirty-four year old woman decided to kill herself. And she died. But the Paramedics managed to revive her. Waking up from a coma two days later, the woman was assessed as having no long-term mental or physical injury as a result of the suicide attempt.
Having been given that all-clear, she was discharged from the Intensive Care Unit to a Psychiatric Unit.
After two months with the service, the woman had an appointment with her Psychiatrist where she asked to be discharged. The woman felt that her request was quite reasonable; she was physically well and much stronger than she had been on admission, and her immediate acute mental illness symptoms had been addressed.
The Psychiatrist refused to even entertain any notion of discharge at this time. Her primary reason being that the woman was not in relationship with anyone or anything. ‘You see...’, she argued, ‘...being in relationship with people is absolutely fundamental to living well.’
So that is what the woman spent the remainder of her time – a further five months – doing, working on relearning and actively practising being in relationship with herself, her family, her friends and her community.
And what is she doing now? Actively engaging in her roles as a mother and a wife, working, dancing, writing, holidaying and shopping - something which I particularly enjoy.
I talk about suicide from the perspective of someone who has attempted and survived it.
Karlo Mila-Schaaf: How difficult it is to speak into this space – and I am someone that is used to speaking publicly. And my name is Doctor Karlo Mila-Schaaf, and I’m a Post-Doctoral Research Fellow in the Social Psychiatry and Population Mental Health Research Unit at the University of Otago Wellington School of Medicine.
I’m a poet and a former mental health funding bureaucrat in one hat, but I too am someone that brings an experience of surviving a really serious suicide attempt. And it’s hard to know what to bring to the table here, and it’s hard to know how to talk about these things, and I guess I’m just bringing my discomfort and unease to the room and letting it go, and thanking Sarah for... it’s particularly difficult to speak into that space after we’ve heard the grief experienced in the earlier panel, and I... it just triggered something for me, I remember turning to my step-father and saying ‘I think I’m going to commit suicide, I can’t do this anymore’ and he said to me ‘that would be the most selfish thing in the world, Karlo Mila’, and I said ‘well you better take me to A&E now then’, because I had already ingested multiple pills. And how he was just so much on the other side of a bridge, and I was completely in another territory, and it frightens me almost that the distance between feeling that way and being back on that other side of the bridge, and trying to have those conversations across.
Simon Hatcher: The first group of questions is really around what specific things can you effectively do for someone who is at high-risk or is threatening suicide.
Sarah Gordon: I think it’s about being with them, or organising somebody else to be with them twenty-four seven, basically. And obviously that’s quite difficult for an individual to manage on their own, so it’s important to get a group of people around, I think.
And I think it’s important to acknowledge that it’s very energy-intensive work, being with someone who is suicidal, so having the more people as possible is good.
To my mind one of the worst things you can do is isolate or seclude someone who is at high risk, or threatening suicide, which is still done today.
This person is struggling with their connections to this world so much so that they are considering taking an action that is a very final form of disconnection. To use interventions that impose disconnections like seclusion or isolation are the exact opposite of what is needed.
David Codyre: One of the things that I often hear, and that evokes a very visceral reaction to me is when people use the words ‘someone’s chosen to end their life’ or ‘chosen to commit suicide’. And I guess the reason that I have that visceral reaction is because I’ve, through I guess talking to people on the pre-contemplation of suicide, and also having tried is that it seems to me that it’s an act that is driven by the absence of any other choice more than an act of choice, and that yes it is about first and foremost connection, how as help and support agencies we can first and foremost connect with a person to try and understand why they are where they are, and to try and give some sense of their being other options and other choices, as well as obviously just figuring out how much there is real risk and being able to put enough support around a person to ensure they are safe through what is invariably a temporary time, a time that if the person can be kept in this world they will almost invariably come through to the other side of.
Mark Benefield: From a policing perspective, and dealing with crisis, the staff do, at times, have very difficult situations where a person is at... has called for help, or is, as you say, isolated and needs that support.
Generally, in most cases, we are able to pass over to the Health Authorities and they give great service. There are times, though, when that call for service may not be recognised, not necessarily by the Police staff, but maybe by the Health Authorities, and they are then left with the family members.
Our organisation, obviously we try as far as we can go for prevention, though in the health side we don’t have a major involvement in that aspect of it. But the staff that have to deal with those situations, it can be time... I think you used the term ‘time’... energy-sapping is the word, and they do their best to deal with or keep that person.
Sometimes if there are... obviously we have people who are arrested for serious offences who we then recognise... we try to recognise the signs that while in our care - we have a duty of care to everybody, not only victims but also offenders – and we go through that aspect to try and ensure that when they’re in our care we either pass them on to somebody who’s going to take responsibility for that person so they’re not left on their own.
In our own welfare situation for our staff, obviously our roles we have a lot of people that get stressed and deal in... have sadly taken their lives, but we have a really good welfare system – well I believe we do – that supports our own staff where they are once identified maybe being at risk.
Irene Walker: For Maori perspective, first and foremost is that we remove all means of suicide when we are working with the whanau or threatening suicide, but I think most importantly is that we, for ourselves who are caring for a whanau member, is that we also get care ourselves to support us along this journey. And particularly not only from the whanau side of things, where our whanau member will... can trust that person, but also professional help as well.
But not saying that our whanau aren’t professional out there, for most whanau would be number one call for... for me, and for our whanau member, and it could be not so much their mum or dad, it could be their nan, or their koro, or even their favourite aunty.
So for me, and working in helping someone, is finding help for you to help that person. Because as my colleagues have spoken before, it is a high-energy task that we’re actually taking on at that time.
Simon Hatcher: One of the things that I sometimes come... well often come across clinically which sort of follows on from some of the remarks that you mentioned, is the role of the family. And we’ve talked about the family, well whanau, about being supportive, but they’re often part of the problem as well. How do you manage that?
Irene Walker: I suppose I... we can say that that happens in both areas, not only for whanau there could be problem areas, but also for Clinicians as well, is that they probably don’t actually understand the whanau concept, but also that they may be peered upon as this is some mental health issue, especially when dealing with matekite or mate Maori.
When working with whanau that are an issue, or have those issues for the family, it’s always... it’s not that our whanau member is incoherent, they are able to speak to us and actually indicate who is the best person they would like here with them. So it is about speaking to our whanau member, who would they like there with them.
David Codyre: There is an individual level too, what gets people into that dark place, but my observation is that there are often knots that families are tied up into, and of which this is but one manifestation. And so I think that the key thing is at some point in the process, how you kind of help that family or whanau understand what’s got them to this place, and how to unravel the kind of complexity of that which sometimes does go back not just one, but two or three generations, so...
Simon Hatcher: How do you deal with people who refuse help?
Mark Benefield: From a policing perspective, I... obviously the prevention side of things is difficult once... to follow on after an attempt, but the people that it’s very difficult to... we have a number that do refuse help, we call in the Health Authorities, they just don’t want to be involved, they don’t want the ambulance here, they don’t want... they don’t want doctors or family members in. We’re left in a quandary sometimes where we have to try and do our best to pass them onto somebody, but we will endeavour on most occasions to pass them onto someone to intervene, to give them that support there and then. But again, sometimes we’re left in that horrible place where we just can’t do that much for them.
David Codyre: For me, first and foremost, it’s about trying to establish a connection, and if I can’t do it, figuring out who might be able to. Because when there is a connection I think that the draw to suicide starts to diminish.
I must admit – and I’m going to put myself out there saying this, and others may disapprove – but I mean if I get to a point where I’ll sometimes use out and out emotional blackmail, i.e. telling a mother or a father that he or she kill themselves they’re murdering their children’s parent, for example, just helping to shock people to seeing outside of the... the kind of place they’ve got to.
But I mean ultimately, you know, I mean ultimately, at the end of the day, sometimes, very rarely, I mean it does get to the point where it is that circumstance where someone else has to take control, I guess, doesn’t it? And that’s where, I guess, police action, but also the Mental Health Act comes into play. And to me, I mean that’s always a very, very last resort, but I mean if it’s what’s required to keep someone alive to get to the other side of it, then that’s what it’s there for.
Irene Walker: Although a whanau member may not want help, they are in a space where they are unwell. And I think it’s only best that whoever’s in that position actually speaks out. And speaks out whether we actually find someone to help them, or whether that be a service or another whanau member who is actually caring for that individual, even if that individual is refusing help, even if they just act as their watchdog.
I think it’s so sad if we leave them ‘well they didn’t want any help, so we didn’t bother to help’. And I think that, in itself, is... is a statement that should be long gone thrown out.
Simon Hatcher: In most languages that I’ve come across there’s no word for ‘suicide’, it’s ‘self murder’, and suicide is a relatively new word in the English language, it’s only been around for like two hundred years. Before that it was always self-murder. And people who committed suicide were treated as murderers. And suicide was only legalised in New Zealand in 1961.
Sarah Gordon: Thank heavens. Really important to always keep... keep trying. I’m really lucky, incredibly lucky that my family just have never, ever given up on me. And they talk about it being continuous, at times feeling like it’s unresolvable, and they’re constantly trying to think of what to do next, and despairing at times when they felt that they’d run out of ideas. They talk about it being like a rollercoaster ride, thinking that you’re on the right track and then realising you’re back to square one. But I just feel I’ve been so lucky because through all that, they just keep going and keep trying to support me, and it’s... it’s unconditional, and that’s why I believe that I’ve had good outcomes, because they’ve never, ever given up on me.
Audience Member: My name’s Teresa, I’m a midwife from Hawkes Bay, and my son, Ryan, committed suicide about twenty months ago, and he was sixteen. And my question is how do I help the community of young Maori friends that he had that are fairly high risk – two of them have since committed suicide over about fifteen months, and they’re on this rollercoaster of drinking to numb the pain, smoking a lot of weed so that they don’t need to feel it anymore. And the texts that we get in the middle of the night, that I can’t do it anymore, you know, do you have any ideas of how we can help?
Karlo Mila-Schaaf: It’s a really hard time to be young right now, and Mason Durie talks about unkind relationships, you know, and how at the end of the day... in my PhD I was looking at Pacific young people, and there were... I looked at a... I did some number-crunching... a thousand Pacific young people, and I was looking at what was protective, like who were the ones that weren’t committing suicide, and why not.
And fundamentally one of the associations that was really strong is the young... like if they were Samoan or Cook Island, if they felt accepted by other Cook Islanders, and they felt accepted by others generally, then they were seventy percent less likely to have made a suicide attempt in the previous year.
And I thought there’s something in that, in feeling accepted no matter what, like, you know, in really unconditional sorts of ways – feeling accepted by your communities, being accepted by the wider community, and not being given up on. It’s really... it’s tough stuff.
I also found that the young people that felt proud of their ethnic identity, and that their cultural values were still important to them, that that was protective of suicide. And I know a colleague of mine using the same dataset, looking at Maori young people, found that feeling comfortable in Pakeha settings was protective for suicide. So those are environments that, in some ways, are not enabling, you know, not enabling a particular group of young people to thrive and feel like their lives are worth living. And so it’s just about realising what you’re up against, and providing as much acceptance and support as you can.
Simon Hatcher: One of the things we’ve been looking at in the research we’ve been doing, which people have talked a lot about here, is sense of belonging. And it’s a really useful idea, because everybody’s got a sense of belonging, it doesn’t... well everyone has culture. And it’s a bit like tree roots.
What we’ve been trying to do in the intervention studies we’ve been doing is to try and get people to have deeper roots by improving their sense of belonging, so they’re not blown over by light storms as they come passing through. And it’s a useful conversation to have with people to try and work out where do you belong, and what can you do to increase people’s sense of belonging, and how can you make their roots deeper. And maybe that’s something that... a way of thinking, or a way of approaching this group which might be useful.
The other thing is to give them choices. People... as David’s already said, people end up harming themselves and committing suicide because they’ve run out of choices, they’ve run out of options.
David Codyre: Look, I don’t know if that group of kids have had access just to a supportive place to be able to talk and process what they’ve been through, but I mean that is often really helpful just to help people kind of move out of that same dark place, just to be able to kind of have some facilitated process around sharing grieving and being able to then see a life beyond that.
So I mean it does mean services having to think outside the square, but, you know, I mean Hawkes Bay, like everywhere in the country, has a primary mental health programme, it’s got one... I think one... one only primary care organisation down there. And certainly in the context I work with, we’ve at times just looked at how to flexibly take resource and use it for things such as intervention with a group of kids who are struggling with a particular issue.
Audience Member: I would like to go to the other end of the spectrum... age spectrum. I work with the elderly, and I don’t find a lot of information, a lot of research that’s been done on suicide in the elderly. Sometimes it’s not recognised because they’re frail. I don’t find it in the Maori people that I visit, but I do find it more in Pakeha. They feel that their children are busy... too busy to come and visit, they’re disconnected now. They might move closer to be with their family, and their family suddenly move off someone else.
I want everybody to kind of just give... spare a thought to the elderly in our community that are isolated. I’ve had two suicides in the elderly this year, feeling that they... one after an operation, felt that he was no longer any use to his family.
Irene Walker: For us, from Maoridom], our elderly are actually our rangatira which are... we’re treated at the highest level. And we treasure them dearly. They live with us, or we try to live with them, or they try to move us out – but no... yes, so thank you for your comments.
Mark Benefield: Our communities, especially metropolitan-wise, we’ve lost that sense of identity and the belonging to a community. One of our strategies is around increasing that awareness around... a) to assist us, to reduce demand on our calls for service, is to try and align our communities into neighbourhood policing teams is one strategy that we’re looking at, and that’s where we’re going to throw resources into small communities to fix their problems – not what we perceive their problems, you know, generally we’ll all come and say ‘ay, it’s burglary’, and in fact sometimes we know it happens, but that’s not what they’re really caring about, they care about some elderly, they might be fearful. And our main aim is going to be ‘Be Safe, Feel Safe’. Albeit we always look at crime, but as you can see, eight thousand eight hundred calls for service related to suicide is a major part that we want to reduce so we can go out and do more crime prevention as opposed... so community is where it sits in my... well, from our perspective.
If the same emphasis on the road toll was put into suicide, we could maybe do something.
Irene Walker: Just for our elderly, for Maori, their... our kaumatua are one of the greatest assets that we have in suicide prevention, and that’s because they hold all the knowledge.
So for our elderly within the community, we need to use them as much as we can. And I... and also for them, they also feel that sense of belonging. And just by telling stories, that also helps our rangatahi through as well. That’s our young people through.
Audience Member: I’ve just got a question, you talk a lot about the importance of being in community, and the importance of them being accepted and feeling like they belong. I just want to know if, and what is done for them to be encouraged to be in community, outside of family, like things like going to youth groups, or community youth centres, being a part of churches or things like that where they can actually find a place to belong, to be accepted, and to feel like they’re in community outside of whanau and family.
David Codyre: Helping someone through the immediate crisis is one thing, but then it’s helping people to establish connections that, for them, are meaningful into whatever there is out there in community is key.
I mean personal relationships are important, but also linking people into other things, and I think that’s where, with the Mental Health services, the value of having community and peer support kind of roles, to help people develop those connections and, you know, bridge them through the process of them feeling they belong in places.
Sarah Gordon: Relationships are just so key, and, you know, people who have attempted suicide or are at risk of suicide, generally do feel disconnected and there are issues around their relationships. And what is key to their recovery is supporting and enhancing relationships to be re-established, or... and developed.
I know the last time I was in hospital, what the service did when they were working with me on my relationships is sat down and said ‘Now, Sarah, tell us about something that you’d like to go and do in the community’. And I really enjoy getting my nails done, so the first outing that I had in the community with my nurse was to go and get my nails done, and it involved interacting with someone, and talking and that kind of thing.
And when I came to be discharged five months later, the last thing I went to do before I left was I went and got my nails done, and the woman said to me ‘Oh my gosh, you’re so much better than when you first came to see me’, and I said ‘well how do you know?’, and she said ‘well now actually you talk’. And that... it’s those... it takes... the thing about relationships and supporting relationships is that it takes time, and often our services and supports don’t necessarily have that time to be able to support people in that way.
I think it’s also key is about it being the community, rather than us establishing specific groups within the hospital or within services where, you know, all the patients go together and do something together. Because if you’re establishing them in the community in a natural way, then that continues... that continues after the service. And what services, to my mind, should be doing, is working to make themselves redundant. So that means supporting those relationships and those connections through community, not through the service.
Karlo Mila-Schaaf: I’m only speaking here for the Pacific sample, but I did test church go[ers]... I think I’m going to be hit by a bolt of lightning for saying this now in this context, but I did test regular church going and spirituality as being protective, and it actually wasn’t in this case. What... it was protective for substance abuse and other things, so I think ultimately... I’ve been interviewing consumers now around their experiences, and some of their experiences have been that they wish that there was more understanding within those church groups, so I think the issue is that the relationships are positive and accepting. Just because you asked specifically about youth group, that’s... that was what came through as statistically significant.
Audience Member: What I am afraid, and I know that for certain, that the issues around the drugs effect on sui[cide]...
Simon Hatcher: So the question is about the paradox that antidepressants can make you more depressed and suicidal.
David Codyre: Across the board, for some people who are severely depressed, medication is a part of lifting them above water enough to then be able to do the other things to help get well. But on the other hand, it is true that there are a sub-group of people who, for any particular medication, it may actually temporarily at least make mood worse, and induce, or worsen suicidal thoughts and urges, and that is a very real issue, I agree. And I think it’s a complex one, and I don’t think that necessarily it’s addressed that well across the board.
Audience Member: Kia ora. My name’s Ihaka Smith, I’m from Kawerau. I’m pretty shy. I’ve been through a lot in my life. I’ve grown up in life living with my grandmother, and she’s pretty much been the root of my life. She passed away about five years ago, and my life started changing dramatically. I had to start living for myself. Yeah, I had to start living for myself. But my dad – we’re really close – he took me in, took very good care of me. I gave him a lot of trouble after my nan passed, but he still held me in. I’ve been in and out of my mother’s and in my father’s house – they’ve split up – so I’ve been in and out of their houses a lot of times.
Kawerau is known for the youth suicides, it’s really big. It’s not something that we would... it’s not something that we would really like, but it’s really hard in Kawerau. I go to Kawerau College, so we deal with it every day. The college provided support, but you don’t really want to talk to a stranger, you want to talk to people you know. And, so, yeah, during college, or my last year of Intermediate, I started torturing myself, I started to get into a lot of fights, I used to be like a hard-out like kind of gang-affiliated boy. And my dad sat down and had a talk to me, and we got through a lot of stuff, but during college... during college we... we expected life to get better and better, but it’s pretty hard.
A couple of adults in their own time formed a group for the teenagers, or... all the people in harm in Kawerau. They provide support for us, they bring us on trips like we are today, they organise things for us – yesterday we were with Maori Television and it was a pretty awesome experience.
In Kawerau it’s really not a bad town, I love the town, and I know a lot of people, and I do a lot of sports, I help out kids and teenagers, they help me out a lot. I’m not really good at my schoolwork, but I’m good at practical stuff like I could probably set up a recording studio, or something... anything like technical in about a day or two days.
We run functions for our town. A couple of months ago we had a concert for the youth of Kawerau to all come together. It was all free, we got sponsored, we made everything free, did a sausage sizzle at the door and stuff, and it was based around youth suicide in Kawerau and the whole of New Zealand. How do we encourage agencies to see the benefit and the importance of upskilling their staff so that they can better assist people at risk?
Simon Hatcher: Thank you. Thank you for sharing your story and your strength with us. Thank you.
Mark Benefield: In the Police we have major agency partnerships with groups, but training is a major part, especially around suicide and recognising the signs, and the risk factors. So we definitely have a training package for our staff to try and assist people who are at risk, and do the best they can before we pass them on to someone else.
David Codyre: Yeah, the easy answer is just teaching people how to recognise the signs when someone’s at risk, and to know what to do. The harder part, ironically, is just teaching people to listen, to actually see every person as a person and look for what’s going on in their life. And also to not kind of get hardened to it when you’re dealing with it day after day, I mean I think those are the... probably the bigger challenges, and so supporting people to maintain their humanity and doing what is often difficult, challenging and draining work.
Irene Walker: Workforce development, I think, you know, the upskilling of our staff is so important. But most importantly for me, working in Maori suicide prevention, but also with our Maori people, especially our rangatahi, is having appropriate training and resources.
I’m not quite sure if you’ve heard of a resource called Te Whakauruora, which is a resource that was developed for Maori communities, which actually not only focuses on Maori communities, but also an opportunity to work with rangatahi, but also where my world rocks, where... which is on the marae, that allows us to actually practice tikanga that actually helps our... not only our rangatahi, but also our kaumatua who also is sitting in a situation how can they help in this situation as well.
So for me, myself, upskilling is at the upmost. But for me, the upmost of my upskilling comes from my kaumatua, our elders. But even more, it’s from our rangatahi. I learnt a lot from you today, especially the courage for you to stand and korero with us.
