UBC Theses and Dissertations

UBC Theses Logo

UBC Theses and Dissertations

In their own words : exploring survival factors in suicidal Aboriginal youth : a critical incident study Arato-Bollivar, Juliette 2004

Your browser doesn't seem to have a PDF viewer, please download the PDF to view this item.

Item Metadata


831-ubc_2004-994236.pdf [ 5.25MB ]
JSON: 831-1.0099786.json
JSON-LD: 831-1.0099786-ld.json
RDF/XML (Pretty): 831-1.0099786-rdf.xml
RDF/JSON: 831-1.0099786-rdf.json
Turtle: 831-1.0099786-turtle.txt
N-Triples: 831-1.0099786-rdf-ntriples.txt
Original Record: 831-1.0099786-source.json
Full Text

Full Text

IN THEIR OWN WORDS: EXPLORING SURVIVAL FACTORS IN SUICIDAL ABORIGINAL YOUTH: A CRITICAL INCIDENT STUDY by JULIETTE ARATO-BOLLTVAR B.A., University of British Columbia. 1993 M.Sc, University of Calgary, 1999 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY in THE FACULTY OF GRADUATE STUDIES (Department of Educational and Counselling Psychology and Special Education) We accept this thesis as conforming To tlj£ required standard UNIVERSITY OF BRITISH COLUMBIA September 2004 © Juliette Arato-Bollivar, 2004 ABSTRACT This study explores the survival factors that suicidal Aboriginal Youth used to keep themselves alive. The purpose of this study was to develop categories that would identify themes in the events reported by Aboriginal individuals, by exploring the research question: "What are the critical incidents contributing to survival in suicidal aboriginal youth?". The research method involved interviews with 20 adult (18 and over) Aboriginal volunteers (all residents of British Columbia) who possessed the ability to articulate, identify and discuss their stories of survival. The Critical Incident Technique (Flanagan, 1954) was utilized to elicit 254 incidents from 20 participants. Fourteen categories were created from the analysis of all events reported. Thorough validation techniques were applied in order to test the soundness and comprehensiveness of the categories. In addition, efforts were made to examine fit with the literature of the categories and expert commentary concerning the results was provided. The categories reflected that survival factors included: Responsibility to Others, Connection to/Love of Family, Professional Support, Support of Non family/ Non Professional Individuals, Cognitive Shift/ Change in Thinking, Avoiding a Negative Environment, Formal Education, Connection to Cultural Heritage, Getting Sober, Normalizing One's Difficult Experiences/Learning You Are Not Alone, Spirituality, Connection to Nature, Self Acceptance/Love/Care, and Sense of Purpose/Making a Difference. In addition, gender differences were examined and, through incidental commentary of the participants, factors hindering survival were identified. The findings of this study contribute to the field of counselling psychology by providing a scheme of categories that attempt to describe, from the perspective of Aboriginal people, what has aided them in surviving suicidal thoughts, actions and behaviours, in their youth. This research suggests promising developments in Aboriginal survival and contains implications for practice and research. TABLE OF CONTENTS Page ABSTRACT i i TABLE OF CONTENTS iv LIST OF TABLES vi ACKNOWLEDGEMENTS vii DEDICATION viii CHAPTER 1: INTRODUCTION 1 The Research Problem 2 Rationale 4 Significance of Research 5 The Research Question 6 Situating the Researcher 6 Significance to Counselling Psychology 8 Proviso 9 CHAPTER II: LITERATURE REVIEW 10 Adolescent Suicide in General 11 Adolescent Suicide 15 Adolescent Suicide and Attachment Theory 17 Aboriginal Suicide 19 Survival and Protective Factors towards Suicidality in General Population 23 Survival/ Resiliency Literature for Aboriginal Youth 26 Summary & Final Rationale 33 CHAPTER III: METHODOLOGY 34 The Critical Incident Technique 34 Participants 37 The Critical Incident Interview 39 Procedure 40 Incident Analysis & Category Formulation 43 Validation and Reliability Procedures for Categories 44 Process Summary 47 iv CHAPTER IV: FINDINGS 49 Description of Categories 49 Connection to/Love of Family (Includes Spouse) 51 Professional Support 53 Responsibility to Others/Desire to Care & Protect 55 Formal Education 58 Support of Non family/ Non Professional Individuals 59 Cognitive Shift/ Change in Thinking 62 Avoiding a Negative Environment 64 Connection to Cultural Heritage 66 Getting Sober-Stopping Drug & Alcohol Use 69 Spirituality 70 Normalizing One's Difficult Experiences/ Learning You Are Not Alone 72 Connection to Nature 74 Self Acceptance/Love/Care 76 Sense of Purpose/ Making a Difference 77 Validation of the Categories 78 Reliability 78 Comprehensiveness 79 Participation rate 80 Expert Commentary 82 Unique Findings & Fit with the Literature 83 Gender 86 Factors that are Harmful towards Survival 89 CHAPTER V: DISCUSSION 91 Summary of Results 91 Linking the Literature to the Results 91 Unique Findings 94 Implications for Research & Theory 95 Implications for Practice 98 Implications for Further Research 101 Limitations 102 Commentary & Summary 103 Summary 104 REFERENCES 106 APPENDICES APPENDIX A: LETTER OF CONSENT 112 APPENDIX B: INFORMATION F O R M 115 v LIST OF TABLES TABLE 1: CRITICAL INCIDENT CATEGORIES 50 TABLE 2: RELIABILITY OF CATEGORY SCHEMES 79 TABLE 3: PARTICIPATION RATE IN EACH CATEGORY 81 TABLE 4: CATEGORIES DIVIDED BY GENDER 88 TABLE 5: EVENTS THAT ARE HARMFUL TOWARDS SURVIVAL 90 vi ACKNOLWEDGEMENTS I would like to thank my research supervisor Dr. Rod McCormick for his guidance, support and encouragement throughout my work on this project. His expertise in this area and belief in the successful completion of this study were appreciated. I am especially grateful for the guidance offered by Dr. B i l l Borgen and Dr. Marv Westwood, my committee members. I am so appreciative of their support both academic and emotional. I could not have completed this without the extra efforts they made to assist me. Thank you to my University examiners, Dr. Betty Calam and Dr. Ishu Ishiyama for their insight and expertise reviewing my dissertation. I am indebted to the staff at the Nenqayni Treatment Centre at Williams Lake, including clinical director Ralph Wright, for their help in recruitment, offering the use of their facility and overall support of my work. I am especially and forever grateful to Anne Marie Dufour, for her relentless pursuit of participants and belief in my work. Her friendship and tireless efforts are one of the sole reasons that this project is in existence. She was truly a shining light throughout this process. Thanks to my colleagues and friends who helped as judges, expert commentators, and proofreaders. This type of help was invaluable and will not be forgotten. To my other supportive friends who were there as cheerleaders and general therapists to me, you all know who you are. Thank you and I love you. Special thanks to my family, parents Marian and Gabor and sisters, Karolyn and Trish. They have always believed in me and loved me regardless of how many degrees I try to complete. Thank you for your love, support and ability to keep me as sane as I ' l l ever be. This project would not be a reality without the 20 individuals who were courageous enough to volunteer their stories of struggle and survival. To these people I say thank you and be well. I wish I could express just how important your stories are and how beautiful you all are as survivors. Your participation is a gift. Lastly, I must thank my husband and best friend, Shawn, who always believes in me when I cannot. Thank you for your love, your support and undying belief that I am smarter than I think. You are my lobster. vii DEDICATION To those who told me their stories of survival And who continue to survive And to Shawn, M y Survival Factor Survival Factors in Suicidal Aboriginal Youth CHAPTER 1: INTRODUCTION Suicide is a complex and multileveled phenomenon that poses many puzzling and unanswered questions. It tragically impacts individuals, their families, their community and ultimately the global village that serves them. Adolescent suicide is particularly distressing as these individuals are so soon out of childhood yet so near adulthood. The choices they make have a lasting impact and, unfortunately, suicide is the deadliest choice of all. This study searches to explore adolescent suicide and, more specifically, turn the focus to aboriginal adolescent suicide. Researchers who examine Canadian First Nations* and Inuit communities report statistics that range from 0 to 15 times that of the general population and estimate on the whole that suicide rates within these communities average from three to five times the Canadian population rates (Ministry of National Health and Welfare, 1994). The Ministry of National Health and Welfare (1994) phrases the problem succinctly in that there are ".. .a multitude of conflicting theories concerning the roles played by environmental influences and mental disorder, the existence and nature of predisposing genetic or biochemical factors, and the parallel issues of proper and effective treatment and prevention. The questions are complex as they are obvious. Suicide is an action not an illness. Identifying the chains of causal and triggering factors, which may in any case be highly individual, and deriving from this an overall prevention and treatment strategy is perhaps one of the most challenging problems facing professionals in the health sciences." (1994, p. 1). * For the purpose of this study, as the literature uses different terms, the terms 'First Nations", "Native" and "Aboriginal" are used interchangeably and refer to the same people 1 Survival Factors in Suicidal Aboriginal Youth Research concerning the area of suicide includes examination of gender, age and cultural differences and trends. In the U.S., four fifths of all suicides are committed by men while two thirds of suicide attempts are committed by women (Jacobs, Brewer & Klein-Benheim, 1999). When examining information pertinent to aboriginal suicide in Canada, most of the research focuses on Status or Treaty Natives and the rates are most severely elevated among the age range of 15-34, primarily in males (Cooper, Karlberg & Pelletier-Adams, 1991). Mortensen and Tanney (1988) state that risk factors for native youth include "early losses, disruptive relationships, alcohol and drug abuse, hopelessness and depression.. .the environment many Natives find themselves in today results in the majority having these high risk factors in their background". The general issues pertaining to adolescent suicide are all applicable to the area of aboriginal youth and appear to be magnified within this particular cultural community. It is therefore necessary to examine adolescent suicide in general, then focus on native youth, and then examine how this study can contribute something useful to this arena. The Research Problem As research continues in the area of youth suicide, practitioners and researchers state possible causes and possible preventions for the native community and the high youth suicide rate. However, certain ideas put forth by the scientific community contradict each other and, most often, take on a non-Aboriginal perspective on an issue that is primarily native. For example, a research finding in Southwestern native tribes and pueblos in the U.S. is that the more a tribe adheres to the cultural and religious traditions of their community, the fewer mental health problems and the smaller the number of suicides (Berlin, 1987). The less 2 Survival Factors in Suicidal Aboriginal Youth traditional tribes have greater pressure to acculturate and extensive tribal conflict about maintaining traditional religion, governmental structure, clans, societies and extended families. More mental health problems occur and the suicide rate in the adolescent population is high (Berlin, 1987). However, suicide expert and psychologist David Lester states that while strengthening aboriginal culture and improving reserve conditions would help in the short term, Canadian aboriginals would be benefited by leaving their reserves in the long term. He states that it would be counterproductive for natives to opt out of mainstream culture (Ferry, 2000). This is in direct opposition to other research by individuals of Native origin who urge the native population to re-connect with their ethnicity, families and cultural traditions (Duran & Duran, 1995). One of the most prevalent themes in First Nation culture is that of interconnectedness, harmony and balance within the community (Ross, 1992). Chandler and Lalonde (1998) discuss how the notion of self-continuity can aid native youth in reconnecting with their traditions and how losing one's sense of continuity with their culture and the overall global community can have devastating effects. McCormick (1995) speaks of the Medicine Wheel and how all four parts of the Wheel; mental, emotional, physical and spiritual must exist in harmony. To upset the balance indicates many types of problems, including those dealing with what the Western community denotes as mental health. Researchers state that most of the literature on native suicide trends is biased as it is written by the majority culture and has less insight than the individuals experiencing the phenomena themselves. Moreover, the literature indicates that aboriginal individuals tend not to access the mental health services provided by the majority culture and are less likely to respond to counselling or return after a first session i f they do access services (Trimble & 3 Survival Factors in Suicidal Aboriginal Youth Fleming, 1990). It has been suggested that community based models of care that utilize the natural healing methods of First Nations individuals are more effective methods of recovery and healing than those of the majority population psychotherapeutic models for these individuals (McCormick, 1995). Nwachuku and Ivey (1991) discuss culture specific counselling and state, "in the culture specific approach, we start with the culture and its peoples and search out natural helping styles. In contrast with the conventional approach of adapting existing counseling theory to "fit" a new culture, the culture specific method seeks to generate new theory and technologies of helping" (p. 106). This could suggest that we should examine the possibility of culture-specific research methods when examining different cultures. Much of the research on suicidality is culture-specific in regards to the Western methodology and interpretations made by researchers regardless of populations examined. Rationale As will be explored in the subsequent chapter, the research focus has been placed on protective, preventative and treatment factors for suicidality in adolescent populations in general as well as Aboriginal youth. However, the individual experiences of survival are not directly examined in detail and there is little information exploring the experiential data of Aboriginal youth suicide survivors. To this end, Rod McCormick, an Aboriginal counsellor and educator, states that" millions of dollars have been spent trying to tackle the problem of suicide amongst aboriginal youth, but researchers have not explored the insights and experiences of First Nations youth themselves in order to determine the best way to facilitate healing" (Ferry, 2000). It is for this reason that this study examined the problem of aboriginal adolescent suicide from the perspective of First Nations individuals, using their own words. 4 Survival Factors in Suicidal Aboriginal Youth The concepts used in native communities are often similar to the majority population-however, there are more levels, and a deeper processing that is firmly connected to spirituality and nature. For example, Navajo medicine men and women use ritual to help restore mental and physical health. "They do not reject Western medicine or psychological concepts-they only see them as limited. They see the universe as filled with many enormously powerful forces, all of which hold the potential for good and evil. If, for some reason, the balance between good and evil is upset, people get sick. You have to keep in balance i f you want to stay healthy" (Hammerschlag, 1988). An effort was made, in this study, to keep in mind all past information regarding suicide in general yet viewing it through the lens of the aboriginal community. I examined what helps in the struggle to avoid suicide as the ultimate and final choice. Significance of Research Most literature on adolescent suicide has amassed a vast amount of important information delineating what factors influence suicide and what issues are most commonly present when youth are contemplating suicide. This information is covered, and detailed in Chapter II of this study. The Western research community is so often consumed with the idea that all will be solved i f we can answer the essential question of "Why". However, there will never be an immutable truth, a clear causal factor that is generalizable to all suicides, all ideation or suicidal behavior. Therefore, this study examined the phenomenon from a different angle, the opposite view. Those who have been suicidal in their youth and survived were questioned and interviewed to identify critical events in their lives that aided them towards survival and healing. These were the suicidal aboriginal individuals who made it, 5 Survival Factors in Suicidal Aboriginal Youth who journeyed to the other side of the tunnel. The information, the stories that they alone can tell, may provide crucial information towards planning future interventions and preventions. A methodology will be required that allows for semi-structured interviews that examine events that can then be classified into categories that result in aiding survival and healing. The methodology chosen for this study will be the Critical Incident Technique (Flanagan, 1954). The Research Question To specifically define the research question, then, the phrasing is such: This study will take a qualitative approach to answering the research question, "What are the critical incidents contributing to survival in suicidal aboriginal youth?" As mentioned previously, the methodology used will be a critical incident study, fully described in Chapter III. Situating the Researcher As stated earlier, so much of the research is written from a non-Aboriginal perspective when examining native aboriginal culture. How then, will this study be any different, as I myself am a member of the majority-a white, middle class graduate student? As a 32 year old white woman raised by European parents, what can I offer to the data and, conversely, what biases will I have that will shape and impact the data? It is important to situate myself within the data and be vigilant of my own perceptions-how they will impact how I listen to the stories that I was told. As with any individual, regardless of their culture, we all posses unique and biased views of 6 Survival Factors in Suicidal Aboriginal Youth circumstances, according to our own experiences. Nevertheless, our culture creates significant and formative associations when we experience the world around us. Pedersen (1991) states that "before we were born, cultural patterns of thought and action were already prepared to guide our ideas, influence our decisions, and help us take control of our lives. We inherited theses cultural patterns from our parents and teachers who taught us the 'rules of the game' " (p.6). It is thus with this awareness that I will choose to recognize the differences in my cognitive processes from those participating in this study. With this in mind, I will attempt to let their words speak to their truths and attempt to place my truth in the background. While there are obvious differences in culture, I see myself sharing in some of the experiences of my participants and hope to use this as a means to connecting with their stories. It is important to share with the reader that I experienced severe suicidal thoughts, behaviors and actions as an adolescent and young adult myself. It is because of those experiences that I first became involved in this area of research and hope to discover how others also experienced suicidal behavior without ultimately committing suicide. The purpose of this study is to discover critical incidents or factors leading to prevention of suicide. These factors could be postulated as issues leading to healing and aiding in resilience. As I have benefited from telling my story from my point of view, I hope to provide an arena for the participants of my study to relay their stories from their point of view. The common thread joining all the participants and myself is that, despite multiple risk factors (which the research will support), certain events occurred to create an ability to survive, to heal in some way in order to continue living. By learning from the stories of my participants, I believe that I discovered categories that will have implications for counselling practice. In addition, the 7 Survival Factors in Suicidal Aboriginal Youth contributions to practice, future research and theory are discussed and the significant findings can be applied in all these areas. It is personally meaningful to be a part of this research. Coming from a place where hope was lost, I believe the human spirit has the ability and gift to create light when there is darkness. Survival and healing are powerful concepts that must be studied. By telling my story and the story of others, we can aspire to change future suicide stories that have not yet been written. Significance to Counselling; Psychology Research in the field of suicide and adolescent suicide has been expanding over the last several years. The aim has been to explore risk factors, co-morbid factors and finding causes and trigger events. The search for the "ultimate cause of suicide" has offered little benefit to practitioners dealing with individual cases.. This study will be significant to counselling psychology, as it will increase knowledge in the field to better inform researchers and practitioners on issues related to surviving adolescent suicidality. In addition, due to the gap in the literature about direct survival stories and the few 'after the fact' suggestions to practitioners, the results of this study may indicate a more specific direction counsellors and educators may take towards working with suicidal Aboriginal clients. Moreover, the focus on aboriginal suicide and the cultural specificities will hopefully add new insight. Practitioners may benefit from hearing the Native voice speak to areas that help survival. Another important contribution to the field of counselling psychology is the use of the Critical Incident Technique (Flanagan, 1954) to elicit specific events leading to survival. Such discussion can be translated for the practitioner and could provide ideas for culture-Survival Factors in Suicidal Aboriginal Youth specific counselling techniques. The resulting categories will provide information concerning what facilitates survival for First Nations youth. Information will be provided concerning what was harmful towards the survival of the participants. This could give direction to the practitioner as to locating resources for the client. The findings also inform research and theory as well as practical implications. It will be suggested that areas of social learning, identity formation and cultural versus individual realities could be enhanced through the results of this study. Proviso It is essential to recognize the diversity amongst the Aboriginal peoples of Canada. In British Columbia alone there are 200 different bands. Therefore, before describing this study, it must be made clear that no attempts will be made to generalize the results of this study towards all Aboriginal peoples. The study refers to the experiences of the participants in this project and will be used to illuminate researchers and posit possible directions for future research, and suggest theoretical and practical implications. 9 Survival Factors in Suicidal Aboriginal Youth CHAPTER II: LITERATURE REVIEW You are an Indian And you are lost You don't know who you are Because you don't know where you have come from And if you don't know where you have come from Then you can't know where you are going Art Solomon, Ojibway Elder, 1990 The field of suicide research has expanded to accumulate an extensive amount of information that, unfortunately, cannot be generalized to provide any certainty as to what causes individuals to voluntarily end their own lives. There is a vast amount of information stating what may be issues relevant or what co-morbid factors could be present. The primary source of information applied to suicide data in the United States is death certificate information reported by each state to the National Center for Health Statistics (Moscicki, 1999). In Canada, there are three systems for certifying deaths: the Coroner System, the Medical Examiner's System and the Judicial System (Cooper et al., 1991). While statistics on deaths certified as suicide provide some data towards the demographics pertaining to this field, deaths may not be classified as suicide to protect families (Moscicki 1999; Cooper et al., 1991) and reported suicides are notoriously underrepresented in statistical reporting (Jacobs, Brewer & Klein-Blenheim, 1999). This chapter will explore the multiple areas related to suicide, including prevalence in youth, methods and contributing co-morbid factors. With this background information established, this chapter will also explore the specific group of aboriginal youth and suicide. This area will include trends, band specifics and theories regarding the alarming rate of aboriginal youth suicides. Ultimately the purpose is to establish the existence of the problem, the reason why this needs to be examined and why and 10 Survival Factors in Suicidal Aboriginal Youth how this study must be done. We need to find ways to combat adolescent suicide, aboriginal adolescent suicide specifically, and it is hypothesized in this study that the best way is to ask the native youth themselves, something that is rarely done in research. The rationale for the why and how of this study pertain to the gap in the literature and research that pertain specifically to survival and Aboriginal suicidal youth. The term 'survival' is rarely explored in this area and experiential participant reports are rare. This study addresses both of these factors and strives to contribute unique findings as well as supporting the current literature. Adolescent Suicide in General When examining the research area of adolescent suicide in general, words such as "ominous", "dire" and "epidemic" have been used. Statistics are often quoted to prove the overwhelming concern practitioners and researchers alike are attempting to express. For example, Rotheram-Borus, Walker and Frens (1996) have stated that the frequency of adolescent suicide in the U.S. has increased approximately 300% in the last 25 years, with adolescents committing suicide at a rate of 10 per 100,000 each year. This statistic has since been updated to the rate for 15-24 year-olds at 13.8 per 100,000 in the U.S. (King, 1999). Suicide is seen by many as the second leading cause of death among adolescents and the rate among this group now equals that of the general population (Fremouw, Callahan, & Kashden, 1993). Furthermore it is important to note that many suicides go unreported or are misconstrued as accidents. Therefore, the statistics of adolescent suicide could be even higher that initially reported. According to the Ministry of National Health and Welfare (1994), Canadian suicide rates overtook the U.S. rates during the 1970s and have stayed consistently ahead. For persons aged 10-19 years the rates began to increase dramatically in 11 Survival Factors in Suicidal Aboriginal Youth the mid 1950s, appreciably more in males that females, and reached a peak in the early 80s. Adolescent females are more likely than males to have thought about suicide and attempted it (1.5 to 2 times more likely to report suicidal ideation and 3 to 4 times more likely to attempt). Adolescent males are 4 to 5.5 times more likely to complete a suicide attempt. Adolescent females complete one out of every 25 attempts while adolescent males complete one in three (King, 1999). In the U.S. firearms are the primary method of suicide death for both men and women across all age groups. The second most common method for men is hanging and for women is self-poisoning (Moscicki, 1999). The statistics in Canada are similar with the exception being the most preferred method for females is self poisoning (Ministry of National Health and Welfare, 1994). Unlike information on suicide mortality, the area of suicidal ideation and suicide attempts is far from clear with no primary data source (Moscicki, 1999). There is little agreement as to the exact definition of ideation and it is not regularly reported. Suicide attempts are usually only recorded when individuals receive treatment. Both lethality and intent are important issues to be factored into examining suicide attempts (Jacobs et al., 1999). It is necessary to observe the multidimensional factors that are emerging (O'Carroll, 1993) to create an environment that may predispose an individual towards suicidal ideation and, eventually, suicidal behavior. Violato (1996) stated that " there are.. .no compelling explanations in general of suicide, notwithstanding current research efforts. There are, however, a number of factors which have been found to be related to, or implicated in, suicide" (p. 312). A report of suicide in Canada provided this list reviewing the factors contributing to suicide and/or suicidal behaviors: 12 Survival Factors in Suicidal Aboriginal Youth 1 Sociocultural, Economic and Cultural Factors i . -unemployment-related factors 11. -income 2 Psychiatric Conditions i . -depression n. abuse of alcohol and other substances in . schizophrenia iv. other disorders 3. Neurpbiological Findings 4. Genetic and Family Background 5. Life Events 6. AIDS/Terminal Illness 7. Personality and Psychological Influences The difficulty in attempting to isolate individual, causal or co-morbid factors contributing to this phenomenon is rooted in the nature of the research in this area. Many factors are rarely considered "necessary" or "sufficient". Cases are discussed with unique combinations of factors and one cannot discuss, for example, depression, without mentioning a particular life stressor. To further explain this point, the following is a quote from a paper discussing the neurobiology of suicidal behavior (Mann & Arango, 1999). Of particular note, is the mention of several other factors necessary to consider when examining the possible neurobiology of a case. A consideration of the neurobiology of suicide requires recognition that suicide is the outcome of a complex set of factors. The neurobiological changes may reflect any or all risk factors that include a psychiatric disorder in over 90 percent of suicides, as well as predisposing personality traits such as aggression and impulsivity, social stressors such as unemployment and bereavement, male gender, substances and alcohol abuse, and familial 13 Survival Factors in Suicidal Aboriginal Youth and genetic transmission of much of the preceding. Finally, in postmortem studies, it is critical to consider effects of medications, drugs of abuse, and the degradative effects of postmortem decay. Another challenge is to distinguish between biological effects that are consequences of the suicidal act and not related to the risk factors for the act. Such biological consequences can result from the effects of ingested substances, medications or drugs used in an overdose; medical injuries; the postattempt medical treatment or agonal effects where death is not rapid." (Mann & Arango, 1999, p. 98) From this quote, it is obvious that with each "risk factor" there are several possible linkages to other factors, predisposing issues etc. This literature and research is detailed here to build a case for the necessity for this study, which will examine the phenomenon of suicidality from the perspective of those that have survived suicidal thoughts and actions rather than attempting to discover why individuals succumbed to them. In this research, the individual has been suicidal and has managed to survive despite whatever risk factors caused or contributed to suicidal behavior. It is despite the risks and suicidal behavior that these individuals survived. There are several myths concerning suicide that promote misinformation (Reynolds, 1987). One major misguided belief concerns the cause of suicide. Some believe that even i f one grants that multiple factors do indeed work together to cause a particular death from suicide, one factor must somehow be more responsible than the others (O'Carroll, 1993). This denies the very nature of multiple causation. The Canadian Ministry of Mental Health (1994) recognizes that the problem "arises in seeing all suicides as irrational, and in drawing a direct causal link between mental disorder and suicide" (p.2). Santrock (1993) has discussed suicide in terms of immediate (proximal) and earlier (distal) experiences. The problem with discussing proximal experiences is that so-called 14 Survival Factors in Suicidal Aboriginal Youth "trigger" events can be misinterpreted. One event cannot be the cause of suicide without a preexisting environment that contributes to the situation. Nevertheless, this terminology can be useful when applied appropriately. Moscicki (1999) is able to distinguish between proximal and distal factors in the following statement. It is helpful, therefore, to organize knowledge of suicide risk factors into a framework that distinguishes between distal and proximal risk factors.. .Distal risk factors may be thought of as the foundation for attempted and completed suicides. Distal risk factors may not obviously occur immediately antecedent to the suicidal event itself. They are necessary, but not sufficient, for suicide. Proximal risk factors, on the other hand, are closely associated with the suicide event, and can be thought of as precipitants or "triggers" for suicidal behavior. Unlike distal risk factors, proximal risk factors are neither necessary nor sufficient for suicide in and of themselves. (p.44) It is essential to note that neither types of risk factor can be considered necessary and sufficient. It appears that it is the co-occurrence and interaction among "a variety of risk factors that can result in the necessary and sufficient conditions for attempted or completed suicide". Adolescent Suicide Several factors have been identified as assisting in creating an environment for an adolescent that is conducive to suicidal ideation, which may lead to suicidal behavior. Of the several main contributing factors concerning suicide, depression has been identified as a prominent symptom (Violato, 1996) and is found consistently in attempted and completed adolescent suicide (Allberg & Chu, 1990). Others researchers believe that suicidal 15 Survival Factors in Suicidal Aboriginal Youth adolescents have depressive personality structures (Triolo, McKenry, Tishler & Blyth, 1984). The issue with depression and suicide is that it cannot be labeled as a cause or even a precipitate of suicide (Violato, 1996) merely that it is very often present in suicidal adolescents. A similar concept is that of hopelessness/ helplessness. Many suicidal adolescents are reported to be withdrawn, lonely, hopeless and helpless (Dukes & Lorch, 1989). It is posited that adolescents may turn to suicide if they view themselves in a hopeless situation (Triolo et al., 1984). Goldman and Beardslee (1999) have compiled a comprehensive list examining suicide in adolescents and discussed: 1) Vulnerability- Family vulnerability and cultural/social vulnerability. (This includes family psychopathology, history of abuse or violence, substance abuse , prior suicide attempts) 2) Stress-an inability to cope with stressors during adolescence may shift the balance towards self-destructiveness 3) Problem solving abilities-adolescents in the hopeless and helpless 'presuicidal' stage lose their capacity to problem solve 4) Access to lethal means-access to serious methods of self-harm, particularly firearms and motor vehicles, increase the risk of suicide. Much is made of the relationship between adolescent attitudes and behavior in the literature. Many studies have suggested that attitudes may exert significant influence on actions (Stein, Witztum, Brom, DeNour & Elizur, 1992). What should be the focus, then, is addressing how the attitudes that effect behavior are formed. Both children and adolescents' ability to cope and problem solve differ significantly from that of an adult (Reynolds & Mazza, 1994). Depression and hopelessness are certainly factors present. Hawton, O'Grady, 16 Survival Factors in Suicidal Aboriginal Youth Osborn and Cole (1982) have stated that family problems are ranked as one of the most contributory factors to adolescent suicide. Family problems have been defined as poor communication, value conflict with parents, alienation of the adolescent from the family, as well as inadequate love, affection and support provided by family members (Dukes & Lorch, 1989). Adolescent Suicide and Attachment Theory A recent approach that has appeared promising in examining adolescent suicidality is attachment theory and research. Attachment patterns in young children have shown to have a great impact on behavior and psychological adjustment. Attachment has been defined as an affectionate bond between two individuals that endures through space and time and serves to join them emotionally (Fahlberg, 1979). Bowlby (1969/1982, 1973, 1980) views an individual's attachment to the primary caregiver as the lynchpin to which every perception concerned with relating to others revolves around. The attachment between an infant and its primary caregiver allows a child to develop trust in others and reliance upon oneself, to think logically, develop a conscience, cope with stress and frustration and handle fear and worry (Fahlberg, 1979). Therefore, at the root of Attachment theory is the notion that the absence of a durable attachment relationship during the first years of life leads to problems in future emotional development (Tavecchio & Van IJzendoorm, 1987). Theorists, such as Bowlby (1969/1982, 1973, 1980), have focused on the organizing principles of attachment theory, to examine affect, behavior and cognitive functions. The working framework that is developed by early association between the primary caregiver and the child affects each of these areas. Attachment is discussed in most of the research 17 Survival Factors in Suicidal Aboriginal Youth literature as a prominent developmental issue, which exists throughout the life span (Rosenstein & Horowitz, 1996). In a meta-analysis of 81 studies examining the predictability of suicidal behavior, it was concluded that the attempters' way of life was consistently less stable than the nonattempters (Van Egmond & Diekstra, 1988). Linked with this discovery must be consideration of issues around early loss and attachment. Certain research has likened the behavior of individuals after an unsuccessful suicide attempt to behavior of children following separation and/or loss of the mother (Adam, 1980). Secure attachment or connectedness to parents has been shown to promote competent peer relations and positive, close relationships outside the family (Santrock, 1993). Those adolescents deemed as insecurely attached are predicted to have difficulties in relationships in later development. Grossi and Violato (1992) claimed in their research that disturbed attachment and loss produced the most powerful separation of suicidal and nonsuicidal youths. Violato (1996) has used this information to suggest that the importance of early loss is connected to subsequent psychopathology. From all the aforementioned contributing factors, one can draw the conclusion that suicide risk increases when negative life stresses are experienced in a consistent developing pattern (Fremouw, Callahan & Kashden, 1993). If one's family environment is unstable, there is a history of psychopathology (depression and hopelessness) and substance abuse, one's cognitions appear more predisposed towards suicidal ideation. The very nature of instability in a child's environment could hypothetically be associated with their attachments and the classification of said attachment (secure or insecure). Emotional stability, affiliative behaviors and level of psychological adaptation are viewed by many in the psychological community to be rooted in childhood attachments 18 Survival Factors in Suicidal Aboriginal Youth (Fahlberg, 1979). Attachment models both shape an individual's beliefs about" whether the self is worthy of love and whether others can be trusted to provide love and support and also influence the kinds of interactions individuals have with others and their interpretations of these interactions" (Mickelson, Kessler & Shaver, 1997 p. 1092). It follows then, that insecure and disorganized childhood attachment patterns could be predictors of psychological adaptation and behavior and also psychopathology in adolescence and adulthood (Ainsworth, 1991). Several studies have taken this issue and explored certain facets of this argument. In my Masters Thesis (Arato, 1999), a stepwise discriminant analysis was used to examine the nature of the relationship between secure and insecure attachment and suicidality in adolescents. Significant findings resulted in a strong link between early childhood insecure attachment and subsequent suicidal behavior in adolescence. It appears that the suicidal group in my Masters' study (compared to the non-suicidal group) were all classified as being insecurely attached to their primary caregiver- they had more exposure to alcohol, drugs crime, physical abuse and sexual abuse. The broader topic of adolescent suicide prepares the reader by examining risk factors, prevalence and methods when examining specific groups of adolescent who are suicidal. The aboriginal community has an alarming rate of adolescent suicidal behavior. Aboriginal Suicide As stated previously, the suicide rates for aboriginal youth is higher than the rate for non-Aboriginals of the same age. When examining rates of youth suicide among British Columbia's aboriginal bands, the overall rate is some three to five times higher than that for the country as a whole (Chandler & Lalonde, 1998). However, it is essential to note that Survival Factors in Suicidal Aboriginal Youth there are close to 200 different bands in BC and the rate of suicide across these bands is in no way identical (Berlin, 1987). Not every Aboriginal community is experiencing high rates of adolescent deaths due to suicide-some bands have rates 800 times the national average while others have almost nonexistent rates of suicide (Chandler & Lalonde, 1998). These authors indicate that this information is essential for practitioners, researchers and community leaders to inspire hope for a lowering of increasing suicide rates. They also indicate that bands can examine trends, methods and traditions that are useful in maintaining a sense of interconnectedness between the youth and the rest of the community. In addition, Chandler and Lalonde (1998) speak of markers of cultural continuity that aid in drawing a community closer together. Specifically to BC, they see these markers as: self government, land claims, education, health services, cultural facilities and police and fire services. Berlin (1987) speaks to the necessity of bands reaffirming cultural traditions and not bending to the pressures of acculturation as a means to maintaining balance and harmony and thus lower suicide rates. As has been stated several times, there is a non-Aboriginal bias to much of the literature in adolescent suicide in general and in aboriginal suicide research. Eduardo Duran's ethnic background is Pueblo and Apache. He is one of a small collection of researchers with a Native background to publish in this area. His frustration at the Western bias is apparent in his writing. He discusses the "gross oversimplification and cultural hegemony is obvious to all except to some of the critical thinkers who are working in these research areas. The loss of culture-or rather, the destruction of the culture-is one factor that seems to have an effect on the suicide statistics", (p. 176-177). One study (Berlin, 1985) reports that youth living in unstable communities had pressure to belong to their native culture while at the same time succeeding in dominant 20 Survival Factors in Suicidal Aboriginal Youth mainstream culture. Aboriginal youth may perceive a pattern of hopelessness as the result of poverty in their community and may engage in self destructive behaviour, putting them at higher risk for suicide (Health Canada, 1994). Most statistical reports on aboriginal adolescents include many of the previously mentioned risk factors and most at a higher rate than non-Aboriginal youths. For example, White and Jodoin (2004), in a manual for aboriginal youth and prevention strategies for suicide, list each of the areas that they see as crucial to the high rates of youth suicide and how aboriginal youth factor into these areas. 1) Mental disorders-It is possible that Aboriginal people may be more vulnerable to poor mental health because of the depressed social conditions in their communities 2) Substance abuse- Studies of adult Aboriginal suicides in B.C., Alberta and Manitoba have estimated that between 75% and 90% of the victims are intoxicated at the time of their death. Alcohol and drug problems remain a significant problem in many Canadian Aboriginal communities. 3) Suicide in family members or friends- A high number of aboriginal people are witness to at least one, i f not several suicides in the course of their young lifetimes, because of the high rates experienced by many Canadian Aboriginal communities. 4) Childhood separation and loss- Almost one third of all Aboriginal children under the age of 15 live in a single-parent family. (Note-this information can be closely linked to the previously mentioned research on insecure attachment and loss). 5) Family background- A number of studies have confirmed that a history of physical and sexual abuse represent risk factors for suicide attempts among American male and female Aboriginal youth 21 Survival Factors in Suicidal Aboriginal Youth 6) Access to lethal methods-Firearms were used by 31 % of suicides among first Nations people in Canada. 7) Poverty-84% of Aboriginal households live below the poverty line. For the on-reserve Aboriginal population, the average income is 56% below the Canadian average. 8) Unemployment-In 1991, the percentage of all Aboriginal people over the age of 15 years who relied on social assistance for at least part of the year 1990 was 28.6, compared to 8.1 percent of the general Canadian population. 9) Housing conditions-29% of Aboriginal people live in overcrowded housing, compared with 2% of the general Canadian population. 23% of on-reserve hoses have neither piped nor well-water. 10) Cultural disruption 11) Marginalization The literature in the area of precipitating factors of suicide can be presented in demographic lists as indicated above. In addition, personal stories can also provide relevant information. For example, when examining the dismal statistics and grim comments in this area, personal stories provide valuable impact in fully grasping the severity of the aboriginal youth who is suicidal. In a circumstance unlike many of the reasons for suicide in the aboriginal community, York (1990) tells the story of the town of Hobbema in Alberta and how, from 1980 to 1987, this little town had one of the highest suicide rates in North America. There was a huge influx of money when oil was discovered in the land and the social upheaval was traumatic. There were as many as 300 suicide attempts by Hobbema Indians every year and 22 Survival Factors in Suicidal Aboriginal Youth the suicide rates for the young men was 83 times that of the national average. It is the Native voice of these people that explained why these ghastly events occurred: When we had no money, we had a lot of family unity. Then we had all this money and people could buy anything they wanted. It replaced the old values. If you weren't sure of the old values of the community, money brought in a value of its own. It doesn't bring happiness. It put more value on materialistic possessions. The family and the value of spirituality got lost. (p. 90) This demonstrates the impact of the language of the Native. York also refers to Durkheim's (1951) work on suicide and ties in the multiple causal factors of these people, stating The fate of any community is a product of a complex web of factors. At Hobbema, the influx of money was certainly one factor. The lack of proper management and control of the money was another. And the history of the community-a history of dire poverty and harsh treatment at residential schools-had an equally important influence. The invasion of oil money was the culmination of a century of turmoil, just one more way in which the harmony of an Indian community was destroyed by powerful outside forces, (p. 91) Clarkson (2004) reports that loss for Aboriginal youth occurs on three basic levels: Historical loss (residential school, cultural genocide, illness, language, traditions, parenting skills) Personal loss (family violence, substance abuse, grief and mourning, socio-economic stress, abuse) and Social loss (traditional roles in family and accompanying teachings, youth roles and responsibility, identity formation, developmental tasks, conflict within two cultures). Survival and Protective Factors towards Suicidality in General Population The literature on suicidality and protective factors focuses mainly on prevention and intervention. The terminology of 'survival' is generally absent from research and this 23 Survival Factors in Suicidal Aboriginal Youth demonstrates a gap in the literature. Nevertheless, there is a great deal written on prevention, intervention and 'best practices' for youth suicidality. White and Jodoin (1998), in their manual on youth suicide prevention, address best practices. Best Practices are defined as " those activities and programs that are in keeping with the best possible evidence about what works" (Health Systems Research Unit, 1996). By reviewing the literature, White and Jodoin (1998) strive to provide strategies that they believe have the best chance of having an impact on youth suicide in all communities. They indicate that through a review of the literature and research, they have developed 15 'before-the fact" youth suicide prevention strategies that have been proven to work or that are showing significant promise (1998). These are broken down into 3 categories: Youth/Family: Generic skill building, suicide awareness education, family support, support groups for youth, screening School: School gatekeeper training, peer helping, school policy, school climate Community: Community gatekeeper training, means restriction, media education, youth participation, system-wide protocols, community development. White and Jodoin (1998) reported that these strategies " focus on the individual or family environment, while others are designed to be implemented within the context of school and communities" (p. 33). Perhaps the best summary of what the literature and research has uncovered when. addressing creating protective and 'before the fact' suicide prevention strategies is effectively captured in White and Jodoin's (1998) summary, indicating that: Over the last several decades, there has been an abundance of prevention programs developed to (a) enhance the mental health of children and adolescents, and (b) 24 Survival Factors in Suicidal Aboriginal Youth prevent the emergence of negative behavior and mental disorders. Research into the effectiveness of such programs has begun to clarify why some programs accomplish their goals while others fail to do so. As a result, we are now able to identify those key components that characterize the most successful prevention programs (p.271) These aforementioned components include: 1. Focus on risk and protective factors 2. Working with youth and the environment they live in 3. Emphasis on developing skills 4. Comprehensive multi-level programs 5. Focus on schools 6. Peers and families have defined roles 7. Timing of interventions is critical 8. Efforts must be intensive, maintained, and developmentally appropriate 9. Importance of training and support 10. Need for monitoring and evaluation The BC Ministry of Children and Family Development released practice principles (2001) for working with suicidal youth. The recommendations included assessing suicide risk and managing safety and treatment planning. The suggested techniques for mental health workers included using brief cognitive behavioural approaches, problem-solving skills, solution focused brief therapy and dialectical behavioural therapy. Subsequent to suicide attempts, this manual suggested enhancing links between the youth, the mental health services and the community. This manual also included White and Jodoin's (1998) strategies listed above, titling them 'before the fact' prevention in the community. The area of adolescent suicidality, and mental health in general has mainly focused on prevention with some areas of treatment. Kazdin (1993) stated: 25 Survival Factors in Suicidal Aboriginal Youth Adolescent mental health represents a neglected area of research. Mental health objectives include the promotion of optimal functioning as well as the prevention and reduction of maladaptive functioning (p. 127) In addition, researchers and practitioners must also take into account developmental changes that occur during adolescence. Kazdin (1993) also refers to this when reporting that Adolescence is significant because of the opportunities that emerge for intervention. The transitional nature and normal disequilibrium of adolescence (e.g. dependence to autonomy, from parent to peer influence) may represent an especially sensitive and hence opportune period for intervention. Several interventions based on cognitive development, peer influences, and transition periods (e.g., in schools) in adolescence may provide intervention opportunities. .. .From the standpoint of intervention, research can help identify ways to direct youth and determine peer, familial and social supports to promote mental health. Prevention and treatment programs often emphasize the interventions or techniques as a basis for improving or ameliorating dysfunction.. .(p. 139) Several areas have been examined concerning adolescent suicidality and prevention/intervention. While one can postulate that survival is very much a part of this and can link to healing (which is addressed with the Aboriginal youth population in the subsequent section), direct use of the terminology 'survival' is uncommon. In addition, direct experiential reporting from suicidal youth is not common in this area of research. Survival/ Resiliency Literature for Aboriginal Youth In an examination of recent literature on Aboriginal mental health, suicidality and healing, Laurence Kirmayer (2003) stated that 26 Survival Factors in Suicidal Aboriginal Youth Although direct causal links are difficult to demonstrate with quantitative methods, there is clear and compelling evidence that the long history of cultural oppression and marginalisation has contributed to the high levels of mental health problems found in many communities. There is evidence that strengthening ethnocultural identity, community integration and political empowerment can contribute to improving mental health in this population. The social origins of mental health problems in Aboriginal communities demand social and political solutions. Research on variations in the prevalence of mental health disorders across communities may provide important information about community-level variables to supplement literature that focuses primarily on individual-level factors. Mental health promotion that emphasizes youth and community empowerment is likely to have broad effects on mental health and well-being in Aboriginal communities, (p.l) The literature on resiliency and suicidality in Aboriginal youth does not often use the term 'survival. However, the research in this area, similar to adolescent suicide in general also strives to produce prevention, intervention and treatment. The Suicide Prevention Advisory Group (SPAG) was formed in 2001. A description of this group is presented in report called the ' S P A G REPORT" on preventing youth suicide in First Nations. In 2001, the National Chief of the Assembly of First Nations Matthew Coon Come, and former Minister of Health, Allan Rock, appointed a panel of eight Aboriginal and non-Aboriginal researchers and health practitioners to make recommendations regarding the prevention of suicide among First Nations youth. .. .National Chief Coon and Minister Rock commissioned the Advisory Group to develop specific, viable strategies for short and long term action to address this issue, based on reviews of previous studies, current literature and assessment of service delivery gaps (p. 17) 27 Survival Factors in Suicidal Aboriginal Youth The members include: Dr. Peter Hettinga, Dr. Laurence Kirmayer, Mr. Clark MacFarlane, Dr. Harriet MacMillan, Mr. B i l l Mussell, Rev. Doreen South, Madeline Dion Stout and Dr. Cornelia Weiman. The SPAG Report (2003) provides several recommendations that speak to key concerns and recommendations. It addresses preventative ways that may include ways that they feel encourage survival and healing for suicidal aboriginal youth. The four areas these encompass are: 1. Increasing what we know (Through research, conferences, national co-ordinating, pilot studies, websites, best practices model) 2. Developing effective and integrated holistic health care (Through funding, mandates, educational materials, training to support client services, interdisciplinary teamwork, create national mental health strategy, optimise health resources to communities in crisis, consultation, national resource bank of practitioners, community workers) 3. Support community driven approaches (Through co-ordinating committees, collaboration between provincial and federal, develop a pool of facilitators knowledgeable in First Nations cultures, guidelines and links to resources in communities, engage communities through demonstration projects) 4. Supporting Youth Identity, Resilience and Culture (Through youth roundtable, promote role of youth as peer counsellors, develop projects aimed at youth resilience, identity and culture). This report speaks directly to resiliency, reporting that Resilience plays an important role in shaping people's response to problems in their lives. Individuals lacking resilience are more likely to have feelings of hopelessness 28 Survival Factors in Suicidal Aboriginal Youth and believe that suicide is the only available option. In order to foster resilience in First Nations youth, attention must be focussed on strengthening the protective factors that wil l allow the young people to meet and overcome the challenges in their lives.. .these can include aspects ranging from family connectedness, informal support networks and community cohesiveness, to well-developed problem solving skills and a sense of personal autonomy, (p. 89) According to McCormick (1997), the academic community has "paid little attention to the ways in which various cultural groups have organized their own means of obtaining help". Likewise, Sue and Sue (1990) point out that mainstream clinical approaches ought be informed by the traditional healing methods of other cultures when responding to the needs of an individual from that culture. The notion of indigenous psychology can be described as a broadly accepted view of the psyche and is a descriptive rather than proscriptive locally based belief that sustains one's sense of self, socio-cultural relations and community institutions. Researchers have indicated that strong and cohesive Aboriginal communities maintain lower suicide rates (Levy, 1965; Van Winkle and May, 1986). Thus healing must be considered in terms that are relevant to Aboriginal people rather than Western ideology. Traditionally, Aboriginal healing has been congruent with the teachings often identified with the Medicine wheel: interconnectedness is emphasized versus an individualistic centre, around which one's social and natural world clusters. Emotional, physical, mental, and spiritual aspects of the psyche cannot be isolated, nor can the interconnection between friends, family, community, culture, and nature be de-emphasized. Throughout the history of the First Nations people, the definition of health evolved around the whole being of the person-the physical, emotional, mental, and spiritual aspects of a person being in balance and harmony with each other as well as with the environment and other beings. This has clashed with the Western medical model, 29 Survival Factors in Suicidal Aboriginal Youth which, until very recently has perpetuated the concept of health being the absence of disease (Favel-King, 1993, p. 125) Traditionally, healing reaffirmed cultural values and served to integrate the individual in the context of their community (Torrey, 1972). Thus as has been recognized, many Aboriginal individuals are more likely to seek help from family, friends, and traditional healers, rather than from strangers (e.g., professional clinicians) (Paterson, 1990). Acknowledging that clinicians do not provide the only support for resiliency and healing in the experience of Aboriginal survivors of suicidal ideation and behaviour, Ross (1997-in Paproski) identifies seven sources of Aboriginal healing: crying, talking, dancing, singing, sweating, praying, and yelling. One of the few instances that examine 'after the fact' recommendations for clinicians dealing with suicidal Aboriginal youth is described in White and Jodoin's (2004) manual dealing specifically with Aboriginal youth and suicide prevention. They suggest • Individual assessment/treatment • Family therapy • Clinical training • Case management • 24 hour crisis response programs • Hospital in-patient programs • Drug interventions (p. 21) As will be indicated in Chapter 3, one of the most relevant studies to the current study is that of McCormick's 1995 study, which examined the facilitation of healing for Aboriginal, people. McCormick (1995) detailed factors in his study that are believed to facilitate healing for Aboriginal peoples. These are: knowledge of First Nations culture and traditions, obtaining help from others in dealing with problems, interconnectedness, 30 Survival Factors in Suicidal Aboriginal Youth spirituality, exercise, expressing oneself, healing ceremonies, gaining an understanding of the problem, role models and nature. McCormick reported that These categories were organized into four divisions: separating from an unhealthy life, obtaining social support and resources, experiencing a healthy life and living a healthy life. A preliminary examination of the healing outcomes for Aboriginal people was thought to invoke empowerment, cleansing, balance, discipline, and belonging. Distinct themes in Aboriginal healing were also developed as a result of analyzing narrative accounts of participants. These themes are: a broad spectrum of healing resources are available to Aboriginal people; Aboriginal people have a different way of seeing the world which has to be understood before effective counselling services can be provided; Aboriginal people expect that whatever is healing should help them to attain and/or maintain balance; self transcendence followed by connectedness is a common route to healing for Aboriginal people, and Aboriginal people act as agents for their own healing, (p.251) In an additional study, McCormick (1997b) indicated that mainstream healers who are able to integrate the healing ways of others are likely to create new and effective theory and practice. McCormick (1997b) demonstrates how a traditional Aboriginal ceremony and a well-known mainstream psychological theory can have very similar teachings. He reports that non-Aboriginal healers are only now starting to see the therapeutic benefits of traditional Aboriginal healing methods. As Sue & Sue (1990) indicate, some of these traditional methods of healing have been seen by non-Aboriginal healers as "unscientific, unprofessional, and supernatural". They instead argue that the mental health profession needs to examine the viability of traditional methods of healing and determine how they might be combined with Western healing (Sue & Sue, 1990, p. 187). McCormick (1997c) discovered that because there are very few trained Aboriginal counsellors working with Aboriginal 31 Survival Factors in Suicidal Aboriginal Youth clients, the majority of Aboriginal people must see a non-Aboriginal counsellor. The differences in the non-Aboriginal counsellor's and the Aboriginal client's respective world views can result in conflicting values and beliefs between the client and the counsellor as to the cause and solution of the clients mental health problems. One solution to the problem of these conflicting worldviews is to train Aboriginal people to provide informed and culturally relevant counselling services to other Aboriginal people. Lastly, in a preliminary study with McCormick and Arvay (in press), critical incident interviews were conducted to examine what facilitated healing in suicidal Aboriginal youth. The pilot study is closely connected to the current study. While results have not yet been published, this indicates attention and direction towards facilitation towards prevention in Aboriginal youth suicide. Although healing and survival are not identical concepts there are clear connections. In addition, this study also uses first hand experiential reports from the Aboriginal youth themselves. Summary & Final Rationale A review of the literature on adolescent suicide and Aboriginal adolescent suicide demonstrates the severity of the problem. A review of protective factors explored in the literature towards adolescent suicidality in general and Aboriginal adolescent suicide has demonstrated that while there is a base of literature on 'before the fact' prevention, intervention and treatment strategies, there are less 'after the fact" strategies. The recommendations that exist are helpful. Nevertheless, there appears to be a paucity of research directly exploring the individual experience of surviving suicidality. The review of 32 Survival Factors in Suicidal Aboriginal Youth literature demonstrates this gap and aids in strengthening the rationale for the present study. The terminology of 'survival' is not clearly defined in the current literature. This study strove to discover stories of survival in suicidal Aboriginal youth in the hope that by discovering what individuals at risk have done to survive, others can learn from this. In no way does this study aim to solve the social and cultural problems that the aboriginal and non-Aboriginal communities suffer from. It appears that the suicidal behavior in youth is prevalent and wil l continue to occur. Perhaps, by using the evidence from surviving suicidal Aboriginal youth, implications for practice, research and community programs will be discovered. It is because of this that the research question before us is this: "What are the critical incidents contributing to survival in suicidal aboriginal youth?" Using the qualitative research method of Critical Incident (Flanaghan, 1954), this question was researched and the findings are reported here. 33 Survival Factors in Suicidal Aboriginal Youth C H A P T E R III: M E T H O D O L O G Y Milton Erickson, the master hypnotherapist, understood that to begin a story by saying "Remember when " was already to begin to place the audience into an altered state of consciousness-the very act of remembering is a kind of trance in itself. Erickson also knew that when you tell a story, you are speaking directly to the unconscious, the very essence of the listener. Carl A Hammerschlag, The Dancing Healers M y primary goal for this study was to discover my participants' journey towards survival during a time in their lives where they were experiencing suicidal thoughts, behaviors and/or actions. The aforementioned literature has examined how most research on aboriginal experiences is fraught with non-Aboriginal bias and interpretation. While this study also had a non-Aboriginal perception as the primary researcher, myself, is non-Aboriginal, I aimed to utilize a methodology wherein there was flexibility to allow the participant to recollect significant events and relate as to whether these events helped their survival while attempting to focus on their own voices. In order to uncover the events leading to survival, I had to choose my method extremely carefully. As stated on several occasions in this study, it was vital that the voice of the Aboriginal youth be heard. Therefore, the methodology allowed for the participant's own words to be heard and analyzed. In addition, the events mentioned had to be categorized in order to provide several areas that encompassed survival. It is with these factors in mind that I chose my methodology as the Critical Incident Technique. The Critical Incident Technique The Critical Incident Technique is a form of research that uses interviews to allow participants to recollect and describe accounts of events that facilitated or hindered a 34 Survival Factors in Suicidal Aboriginal Youth particular aim. Flanagan (1954) originated the critical incident method and defined it as such, "the critical incident technique consists of a set of procedures for collecting direct observations of human behavior in such a way as to facilitate their potential usefulness in solving practical problems and developing broad psychological principles"(p. 327). Since Flanagan's 1954 publication, numerous research studies have utilized the critical incident method and modified the process to suit different areas of research. Flanagan's original study examined job analysis and this technique has been utilized for multiple employment situations and occupation. Anderson and Nilsson (1964) stated The Critical Incident Technique is a procedure used in the collection and analysis of incidents in which the holder of a position in a certain occupation has acted in a way which, according to some criterion, has been of decisive significance for his success or failure in a task (p. 398) From Flanagan's research, the Critical Incident Technique has been used within areas such as work motivation (Herzberg, Mausner & Snyderman, 1959), critical situations in group process & group leaders (Cohen & Smith, 1976), quality of life in America (Flanagan, 1978), nurses' roles in treating rehabilitation patients (Rimon, 1979) and critical incidents related to the clinical training of nurses (Dachelet, Wemett, Garling, Craig-Kuhn, Kent & Kitzman, 1981). In addition, several studies from the University of British Columbia have been conducted, with researchers using the method to address issue including cross cultural clinical supervision (Wong, 2000), HIV diagnosis and depression (Alfonso, 1997), and work engagement in R C M P officers (Morley 2003). Borgen, Amundson & McVicar (2002) utilized the critical incident method in their research study exploring the experience of unemployment for fisheries workers in Newfoundland. The researchers conducted 53 critical 35 Survival Factors in Suicidal Aboriginal Youth incident interviews, using an open-ended interview approach, which later moved towards a focus on specific critical incidents. 373 critical incidents were identified and classified into 12 categories. This study, along with above studies, shows the variety of uses of the critical incident method and that this method continues to be effectively utilized in a variety of populations. The most relevant study, which indicates the methodology could be a good fit with the current study, is McCormick's (1995) study, which uses the critical incident methodology to examine healing with aboriginal people. The critical incident method has been expanded in its application to include not only direct observations of behavior, but also psychological states. In the present study, it was essential to allow the participant to tell their story but also to elicit meaning and context to the critical incidents in order to gather complete information to identify categories towards surviving suicidal thoughts, behaviors and actions. I believe that it was impossible to collect information about events that helped the participant to survive suicidal actions without gathering information rich with meaning and context. Making meaning of these incidents is an interpretive process. It is with this in mind that these categories were validated in five different ways by answering five different types of questions regarding the soundness and trustworthiness of the category system. These validation procedures wil l be discussed subsequently in this chapter. The aim of validating the categories is to maintain some objectivity in a somewhat subjective process, creating categories from my participants' stories of events. 36 Survival Factors in Suicidal Aboriginal Youth Participants Recruitment occurred primarily by word of mouth through professional contacts, and attempts to liaise with the First Nations communities in B.C. A third party in the community, who worked at a treatment center and was well connected to the community, distributed my information sheet and consent form to different band offices and reserves throughout the community. Individuals called her if they were interested in volunteering. Any questions they had were relayed to me. I had little contact with these individuals until meeting them. A l l individuals were fully recovered from suicidal experiences and efforts were made to ensure all participants had resources and an opportunity to debrief the experience should they wish to do so with myself or other community healers. A l l individuals were past the stage of adolescence (17 years old), and had considered themselves suicidal at one or more times in their lives (during their youth, ranging from teenage years to 30) but no longer felt so. The operationalization of "being suicidal" included reports of extreme ideation, attempts and/or hospitalization following an attempt. These individuals were all volunteers and the nature of the study was explained in a formal letter (Appendix A), the letter of consent (Appendix B) and during the orientation part of the interview. They were informed that they were able to withdraw from the study at any time. The main criteria for the participants was that they were identified as a First Nations member of British Columbia, they could recall incidents of "being suicidal" and incidents that helped them towards survival and, lastly, the individual were able to relay their experiences in an interview format in the English language. Every attempt was made to explain why this study was taking place and the importance of it to the Native and non-Native communities. In addition, I consulted with individuals more knowledgeable in the culture and 37 Survival Factors in Suicidal Aboriginal Youth traditions of the Aboriginal community so that I could be educated in the appropriate ways to conduct interviews and research in this culture. For example, it was suggested that my semi-structured interview style include many pauses and silence, providing an opportunity for the participants to engage in self-reflection without feeling rushed or pressured to speed up their stories. The 20 participants ranged in age from 18 to 61. The mean age was 37.5. The majority of the participants were in their mid 30s to 40s. Geographically, all individuals were born and grew up in British Columbia with 18 currently living in a small Northern community in BC. Nineteen of the 20 participants grew up in different rural BC communities, with the twentieth raised in a large city. The majority of the participants identified both parents with Aboriginal origin, with 2 stating only one parent was of Native origin. Fourteen of the participants were female and six were male. The uneven distribution of gender could be postulated that, as indicated in the literature review, males successfully complete suicide more frequently than females and there are fewer males available to interview. However, it appeared throughout the recruitment process that females were more willing to participate in the interviews, as several males that were approached to participate were reluctant and/or unwilling. A l l the participants self identified that they had, at some time in their 'youth', considered themselves suicidal. Many had attempted suicide and ended up in the hospital. Others indicated that they had experienced severe suicidal ideation. One participant indicated they had engaged in self-harm behavior. The methods of suicide attempts included taking pills, hanging, shooting themselves with a shotgun, stabbing themselves and driving dangerously. A l l participants indicated that they considered themselves recovered. In addition, as I am a trained therapist, I assessed each individual for 38 Survival Factors in Suicidal Aboriginal Youth risk prior, during and subsequent to each interview. Efforts were made to ensure each individual had adequate support and resources in their lives and contact information should they want to get in touch with me. Lastly, participants were encouraged to reflect on each survival factor they identified, despite all the challenges they had experienced, in an attempt to empower them. Several participants revealed that the interview left them feeling 'uplifted' and able to reflect on all that they had achieved to survive and carry on. Such an experience may imply further reflection of survival and healing. The Critical Incident Interview Woolsey (1986) examines the Critical Incident Technique as particularly useful for foundational and exploratory work. She states that this type of research is "particularly useful in the early stages of research because they generate both exploratory information and theory or model-building" (p. 252). This is particularly relevant to this study as there is very little research using the Native voice and examining suicide from the perspective of survival. Woolsey (1986) also lays out five steps for a critical incident study. These include determining the aim of the activity to be studied, setting plans, specifications, and criteria for the information to be obtained (dealing with the observers, the observations and the specific behaviors or experiences), collecting data, analyzing the data (exploring the frame of reference, the categories and level of generality), and reporting the findings. Woolsey (1986) states, "The most effective statements of aims use simple everyday language to convey an obvious meaning"(p. 244) and that "the major purpose of a critical incident study is to provide complete coverage of the content domain"(p. 245). This was interpreted for this study to mean that by using the everyday language of my participants, I 39 S u r v i v a l F a c t o r s i n S u i c i d a l A b o r i g i n a l Y o u t h created a window of opportunity to view the Aboriginal experience of surviving suicidal intent. To get "complete coverage of the content domain", I continued eliciting as many events as possible to create categories by achieving redundancy and saturation. Incidents were collected until redundancy appeared. Woolsey suggested that this occurs when only two or three new critical behaviors are added by 100 incidents. By interviewing the 20 participants, I elicited 254 events, which were ultimately grouped into 14 categories. Procedure The aim of this activity was to discover whether the participants would identify events in their lives that contributed to survival when they were suicidal. This was achieved through an orientation with the participants and then an elicitation of incidents. According to McCormick (1995), the orientation clarifies the nature of the study and provides time to establish rapport. As stated previously, as a Non-Aboriginal researcher attempting to discover what can often be painful and difficult events for the Native participant, it was essential that I listened carefully, be respectful and provide space for the participants to ask questions, be silent and feel comfortable with this process. During the orientation, I attempted to communicate the aim and nature of events to be reported. I explained the nature of the study, my personal interest in survival stories and my efforts to reflect the Native voice despite my differing ethnic origins. Together, we went over the letter of consent, confidentiality and the voluntary nature of participation. Once orientation was complete, the semi-structured interview moved into the elicitation of events phase. I asked each participant to remember a time during the suicidal period of his or her life and to recall what events assisted towards survival. Kvale (1996) 4 0 Survival Factors in Suicidal Aboriginal Youth states, "a qualitative interview seeks to cover both a factual and a meaning level, though it is usually harder to interview on a meaning level. It is necessary to listen to the explicit descriptions and meanings as well as to what is "said between the lines". The interviewer may seek to formulate the "implicit message", "send it back" to the subject, and obtain an immediate confirmation or disconfirmation of the interviewer's interpretation of what the interviewee is saying"(p. 32). This being understood, I made every attempt to be uniform in my questioning to each participant. After orientation, feeling that the participant understands what will be asked of him/her and the topic of suicidality has been broached, I began this part of the interview by asking. I would like you to think back to a time in your life that you would consider a low point. During this time you either had thoughts, behaviour and/or actions towards wanting to end your life. Tell me a bit about that. Once the participant discussed such a time in their life, I would often get more detail and, upon situating them in the 'suicidal' moment, I then asked them At that moment, what was the first thing that you felt helped your survival, helped you live. This would begin the elicitation of events and aid in getting a sense of what was helpful to survive wanting to kil l themselves. I would often follow up with a question such as What specifically helped you survive? Tell me more about that. Or What else in that moment helped you survive? Survival Factors in Suicidal Aboriginal Youth Other statements, empathic reflections or questions were used to gather further information and clarification. I used open ended question and empathic reflections in order to elicit information, context and meaning. These are all reflected in the direct quotes I used as coded events. The specific criteria for an event is the direct response a participant gave that identified what they felt helped them survive immediately following the 'low' incident. Each interview lasted anywhere from 30 minutes to 75 minutes. It was essential that I took care not to ask leading questions or give hints to the participants as to what I was looking for in this data. Once all events were elicited from one 'low time' in a participant's life wherein they were suicidal, I would then ask them to remember another 'low time'. In general, participants had several of these low times each with several events that aided in survival. Once participants ran out of low moments and events, or repeated the same events (saturation) we ended the interview. Although the emphasis of this study was on survival factors, each participant mentioned factors that led to their suicidality. In other words, factors that were not facilitative towards their survival. The comments occurred naturally throughout each interview. By going over transcripts and listening to the tapes, I noted each time a participant spoke of a negative event that they identified as contributing towards feeling suicidal. I created a list of these factors and how frequently these factors were mentioned and distributed among the participants. The last section of the chapter on findings will deal with this. The interviews were all audiotaped and each participant assigned a code number. Ten of the twenty tapes were transcribed and the remaining ten were analyzed directly from listening to the audiotapes. I found that once the spoken word was put into the written word, meaning could be shifted and/or altered. It was important to re-listen to interviews when 42 Survival Factors in Suicidal Aboriginal Youth going over the transcripts, as it is almost impossible for these shifts in meaning not to occur. Kvale (1996) refers to this problem and indicates that in order to minimize shifts in context, one must state explicitly in the report how the transcripts were made. A detailed, standardized format was used for transcribing each interview. By using the transcriptions for ten of the tapes and listening to the spoken word (for all 20 of the interviews), all comments were carefully studied in order that the richer meaning of the statement was understood before each event was extracted. Incident Analysis & Category Formulation When analyzing the data, I attempted to recognize thematic content through inductive reasoning. Specifically, categories were formed by grouping together clusters of incidents that were in some way connected to one another. Each incident was recorded onto a card. These included the exact words used by the participants and many are displayed in Chapter 4. The meaning was derived by carefully studying the tapes and transcripts of each interview. Initially, I recorded everything that could be construed as an event but ultimately pared down all vague events to create events that are clear, the action taken and an outcome for each event (McCormick, 1995). The source of each event was the assumption that the event identified is an answer to the question "at that moment of wanting to end your life, what helped you survive?". This facilitated the grouping of the events. The cards were grouped by similarities and put into categories (with 10% of the events withheld prior to category formation as per the first validation procedure outlined in the subsequent section). It is essential to remember that the language of the participants creates the events and categories. They are the experts of their own experience. To create categories that thoroughly 43 Survival Factors in Suicidal Aboriginal Youth describe and clearly establish what we were examining, the language must always be remembered and interpreted as little as possible. It is because of this that the events were represented solely as a quote directly from the participant with no title or other identifier. Wong (2000) states that "the descriptions of critical incidents measure what the researcher purports to measure, because the participants are given clear and specific instructions to report only incidents relevant to the purpose of the study. Construct validity is also demonstrated by the fact that all participants are qualified to observe the designated activity and they make similar observations"(p. 50). Each category was subjected to tests of reliability and validity, explained in the next section of this chapter. The tests of reliability and validity resulted in refinement of the categories, minimized ambiguities between categories and accommodated all identified events. Validation and Reliability Procedures for Categories Following the validation procedures used in McCormick's study (1995), five specific steps were taken to ensure soundness and trustworthiness of the categories I created from the events reported by the participants. The first step focused on the examination of the soundness of the categories by examining the comprehensiveness of the categories. Consequently, there was an examination of how well I formulated the categories. In other words, have I covered all areas of the event? Are the categories comprehensive and complete? Following McCormick (1995) and Anderson and Nilsson (1964), I held back approximately ten percent of the events (24) before I created the categories. Once I created the categories, I placed all other events in said 44 Survival Factors in Suicidal Aboriginal Youth categories and 230 events were placed into 14 categories. At this point, the withheld events were uncovered and I attempted to place them in the existing categories. I was able to do this with relative ease, and this aided in suggesting the completeness and comprehensive quality of the categories. The second step ascertained whether different people could use the categories in a consistent manner. By this I mean would others be able to place events in the categories I created in the same way? I used independent judges not involved in this study to place a random sample of events into the categories. Three individuals voluntarily agreed to be my independent judges, two of whom were registered psychologists with the third having a doctorate in counselling psychology. The judges were asked to sort ten percent (24 events) of the incidents into the categories, to see whether they would classify the incidents in a manner consistent with the researcher. As will be discussed in Chapter 4, the three independent judges agreed with the classification 92%, 92% and 96% respectively (See Table 2). When dealing with inter-rater consistency in Critical Incident techniques, Woolsey (1986) has suggested that a 75-85% agreement is acceptable. Therefore, as the agreement level is higher than this suggested level, an assumption of reasonable reliability can said to have been established. The independent judges' agreement rate indicated that construct validity was adequately achieved. The third procedure assessed the validity and reliability of the categories by examining the participation rate for the categories. When I formed each category, it was because I observed a similarity among a group of incidents recalled by different individuals. This led to the assumption that these multiple individuals reported the same kind of event. McCormick (1995) states that "it is possible to determine whether a category is sound or well 45 Survival Factors in Suicidal Aboriginal Youth founded by examining the level of agreement amongst the participants in the study in reporting the same thing". Once the categories were formed and all incidents were placed in them, an analysis of participant agreement was undertaken. As will be described in detail in Chapter 4, the participation rates ranged from 90% to 25%, with only five of the fourteen categories being under 50%. Table 3 delineates the rate for each category. Borgen and Amundson (1984) indicated that a participation rate of 25% and higher is an indication of robustness, indicating further confirmation of reasonable validity for the results of this study The fourth procedure assesses the soundness of the categories by means of expert commentary. I attempted to place this research study in the context of the counselling field by seeking out experts in the field to review the data and my categories. In addition, it was also important to approach expert individuals in the field of Aboriginal' research and gain insight from their perceptions of the data and my categories. Both groups were able to report whether my findings are consistent with information they have discovered and reported through their work. It was important to find individuals experienced and knowledgeable in the areas I wish to examine. I asked them to examine my categories and judge them on the basis of relevance and usefulness. I approached 2 individuals who have worked in the Aboriginal community in a professional capacity for over 25 years and they indicated agreement and familiarity with the categories that I had created, indicating that this was consistent with what they had experienced in their interactions with the First Nations community in BC. The fifth and last procedure assessing the validity of the categories follows the fourth procedure closely. In addition to consulting with 'experts' in the field, I also reviewed the current and past literature. When examining past research in the areas of adolescent suicide, 46 Survival Factors in Suicidal Aboriginal Youth aboriginal adolescent suicide, cultural differences, and themes of survival, I searched for agreement. By comparing the categories formed from this data, I was able to see i f they are similar to what has already been found. By examining previous research and informed opinion, agreement with my categories was established. As is demonstrated in the following chapter, the findings are reported as categories with self-explanatory titles and accurate descriptions. In keeping with the desire to let the Native voice speak from my data, the detailed descriptions that are provided for all categories and sub-categories attempt to reflect the participants' own voices. Example incidents are provided for each category. A n additional validation check involved a return to the participants and showing them the categories that were formed from the incidents identified. I have consulted with two participants. Upon reading these categories, each participant commented that they believed the categories to be a good fit to survival factors. Each commented that even though they may not have covered all categories themselves, they connected with all categories. It appears that the categories formed resonated with the participants, which indicates an accurate fit of the data analysis. Process Summary To summarize and clarify the research methodology and procedure, it can be understood as follows: 1. Volunteer participants were recruited and arrangements made for the interview 2. Participants were given informed consent forms and oriented to the study 47 Survival Factors in Suicidal Aboriginal Youth 3. Open ended, semi-structured interviews were conducted to elicit critical incidents contributing to the participants' survival. Every effort was made to note meaning and context. Each interview was audio taped 4. Ten of the interviews were transcribed 5. Audiotapes and transcripts were reviewed at length to identify critical incidents from the interviews. The participants' exact words were used in an attempt to reflect their language and minimize the researcher's ethnic bias. 254 incidents were identified 6. First 229 critical incidents (minus 24-10% of the events) were grouped into 14 categories through the process of analysis and inductive reasoning 7. Categories reviewed and discussed with research supervisor 8. Withheld, remaining events (10%-24 incidents) analyzed and fit into existing categories with no new categories needing to be created 9. 24 random critical incidents presented to three independent judges for classification into categories 10. Two participants asked to review the categories and comment on resonance of them. 11. Two 'experts' in the field given categories and asked to discuss their experiences with them and similar findings 12. Findings reported I have attempted to reflect my participants' truths, their stories about what helped them survive and heal. By sharing this with others, I believe this study will have substantial merit. I also believe that such qualitative research serves to illuminate and provide focus and direction for further study. 48 Survival Factors in Suicidal Aboriginal Youth CHAPTER IV: FINDINGS "I am a survivor because I am alive " Gerry Oleman (Residential School Project) Through interviews with 20 First Nations individuals (6 men, 14 women), 254 critical incidents were elicited concerning what facilitated survival following suicidal thoughts, behaviour and/or actions during each participant's youth. The participants provided between 10 and 17 incidents per interview with the average amount of incidents per interview being 12.7. When dividing the participants by gender, the female participants ranged between 10 and 17 (average 12.6 incidents) and the male participants between 10 and 16 (average 13 incidents) A l l 254 critical incidents have been grouped into fourteen categories. Each category is presented and described below with examples of critical incidents given for each category. They are presented in order of participation rate -the highest to lowest. Table 1 has been provided to reflect all categories and amounts. Table 3 indicates participant rate distributed throughout each category. After the category description, a description of gender difference will be discussed and Table 4 will display them. Lastly, a section describing what participants mentioned contributed towards their suicidality, factors harmful towards survival, will be described and presented in Table 5. This was done to accurately reflect the reasons behind the participants' journey from suicidality to survival. Description of Categories This section will present each of the 14 categories by providing a description of the category and samples of direct quotes from the participants. Each quote wil l reflect the direct 49 Survival Factors in Suicidal Aboriginal Youth response of the participants answering the question "What helped you survive?". This question followed what each participant described as a 'low' point in their life when they either had extreme suicidal ideation or acted in a way to end their life. The categories are presented according to percentage of participation rate. This will also include the number of incidents per category. As indicated previously, participation rate is an indication of robustness. This in no way indicates levels of importance or higher meaning, only what this sample of participants reflected. TABLE 1: CRITICAL INCIDENT CATEGORIES PARTICIPATION NUMBER OF CATEGORY RATE INCIDENTS Connection to/Love of Family (Includes Spouse) 90% 34 Professional Support 80% 30 Responsibility to Others/Desire to Care & Protect 75% 34 Formal Education 75% 18 Support of Non family/ Non Professional Individuals 70% 25 Cognitive Shift/ Change in Thinking 70% 24 Avoiding a Negative Environment 70% 22 Connection to Cultural Heritage 65% 17 Getting Sober- Stop Drug & Alcohol Use 50% 11 Spirituality 45% 10 Normalizing One's Difficult Experiences/Learning You Are Not Alone 35% 10 Connection to Nature 35% 7 Self Acceptance/Love/Care 30% 7 Sense of Purpose/Making a Difference 25% 5 50 Survival Factors in Suicidal Aboriginal Youth Connection to/Love of Family (Includes Spouse) This category had the highest participation rate at 90%. Eighteen out the twenty participants contributed to this category. It comprised of 34 incidents. The definition given to the independent judges for this category read: This category is defined by the perception of connectedness and/or love offamily. This includes an appreciation offamily's love, support, help, teachings and forgiveness. This may also include activities with family, being cared for and memories offamily. This may also include feeling protected by family, feeling safe or feeling saved. This category differs from other categories (especially Responsibility to Others) by way of the theme of support of family rather than responsibility to individuals, including family. The events ranged from feeling unconditional love of one's parents, to being physically cared for by one's family, not being judged by a relatives and feeling safe when staying at one's mother's house. For example, I remember all my family being around the bed when I woke up.. .they just let me think about it, they were just there to listen, to support me and just to talk about it... M y whole family.. .both my grandparents, I was very close to my great-grandmother, it was helpful.. .it was like we didn't even need to speak.. .just knowing that their love was unconditional.. .family is who you are... 51 Survival Factors in Suicidal Aboriginal Youth Seeing my mother.. .I'm pretty close to my mother and family.. .seeing her made me feel a little bit more safe.. .she never asked any questions why.. .1 always felt good around her, because she loves me... M y mom, she helped me. I told her about it [being in the sex trade].. .she gave me a hug and she said she wasn't ashamed of me. She didn't push me away.. .it was comforting just her being there... Probably the other thing that pulled me through was my belief that I was loved by my family.. .1 really felt that my younger brother and my Dad loved me unconditionally, yeah, I would think, yeah, the unconditional love... Other events in this category concerned feeling supported and/or saved literally from suicidal thoughts or actions and that this saving support was a crucial survival factor. For example, My cousin came in and said 'what are you doing?" [participant was in the process of hanging herself] and she grabbed the, she saved me. She saved me...after she took it off me I dropped to the floor and she grabbed me, she hugged me. I started crying and she hugged me. She just dropped down on the floor and wrapped me in her arms and she held onto me and I just cried and cried and cried. Somebody came in and she just told them to get out and she held onto me until I calmed down and then she said 'It's okay and you don't have to be alone"... 52 Survival Factors in Suicidal Aboriginal Youth She [participant's wife] encouraged me to stay home, be with her and talk things over...I said T might as well just kill myself because we were arguing over some stupid little thing.. .1 said 'there's no use in me being around' cause it clicks right away [feeling suicidal] When I said that, the thing she told me what changed my mind was 'Please don't go, I love you with all my heart". I stopped in my tracks right there and I turned around and gave her a hug and I told her I loved her too. We made up and things went good... M y mom took the knife away from me. My mom talked to me, she tried to..[it helped] because somebody cared at that moment... It appears that having a family member demonstrate caring and support in ways ranging from simply providing a presence, offering a shoulder to cry on, listening without judgment and literally saving them creates one of the strongest survival factors presented in this study. Professional Support This category had the second highest participation rate at 80%. Sixteen out of the twenty participants contributed to this category. There were 30 incidents in this category. The definition supplied to the independent judges read: This category is defined by accessing support by individuals trained to give aid (e.g. psychologist, counsellor, teacher, nurse, worker, therapy, treatment centre, pastor, instructor). There is a perception of support, therapeutic connection, teaching or provision 53 Survival Factors in Suicidal Aboriginal Youth of advice. This may include feeling encouraged, cared for or believed in (they have faith in them). Professional services appeared to be very helpful towards survival for these participants. 'Professional' is operationalized as any individual trained in the helping, educating field. Therefore, counsellors, psychologists and pastors are in this category along with teachers, instructors and nurses. For example, Seeing a counsellor because they listen to you, and you're not like, frowned upon. They give you feedback on how you can help yourself... [Seeing a counsellor] her patience, her caring, her empathy, really you know for me what it meant to me at that time was someone does care that I'm alive.. .that had a huge effect and a huge bearing on where I am today... .to work through my issues, she was the one that actually opened the door up... Talking with the A & D (Alcohol and Drug) counsellor.. .through counselling and everything, I thought everything was my fault and stuff and I was the bad person but went through all the counseling and stuff. I've learned that it had nothing to do with me and what happened happened. There's nothing I can do to change it and i f I choose to keep running from it, hiding from it whatever, then it's just going to eat me and eat me, it's just going to make me worse.. .so it really helps, through counseling... 54 Survival Factors in Suicidal Aboriginal Youth I started seeing a pastor in a church. He listened and he also helped me process the feelings that I had instead of me just fighting them in my head, I believe, what we call 'stinking thinking' and fighting stuff alone... There was this one teacher in high school. Even though I didn't do my homework, I didn't do it, I was kind of high all the time. He used to always believe in me. He used to always say ' X , one day you're going to change, one day". No matter what he'd always have something good to say.. .that's all he'd say.. .1 used to look forward to his class, he'd say those words and let me be.. .that was the only person who was there... These incidents focused on a professional individual providing aid, in the form of support, advice and/or feedback. It appears that the ability of these individuals to help the participants felt supported and process some of what they were going through was helpful towards their survival. Responsibility to Others/Desire to Care & Protect This category had a 75% participation rate, with fifteen of the twenty participants contributing events to this category. There were 34 incidents in this category. The definition given to the independent judges for this category read: This category is defined by the perception of being responsible for another individual. There is a desire to care for and/or protect. This may include a need to be needed, setting 55 Survival Factors in Suicidal Aboriginal Youth an example, or nurturing someone. This may also include caring for someone by not causing him or her emotional distress. The majority of these events included a participant, male or female, indicating the concern for an individual and the consequence for this individual i f the participant killed himself or herself. The events ranged from including the need to be needed to not wanting to cause an individual emotional distress. This individual was often the participant's child. Several of the participants indicated that they became parents in their late teens or early twenties and thus during their 'youth'. Their responsibility to others usually involved children and often other family members. There was often a need to belong or simply being needed. For example M y sons.. .I'd just look at them and know that they meant so much to me.. .by looking at them and keeping focus and keeping a schedule for my children.. .1 was able to say i f I'm gone, who is going to look after them.. .they brought me back to reality or they kept my feet on the ground as part of reality.. .they were always going to know that they were loved and they're going to always know that they were wanted... M y kids.. .It was helpful that I had other people to think about. I couldn't be completely selfish and also thinking about what my family had gone through with my brother [who had committed suicide] Having to see my mother go through that.. .1 have too many people who care about me. I was the primary caregiver of my kids... 56 Survival Factors in Suicidal Aboriginal Youth I had to be there for them [her children] because they couldn't go through that same thing, like I had to show them they were loved.. .1 realized they do need me, they told me they needed me... I had my daughter. [It helped] to have someone to love me back...I just wanted to feel like I belonged somewhere, I did with my daughter... Other participants cared for individuals that were like a child to them and felt obligations and/or responsibility to them. M y nephew X , I was not going to get attached to him.. .1 call him sunshine now...I was going through a rough time and thinking about doing it really and thinking about how it would be for him i f he lost me.. .he's like the kid I ' l l never have.. .we're really close and whenever I'm down or anything like that now, I think about him... Lastly, there were several events focusing on not wanting to cause others emotional distress by the very act of killing themselves. I put a gun in my mouth and what stopped me was my youngest brother walking in at the time at the house.. .the thought of him discovering me, how traumatic that would be to a ten year old boy, I didn't want him to see that, so I didn't do it.... 57 Survival Factors in Suicidal Aboriginal Youth As will be discussed in the subsequent discussion chapter, it appears that a sense of responsibility, commitment and duty to another individual in their life that cared for them was a crucial element to survival in the participants' stories. Formal Education This category also had a 75% participation rate, with 15 out of 20 participants contributing. There were 18 incidents in this category. The definition supplied to the independent judges read: This category is defined by the helpful effects of seeking out some form of education (e.g. school, classes, courses, workshops, training programs). This includes a desire to learn, teach and to grow. This may also include a perception of benefiting from feeling motivated, challenged or escaping through learning. The emphasis of this category is learning and educating oneself. The recurring theme was self- education that leads to growth and understanding. The incidents ranged from going to school, taking courses, attending workshops and other training opportunities. It appears that the very act of education and reasons behind this act was important. The meaning behind wanting to educate themselves was identified by the participants as helpful towards survival. For example, Going back to school. I missed a lot of school.. .because of all the alcohol, taking care of my sister and I felt like I wanted to do something for me... 58 Survival Factors in Suicidal Aboriginal Youth Schooling, it gives me something to do. I want to finish my schooling so I can go to Vancouver.. .cause that's what I want to do, is make movies. I've wanted it for 10 years.. .it's expensive, but it's worth it... Workshops and training. It helps me to understand an awareness of myself. How what I went through effected me. Going to school.. .connection to the university.. .a decision to do something with my life.. .1 was always a pretty good student.. .the more educated you are, the better your outcome in life.. .absolutely [it helped]... I challenged myself like to take a risk and go to school in Vancouver for computer course for 6 months and I arranged it. I went and then I made it and I came home like trying to see how it is outside. The last example and others focused on the participant's experience of self efficacy and choosing education as an important survival tool to help them focus on living. This may indicate some overlap with the final category, Sense of Purpose. Support of Non family/ Non Professional Individuals This category had a 70% participation rate with fourteen out of the twenty participants contributing incidents. There were 25 incidents. The definition supplied to the independent judges read: Survival Factors in Suicidal Aboriginal Youth This category is defined by the perception of support and/or love of nonfamily/nonprofessional individuals (e.g. friends, community, team mates, elders, foster, animals). This includes experiencing support, comfort, respect, well wishes and encouragement. This may also include the sharing of information, teachings and feeling heard (listened to). Similar to the category of 'Connection to/Love of Family', this category focuses on the participant receiving support from an individual which they view as helpful towards survival during a time in their life they considered suicide. However, the individuals in this category are not relatives, nor are they professionals. Instead, these individuals are usually friends, community members, teammates, elders or foster caregivers. The events include these individuals listening, giving support, offering employment and/or saving them from a suicide attempt. For example, I have lots of friends, they help a lot. When I was doing that [attempting suicide], one of my friends was there and she got mad. She took that knife, she grabbed it and threw it.. .she was mad at me, she got it through my head. She talked to me and started crying and we both hugged... M y friends were very supportive.. .they were there and being there for you but not treating you like a china doll [after attempt].. .treating me just the same.. .1 think i f they would have gone the other way I probably would have maybe slipped back 60 Survival Factors in Suicidal Aboriginal Youth in.. .they let me know they were there, tough love...never let you feel sorry for yourself because there's no use in doing that. We had classes on the reserve on the weekends. The community would always come to suppers. They would always congratulate us of they'd always have this ceremony for us to acknowledge that we're doing something for the good of not only the community but ourselves... This friend of mine, he went through the same thing with his ex-wife running around on him. It was just helpful to talk to him, to have him understand, to connect with him... The woman [foster caregiver] I was staying with, she would always sit me down and talk to me about, she'd make me talk to her about what was going on and she was really nice, she cared... M y ex-employer, a Chinese guy who hired me to be a waitress. One time we were gonna move 10 miles out of town and I needed a car to continue working and just kiddingly I asked i f he would co-sign for me for a car and he said 'sure' and he did! It was like, 'wow'.. .just wonderful.. .it was something to look forward to... I could relate to the elders pretty good.. .they were kind of like a support.. .the elders were a big influence on me, like I just kind of sensed their peacefulness, calmness and 61 Survival Factors in Suicidal Aboriginal Youth how good they feel about me speaking my language to them.. .they were happy to see me, that made me feel good. Each event in this category speaks towards a sense of support and caring from an individual outside of one's family, outside of the professional helping arena. Cognitive Shift/ Change in Thinking This category also had a 70% participation rate with fourteen out of the twenty participants contributing. There were 24 incidents. The definition supplied to the independent judges read: This category is defined by a change in thinking which may involve a change in perspective, a decision-making process or acceptance of change. This may also include self reflection, goal setting, perseverance or a change in behaviour. The events in this category reflect the participants' process during a low point in their life and how a certain type of self reflective, cognitive shift helped them to survive. The essence of this category is that the participant consciously identified this cognitive process as a vital survival factor. The events ranged from a specific thought, a decision making process, a character trait and/or a self-realization. For example, I just kept thinking in my head, 'I'm a young man and I've got a lot ahead for myself... 62 Survival Factors in Suicidal Aboriginal Youth Just the fact that I was young, still going to school. Just trying to live my life, spend time for myself, by myself and try to figure out what I wanted to do for the rest of my life... I came to one morning and thought there had to be something better, something more to life. And then.. .it was just, some kind of conscious awakening and I knew I had to do something. I think finally opening my eyes to not only the negative but the positive and I always looked at the negative part of my life like I'm traumatized or I've gone through a lot of bad stuff. It's easy to look at that stuff but I somehow switched to looking at what's on the other side... Tenacity, I think. Resilience. Trying to find it in myself like what makes me tick, what makes me want more, what makes me .. .learn. To always be learning something each and every day, that's something I really like doing... The key element to this category is that something happened in the participant's thought process that they can now consciously identify helped turn a situation in their life from hindering survival, to helping it. It's very hard to accept, it's tough.. .once I accepted things.. .1 can accept it and go on, but holding it for all those years.. .once I realized that, it was okay... 63 Survival Factors in Suicidal Aboriginal Youth I had to open up my eyes and change my life.. .being able to recognize my mistakes.. .1 could have hurt somebody else [driving drunk, had a car accident] I did not want that on my conscious, so I had to start changing my life at that time... Avoiding a Negative Environment This category had a 70 % participation rate, with 14 out of 20 participants contributing. There were 22 incidents. The definition of the category that was given to the independent judges consisted of the following: This category is defined by avoidance of an unhelpful/negative environment, which includes a person or place. ' Avoidance' can be described several ways. This includes physically leaving this environment either permanently or temporarily. It could also mean avoidance through distraction or escape (by activities or behaviour). This may include feeling as if one 'takes a break' or 'get out of one's head'. This may also include feeling freer or able to express emotions otherwise suppressed through the negative environment. This category had a broad range of descriptors ranging from temporarily leaving one's environment to permanently moving. It also includes avoiding certain people, escaping through an activity like sports, reading a book or getting high. It is important to emphasize that such an event was only identified as a survival factor i f the participant specifically identified this as something that directly aided in their survival. For example, 64 Survival Factors in Suicidal Aboriginal Youth Staying away from home [helped]. I'd go and visit my friend and spend the night at my friends or go to my cousin's house where there's no drinking or drugs and have fun with my cousins, play baseball or soccer or whatever, just keep my mind occupied... Well I escaped. I never thought of it that way, but I left home at a very early age. I was actually 16.. .It helped me, not seeing all the drinking going on, I was kind of on my own.. .to get away and not see it and probably thinking I was all grown up and could make it on my own... Dysfunctional home, I couldn't do that anymore and I didn't want to live in it. But I also felt really guilty because of leaving my siblings in that, I call it a cesspool.. .But yet for my own survival I had to get out of that.. .1 finally got into a dormitory... I participated and competed in so many sports and I was very good at it. So that was my escape, to play on the basketball team, the volleyball team, track and field... The drugs, to be honest, it just helped me to forget and just put everything on the back burner... escape... It was getting high, I got high.. .it changed my feelings. When I was eleven or twelve, when school was getting problems.. .it would just get me out of my head... 65 Survival Factors in Suicidal Aboriginal Youth It is essential to note that the individuals who identified drug use as a survival factor during a low point in their life when they were suicidal, later identified getting sober as a survival factor. Therefore this emphasizes that each event identified as a survival factor is isolated in the context and meaning of each participants' narrative. The categorization process attempts to place the contextualized events into categories that echo similar meaning at that low moment. Each individuals' moment is unique. However, by gathering similarities, we strive to work towards implications, discussed in the subsequent chapter. Connection to Cultural Heritage This category had a 65% participant rate with 13 of the twenty participants contributing events. There were 17 incidents. The definition provided to the independent judges read: This category is defined by the recognition of cultural heritage as a support, a survival tool. This includes learning about one's culture, having pride in and/or respect for one's traditions. It may also include observations of cleansing or connectedness through cultural activities (e.g. smudges, sweats, pow wows, circle, story telling, speaking the language). It may also include a feeling of identity, belonging. Similar to categories that stated family, professional and non professional/ non related individual's provided support, love and/or connectedness, this category examines cultural heritage and identity as a survival tool. It appears that providing connectedness to said First Nations heritage is the focus that aided the participant in staying alive. For example, 66 Survival Factors in Suicidal Aboriginal Youth Getting a job at the museum of Anthropology through the Native Youth Program.. .That was really good because it opened up my eyes and my sense of self to my father's past and my mother's past.. .so that experience working at the museum and getting a very positive image of what it meant to be Aboriginal or Native really, it served me well. . . In this event, the participant mentions employment and sense of self and that could be argued as part of the event. However, it appears upon examination of the participant's words, they focus on the cultural identification, what it meant to be Native as the essential aspect of that survival factor. I did meet, I did end up working on a reserve. So I did meet some people, an old guy, an elder-who tried to talk to me. [It was helpful] because he was trying to teach me about tradition and culture. To be proud of who you are, you have to be proud of where you come from and that's one of the things I didn't grow up with.. .[a] strong connection to who I am... Again, this event involves a participant mentioning employment and an individual (non relative, non professional) who attempts to educate him. By examining the words and meaning, it is the connection to cultural heritage, tradition, and identifying with the aboriginal roots that makes up the core of this event. 67 Survival Factors in Suicidal Aboriginal Youth The smudging I find is really helpful. Cause I felt it cleansed me, I feel so cleansed and my mind goes happy. I think happier thoughts... More of the smudging and the family circle.. .the cleansing of the body and stuff.. .the cultural part was really helpful, I mean like getting into the pow wows and the smudging and sweats and stuff. We started to go to pow wows. It was good, to keep us busy, rather than go in the wrong direction. Then you start to learn about your culture... To be proud to be Indian is good.. .it's helpful because I didn't grow up with that, to be proud of who you are.. .it helped me. ..the more I learn like I never learned how to drum and sing. Now I know how to drum and sing-I'm teaching my son how to drum and sing. I never knew what the sweat lodge was. I never knew about those parts of me. The more that I learn about it, the stronger that I feel and the more proud that I feel of myself... 68 Survival Factors in Suicidal Aboriginal Youth Getting Sober-Stopping Drug & Alcohol Use This category had a 50% participation rate with 10 out of 20 participants contributing events. There were 11 events. The definition given to the independent judges consisted of this statement: This category is defined by the positive perception of getting sober. This includes stopping alcohol consumption and/or drug use, either permanently or during a period of time. This may also include getting sober from any addictive behaviour. This category is quite straightforward in the definition of removing alcohol or drugs from one's life and the benefits both physically, emotionally and spiritually that result from this. Such circumstances were identified as important towards survival. For example, When I finally got clean and sober.. .that was the hugest, that was the big one.. .[because when I was using] I was trash, I was ugly, it didn't matter.. .1 would say my survival [was in] admitting of the alcohol and drugs, it was the biggest turning point in my life, it was huge... Basically, well just getting healthy again, I mean I'd been on drugs for a long, long time, getting healthy, having balanced meals, getting rest and just the abstinence for awhile to stir up my thinking because it was a downward spiral [before]... 69 S u r v i v a l F a c t o r s i n S u i c i d a l A b o r i g i n a l Y o u t h I stopped drinking shortly after that [attempt].. .1 went away to treatment. It helped a bit, I stayed sober after treatment for six months.. .[It helped] just staying sober, staying home... I stayed away from the drugs and drinking...[It was helpful] for a while.. .you can only drink so much and your body gets lazy and got no motivation... This category appeared to be a basic survival tool that aided the individual to become clearheaded, safer and more able to live. Spirituality This category had a 45% participation rate with 9 out of the 20 participants contributing. There were 10 events. The definition for this category provided for the independent judges was: This category is defined by a connection to one's spirituality. 'Spirituality' includes one's religious beliefs, one's perception offaith and/or belief in a Creator. This includes the experience of something 'bigger than them', which may give an individual a feeling of peace or a reason to live. It may also include a sense of hope and/or a desire to pray. Spirituality encompasses many different areas and can mean different concepts for different individuals. For this study, the events in this category range from a specific Christian faith, the Native concept of the Creator to a general belief in a 'higher power greater than us'. 70 Survival Factors in Suicidal Aboriginal Youth For example, I had enough serenity or I would have to say enough spirituality in me to know that and that was a lot of when times were low I knew there was a God. I continually always talked to him...that was part of it [survival].. .1 believe God was there.. .1 would say that's how I got through it. Just the belief that there was something else besides me, you know, something, a higher power.. .or Creator.. .then the focus is off myself and not what I wanted or cared about, just maybe I was here for a reason That night in that room.. .something happened, out of the blue I said 'God change me or let me die'. Something happened, some kind of, something went over the inside of me, my body, my whole being and I went to sleep. In that instant I never felt alone, I never felt without hope, I just felt kind of in a way, a peace, that was I think the first real time in my life that I prayed. No one was there to tell me, it just happened that way and I put the knife down and I felt okay.. .In that instant I believe my life changed, after that I never stopped praying I suppose it was religion, my belief in God. M y mom was a very strong Catholic. I know that a lot of First Nations really shun the church these days, but despite that, there were times I remember my mom and dad gathering us kids around their bed and 71 Survival Factors in Suicidal Aboriginal Youth we'd kneel down and pray. We were taught what was right, what was wrong. I guess morally, religiously I knew that in the church's eyes, suicide is wrong.. .it's a sin... When that first happened [severe suicidal ideation], my response was to go into the bathroom and I started praying. I was brought up Catholic, so I started intensely praying.. .yeah I would say it was [helpful].. .at that time it was very important... The key element in this category, and exemplified in the above quotes, is the belief in something greater than the participant. It appears to be a trust or need for faith in a higher being. This belief appears to be a powerful survival tool for these individuals. Normalizing One's Difficult Experiences/ Learning You Are Not Alone This category had 40% participation rate with 7 out of 20 participants contributing. There were 10 events. The description of this category provided for the independent judges included the following: This category is defined by the perception of normalizing one's experiences of suicidality, abuse etc. through the sharing of others' similar experiences. This may include hearing others' stories, sharing one's stories and/or learning that one is 'not alone'. This may also include feeling as though one is less isolated, identifying with others and possible relief that others are 'worse off than themselves. This category had very clear incidents, with little room for uncertainty or overlap. These events focused on the realization that there are others with similar experiences. That 72 S u r v i v a l F a c t o r s i n S u i c i d a l A b o r i g i n a l Y o u t h realization appeared to impact the participant in a manner that was very helpful to survival and thus helped them to go on living. For example, Learning that other people have gone through same things.. .that people had tougher times and stuff, just hearing the different stories was really helpful ... That was hugely [helpful], not only for my survival but to the realization that there was lots of people in this world that need to talk to somebody and that probably was the beginning of my plan to go on with my life... Getting a different perspective of things and seeing other people that had done it [attempted suicide], being in the same place I was.. .sharing stories and just seeing that they were happy... [By sharing my story] it was helpful for me by letting them know that I'm a survivor and they can survive as well by opening up and trusting someone... It was hard like [you think] nobody, nobody had to go through it and like you know you hear [other's] stories and it's kind of helpful.. .because being isolated, you know, you don't know... 73 Survival Factors in Suicidal Aboriginal Youth In A A meetings.. .being able to identify myself with other people's problems.. .there were some people that have bigger problems than I have... This category focuses on how important identifying with other's similar experiences and feeling validated by this connection is and that this was a powerful survival factor for these . participants. Connection to Nature This category had a 35% participation rate, with 7 out of the 20 participants contributing towards this category. There were 7 incidents. The definition supplied to the independent j udges was: This category is defined by a perceived connection to Nature, the outdoors. This includes experiences of the calming, unchanging quietness of the outdoors. It may also involve a feeling of peace while in Nature-and ofpeaceful isolation and relaxation. Similar to the Getting Sober category, this is a fairly straightforward category that involves the participant being in Nature as a survival tool. For example, What I always did, when it really got bad I would go out and walk in the woods, that was a huge, huge part.. .1 think it was all the smells, it was the sounds.. .1 was safe.. .1 never ever felt threatened, that was a place I could be quiet. I didn't have to think what's going to happen next.. .a way to de-stress, it's that kind of moment.. .being out being connected with the trees... 74 Survival Factors in Suicidal Aboriginal Youth I did, it did help me.. .1 moved right into the middle of the bush on a ranch and it helped me to be out in the middle of nowhere, in nature.. .it's still a part of my life, it's peaceful, it's real. The opportunity of just getting away by myself and just going out, jump in the car and take off to the country.. .time to be by yourself, to think.. .the ocean was calming...it's just so much bigger than me.. .[to] unwind We used to walk a lot and berry pick, I remember that was getting in touch with nature and I still do that, I ' l l just go out in the bush and pick berries because it was, it's real, it's earth, it's not going to change, you know, the old tree is going to be there... It's not the people, it's the land that calls me home, so there was an acceptance and a peace within me when I came home.. .there was a peace that came even through all [my] addictions, I always loved nature.. .1 love that isolation or aloneness with mother earth.. .1 mean that's just part of my healer is the land... It appears that connectedness with the peace of nature provided strength to survive. Similar to the Spirituality category, there is a sense of something 'bigger' and, in the case of nature, older and permanent that seems to help the participant strive to live. 75 Survival Factors in Suicidal Aboriginal Youth Self Acceptance/Love/Care This category has a 30% participation rate with 6 out of the 20 participants contributing. There were 7 incidents. The definition distributed to the independent judges contained the following: This category is defined by a sense of self-acceptance, self love and self respect. This includes self-expression, one working to believe in oneself and caring for oneself. Although other categories may include feelings of acceptance, love or care (through spirituality, nature or a caring individual), the events specific to this category consist of a explicit, self- identified statement that self- acceptance/love was the key to the survival factor. For example, Believing in myself, accepting myself. The biggest thing I got out of recovering is to look in the mirror and say T accept you, X ' . That's the biggest thing I got. Taking care of myself. Even now.. .I ' l l do whatever it takes to take care of X . . . Part of my journey going along would be not to just survive.. .1 wanted to live and really live and part of that was loving me...I didn't know that's what I needed to do... Love is probably more healing than life itself. You've got to love yourself and love other people.. .1 do, I would not be here i f I didn't... 76 Survival Factors in Suicidal Aboriginal Youth Making the decision of accepting oneself, loving oneself and caring for oneself, appears the key element in each of the elements in this category. Sense of Purpose/ Making a Difference This category has a 25% participation rate with 5 out of the 20 participants contributing. There were 5 incidents. The definition given to the independent judges for this category read: This category is defined by a perception of having a sense of purpose and/or making a difference. This includes a desire to contribute and/or help others. As the category with the fewest number of incidents, the specific language of this category speaks to an individual's sense of purpose and helping others as the key survival factor. For example, M y job helped me, it gave me a sense of purpose.. .just talking with the youth and just being honest with them... I got my work ethic from my parents.. .That's what I needed, to do something, feel like I'm contributing, feel useful, feel like I had a purpose... I did Red Cross for awhile to help people.. .1 would be there for the people that were in a car accident.. .what made me decide hey I think I'm cut out to help people.. .1 wanted to help people.. .I'd think, you're doing stuff for yourself... 77 Survival Factors in Suicidal Aboriginal Youth Validation of the Categories As mentioned in the previous chapter, there are 5 validation techniques in critical incident methodology that are used to establish confidence in the categories created through analysis of the events. These include Reliability- through independent judges placing a sample of events in the categories. Comprehensiveness- by withholding 10% of the events prior to category formulation and subsequently attempting to fit them into the categories, Participation Rate for categories, Expert Commentary and Fit with the Literature. Reliability As discussed in the chapter on Methodology, a good indication of trustworthiness is reliability. By establishing whether different people use the categories in a consistent way, a category scheme can be viewed as reliable. In this study, a sample of 24 incidents was randomly drawn from the total 254 events. This sample size consisted of roughly 10% of the events. Three individuals voluntarily agreed to be my independent judges, two of whom were registered psychologists with the third having a doctorate in counselling psychology. These individuals were provided with a description of each category (included in the descriptions in this chapter) and asked to place random incidents in the category they felt was most appropriate. This procedure took approximately 20-30 minutes for each judge. They agreed with the classification 92%, 92% and 96% respectively (See Table 2), which clearly meets 78 Survival Factors in Suicidal Aboriginal Youth the suggested 75% agreement by Flanaghan (1954) and the 75-85%) suggested agreement by Woolsey(1986). TABLE 2: RELIABILITY OF CATEGORY SCHEMES Judges Percentage Agreement Registered Psychologist #1 92% Registered Psychologist #2 Doctorate in Counselling Psychology 92% 96% Comprehensiveness An important way of determining soundness of a category scheme is to determine whether or not the category scheme is comprehensive or complete (Andersson & Nilsson, 1964). As mentioned in the previous chapter, this was established by withholding 10 %. (24 incidents) when creating the categories. Once the category formation was completed, the withheld incidents were then brought back and classified. A l l withheld incidents were easily placed within the categories. Had this not occurred, it would have been necessary to form new categories until all withheld events were placed into an appropriate category. In addition, had redundancy not occurred, it would have been necessary to interview more participants. As this did not need to occur, an assumption could be claimed that these categories are provisionally comprehensive for the events of the participants. 7 9 Survival Factors in Suicidal Aboriginal Youth Participation rate This validation technique also strives to determine whether a category is sound and/or well founded. By examining the level of agreement amongst the participants, one examines whether the participants are reporting the same or similar events. The formation of a category is done by the researcher identifying similarities amongst events reported by different people. If only one person reported a category of an event, the soundness of said category may be held in contention. As we are asking the participants to 'remember when', there is always a possibility of distortion or fabrication, therefore, when several people report and discuss similar events, soundness is more firmly established. Agreement is measured by the participation rate for each category which involves the number of participants reporting a category of events divided by the total number of participants (See Table 3 below). The. categories with the highest participation rate are thus those with the highest level of agreement. Participation rates ranged from 90% (Connection to/Love of Family) to 25% (Sense of Purpose). The mean participation rate across categories was 58.2%. Other categories with a participation rate of 50% or higher included: Responsibility to Others, Professional Support, Support of Non Family/Non Professional, Cognitive Shift, Avoiding a Negative Environment, Formal Education, Connection to Cultural Heritage and Getting Sober. Being that there were over half of the categories ranging from 65% to 90%, one could suggest that such high participation rates indicate the accuracy of events coded and categories formed. The remaining categories of Spirituality, Normalizing One's Experiences, Connection to Nature and Self Acceptance had rates of 45%, 35%, 35% and 30% respectively. The categories with less than 50% are still considered sound due to other 8 0 Survival Factors in Suicidal Aboriginal Youth validation techniques of comprehensiveness, what the experts said, fit with the literature and comments from the participants' themselves. It is perhaps due to the nature of the sample size that there is a lower participation rate for these categories. Moreover, as previously cited, Borgen and Amundson (1984) have reported that a category with at least 25% participation rate is indicative or robustness; as all the categories are 25% or higher, this further confirms trustworthiness. Further research would ultimately help strengthen the thematic nature of these categories. Interpersonal agreement remains a simple test of soundness. TABLE 3: PARTICIPATION RATE IN EACH CATEGORY Category Per Participant Participation rate Responsibility to Others/Desire to Care & Protect Connection to/Love of Family (Includes Spouse) Professional Support Support of Non family/ Non Professional Individuals Cognitive Shift/ Change in Thinking Avoiding a Negative Environment Formal Education Connection to Cultural Heritage Getting Sober- Stopping Drug & Alcohol Use Normalizing One's Difficult Experiences/Learning You Are Not Alone Spirituality Connection to Nature Self Acceptance/Love/Care Sense of Purpose/Making a Difference 15 18 16 14 14 14 15 13 10 7 9 7 6 5 75% 90% 80% 70% 70% 70% 75% 65% 50% 35% 45% 35% 30% 25% 81 Survival Factors in Suicidal Aboriginal Youth Expert Commentary Expert validation is yet another test for soundness of the data. This study accomplished putting the research into the context of the field of Aboriginal Survival by asking people who may be considered 'experts in the field'. When experts are asked to explain whether the findings of a particular study are consistent with their own experiences, their relevant experiences lend weight and trustworthiness to the study (Cronbach, 1971). In this study, I asked two Aboriginal 'experts' working in the mental health field. These individuals had, between them, over 35 years experience with 'survival' and the Aboriginal. They had varied educational backgrounds spanning counselling psychology, anthropology and social work. I conducted an interview with each of the two experts and after providing them with the same definition of each category, I described some of the events in detail. I asked the experts to go through each category and assess them. I was searching for resonance and familiarity with the thematic content of each survival factor. The results of these interviews confirmed that all fourteen categories were recognizable and useful to their practices. The first expert commented that a 'cognitive shift' was 'very common' in the individuals she had worked with. In addition, she stressed the importance of connection to cultural heritage as 'so much has been lost', and that it is so important to survival and healing that individuals learn where they come from and the different traditions for different regions. She viewed education as a 'way out' for many of the clients she had dealt with. Sobriety was discussed as 'vital' to survival. In addition, normalization of experiences and acceptance, for this expert, were quite connected. Connection to Nature and Spiritually were sources of strength. She reported that she had experience with all categories. 82 Survival Factors in Suicidal Aboriginal Youth The other 'expert' also examined each category and stated she had had direct experience with every category with the exception of formal education. She stated that 'absolutely' these categories resonated with her. She pointed out that connection to cultural heritage was essential. She stated that this was not because so much had been lost but had been 'stolen' by the multiple challenges for Aboriginal people and the generational wounds that provoke the need for survival. She commented that many of the categories spoke to the inherent understanding needed for the Aboriginal individual to become connected to who they are in order to survive and heal. This connection consisted of their culture, faith and lived experience. Such analysis adds additional strength to the soundness of the categories. Unique Findings & Fit with the Literature The categories of Cognitive Shift/ Change in Thinking and Avoiding a Negative Environment are unique findings of this study and, as will be discussed in Chapter 5, provide a new and exciting direction for researchers to examine when exploring the concept of survival. Theoretical and practical implications are also discussed. If the remaining categories have echoed agreement with the research literature, soundness is further enhanced. If disagreement is noted, this raises further questions and offers new directions for future research. Therefore it is essential to examine the categories and searching the literature for connections. The very connectedness of the categories and the research leads the exploration of the section to discuss the categories together, rather than separately. When exploring resiliency, the SPAG (2003) reported, as mentioned previously, that 'these can include aspects ranging from family connectedness, informal support networks and 83 Survival Factors in Suicidal Aboriginal Youth community cohesiveness, to well-developed problem solving skills and a sense of personal autonomy, (p. 89). These can all be included in the categories of: Responsibility to Others/Desire to Care & Protect, Connection to/Love of Family (Includes Spouse),Support of Non family/ Non Professional Individuals, Normalizing One's Difficult Experiences/Learning You Are Not Alone. Each of these categories are represented in the literature when exploring support, connectedness and community. The category of Professional Support could also be included in this. In addition, R C A P (1995) noted that There is clear evidence in research and in Aboriginal experience that a clear and positive sense of cultural identity in institutions that allow for collective self control, along with strong bonds of love and mutual support in family and community, can act as protective force against despair, self destructiveness and suicide (RCAP, 1995) This is not only connected to support but also to the category of Cultural Heritage. Chandler and Lalonde's (1998) theory of cultural continuity also resonates with this. The category of Spirituality is connected to cultural heritage and connection to family, support and traditions. The SPAG (2003) report has a specific section dedicated to the importance of spirituality and mentions that Spirituality has been recognized by many as a key part of the whole personal wellness-encompassing body, mind, spirit and feeling. For First Nations people, spirituality has been closely linked to living with the land... Spirituality offers a clear sense of belonging and purpose and a feeling of acceptance and being understood that allows a person to make choices that show self-respect and respect of others because of a strong individual and collective sense of self. (p. 96) 84 S u r v i v a l F a c t o r s i n S u i c i d a l A b o r i g i n a l Y o u t h Related to the aforementioned quote is that of the categories of Self Acceptance/Love/Care and Sense of Purpose/Making a Difference. These are linked to the previous research and also to the concept of identity, which the SPAG report (2003) also refers to. In the transition from childhood to adulthood, people often experience feelings of isolation and alienation as they attempt to define themselves in relation to the world around them. For many First Nations youth, however, these feelings are particularly intense, the result of continuing racism embedded within the systems of non-Aboriginal society, and dislocation from traditional know ledges and practices. The report indicates that fostering a strong sense of identity would be an extremely effective tool against suicidality, which shows clear support for the category in this study. The categories of Getting Sober- Stopping Drug & Alcohol Use and Formal Education are straightforward categories representing a direct activity that contributes towards survival and healing. Researchers have detailed and explored sobriety and education as essential tools of survival and healing. The category of Connection to Nature is also well represented in the literature. Nature plays an integral role in Aboriginal traditions and connectedness to identity. Therefore this category is well connected with the literature in this area. The SPAG report (2003) notes that Land is healing for First nations youth who yield it as a sense of place, a familiar landscape and an educational experience. First, land is a place or territory where family resides and foster their unique cultures and livelihoods. Second, it is steeped in values and in a landscape made familiar by shared stories.. .Third, land represents educational experiences in country settings for First Nations youth who often participate in nation-gathering events, back-to-the-land rituals and survival training activities where they learn skills like responsible living, problem solving, team building and other traditional teachings, which may prevent suicide (pg 92) 85 Survival Factors in Suicidal Aboriginal Youth It appears that the search for fit with literature offers combinations of themes from each category. When linking this information back to White and Jodoin's (1998) best practices manual, each area of Youth/Family, School and Community are echoed in the categories. Gender The intent of this study was not to explore gender differences for male and female aboriginal individuals in terms of survival factors. As mentioned in the literature review, there are gender differences in suicidal attempting behaviours, but less information about resiliency factors in suicidal aboriginal youth. Nevertheless there did appear to be some interesting differences. Table 4, below, documents the categorical breakdown of critical incidents by gender. There was an uneven distribution of gender in this sample, with six of the participants male and 14 female . This translates that 30% of the sample was male while 70% is female. Every individual, either expert commentator or participant, who has been presented with these categories, stated that they resonated with all the categories to a greater or lesser degree. The categories with similar high participation rates were Connection to/Love of family Responsibility to Others and Professional support. A slight difference is noticed with the Cognitive Shift category. It is worth noting that every male participant indicated that Formal Education was a survival factor while just over half of the female participants noted this. Perhaps the most interesting difference worth commenting on is that 83% of the male participants mentioned Spirituality, while only 29% of the female participants noted such an 86 Survival Factors in Suicidal Aboriginal Youth incident. Again, as the division of gender is so unequal, such discussion is hypothetical as there may be other confounding events that could have affected the distribution. Nevertheless, these findings are both unique and of note, as this research question has not been explored before. Further exploration of male versus female language, stories and survival factors should be encouraged. Theoretical implications concerning identity and learning, which will be discussed in Chapter Five could also be explored through a gender lens. Each question raised through the exploration in gender from this study may provide future ideas for research and implications for clinicians. Future research in this area may better illustrate the nature of these differences in this study. 87 _•_ Survival Factors in Suicidal Aboriginal Youth 'TABLE 4: CATEGORIES DIVIDED BY GENDER CATEGORY (PART.RATE) FEMALE FEMALE- FEMALE MALE MALE- MALE Responsibility to Others/Desire to Care & Protect-75% EVENTS (TOTAL PART. RATE) 24 10(50%) PART. RATE 71% EVEN TS To (TOTAL PART. RATE) 5(25%) PART RATE 83% Connection to/Love of Family (Includes Sp6use)-90% 23 12(60%) 85% 11 6 (30%) 100% Professional Support -80% 18 10(50%) 71% 12 6 (30%) 100% Support of Non family/ Non Professional Individuals-70% 17 9 (45%) 64% 8 5 (25%) 83% Cognitive Shift/ Change in TMnking -70% 16 9 (45%) 64% 8 5 (25%) 83% Avoiding a Negative Environment -70% 15 10(50%) 71% 7 4 (20%) 67% Formal Education -75% 10 9 (45%) 64% 8 6 (30%) 100% Connection to Cultural Heritage -65% 10 9 (45%) 64% 7 4 (20%) 67% Getting Sober- Stop Drug & Alcohol Use -50% 6 6 (30%) 43% 5 4 (20%) 67% Normalizing One's Difficult Experiences/Learning You Axe Not Alone -40% 6 5 (25%) 36% 4 3(15%) 50% Spirituality -45% 4 4 (20%) 29% 6 5 (25%) 83% Connection to Nature -35% 5 5 (25%) 36% 2 2(10%) 34% Self Acceptance/Love/Care -25% 3 3(15%) 21% 4 2(10%) 34% Sense of Purpose/Making a Difference -25% 2 2 (10%) 14% 3 3(15%) 50% Survival Factors in Suicidal Aboriginal Youth Factors that are Harmful towards Survival The focus of this study was on survival factors for those individuals enduring suicidal thoughts, behaviours and/or actions. As mentioned in the literature review, there have been numerous causal factors for suicidality researched and reviewed in the literature. As an incidental evaluation (as I did not ask the participants' directly), each participant gave several indications of factors that hindered their survival. I believe that this information adds layers of meaning and context for the events and may serve as a backdrop for the survival factors. As is evident in the lists of harmful factors, the participants are truly 'survivors', enduring many challenges that created extremely difficult environments, provoking a need to seek out survival factors in order to continue living. By listening to each interview on audiotape, I recorded each issue or factor that a participant mentioned, stating that this made them want to kil l themselves and moreover, made it very hard to want to live. I compiled this information and recorded the commonalities among participants, how many indicated similar or different factors. Table 5 represents the largest categories that participants' indicated were harmful towards their survival. These included alcohol and drug use, drug and alcohol use by others, sexual abuse, physical abuse, other's attempting and completing suicide, infidelity of a partner, family violence, death of others, early pregnancy, neglect by a parent, illness (self or other), verbal abuse by parent, racism, separation from one's partner and effects from Residential schooling (either from self or family members). Not included in this Table are other events that participants mentioned that numbered by 4 or fewer participants and are mentioned in the list below: 89 Survival Factors in Suicidal Aboriginal Youth • Depression (4) • Loneliness (3) • Family Arguments (2) • Physical pain from surgeries (2) • Risky Behaviour (2) • Homelessness (1) • Homosexuality (1) • Being in the sex trade (1) • Being arrested (1) • Engaging in self harm (1) The fact that these harmful factors resonate with the literature that explores causal factors in suicide gives credence to the survival factors in this study. It will be important to consider implications for future research concerning additional groups of Aboriginal survivors. TABLE 5: EVENTS THAT ARE HARMFUL TOWARDS SURVIVAL Hindering F.venls 1 otal III^ IIIIHII Alcohol & Drug Use 14 Drug & Alcohol Use of Others 13 Sexual Abuse 11 Physical Abuse 10 Others attempt/commit suicide 10 Infidelity of Partner 9 Family Violence 8 Death of Others 8 Early Pregnancy 7 Neglect by Parent 6 Illness (self or other) 6 Verbal Abuse of Parent 6 Racism 5 Separation from Partner 5 Residential School Effects 5 90 Survival Factors in Suicidal Aboriginal Youth C H A P T E R V : D I S C U S S I O N I will only get well if I want to get well. I will get well Indian ways- not White ways. I will listen to. my own people. If I decide, I will follow the ways of the pipe and not White preaching ' -Kola, 1976 (In Sue & Sue, 1990) Summary of Results Through interviews with 20 participants, 254 incidents were elicited reporting what facilitated survival for Aboriginal individuals of British Columbia. The 254 incidents were analyzed and placed into 14 categories that were found to be reasonably sound. These categories are: Responsibility to Others/Desire to Care & Protect, Connection to/Love of Family (Includes Spouse), Professional Support, Support of Non family/ Non Professional Individuals, Cognitive Shift/ Change in Thinking, Avoiding a Negative Environment, Formal Education, Connection to Cultural Heritage, Getting Sober- Stopping Drug & Alcohol Use, Normalizing One's Difficult Experiences/Learning You Are Not Alone, Spirituality, Connection to Nature, Self Acceptance/Love/Care, and Sense of Purpose/Making a Difference. In addition, gender differences were explored and factors that were harmful towards survival were examined and presented. Linking the Literature to the Results As reported in the results section, with the exception of two categories (Avoiding a Negative environment and Cognitive shift) there are direct links from the literature that support each category of this study. The additional two categories add to what researchers have stated. Specifically, as stated in the literature review, Chandler and Lalonde (1998) 91 Survival Factors in Suicidal Aboriginal Youth discuss the concept of self continuity and cultural continuity. Both of these concepts have clear connections to the categories formed in this study and directly confirm and support the research. Chandler and Lalonde (1998) explored the concept of self continuity through the comments of their subject who, .. .reasoned aloud about their own personal persistence through time, and differently defended the conviction that they necessarily extend forward and backward in time in ways that leave them responsible for their own pasts and committed to their own futures.. .with exceptionless regularity, all of these young subjects were committed to the necessary importance of, and found some conceptual means of succeeding at, the task of weaving a continuous thread through the various episodes of their own and others' lives (p. 196) This explanation, I believe, links directly to the participants in this study who offered their survival events focusing on keeping themselves alive due to connecting to family, friends, identifying their place in a group, acknowledging their responsibility to others and connecting to the community. In the words of the participants, the categories of Responsibility to others, Connection to Family, Support of Non-Family and Normalizing one's experiences all have some aspect of self continuity. The 'thread' that the participants wove throughout each of their 'low points', from these categories included this concept. In addition, one could posit that the category of Professional Support also includes self continuity as this also explores one place in time, one's purpose and responsibilities to others. The concept of Cultural continuity is explored by Chandler and Lalonde (1998) stating, Like other potential sources of continuity and discontinuity, cultures too appear to be double edged swords. At least when they tended to outlive the people who populated them, cultures offer a more 'mythic' time frame that could be relied on to lend a certain age to things, (p. 199) 92 Survival Factors in Suicidal Aboriginal Youth Some First Nations communities succeed in providing their members with an otherwise missing measure of cultural continuity essential to understanding themselves as connected to their own past and building future (p. 208) This concept of connecting to one's culture within one's community as a protective factor against suicide is echoed in the findings of this study through the categories of Connection to Cultural Heritage, Spirituality and Connection to Nature. In each of these categories, participants reflected on the theme of either reconnecting to tradition or being taught traditions through nature, spirituality and direct cultural activies that had been 'lost' or not taught. This connectedness was identified as a survival factor that could also been considered a 'cultural continuity' factor. As mentioned previously, the SPAG report (2003) also records spirituality, culture, identity and nature as important protective factors. Sue and Sue (1990) also point to the essential need to reflect traditional healing methods in clinical approaches and will also be explored in the Implications for Practice section subsequently explored in this chapter. Education services is identified in the Chandler and Lalonde (1998) study as a marker of cultural continuity, effectively creating a preventative recommendation fighting suicides in youth. The category of Formal Education in this study is directly linked and proves that such a survival factor in this study is mirrored in the research. Lastly, the categories of Self Acceptance and Sense of Purpose also have links to Chandler and Lalonde's (1998) study on self and cultural continuity. They indicate that these concepts are the 'ways in which these young persons undertake to. construct and define a sense of identity that allows them to survive as continuous or numerically identical persons despite often dramatic individual and cultural change" (p. 213). Each of the categories 93 Survival Factors in Suicidal Aboriginal Youth mentioned above include the concepts of connectedness, findings one's place and conceptualizing a reason to live. Each suicidal person considers death as an improvement to living. It is within the choice to live that identifies what the survivor uses to 'continue' on and it is that sense of continuity that both the aforementioned article and the categories of this study that are linked. Unique Findings Not only is this study consistent with the literature in the field, it also offers new and unique findings. By its very nature, being a qualitative piece of research, it offers a unique perspective. By focusing on the term 'survival' the categories of Cognitive Shift and Avoiding a Negative Environment were created. Much of the research in this area has focused on healing, a broader term that encapsulates many meanings. By asking the question "At that moment of suicidality, what helped you survive? What helped you live?" It appears that basic survival techniques were explored as well as higher level factors that may also include healing. The category of Avoiding a Negative Environment discusses 'escaping' either temporarily or permanently from an environment that contributes to feeling suicidal. This category has implications for preventative factors and survival programs that could encourage an individual to avoid such a situation and by hearing that others have indeed done this to their success. Such an implication could have far reaching purposes. This unique finding also has implication for theory and practice (discussed in subsequent sections). This may relate to how individuals react to stress, not only in the Aboriginal population but further research may attempt to link these findings to the general population of suicidal adolescents. 94 Survival Factors in Suicidal Aboriginal Youth The category of Cognitive Shift also provides a unique perspective into the suicidal youth's thought processes. By learning that such a shift in thinking leads towards survival, certain clinical and community approaches could be explored to further promote survival and possible healing. This finding could also be explored in the realm of developmental psychology and identity. As was reported in previous chapters, Kazdin (1993) indicated that during the time of adolescence, there is an opportune time to examine the developmental cognitive structure of an adolescent and how this may aid practitioners in their choice of interventions. These findings could indicate that a 'cognitive shift' is possible and effective when dealing with the concept of survival. In addition, identity and survival, knowing that the participants 'identified' with being survivors is very important. Chandler and Lalonde (1998) spoke of self continuity and cultural continuity. Once could extend this concept to identity. While these participants are clearly nested in cultural realities, it appears that through the unique findings, the individual's realities and identities are very important. The choice to change one's thinking and/or avoid a negative environment reflects on one's own reality and identity. These finding encourage further research, new directions for practitioners and theoretical exploration. This study adds to the body of knowledge in this area an understanding of the types of incidents that happen that lead to survival for suicidal First Nations youth. This type of information can be used to inform educators, clinicians, communities and youth. Implications for Research and Theory The present study contributes to research on an empirical basis for survival factors in suicidal Aboriginal youth. Most previous research has discussed resiliency, protective factors 95 Survival Factors in Suicidal Aboriginal Youth and healing journeys. There is little in this field of research that attempts to empirically explore survival. While most of the categories created in this study fit with the current literature, the categories add depth and specifics by using the exact language of the Aboriginal participants. Every category resonated with both experts and participants. In addition, the categories of Cognitive Shift and Avoiding a Negative Environment contributed unique aspects to this area of study. The results of this study suggest that it is essential to understand the belief system, world-view and language of the Aboriginal individual before applying theories and strategies for survival. By acknowledging the bias of the researcher based on their own cultural origins, an attempt was made to reach out to the cultural roots of the participant and acknowledge their inherent experiences as unique and essential to their own survival. Both participants and experts commented that much of their traditions were not taught at a young age possibly due to colonialism, impact of residential school and lack of'mirrored' experiences or role modeling. It was a connectedness to community, family and tradition that helped anchor participants to 'choose life'. From a research perspective, it will be essential to gather context and meaning for Aboriginal youth when exploring survival journeys and question the availability of tradition and whether it has been 'lost' or 'stolen' from them. To disregard their experiences rooted in context or belief systems may result in overlooking vital survival factors. It will also undermine the relationship between researcher and participants as well as therapist and client. Such findings also provide research implication for other populations as these findings indicate a need for deeper knowledge of any cultural group. As mentioned in Ch 2, McCormick (1995) detailed factors in the literature that are believed to facilitate healing for Aboriginal peoples. These are: knowledge of First Nations 96 Survival Factors in Suicidal Aboriginal Youth culture and traditions, obtaining help from others in dealing with problems, interconnectedness, spirituality, exercise, expressing oneself, healing ceremonies, gaining an understanding of the problem, role models and nature. While healing and survival are different concepts, there is connection and one may hypothesize that one must work on surviving first, before striving to heal. These factors are related to and empirically supported by the categories in this study, namely: Connection to Cultural Heritage, Professional Support, Connection to/Love of Family, Support of Non family, Formal Education, Normalizing One's Difficult Experiences, Spirituality, Self Acceptance and Sense of Purpose. The two additional categories of Cognitive Shift and Avoiding a Negative Environment appear to represent unique and additional findings that one may have to establish first for survival in order to heal. The aforementioned need to attempt to understand the context and meaning for each participant confirms the need for cross-cultural understanding in research and counselling, as stated in the literature review part of this study (Nwachuku & Ivey, 1991). They report that counselling research must first start with an exploration of the natural helping styles of a culture before developing theories and approaches for it. As stated previously, the SPAG report (2003) is encouraging community support, resources and education to be applied to research in order to attain additional information that is culturally relevant and applicable. This study provides yet another branching off point by providing categories for survival, which locates the participant in the suicidal moment, and uses their experiences and language to indicate what factors were essential to survival. These categories need to be applied and examined in a broader context, broader theory to see how it works for different regions and territories in the Aboriginal population. 97 Survival Factors in Suicidal Aboriginal Youth From a theoretical perspective, one can look to the contribution that each category has and link to existing theories. The categories indicate connectedness to the individual, community and culture. Such a connectedness has links to social psychology and social learning. As Bandura (1986) indicates, most complex forms of social behaviour are learned, Therefore, both suicidality and survival could be postulated to be encouraged through environment. The impact of stories of survival being taught to others may strengthen the theoretical underpinning of social learning. From the theoretical viewpoint of cognitive behaviour theory, attitudes and behaviours must be examined (Goldstein, 1973). Cognitive and emotional functions exert a causal and organizing influence on behaviour. The findings of this study support this and provide further theoretical implications when examining the importance of cognitive shift. Implication for Practice The implications for practice stem from the conceptualization of the categories. The categories provide a frame for the clinician when exploring survival factors in suicidal aboriginal youth. This can be viewed from a preventative, pro-active stance or an in vivo exposure direction. In other words, there is hope to apply the information gleaned prior to suicidality, or during. The categories examine how aboriginal individuals work through challenges that provoke suicidality. Therefore, from a preventative aspect, communities, educational institutions and cultural leaders need this information. Establishing connection to family, support systems, professional helpers, strengthening cultural connectedness, encouraging sobriety are all aspects that should be provided. In addition, working to help avoid pre-98 Survival Factors in Suicidal Aboriginal Youth existing negative environments. However, should these challenges already exist for the individual and there is suicidality expressed, this study provided data on how others have survived (in vivo exposure). As indicated by both the categories and the examination of factors hindering survival, loss is considered a primary theme in suicide. As reported in Chapter 2, Clarkson (2004) reports that loss occurs on three basic levels: Historical loss (residential school, cultural genocide, illness, language, traditions, parenting skills) Personal loss (family violence, substance abuse, grief and mourning, socio-economic stress, abuse) and Social loss (traditional roles in family and accompanying teachings, youth roles and responsibility, identity formation, developmental tasks, conflict within two cultures). The implication for practice is that despite these losses, they can be 'found' as the participants 'found' them by creating survival factors. Such an indication provides hope and guidance for clinicians and communities alike. There are an abundance of survival resources that can be identified and tapped, strengthening community purpose. Counsellors can use the findings and survival categories to create specific techniques and interventions to aid Aboriginal people in their survival. In addition, counsellors will be encouraged to become immersed in specific Native traditions to ensure survival as well as other behavioural, emotional and cognitive strategies suggested by these findings. The work must be culturally relevant and rooted in the community. Specific researchers have commented on culturally specific and culturally relevant techniques that research creates certain implications (Nwachuku & Ivey, 1991; Pederson, 1991; Sue &Sue 1990). 99 Survival Factors in Suicidal Aboriginal Youth It is essential to review the aforementioned research in culturally specific counselling and how it relates to the findings in this study. Pederson (1991) explores the concept of multiculturalism as a generic approach to counselling. He indicates, "the multicultural perspective combines the extremes of universalism and relativism by explaining behaviour both in terms of those culturally learned perspectives that are unique to a particular culture and in the search for common ground universals that are shared across cultures" (p.6). This concept of searching for commonalities with the client may not be the best approach when examining the findings of this study. While his assertion that a broad definition of culture is 'particularly important in preparing counselors to deal with complex differences among clients from or between every cultural group" (p.7) certainly resonates to the practitioner, the participants indicated that being culturally specific was more beneficial that being multicultural. As has been commented by both the participants and expert commentators, it is the uniqueness of cultures, spirituality and tradition that strengthen survival and that help the suicidal individual become connected with their community and family. Sue and Sue (1990) report forceful and strong beliefs on the effects imposing "traditionally Western counseling techniques". Traditional counseling has bits and pieces that are applicable; yet as an isolated techniques couched in the framework of a White man's field of reference, it leaves much to be desired. Counseling and psychotherapy, from the textbook approach, emphasize Western values and are antagonistic to the Indian value system. As such, they are tools of cultural oppression. As an innocent counselor you may be oriented to be most understanding; however, subtle aspects like the tone of your voice, the manner in which you study the client with your eyes, and innocent little comments may be met with resistance. You must be aware of the fact that suggestions seem like 100 Survival Factors in Suicidal Aboriginal Youth orders to Native people when they come from authority. Ideas at times appear as exploitation, (p. 231) The implications for this study both agree and disagree with the previous quote. While it is important to have counsellors knowledgeable about their culture and not use Western assumptions, it is a fact that in this study, the category of Professional Support had the second highest participation rate (80%) and the third most events. The 'support' included Western counsellors whom the participants identified as extremely important to their survival. I did not explore all the techniques used by these counsellors but it is probable that some Western techniques were used. Further research is necessary to explore this. Nevertheless, it is well supported that culture specific counselling is essential and that this study provides additional support to the body of research. Any indication of 'cultural oppression' through counselling would have damaging effects and not serve to add to survival factors. Implications for Further Research As stated previously, a wider population would be essential in further research endeavors. In addition, expert commentary referred to the importance of identifying origins of tradition and the importance of recognizing regional differences in traditions and cultural rituals. A larger study, identifying regions, bands and history would help examine these categories in a broader context. The assertion that research must acknowledge culture must also then acknowledge differences within the culture and how this may impact survival factors. In addition, a larger net of participants could also then further examine gender differences and whether those findings studied in this research could be applied in a larger 101 Survival Factors in Suicidal Aboriginal Youth context. Therefore, future research could specifically analyze differences with age, gender, geographic location, education and specific band traditions. As this study was undertaken by a non-Aboriginal researcher, it may be useful to conduct additional studies with Aboriginal and non-Aboriginal researchers to address the ethnic disparity. Although I used the exact language of the participants, I myself created the categories and therefore, there are some of my own internal biases in the data. Limitations When we ask individuals to 'remember when' we are asking them to relate their perceptions of events that occurred. This is relayed in the language of their own personal reality. Self- report has its limitations, as subjective perception is hard to categorize objectively. Nevertheless, we learn from their experiences. M y recollections of my "suicidal" past are rooted in my perception of that time and space. It may not reflect other individuals' perceptions of that time period, nor may it be an accurate reflection of fact, as memory may have deteriorated. Nevertheless, if is the perception that remains in the emotions and cognitions. Most stories are made up of the fabric of multiple truths, which resonate within each one of us. Critical incidents obtained through self-reporting are limited to the events that people are able to remember through the interview. It is possible that some events were not mentioned because the participant had forgotten them. Another limitation of the use of self-reporting is that participants could only report what they could articulate. This may have prevented some events from being identified. 102 Survival Factors in Suicidal Aboriginal Youth It is important to note that the 20 participants were all from British Columbia and not representative of any other region. In addition, specific native bands and ethic backgrounds were not identified and regional differences could have greatly affected the results. Commentary & Summary This Research was intended to address survival in relation to aboriginal suicide. While a great deal of attention has been paid to the sources of the disproportionate suicide risk among aboriginal peoples, there is a relative paucity of data addressing the processes and resources involved in survival. To accomplish this, a qualitative methodology was identified as an effective tool in the exploration of the experience of resilient individuals. In addition, such an approach minimizes the risk of imposed non-Aboriginal bias when considering a minority culture investigated by the majority culture. As discussed in the first chapter, due to a "complex mix of social, cultural, economic and psychological dislocations that flow from the past into the present" (RCAP, p. 3), the Aboriginal suicide rate has been higher for the last 30-40 years (3 times higher in the last 15 years). Aboriginal youth are at 510% increased risk, compared with their non-native peers (with girls being at 800% higher risk of dying). The ages of greatest risk is between 20-30 years and youth living in rural or isolated reserves appear to be more likely to die (RCAP). However, the youth and adults in some specific communities are at a significantly lower than the mainstream, a situation that has been connected to 'cultural continuity' (Chandler & Lalonde, 1998) The Critical incident Technique (Flanagan, 1954) is a form of research that uses interviews to allow participants to recollect and describe accounts of events that facilitated or 103 Survival Factors in Suicidal Aboriginal Youth hindered a particular aim. By including the documentation of each Aboriginal individual's experience as narrated in their own words, using direct observations of behaviour and psychological states, the data collected through this process is rich with meaning and context (Woolsey, 1986). Every attempt was made to ensure that each participant was be given an opportunity to tell their story of survival, identifying factors that facilitated surviving suicidal thoughts, behaviour and/or actions. It is hoped that these findings will provide an enhancement of those previously generated namely the identification of factors that help survival in the face of suicidality within the aboriginal sociocultural context. The results could provide a nationally relevant point of entry into the issue of aboriginal suicide and resiliency with implications for suicide prevention. S u m m a r y This study explored the survival factors that suicidal Aboriginal Youth used to keep themselves alive. The purpose of this study was to develop categories that will identify themes in the events reported by Aboriginal individuals, by exploring the research question: "What are the critical incidents contributing to survival in suicidal aboriginal youth?". The research method involved interviews with 20 adult (18 and over) Aboriginal volunteers (all residents of British Columbia) who possessed the ability to articulate, identify and discuss their stories of survival. The Critical Incident Technique (Flanagan, 1954) was utilized to elicit 254 incidents from 20 participants. Fourteen categories were created from the analysis of all events reported. Thorough validation techniques were applied in order to test the soundness and comprehensiveness of the categories. In addition, efforts were made to 104 Survival Factors in Suicidal Aboriginal Youth examine fit to literature of the categories and expert commentary concerning the results. The categories reflected that survival factors included: Responsibility to Others, Connection to/Love of Family, Professional Support, Support of Non family/ Non Professional Individuals, Cognitive Shift/ Change in Thinking, Avoiding a Negative Environment, Formal Education, Connection to Cultural Heritage, Getting Sober, Normalizing One's Difficult Experiences/Learning You Are Not Alone, Spirituality, Connection to Nature, Self Acceptance/Love/Care, and Sense of Purpose/Making a Difference. In addition, gender differences were examined and, through incidental commentary of the participants, factors harmful towards survival were identified. The findings of this study contribute to the field of counselling psychology by providing a scheme of categories that attempt to describe, from the perspective of Aboriginal people, what has aided them in surviving suicidal thoughts, actions and behaviours, in their youth. This research suggests promising developments in Aboriginal survival and contains implications for practice and research. 105 Survival Factors in Suicidal Aboriginal Youth REFERENCES Adam, K . (1980). Interpersonal factors in suicidal attempts. A pilot study in Christ Church. Australian and New Zealand Journal of Psychology, 12, 59-63. Ainsworth, M.D.S. (1991). Attachments and other affectional bonds across the life-cycle. In C M . Parkes, J. Stevenson-Hinde, & P. Marris (Eds.), Attachment across the life cycle. London: Routledge. Alfonso, V . (1997). Overcoming depressed moods after an HIV+ diagnosis: A critical Incident analysis. Unpublished doctoral dissertation, University of British Columbia, Vancouver, BC. Allberg, W.R. & Chu, L. (1990). Understanding adolescent suicide: Correlates in a developmental perspective. The School Counsellor, 37, 343-350. Andersson, B. , & Nilsson, S. (1964). Studies in the reliability and validity of the critical incident technique. Journal of Applied Psychology, 48, 398-403. Arato, J. (1999). The effect of childhood attachment on adolescent suicide: A stepwise discriminant analysis. Unpublished masters thesis, University of Calgary, Calgary, Alberta. Bandura, A . Social foundations of thought and action: A social cognitive theory. Englewood Cliffs, NJ: Prentice-Hall. Berlin, I.N. (1985). Prevention of Adolescent suicide amongst some Native American tribes. In S.C. Feinstein, M.Sugar, A . H . Esman, J.G. Looney, A.Z. Schwartzberg & A.D. Sorosky (Eds.). Annals of the American Society for Adolescent Psychiatry: Volume 12. Adolescent psychiatry: developmental and clinical studies (pp.77-93). Chicago: University of Chicago Press. Berlin, I.N. (1987). Suicide among American Indian adolescents: An overview. Suicide and Life threatening Behavior, 17(3), 218-232. Borgen, W.A. & Amundson, N.E. (1984) The experience of unemployment: Implications for counselling the unemployed. Toronto, Canada: nelson Canada. Borgen, W.A., Amundson, N.E. , & McVicar, J. (2002). The experience of unemployment for fishery workers in Newfoundland: What helps and hinders. Journal of Employment Counseling, 39(3), 117-126. Bowlby, J. (1969/1982). Attachment and loss: Vol . 1. Attachment. London: Hogarth. 106 Survival Factors in Suicidal Aboriginal Youth Bowlby, J. (1973). Attachment and loss: Vol . 2. Separation: Anxiety and anger. London: Hogarth. Bowlby, J. (1980). Attachment and loss: Vol . 3. Loss: Sadness and depression. London: Hogarth. Chandler, M.J. , & Lalonde, C. (1998). Cultural continuity as a hedge against suicide in Canada's First Nations. Transcultural Psychiatry, 35, 191-219. Clarkson, P. (2004) Creating hope: Art and therapy with suicidal First Nations youth. Insights B.C. Association of Clinical Counsellors. Cohen, A . M . , & Smith, R.D. (1976). The critical incident in growth groups: Theory and technique. L A Jolla, C A : University Associates. Cooper, M . , Karlberg, A. , & Pelletier-Adams, L. (1991). Aboriginal suicide in British Columbia. Burnaby, B.C.: Institute on Family Violence Society. Cronbach, (1971). Test validation. In. R.L. Thomdike (ed.). Educational Measurement. Washington, D . C : American Council on Education. Dachelet, C.Z., Wemett, M.F. , Garling, E.J., Craig-Kuhn, K. , Kent, N . , & Kitzman, H.J. (1981).The critical incident techniques applied to the evaluation of the clinical practicum setting. Journal of Nursing Education, 20, 15-31. Dukes, R.L. & Lorch, B. D. (1989). The effects of school, family, self-concept, and deviant behavior on adolescent suicide ideation. Journal of Adolescence, 12, 239-251. Duran, E. & Duran, B. (1995). Native American postcolonial psychology. Albany, N Y : State University of New York Press. Fahlberg, V . (1979). Attachment and separation: Putting the pieces together. Evergreen, Colorado: Michigan Department of Social Services. Favel-King, A . (1993). The treaty right to health. In The Path to Healing: Report of the National Round Table on Aboriginal Health and Social Issues. Royal Commission on Aboriginal Peoples. Ottawa, Ontario. Canada Communication Group Publishing. Ferry, J. (2000). No easy answer to high Native suicide rates. Lancet, 355(9207), 906-909. Flanagan, J.C. (1954). The critical incident technique. Psychological Bulletin, 51(1), 327 -358. Flanagan, J.C. (1978). A research approach to improving our quality of life. American Psychologist, 33, 138-147. 107 Survival Factors in Suicidal Aboriginal Youth Fremouw, W., Callahan, T. & Kashden, J. (1993). Adolescent suicidal risk: Psychological, problem solving, and environmental factors. Suicide and Life- Threatening Behavior, 23(1), 46-54. Goldman, S., & Beardslee, W.R. (1999). Suicide in children and adolescents. . In D.G. Jacobs (Ed.), The Harvard Medical School Guide to Suicide Assessment and Intervention (pp. 417-442). San Francisco: Jossey-Bass Publishers. Goldstein, A.P. (1973). Structured learning therapy. Toward a psychotherapy for the poor. New York: Academic Press. Grossi, V . & Violato, C. (1992). Attempted suicide among adolescents: A stepwise discriminant analysis. Canadian Journal of Behavioral Science, 24, 185-187. Hammerschlag, C A . (1988). The dancing healers. San Francisco: Harper & Row. Hawton, K. , O'Grady, J., Osborn, M . and Cole, D. (1982). Adolescents who take overdoses: Their characteristics, problems and contacts with helping agencies. British Journal of Psychiatry, 140, 118-123. Health Canada (1994). Suicide in Canada: Update of the Report of the Task Force on Suicide in Canada. Ministry of National Health and Welfare. Health Systems Research Unit (1996). Review of best practices in mental health service delivery. Ottawa, On: Clarke Institute of Psychiatry. Jacobs, D.G., Brewer, M . , & Klein-Benheim, M . (1999). Suicide assessment. In D.G. Jacobs (Ed.), The Harvard Medical School Guide to Suicide Assessment and Intervention (pp. 3 -39). San Francisco: Jossey-Bass Publishers. Kazdin, A .E . (1993). Adolescent mental health. Prevention and treatment programs. American Psychologist, 48(2), 127-141. King, K . A . (1999). 15 Myths about adolescent suicide. Educational Digest, 65(1), 68-71. Kirmayer, L., Simpson, C , & Cargo, M . (2003). Indigenous Populations Healing traditions: culture, community and mental health promotion with Canadian Aboriginal peoples. Australasian Psychiatry, Oct2003 Supplement, Vol . 11, pS15, lp Kvale, S.(1996). Interviews: A n introduction to qualitative research interviewing. Thousand Oaks, C A : Sage Levy, J.E. (1965). Navajo Suicide. Human Organization, 24, 308-18 108 Survival Factors in Suicidal Aboriginal Youth Mann, J.J., & Arango, V . (1999). The neurobiology of suicidal behavior. In D.G. Jacobs (Ed.),The Harvard Medical School Guide to Suicide Assessment and Intervention (pp. 98-114). San Francisco: Jossey-Bass Publishers. Mickelson, K. , Kessler, R.C., & Shaver, P.R. (1997). Adult attachment in a nationally representative sample. Journal of Personality and Social Psychology, 73(5), 1092-1106. McCormick, R . M . (1995). The facilitation of healing for the First Nations people of British Columbia. Canadian Journal of Native Education, 21(2), 249-322. McCormick, R . M . (1997). Healing through interdependence: The role of'connecting' in First Nations healing practices. Canadian Journal of Counselling, 12 (2), 27-32. McCormick, R . M . (1997b). An integration of healing wisdom: The vision quest ceremony from an attachment theory perspective. Guidance and Counselling, 12(2), 18-22. McCormick, R. M.(1997c). First Nations Counsellor training: Strengthening the circle. Canadian Journal of Community Mental Health, 16(2).91-100 McCormick, R . M . , & Arvay, M . (in press) The facilitation of healing for Canadian Aboriginal youth who are suicidal. Journal of cultural diversity and ethnic minority development. Mortensen, P . M . , & Tanney, B. (1988). Suicide among Canadian Natives. Calgary: Suicide Information Centre. Moscicki, E.K. (1999). Epidemiology of suicide. In D.G. Jacobs (Ed.), The Harvard Medical School Guide to Suicide Assessment and Intervention (pp. 40-51). San Francisco: Jossey-Bass Publishers. Nwachuku, U.T., & Ivey, A .E . (1991). Culture-specific counseling: A n alternative training model. Journal of Counseling and Development, 70, 106-111. O'Carroll, P. (1993). Suicide causation: Pies, paths, and pointless polemics. Suicide and Life-Threatening Behavior, 23(1), 27-36. Paterson, D.W. (1990). Identified problems, preferred helpers and helper qualities: A cross cultural comparative study of perceptions. Unpublished master's thesis, University of British Columbia, Vancouver, BC. Pedersen, P.B. (1991). Multiculturalism as a generic approach to counselling. Journal of Counseling and Development, 70, 6-12. 109 Survival Factors in Suicidal Aboriginal Youth Reynolds, W . M . (1987). Suicidal Ideation Questionnaire: Professional Manual. Psychological Assessment Resources, Inc Reynolds, W.M. , & Mazza, J.J. (1994). Suicide and suicidal behaviors in children and adolescents . In W . M . Reynolds & H.F. Johnston (Eds.), Handbook of depression in children and adolescents (pp. 525-580). New York: Plenum Press. Rosenstein, D.S. & Horowitz, H.A. (1996). Adolescent attachment and psychopathology. Journal of Consulting and Clinical Psychology, 64(2), 244-253. Ross, R. (1992). Dancing with a ghost: Exploring Indian reality. Ontario, Canada: Octopus Publishing Group. Rotheram-Borus, M.J. , Walker, J.U. & Frens, W. (1996). Suicidal behavior among middle -class adolescents who seek crisis services. Journal of Clinical Psychology, 52(2), 137-143. Royal Commission on Aboriginal Peoples. (1995). Choosing life: Special report on suicide among Aboriginal peoples. Ottawa, Canadian Communication Group. Santrock, J.W. (1993). Adolescence: An Introduction. Madison, Wisconsin: Brown & Benchmark. Suicide Prevention Advisory Group (2003) Acting on what we know: Preventing youth suicide in First Nations. Ottawa, Health Canada Stein, D., Witztum, E. Brom, D., DeNour, A . K . & Elizur, A . (1992). The association between adolescents' attitudes toward suicide and their psychosocial background and suicidal tendencies. Adolescence, 27(108), 949-959. Sue, D.W., & Sue, D. (1990). Counselling the Culturally Different: Theory and Practice. (2 n d ed.). Toronto: John Wiley & Sons. Tavecchio, L.W.C., & Van Ijzendoorm, M . H . (1987). Attachment in social networks. North Holland: Elsevier Science Publishers B.V. Torrey, E.F. (1972). The mind game: Witch doctors and psychiatrists. New York: Emmerson Hall. Trimble, J.E. & Fleming, C M . (1990). Providing counseling services for Native American Indians: Client, counselor, and community characteristics. In P.B. Pederson, J.D. Draguns, W J . Lonner, & J.E. Trimble (Eds.), Counseling across cultures. (3 r d ed., ppl77 -204).Honolulu: University of Hawaii Press. 110 Survival Factors in Suicidal Aboriginal Youth Triolo, SJ . , McKenry, P . C , Tishler, C L . & Blyth, D.A. (1984). Social and psychological discriminants of adolescent suicide: Age and sex differences. Journal of Early Adolescence, 4(3), 239-251. Van Egmond, M . & Diekstra, R.F. (1988). The predictability of suicidal behavior: The results of a meta- analysis of published studies. In R.F. Diekstra, R.A. Mavis, S. Piatt, A . Schmidtke, & G. Sonneck (Eds.), Suicide prevention: The role of attitude and imitation. Leiden: Bril l . Van Winkle, N.W. &May, P.A. (1986). Native American Suicide in New Mexico 1957-79. A comparative study. Human organization, 45 (4), 296-309. Violato, C. (1996). Childhood development: Reading for teachers. Calgary, Alberta: Detselig Enterprises Ltd. White, J. & Jodoin, N . (1998). "Before the fact" interventions: A Manual of best practices in youth suicide prevention. Vancouver, BC: Suicide Prevention Information and Resource Centre of British Columbia. White, J., & Jodoin, N . (2004). Aboriginal youth: A Manual of promising suicide prevention strategies (Draft). Calgary, A B : Suicide Prevention Training Programs. Wong, L . C (2000). What helps and what hinders in cross-cultural clinical supervision. Unpublished doctoral dissertation, University of British Columbia, Vancouver, BC. Woolsey, L .K . (1986). The critical incident technique: A n innovative qualitative method of research. Canadian Journal of Counselling, 20 (4), 242-254. York, G. (1990). The dispossessed: Life and Death in Native Canada. London: Vintage U.K. I l l Survival Factors in Suicidal Aboriginal Youth APPENDIX A: LETTER OF CONSENT 112 S u r v i v a l F a c t o r s i n S u i c i d a l A b o r i g i n a l Y o u t h APPENDIX B: INFORMATION FORM 115 


Citation Scheme:


Citations by CSL (citeproc-js)

Usage Statistics



Customize your widget with the following options, then copy and paste the code below into the HTML of your page to embed this item in your website.
                            <div id="ubcOpenCollectionsWidgetDisplay">
                            <script id="ubcOpenCollectionsWidget"
                            async >
IIIF logo Our image viewer uses the IIIF 2.0 standard. To load this item in other compatible viewers, use this url:


Related Items