1 presenters alan grochulski. bilingual cross cultural senior clinical consultant marylou edwards....

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PresentersAlan Grochulski. Bilingual Cross Cultural Senior Clinical Consultant

Marylou Edwards. Multicultural Problem Gambling Service Manager

Suicide risk assessment, treatment and management for gambling clients from Culturally

and Linguistically Diverse backgrounds

Responsible Gambling Fund Problem Gambling Counselors Conference - April 2012

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Suicide risk assessment, treatment and management for gambling clients from Culturally and Linguistically Diverse background


• Confidentiality

• Supportive and safe environment

• Share our professional experiences

• Interaction that generates questions and discussion

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Learning objectives

• Participants will develop an increased knowledge of clinical practices for suicide assessment, management and treatment of the CALD client in the gambling sector.

• Participants will differentiate the risk factors CALD clients experience from different cultural backgrounds.

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Exercise 1

What do you want to take home

from today’s practice forum?

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Terminology

• Attempted Suicide A suicide act not resulting in death

• Completed Suicide A suicidal act resulting in death

• Deliberate self harm Self harming behaviour or actions causing injury or damage which

may not be accompanied by a clear suicide intent

• Suicide prevention Activities aimed at reducing the rate of death, disability (mortality

and morbidity) resulting from, and risk factors linked to suicidal acts

NSW Suicide Prevention Strategy


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Terminology

• Suicidal ideation Thoughts about suicidal acts

• Suicidal threats Actions suggesting an intention to die from suicide or self-harm

• Suicidal act Self-inflicted injury with an intention to die from suicide, including self-poisoning, possibly resulting in death or serious injury

• Suicidal behaviour Suicidal ideation, suicidal threats or suicidal acts

NSW Suicide Prevention Strategy


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It is estimated that in NSW

• In a given year, up to 90,000 individuals may show possible suicidal behaviour

• In a given year, as many as 30,000 individuals in NSW may attempt suicide

• In a given year, more than 700 individuals in NSW will die from suicide

• Since 1991, more individuals in NSW have died from suicide than road injury

(Sayer et al., 1996)

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Leading causes of death for MEN every year since 1993

• Hanging (2004: 49% of male suicide deaths)

• Poisoning by motor vehicle gas (or other gases and vapors)

• Firearms

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Leading causes of death for WOMEN since 1997

• Hanging (2004: 40% of female suicide deaths)

• Poisoning by drugs• Poisoning by motor vehicle gas (or other

gases and vapors)

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Differences in cultural suicide rates

Prevalence rates of attempted and completed suicide are significantly different across the world. However, due to limitations of data collection, these differences should be considered carefully.

Documented rates are highest in Eastern European countries, such as Lithuania and the Russian Federation

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Prevalence rates of attempted and completed suicide are lowest in countries of Central and South America, such as Peru, Mexico, Brazil and Colombia.

The United States, Western Europe and Asia fall in the middle range.

Unfortunately, for many countries in Africa and some countries in South-East Asia suicide statistics are not yet available.

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• NSW has one of the largest proportions of immigrant populations worldwide (AIHW, 2008)

• 2006 Census (DIAC, 2007)– 45% of all Australians were born overseas or have at

least one parent who was born overseas.

• 1999-2009: Increased diversity (ABS, 2010)– Decline in proportion of immigrants from North west

Europe, Southern and Eastern Europe

– Most rapidly growing population groups are those born in China, India and Iraq.


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McDonald & Steel, 1997•13,580 suicide deaths (1970-1992)•26.5% (1 in 4) overseas born

Australia 2008 (ABS):•2172 suicide deaths, 24% people born overseas

Dusevic, Baume, & Malak (2002) •Cross-Cultural Suicide Prevention, A framework


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Ways of understanding suicide

A behaviour that seeks and finds the solution to an existential problem by making an attempt on the life of the subject… (Beacher, 1972)

The failure of all defence mechanisms… (Freud, 1985)

An individual’s last message to the world… (Wilson, 1994)

An act with a fatal outcome that is deliberately initiated and performed by the person himself or herself in the knowledge, or expectation, of its fatal outcome (WHO, 1997)

A deadly violence directed against self… (Hassan, 1995)

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Ways of understanding suicide

Death from injury, poisoning or suffocation where there is evidence (either explicit or implicit) that the injury was self-inflicted and that the person intended to kill himself/herself (O’Carroll, Berman, Maris, Moscicki, Tanney & Silverman, 1996)

The termination of an individual’s life resulting directly or indirectly from a positive or negative act of the victim himself which he knows will produce this fatal result (Durkheim, 1975)

A fundamental human right… (Szasz, 1978)

Destructive aggression turned inwards… (Kniesl, 1994)

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Exercise: 2

How do these explanations fit into your own views, model and experiences with suicidal clients?

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Kessler – 10 (K10)

• People who score 16-30 on the K10 have 3 times the population risk of making a suicide attempt.

• People who score 30-50 have 20 times the population risk of making a suicide attempt.

www.crufad.org/K10/supportindex.html

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The process

Cause—Psychological stress which becomes unendurable

Stressors—Frustrated psychological needs

Purpose—Try to find a solution

Goal—End ‘consciousness’Schneidman, 1985


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Emotion—Helplessness-hopelessness

Attitude—Internal ambivalence

Mental state—Narrowed constricted

Interpersonal acts—Communication of intent

Action—Find a “way out”Schneidman, 1985


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Exercise 3Discuss with the persons next to you the following:

1. What are the major risk issues

for our gambling clients?

2. Provide a example of a client you have worked with that exhibited these risk issues.

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High risk factors

• At risk mental state, hopelessness, despair, agitation, shame, guilt, anger, psychosis, psychotic thought process, impulsivity, depression

• Recent psychiatric admission

• Recent interpersonal crisis especially separation, rejection, humiliation

• Past/recent suicide attempt

• Recent major loss or trauma or anniversary

• Drug / alcohol intoxication or withdrawal state

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High risk factors

• Chronic pain or illness• Financial difficulties, unemployment• Impending legal prosecution or child custody issues• Cultural or religious conflict• Lack of social support network• Unwillingness to accept help• Definite plan, high intent• Access to means (e.g. guns, medication, poison) and

preparation for attempt

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At risk groups within CALD communities include:

• Older people• Male migrants residing in rural and remote areas• Immigrant women when compared to Australian born

women • Refugees and asylum seekers.• Difficulty accessing help due to language barriers, lack of

information, lack of support or negative experiences with mental health services or government departments prior to immigration

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If suicidal thoughts are suspected ask:

• Have things been so bad lately that you have thought you would rather not be here/ or alive

• Have you had any thoughts of harming yourself?• Have you had any thoughts about killing yourself?• Do you have a plan of what you might do?• Have you had any thoughts about harming someone else?

i.e.. Partner, children or others

Does your service have a policy or procedure for reporting risk or firearms access to Police or other service providers?

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Exercise 4

What are your obligations when assessing a suicidal client?

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Principles of managing individuals with suicidal behaviour

•Engaging the individual •Maintaining the safety of the individual•Ensuring 24 hour access to clinical support•A co-ordinated approach which relates assessment data to the management plan•Addressing any concurrent mental health or drug and alcohol-related issues•Ascertaining possible support mechanisms

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Principles of managing individuals with suicidal behaviour

•Maintaining a non-judgemental and caring stance•Involving the individual in management planning•Documenting the management plan•Providing ongoing assessment •Ensuring ongoing consultation with more experienced colleagues •Providing appropriate follow-up• Keeping up-to-date on available resources

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Detail any suicide plan - Consider:• The means• Preparations• Lethality• Likelihood of intervention and rescue• Planning versus impulsiveness• Determination versus ambivalence

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Referral to a Mental Health Service should be made for the following presentations:

• Persons who present following a suicide attempt or an episode of self-harm

• Those that are preparing for suicide that have definite plans and/or means

• Persons with probable mental illness or disorder• Persons whose presentations suggest a probable mental

health problem• Persons who report accidental overdoses, unexplained

somatic complaints, report repeated accidents, increased risk taking behavior, self harming behaviors,

• Recent assessment by Mental Health Services or recent discharge from hospital for suicide risk or attempt

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Exercise 5

Group discussion of the MHOAT Risk Assessment form

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Risk rating:• High• Medium• Low • Nil

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Exercise 6

Interventions for High risk rating?

What would you do and why?

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Exercise 7

Interventions for Medium risk rating?


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Exercise 8

Interventions for Low risk rating?


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Exercise 9

Interventions for No risk rating?


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Summary for management

Maximizing safety

• Obtaining assistance from others• Immediate risk: never left alone until transported to

hospital or the arrival of a mental health service• Mental Health Act could be invoked• Referral to a Mental Health Service for a

comprehensive mental health assessment including risk assessment

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Review of your take home objectives from the practice forum

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Self care issues - Self• Ensure clinical supervision • Don’t be ashamed to admit if you’re not coping• Practise the self-care skills you already possess• Accept assistance when offered• Be aware of the personal effects of working with

individuals with possible suicidal behaviour• Allow yourself time to grieve

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Self care issues - Peers• Encourage personal care• Support with respect, validation and

reassurance• Share workload where possible• Accept them if they’re not coping

• Be available for informal debriefing

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Self care issues - Organisational• Availability of professional staff support and

counselling• Structural response to suicide death• More education on suicide issues• Sensitivity to individual responses to suicide• Clear policies and guidelines linked to the

management of suicidal clients• Suicide audits—to improve mental health services• Clinical supervision

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Exercise 10

What techniques do you use for your own self care?

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The presenters wish to acknowledge Ms Maria Cassaniti, Centre Manager for

the NSW Transcultural Mental Health Centre for the use of her slides for

parts of this presentation



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www.dhi.gov.au/mpgs

1 presenters alan grochulski. bilingual cross cultural senior clinical consultant marylou edwards....

Documents

gambling clients

suicide assessment

gambling sector

suicide act

terminologyattempted

deathcompleted suicide

harm suicidal act

risk factors cald clients