Reducing the Incidence of Suicide in Indigenous Groups – Strengths United through Networks (RISING SUN): Workshop 1

Sponsored by Office for Research on Disparities and Global Mental Health (ORDGMH), NIMH

On September 19-20, 2015, the NIMH Office for Research on Disparities and Global Mental Health (ORDGMH) conducted the first workshop for a new NIMH initiative aimed at suicide prevention among Indigenous people in the circumpolar Arctic. The initiative, Reducing the Incidence of Suicide in Indigenous Groups – Strengths United through Networks (RISING SUN) is a collaborative effort among key international stakeholders from Arctic Council States affected by suicide including mental health researchers, service providers, government officials, and Indigenous community members.

Day 1: Current Understanding of Suicide and Intervention Efforts

I. Mental Health in the Arctic: Successes and Challenges in Suicide Prevention
Presenters from Canada, Greenland, Norway, Russia, and the U.S. Arctic (Alaska) addressed risk factors, difficulties accessing care, and elements of successful interventions. Risk factors include cultural practices, urban vs. rural living, and large social transitions; barriers to care may be cultural, structural, or geographic; and common elements of success include community engagement and involvement, access to local culturally appropriate interventions, and focus on protective factors such as resilience.

II. Community-Based Research on Mental Health and Suicide Prevention: Advances and Gaps
Presenters shared successful examples of community-based research. A Swedish study identified four themes for understanding suicide; these included recognizing suicide as a wildfire (i.e., spreading rapidly and destructively) in the Sami community; suicide as a consequence of the Sami losing their identity; the Sami fighting for their culture; and the difficulties of the Sami gaining access to mental health services. A strengths-based study in Alaska accomplished the following: 100 Indigenous non-problem drinkers were questioned about youth experiences that may have protected them from harm; researchers developed a way to measure the value of intervention; and community-based participatory research developed a toolbox (Qungasvik) for promoting reasons for living and youth sobriety among Yup’ik communities. Examples of recent programs include two science-based suicide prevention programs initiated by community members for the Sami in Sweden and for the Yup’ik in Alaska, as well as a Canadian initiative seeking points of agreement between Western and Indigenous science. Specifically, the aims of the Canadian initiative include ensuring that Indigenous perspectives on mental wellness and resilience inform the work of suicide prevention researchers. Furthermore, another key goal is to combine Western and Indigenous ways of learning and understanding to provide the skills and knowledge upon which young people can build their lives and enhance well-being.

III. Mobilizing Youth for Resilience and Healing
Presenters noted that Indigenous youth are especially affected by suicide and are at the forefront of contemporary changes and challenges. They discussed concerns and promising efforts related to suicide risk among Indigenous youth throughout the Arctic. Concerns included perceptions of individual, interpersonal, institutional, and systemic oppression; current states of personal crisis; historical trauma; inadequate funding; and culturally-incongruent conceptions of wellness and mental health. Some promising efforts were noted, including restricting access to lethal means, support from community adults, venues for sharing feelings without judgment, follow-up after a suicide attempt, talking safely about suicide, and building a network of partners in service delivery. Examples from Nome and Kotzebue, Alaska, demonstrated successful research and prevention efforts by and for Alaska Native youth.

IV. Health Systems for Good Mental Health Outcomes
Presenters discussed structural challenges and advantages within various health care systems in the circumpolar Arctic. Common challenges include language and cultural barriers; distance to services; limited resources and ability to respond in crisis; budget shortfalls; retention of doctors; and high burnout rates among providers – especially those from the community. Positive developments include new after-care service coordination in Alaska and a culturally appropriate mental health facility for Sami in Sweden. There was general agreement that multi-system reforms are needed in health care, education, social services, and criminal justice. Suggested reforms include, but are not limited to, closing the gaps in the continuum of care; integrating primary and behavioral health services; sustaining workforce recruitment, development, and retention; integrating Western and traditional treatment approaches; and data and program evaluation.

Day 2: Overview and Feedback for the RISING SUN Initiative
Dr. Pamela Collins (NIMH/ORDGMH) introduced the RISING SUN initiative and explained the Delphi process that NIMH proposes to use to assemble a toolkit of outcomes and measures to evaluate suicide prevention efforts. The Delphi process is a method for arriving at consensus among multiple stakeholders by asking them questions in repeated rounds. Each round, stakeholders are asked to reprioritize the answers, and all input remains anonymous. Advantages to the Delphi process are that, because it can occur virtually, it is an inexpensive way to potentially engage a lot of people quickly, and it can be done between RISING SUN workshops.

Breakout Session I – Desired Outcomes
Participants indicated that RISING SUN could provide a powerful international platform for outreach and advocacy and expressed optimism about finding solutions to help reduce the incidence of suicide in their communities. Common themes included community-based interventions and holistic approaches. Participants acknowledged the importance of community-based interventions that include Indigenous experts and culturally appropriate guidance on how to best build and support healthy, thriving communities. Inclusion of holistic, traditional approaches were recognized as important because schools, health care centers, and workplaces that are in conflict with traditional ways make community members less likely to use services or see them as supportive.

Breakout Session II – Evaluation of Desired Outcomes
Participants noted that “best outcomes” are community-specific and should be identified by the communities themselves. They discussed the measurement of progress toward desired outcomes and identified key areas of focus, including moving beyond simply measuring the number of suicides, promoting increased discussion of suicide and access to culturally appropriate care, and documenting the number of policy changes around natural resources and land use practices.

Breakout Session III – General Reactions to RISING SUN
Participants discussed the Delphi Process. One discussion group unreservedly supported using the Delphi process, but others wanted to know more about the methodology. Concerns emerged regarding Delphi, a Western-based process, in that it may not align with an Indigenous perspective and may not coincide with stated goals of RISING SUN to place high value on Indigenous knowledge and community-based approaches.

Conclusion
Participants encouraged a modified approach to the iterative process that would favor consensus over compromise, and suggested a consultative process to help move people forward in the healing process. They recommended using the Delphi method in collaboration with traditional knowledge holders to achieve a culturally acceptable process and outcome. Some wording changes were recommended to maintain consistency with Indigenous language. For example, it was suggested that “building consensus” be replaced with the concept of “building a narrative” or in Indigenous terms, “creating a story.”

Given the financial, logistical, and time constraints for completing RISING SUN by the end of the U.S. Arctic Council Chairmanship, a modified Delphi that is integrated with local community-based approaches (e.g., focus group discussions), as appropriate, is likely to be the most effective strategy for building a narrative and setting priorities to reduce the incidence of suicide among Arctic Indigenous communities.