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Case: Lucy’s Story 

• Lucy is a 16-year-old First Nations youth from Sachigo Lake First Nation (a remote, fly-in community in northwestern Ontario), previously living at home with her parents and has five other siblings.


• Lucy presents to your walk-in clinic in Ottawa stating she wants to end her life. 


• Lucy is thinking of hanging herself in the bathroom of the house she has been staying at, however she has not obtained any rope.

• She is a survivor of childhood sexual abuse from an uncle (himself a survivor of childhood abuse and residential schooling), starting at age 11.

• A few months ago, she and her grandmother came to Ottawa. Lucy came acting as an escort for her grandmother to see a specialist at the Ottawa Hospital.  â€¨
• She is quite close to her grandmother; they speak Ojibwe together and she learned how to cook traditional foods from her.  â€¨
• Unfortunately, her grandmother was admitted to hospital, and Lucy began to explore the city on her own.  â€¨
• She quickly connected with transient youth in the downtown core who “hooked her up” with “something better than oxy’s.” Her fentanyl addiction quickly spiralled out of control, and in order to pay for her drug use, she turned to prostitution.

• Lucy just saw on Facebook that her ex-boyfriend in Sachigo Lake died by hanging last week.


Past History including Substance use


• At age 12, she began experimenting with oxycodone. 

• At age 15, she was using injection opioids.  â€¨

• Both of Lucy’s parents attended residential school in Kenora, Ontario before being returned to their community.  â€¨
• Lucy and her siblings have been apprehended multiple times by Tikinagan Family Services and placed in the care of family members in Sachigo Lake and neighbouring communities because of her parents’ substance abuse and frequent reports of violence.  â€¨

Epidemiology

• Colonization has been devastating for the mental health of Indigenous peoples.

• Before European contact, suicide was rare among Indigenous people, but since then, rates of suicide have risen to several times the Canadian average. (1,4)

  • Inuit suicide rates:

    • 6-11 times the Canadian average (1,2)

    • 101.6 per 100,000 for males; 41.6 per 100,000 for females (5) 

  • First Nations suicide rates:

    • 5 to 6 times the Canadian average (3)

    • 30.0 per 100,000 for males; 25.5 per 100,000 for females (5) 

  • Métis:

    • Because of the way data is collected, rates of suicide in Métis children and youth are difficult to estimate. (2) 

• Indigenous youth likely to die by suicide tend to: (4)

  • Be male, young and single

  • Have been drinking alcohol

  • Have used highly lethal means (guns and hanging)

  • Occur in clusters

• Half of the youth who die by suicide were seen by a primary care provider in the six months before their death, and up to 90% have well-documented untreated (or inadequately treated) mental health issues such as depression and substance abuse. (6)


Terms

Background and History

• Population of 45,000, divided into four main regions of the Canadian Arctic, each with its own association and land claim agreement: Nunatsiavut (Labrador); Nunavik (northern Quebec); Nunavut; and Inuvialuit (western Arctic).

• Language: Inuktitut (Inuvialuktun spoken in the western Arctic).

• Diet: “country foods” include sea and land mammals (whale, seal and polar bear) and berries.

• Perilous conditions in traditional nomadic camps demanded healthy social and psychological systems:

• Highly developed interpersonal communication skills included intentional listening; giving/receiving respectful advice; and strategic use of humour and silence.

• Customary adoption: children were fluidly accepted into the homes of adoptive parents.

• Men and women all actively shared responsibility for child-rearing, including the teaching of Inuit law, guiding development and providing discipline.

• Elders were treated with great respect. They held authority over community law and were responsible for sharing accumulated knowledge.

• Feasts, drum dancing, throat singing and games of dexterity and skill were the centre of community life.

• The circle represented “cyclical aspects of birth, life and death, as well as seasonal cycles marking changes in lifestyle, food, social activities and ceremonies.” (2)

• Medicines were derived from plants and animals.

• First contact with Europeans:

• Frobisher on his quest for the Northwest Passage in the 1500s first encountered the Inuit, and this was followed by European whalers in the mid-1700s.

• In the 1950s, discovery of rich mineral deposits and the demand for strategic NATO air bases marked the onset of forced relocation of the Inuit from ancestral homes and hunting territories to centralized, government-built settlements.


• Population of 734,000 registered First Nations people (does not include non-status First Nations people).

• 57% live on reserves; the remainder often live in larger cities.

• Prior to European contact, there were six major cultural regions: Woodland First Nations in the east, Iroquois First Nations of southeastern Ontario and Quebec, Plains First Nations of the Prairies, Plateau First Nations, Pacific Coast First Nations and First Nations of the Mackenzie and the Yukon River basins.

• Many regional differences in language and customs exist. A general cultural overview is provided below.

• Family structure was matrilineal; clans were comprised of extended families descended from a common female ancestor.

• Gender and gender roles were fluid concepts; however, in general, women were the owners of houses and agricultural land and were responsible for decision making. The men carried out these decisions as well and acted as providers and defenders of the family.  â€¨
• Children learned proper behavior by modelling adults or experiencing the consequences of their misbehaviour and were not disciplined by European standards.

• First Nations peoples were highly skilled in agriculture and willingly shared their knowledge of crop cultivation, particularly with corn, tobacco, and potatoes.

• They prepared, preserved and compounded many medicines (quinine, ipecac, salicin, cathartic laxatives, black cohosh, petroleum jelly).

• The Medicine Wheel is a powerful symbol which “represents balance and completeness in the universe within a framework of ongoing cyclical change and transformation.” (2)


• Population of 292,000 spread throughout Canada, with more than two-thirds living in western urban centres.

• Historically, the term “Métis” applied to the children of French traders and Cree women in the Prairies, and of British traders and Dene women in the North.

• Today, the term is broadly used to describe a group of people of mixed First Nations and European ancestry who can trace their lineage back to traditional Métis Nation territory and see themselves as distinct from other Indigenous people.

• After the fur trade was well established by the Hudson’s Bay Trading Company, a distinct Métis identity began to emerge:

  • Subsistence farming and the biannual buffalo hunt, as well as logging and mining, were a large part of Métis livelihood.

  • Women “produced clothing and footwear for trade, tanned hides, trapped and traded furs, dressed furs for shipment, grew vegetables, fished, built smoking lodges, smoked fish, as well as buffalo, for pemmican, and produced and sold large quantities of a dried fish gelatin.” (2)

  • Many retained strong ties to the Roman Catholic faith as well as aspects of their First Nations spiritual traditions.

• Ancestral knowledge of the healing qualities of things found in nature such as plants, roots and bark was passed down through the generations.

• Language: Michif is a mixture of French nouns tied to the Cree verb system.


Effects of Colonization on Indigenous Peoples 

• The goal of the federal residential school policy was to aggressively assimilate Indigenous children into mainstream Canadian society through physical and cultural disconnection from their families and communities.

• The Indian Act legally removed the rights of Indigenous parents and gave the government authority to remove Indigenous children from their families and place them in residential schools, operated by the four major churches of Canada and designed to “civilize and Christianize” them. (8)

• Many Indigenous students endured what is described as “ritualized abuse” in these schools to further the goal of Indigenous ethnogenocide:

  • Cultural suppression meant children were taught to shame and reject everything about their heritage, ancestors, families and spiritual traditions.

  • Children grew up in institutions, forbidden to speak in their languages, taught that their parents were savages, and forced to adopt a new religion.

  • Many children experienced physical and sexual abuse by multiple perpetrators throughout their entire childhoods.

• Although all churches involved, as well as the Federal Government, have now apologized for their involvement in this tragedy, a great deal of further healing is needed to repair the damage that continues to ripple across generations.


• Imagine being the happy parent of a young child. Then one day, some stranger along with a police officer come to your door and tell you that they are taking your child away. You haven't anything wrong, but that's the law.    
• Following the closure of many residential schools, the Department of Indian Affairs ordered large numbers of First Nations children to be apprehended from their families and placed in non-Indigenous foster homes. (9)

• “By the end of the 1960s, 30%–40% of the children who were wards of the state were Aboriginal, compared to only 1% in 1959.” (8)


• Historical traumas are the “traumatic experiences that are cumulative over the lifespan of individuals, as well as across generations.” (2)

• Survivors of the residential school system grew up without traditional role models for what constitutes a healthy family and healthy relationships.

• Experiences of their own damaged childhoods left residential school survivors few strategies for living other than unacceptable ones, such as violence, abuse, addictions and self-destructive behaviour. (8)

• Residential school survivors often sought refuge in marriage and partnerships. But their own lack of secure childhood attachments meant that they struggled with the complex demands of intimate relationships and parenting, often leaving their children feeling abandoned. (2,8)

• There is an additional loss of Indigenous tradition because of the fractured relationship between children and Elders. (10)

• Disempowerment and loss of self-efficacy were the results of forced sedentarization and social disorganization. (9,10)

• The legacy of the residential school system is “lateral violence” (or intergenerational trauma), a cycle in which the physically or sexually abused become perpetrators themselves. (9,10)

  • 25% of Indigenous women and 13% of men report experiencing violence from a current or previous partner over the past five years; 57% of the women who experienced abuse reported their children had witnessed it. (2)

  • The ratio of Indigenous to non-Indigenous children in the care of a Children’s Aid Society is 7 to 1. (2)

  • Up to 30–40% of children and youth placed in foster care are Indigenous. In fact, there are more living in out-of home care than there were in residential schools at the height of the residential school movement. Additionally, there is a growing trend toward placing Indigenous children in group or institutional care (11)


Clinical Environment

The physical environment of the clinic and your waiting areas can send a powerful message to everyone (including cis-people (i.e. non-LGBTQIA people) as well as to non-Indigenous people) that your clinic is an accepting environment:

• Consider using scents (e.g. cedar), Indigenous artwork and warm earth tone colours.  (7,12)

• Ensure that staff are welcoming and inclusive. Consider cultural competency training for your employees, as part of their professional development.  â€¨
• Use discreet monitoring/safety alerts and barrier-free spaces (11)

• To make your clinic a culturally safe place, having these in the waiting area and the clinic, after first asking a local LGBTQIA organization and/or Indigenous health group for what they would recommend:
  • Rainbow flags or materials to help LGBTQIA patients feel at ease
.
  • Culturally appropriate resource material to help Indigenous patients (2,12)

  • Advertisements for local cultural events
. 
  • Place condoms and shelter information in washrooms and other discrete locations
.  


General Principles 

• Create cultural safety, by understanding how power imbalances, discrimination and colonial relationships have affected Indigenous peoples (12)
, which ultimately leads to better health outcomes (7).
  
  Cultural safety is an endpoint in a continuum of care, whose steps include: 

  • Awareness: This continuum starts with awareness, an acknowledgment of difference between the cultures of provider and patient.
  • Sensitivity: The next level up is sensitivity, which respects the cultural difference.
  • Cultural competence refers to the provider having skills and attitudes for cultural safety. Cultural safety includes the previous phases, but it also includes self-reflection leading to empathy, advocacy and understanding. Cultural safety promotes better health outcomes.
     

• Avoid re-victimization. “Re-victimization” happens when circumstances replicate the original abuse experienced by survivors. They can feel disempowerment, disconnection or pain. (2)

   

• Build trust and connection: (2,7)


  • Accept that the patient may not trust you. The power imbalances between Indigenous youth and non-Indigenous care providers are increased by the historical treatment of Indigenous peoples. In addition, you are an adult, and this youth may not have experienced adults as sufficiently caring and protective.

  • Provide unconditional compassion.


  • Be present and pay close attention.


  • Listen. Seek first to understand.


  • Foster an atmosphere of safety and hope.

     

• Use a patient-centred approach:


  • Try to be flexible if the patient is late for appointments.


  • Patients may have beliefs about causes and cures that do not fit with established medical views. Take time to understand those beliefs and how they may impact treatment. (12)


  • Engage youth in shared decision-making about their treatment, and be careful not to impose directives. (2)


  • Coordinate services so that multiple disclosures are not necessary, and screen or educate referral services about practices that may re-victimize patients. (2)


  • Allow time for traditional healing ceremonies. (12)

     

• Use non-verbal communication:


  • Make youth feel visible and welcome with brief eye contact and a warm smile.  (7) 


  • Pay attention to body language and non-verbal cues. Inuit, in particular, may only nod or blink to acknowledge understanding, raise eyebrows to indicate yes and wrinkle nose for no.


  • Be silent when appropriate (2). Being silent is a way of accepting others, is a highly respected skill and is considered a form of healing itself. When a person shares in a healing circle, there is no interruption. Non-interference is highly valued.


  • Inuit have the longest pause time of any culture. Speaking too much or too quickly may undermine trust. (2)

     

• Verbal communication:


  • Greet patients in their Indigenous language (7), for example: 


    • Inuktitut:  Good morning = Ublaahatkut


    • Ojibwe (an Algonquian language): Hello = Bozhoo


  • Avoid immediate direct and personal questions at onset of relationship.


  • Consider the spirit and intent of all questions and be able to explain the purpose of the information requested. (7)


  • Provide explanations in appropriate, respectful plain language without medical jargon (12)


  • Use a cultural interpreter where appropriate; cultural interpreters not only translate language, but are able to take into account the cultural background of the patient. (10,12)


History and Risk Assessment

Differential Diagnoses and Comorbid Conditions Seen with Suicidal Ideation

• Depressive disorders, including major depressive disorder, adjustment disorder, persistent dysphoric disorder and bipolar disorders

• Anxiety disorders

• Psychotic disorders, e.g. schizophrenia, substance-induced psychotic disorder

• Post-traumatic stress disorder (PTSD)

• Alcohol / substance use disorders

• Oppositional defiant disorder / conduct disorder
• Cluster B personality traits (borderline personality traits, antisocial personality traits) 


Physical Exam (Px)

Investigations

• Strongly consider a pregnancy test in young women.


Prevention of Suicidal Ideation in Primary Care

• Be optimistic and hopeful, which encourages hope in your patient


• Use a holistic, integrative approach that "seeks to balance the mind, body, and spirit with community and environment” and is strongly related to the social determinants of health. (21)


• Help youth find meaning in their lives and discover a sense of belonging with their peers, families, communities and culture through:

  • Engagement in sports

  • Helping others

  • Traditional activities. (20)


• Consider referral to healthy parenting programs. (3)


• Consider therapeutic programs and activities that may be able to help with life skills, self-acceptance, healthy relationships, coping strategies for depression anger, as well as health-promoting skills and a sense of well-being, self-esteem and competency. (4)


• Recreation programs (8) can be a way out of the monotonous life of non-work and non-school that faces so many Indigenous youth and help them develop physical, social and emotional skills and self-confidence.  â€¨

Management of Suicidal Ideation in Primary Care

• Consider referral to more specialized mental health services such as a crisis centre, particularly if the centre is run by Indigenous persons. (10)

• Strict supervision is essential for anyone considered to be at high risk of an immediate suicide attempt, until the crisis has passed. (8)

• This may necessitate hospitalization and transfer to a tertiary care centre, if working in a remote or rural area.


• Limit the patient's access to lethal methods used for suicide. 
Ensure that family members safely store all medications and poisonous substances and remove all firearms and closet rods from home. (8,10,16) 

   
• Advise the patient to abstain alcohol and other substances.
   
• Refer for detoxification or substance use treatment as necessary.

   
• Create a Safety Plan with the youth and family, including key strategies that can be used in times of crisis or stress. A safety plan is written down and can be carried with the youth at all times (13). It typically includes:  â€¨
  • What 3 things can I do that are meaningful for me?

  • If I am starting to get stressed, what are 3 things that are calming and soothing for me?

  • Which adults can I call when I am starting to feel sad or worried?

  • What are my reasons for living?

  • Who are my trusted resources I can call if I don’t feel better? Include their phone numbers.

  • What are my local emergency services and how do I contact them?

  • What local professional can I call or go see?

  • Sample crisis plan on eMentalHealth.ca
     
• Refer to mental health supports/treatment. Effectiveness and cultural appropriateness of psychotherapy has not been conclusively demonstrated for Indigenous peoples, however, consider referral to: (8)

  • “Just” therapy (2): 
Considers the historical, social and political context of Indigenous people, reduces their feelings of self-blame and guilt, and fosters empowerment.

  • Mindfulness therapy (22): Is consistent with traditional Indigenous ways of being and may help youth to connect to their inner wisdom.
 Decreases stress, impulsivity and distress intolerance by increasing self-regulation and emotional regulation skills.

  • Counselling with Elders:
 Counsel provided directly to youth, but primary care providers can also advise caregivers on how to use culturally appropriate psychotherapeutic techniques. (10)

     
• Refer to cultural supports, which are essential in effective healing work with Indigenous people (2). 

   
• Coordinate care and care planning:
 Many Indigenous centres have care coordinators who can help youth access and navigate the available services.
 Ensure close follow-up with at least one consistent professional.


• Support and aftercare: (8)

  • Ensure appropriate follow-up. The “simple effort to contact someone after the acute crisis or hospitalization is over may send a powerful message of caring and concern.” (10)

  • “Interventions that increase contact between youth and trained professionals show promise in preventing youth suicide attempts and suicidal ideation.” (6)

     
• Cultural enhancement: (4)

  • Refer to cultural supports (2). “Culture is treatment, and all healing is spiritual.” (1)

  • Help promote meaningful relationships between youth and Elders (3). An Elder is “someone who is considered exceptionally wise in the ways of their culture and the teachings of the Great Spirit. They are recognized for their wisdom, their stability, their humour and their ability to know what is appropriate in a particular situation. The community looks to them for guidance and sound judgement.” (2)

  • Strengthen the cultural identity of youth in “order to provide them with a feeling of security, a sense of belonging, and hope for the future” (4). Reinforce with youth the importance of Indigenous culture and traditions.
    

• Traditional healing practices: (2,4,22)

  • Promote traditional healing practices so that the young person can:

  • Recognize and stop using unhealthy coping strategies.

  • Start using positive healing strategies.

  • Examples of traditional healing practices that may be used by Elders:

  • Healing circles: connect with others through mutual disclosure
  • Smudging: cleanse negative energy by burning sage, sweetgrass or tobacco
  • Prayer: communicate with the creative spirit of the universe
  • Sacred objects: eagle feather or talking stick guide the circle
  • Dream imagery: gain insight on a person’s life journey
  • Sweat lodge: cleansing and purification ceremony
  • Lighting of the qulliq: honour the spirit and wisdom of the ancestors
  • Dance: honour connections with community.
  • Drum dancing (Inuit), Reveillons jigs (Métis), Pow Wows and Sunrise Ceremonies (First Nations)
  • Vision quest: developmental ritual at adolescence of self-reflection and self-understanding
  • Fasting: seek new direction in life by shedding old or negative energy and replenishing positive energy
  • Seven sacred gifts (Respect, Humility, Compassion, Honesty, Truth, Wisdom and Love): everyone was given gifts from the Creator at birth to use as medicine for the mind, body, heart and spirit
  • Art and music (new trend for Indigenous youth to engage in learning rap music)
  • Humour and play (traditional Inuit throat singing and games with goal of making opponent laugh)

• Support the survivors with follow-up services and education prevention to reduce the risk of contagion and suicide clusters. (3)


Case: Lucy’s Story, Part 2  

• Your risk assessment shows that Lucy is not in immediate danger of ending her life.

• You notice that she is not yet connected to any Indigenous supports and services. You contact Minwaashin Lodge, which provides culturally appropriate, Indigenous mental health support as well as a drop-in, and you are able to set up an appointment for her to meet with an intake worker. The worker will help her find safe housing following a short stay in a detoxification centre.

• You give Lucy the phone number for the agency (and name of worker), as well as the local crisis line number.

• As her grandmother is admitted to hospital, you also leave a message with her grandmother’s doctor to see if there is a social worker at the hospital who can help support Lucy.

• You also encourage Lucy to seek wisdom and counsel from her grandmother or an Elder at one of the Elder’s Lodges.

• You make a follow-up appointment for Lucy to see you in a week or so, in order to continue getting to know her.

• You will attempt to: 1) ensure she is connected to healthy adults, and 2) encourage her to connect to people and activities that give her a sense of meaning and belonging.


Patient and Family Education  

• eMentalHealth.ca has a variety of handouts written specifically for parents and written specifically for youth. Although the information is not tailored for Indigenous people, the approach to depression, anxiety and other conditions is based on attachment and strengthening the child/youth’s connection to healthy people. This is similar to the First Nations concept of mental wellness. Relevant topics for children/youth feeling suicidal include: 1) suicide; 2) depression; 3) self-cutting; 4) safety plans; and 5) self-compassion.
  http://www.eMentalHealth.ca
   
• Child & Teen Suicide Prevention - Government of British Columbia
  http://www2.gov.bc.ca/gov/content/health/managing-your-health/mental-health-substance-use/child-teen-mental-health/child-teen-suicide-prevention
   
• Suicide - Teen Mental Health - Information from Dr. Stan Kutcher's team 
  http://teenmentalhealth.org/learn/suicide/

For Youth

• "Darkness Calls" is a graphic novel on suicide for youth, visual learners and hard to reach populations by Steve Sanderson and The Healthy Aboriginal Network.
  http://ccamhr.ca/resources/Darkness_Calls.pdf
  http://www.turtleisland.org/healing/abcomic1.pdf  

Medication Treatment

• If non-medication strategies have not been helpful, then consider medications for treatable conditions such as anxiety and depression.

• Antidepressants may increase short-term suicide risk in some adolescents. However, this increase is balanced by overall reductions in suicide-related behaviours associated with drug treatment of adolescent depression. (6)

• If there are issues with addictions, consult with addiction medicine specialists, as there may be options such as anti-craving medications or opioid antagonists in older youth/young adults
.

When to Refer

• Refer to Psychiatry for the diagnosis and treatment of any psychiatric illness you are uncomfortable managing in primary care.

• ALWAYS include referral to Indigenous programs that enhance cultural connection.


Where to Refer in Ottawa, Ontario

Clinical Guidelines

Wilson D et al.: Health Professionals Working with First Nations, Inuit, and Métis Consensus Guideline, J. Obstet Gynaecol Can 2013; 35(6):550-553. 
http://www.jogc.com/article/S1701-2163(15)30915-4/pdf 

Further Reading

http://nnapf.com/first-nations-mental-wellness-continuum-framework/

Quiz Questions

Summary 

About This Document

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