Adapting a zero suicide approach to Indigenous communities

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May 2, 2022 — Edwina Valdo found herself on the receiving end of a desperate phone call last year on the Acoma Pueblo Behavioral Health Services suicide hotline in New Mexico. Valdo, whose regular job is as a grants manager, was filling in because the pandemic had left the institution short-staffed.

“I did my best to keep her on the phone, to try to find out where she was and who she was,” says Valdo, a member of the Pueblo of Acoma tribe in New Mexico.

The caller told Valdo that she was being verbally abused at home and had suicidal thoughts. Because the woman did not want to involve law enforcement or emergency services, Valdo drove her to a local shelter herself.

“I was really happy to be able to be there for her,” says Valdo. “She was one of mine, so I was more than happy to support her in this time of crisis.”

Acoma is one of eight Indian Health Service-supported sites working to adapt a long-established suicide prevention program known as the Zero Suicide Initiative to their communities. Institutions are at the forefront of a culturally competent approach to suicide care that combines research-based practices with traditional healing, even in the face of funding challenges and lingering suicide stigma.

Customizing Zero Suicide for Indigenous Peoples

Native Americans have the the highest suicide rates of any racial or ethnic group in the United States. In the first year of the COVID-19 pandemic, a National Council for Mental Wellness survey found that 45% of Native American adults reported having more stress and mental health issues, while only 24% had received treatment for mental health.

While Native Americans have high suicide rates and unique cultural challenges, prevention programs have rarely been designed for their specific needs.

Zero Suicide is a widespread suicide program that was first launched in 2012, promoting the adoption of “zero suicide” as a goal across all US healthcare systems. He has since mobilized the field of suicide care worldwide.

The program uses seven components, including suicide risk assessment, working with patients on safety plans, suicide-specific treatment, and follow-up care. It also expands suicide prevention training for healthcare workers and engages the wider community, including family members of those receiving care.

This model was shown at work in the general population but has not been validated for indigenous communities. Research on effective suicide prevention in Indigenous communities is sparse, says Sadé Heart of the Hawk Ali, tribal leader and senior project associate for the Zero Suicide Institute in Waltham, MA.

One reason is that federal funding is rarely available to support ideas like traditional healing, says William Hartmann, PhD, assistant professor of clinical psychology at the University of Washington.

“This is one of the biggest challenges I’ve heard administrators in community health organizations tackle,” he says. “How to reconcile local visions of health and well-being with what is reasonably fundable by the federal government. »

Zero Suicide has since developed a accompanying toolkit which recommends how to use the program in Indigenous communities. The toolkit offers steps for adapting the program to indigenous-serving health systems that are owned or operated by the Indian Health Service (IHS) tribe.

IHS, a US government agency that provides medical and public health resources to Indigenous communities, launched its Zero Suicide Initiative at 10 Indigenous health sites in 2016. Last November, IHS announced $46.4 million in financing to help expand behavioral health programs. Approximately $2 million will directly support the Zero Suicide initiative at IHS facilities that have applied for the additional funding.

Ali says suicide prevention programs must be tailored to the individual cultures of Indigenous communities.

“Everyone has different ways, different stories, different dances, different ways of articulating what is health and what is wellness in our communities,” she says.

With decades of behavioral health experience, Ali says the program offers a chance to personalize care to the needs of each tribe. Some tribes don’t have a word for suicide, she said. For others, talking about the problem may be taboo. To fight the taboo, some have changed the name of the program. At the Chinle Comprehensive Health Care Facility in Chinle, AZ, the program is known as “Iiná Ayóó’oo’nii: Embrace Life Project”.

Indigenous healthcare providers also adapted the Zero Suicide screening tool and risk assessment process in a culturally sensitive way. Instead of directly asking questions about suicidal thoughts, health care providers reframe the question: rather than, “Do you want to kill yourself?” they can ask the following question: “Do you want to end your life?”

“The idea is for everyone to feel comfortable and confident in their cultural perspective,” says Ali.

According to Ali, effective and culturally informed suicide care does not focus only on those at risk, but rather on the whole community, involving elders, tribal leaders and other community members in order to create a safety net.

At the Chickasaw Nation, Indigenous patients stay with their families during their crisis, use community and cultural supports and are more likely to see health care providers sooner, according to a Chickasaw Nation Ministries of Health and Family Services Report.

Legitimize traditional medicine

Zero Suicide began in Detroit’s Henry Ford Health System as a way for the hospital system to better provide suicide-specific care, rather than addressing suicide as part of other mental health issues such as depression. says Brian Ahmedani, PhD, director of the Center for Health Policy and Health Services Research at Henry Ford.

“We recognize that Indigenous communities have very important cultural ways and medical approaches,” he says. “It is really important to work to adapt this type of model in order to integrate these cultural approaches.”

The Zero Suicide framework involves clinical practices focused on caring for those at risk, including screening, assessment, safety planning, and follow-up. The effort also aims to expand suicide prevention training for healthcare workers and involve the wider community.

The framework’s approach has consistently reduced suicide rates by 65% ​​to 75%, according to the Zero Suicide Institute website. But research on Zero Suicide is still in development. Published research on its impact remains limited.

Now Ali’s work is focused on creating that sense of validation by fusing traditional Indigenous health practices with the research-based framework of Zero Suicide.

Ali also believes that using traditional medicine and practices with the Zero Suicide structure can make the healing process even more effective, even for Native Americans who may not feel as connected to their culture.

These practices may include prayer, talking circles, and the use of sacred herbs, depending on Native American connectionsan organization that provides health services to Indigenous communities in central Phoenix.

The adapted Zero Suicide Toolkit emphasizes that combining Western medicine methods with the use of traditional healers and medicine can be more effective in Indigenous communities.

“Our people believe that our culture is our medicine, and so just being able to teach some of these things and come back to some of these ways has been so beneficial to the nations we work with,” Ali says.

It’s about legitimizing approaches to suicide management that aren’t found in the research literature, she says.

“I can trace my people back 30,000 years ago,” Ali says. “Our ways are ancient. You’re not going to find them in peer-reviewed journals. You won’t find any research on them, but we know they worked.

Specific challenges Adapting Zero Suicide to Acoma

Valdo, the director of health and wellness programs at Acoma, has worked with his Zero Suicide initiative since the facility first received funding from the Indian Health Service in 2017. In addition to suicide prevention techniques research-based suicide, Acoma offers language classes, sewing and other cultural activities. Activities.

While Zero Suicide’s goal is to directly address suicide, she says many in the community opt for treatment focused on another condition, such as substance abuse. Others refuse services altogether.

Due to stigma, some tribal leaders are reluctant to confront issues related to suicide. Valdo says recent Acoma leadership has openly addressed mental health and supports Zero Suicide’s goals in the community.

“Sometimes it takes that leadership position to help drive change,” Valdo says. “In a small community, people feel very stigmatized. If their vehicle is simply parked outside [the facility]most people know that, don’t they? »

She says Acoma has also been successful in breaking the stigma around suicide through community outreach. The organization can attract 500 or more people for Spirit Week, Suicide Prevention Week and other events.

“It has always been considered a taboo subject,” says Valdo. “We let the community know, any time of the year, any day, that resources are available and we’re here if they need to contact us.”

Acoma’s program still faces staffing challenges when it comes to Zero Suicide, as the closest metropolitan area is approximately 60 miles away. Representation is another challenge. Of nine health care providers, two are Aboriginal. This highlights a larger problem with the nationwide shortage of Native American doctors.

More recently, Acoma has focused on preparing for a future without financial support from IHS, as its Zero Suicide grant expired in April. Valdo said staff were actively planning how they intended to continue programming and had applied for a second round of funding.

Despite the challenges, Valdo says the program has improved since its launch in 2017, paving the way for new suicide-specific care for the community in the process.

“It’s not just about putting this beautiful setting in these communities, but creating this way of bringing these two worlds together, these schools of thought,” Ali says. “We know these things work.”

Jordan Anderson and Dhivya Sridara are student reporters for Medill News Service at the Medill School of Journalism.

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