Crisis services play an important role as part of a comprehensive approach to suicide prevention
The Report Implementing Integrated Suicide Prevention In Aboriginal And Torres Strait Islander Communities A Guide For Primary Health Networks (Dudgeon et al. 2019) confirms the need for crisis intervention to ensure communities have the capacity to respond to crises with appropriate postvention interventions to improve the type of caring for people who have survived as well as those affected by suicide attempts. Providing a full range of crisis services can reduce suicides when coupled with mental health follow-up care. Crisis services and systems can be effective and cost saving alternatives to emergency room services and hospitalisations, providing safe transitions to care and support for people experiencing a crisis. Effective suicide prevention requires a full continuum of services designed to provide the right care at the right time for different population groups in a setting where people feel most relaxed.
Crisis services can be provided in many different settings and can include:
Crisis helplines and hotlines that help callers who are in a suicidal crisis (e.g. Lifeline)
Peer-based crisis services (e.g the Safe Haven, Vic).
Peer-based crisis services are crisis alternatives located in a house or community setting with the aim of diverting hospitalisation. They are generally staffed and operated by peers who have professional training in providing crisis support to build mutual, trusting relationships within a safe environment for people to overcome crisis.
Postvention and critical responses to suicide or traumatic crisis are an important part of a systems approach to suicide prevention in Indigenous communities, including reducing the risk of suicide clusters.
The Fifth Mental Health Plan has adopted the European Alliance Against Depression (EAAD) model which has 4 levels of intervention, one of which involves providing high-risk groups young people in adolescent crisis and persons after suicide attempt (and their relatives) with “Emergency Cards” guaranteeing direct access to professional help in a suicidal crisis.
Other initiatives recommended include establishing:
Regional self-help groups and supporting them with expert advice.
Partnerships with patient associations and intensifying support for existing groups.
The program development was guided by the findings from the Aboriginal and Torres Strait Islander Suicide Prevention Evaluation Project (ATSISPEP). Community consultation was carried out by the Country SA PHN and the Black Dog Institute.
This project was initiated by the Country SA PHN (CSA PHN) under the National Suicide Prevention Trial.
The CSA PHN worked with the Black Dog Institute on a series of community forums in the Port Augusta area as it had a relatively high Indigenous suicide rate and its population – 14,000 people from 27 language groups – meant there was ‘critical mass’ to evaluate a new approach.
Community consultations in 2017 indicated people were keen for follow-up services for people leaving hospital after a suicide crisis, identifying this as a gap in local services.1
An Aboriginal working group was established in collaboration with the local community, including people with lived experience and representatives from the local health network and Aboriginal Community Controlled Health Organisation (ACCHO). The group spent eight months documenting the co-design process and developing a model, followed by four months of stakeholder consultation.
CSA PHN commissioned the Pika Wiya Health Service Aboriginal Corporation to deliver the Aboriginal Aftercare Service in Port Augusta. Pika Wiya Health Service Corporation recruited an aftercare team comprising the clinical team leader, who is a social worker, and two Aboriginal health workers. The aftercare team sits within the social and emotional wellbeing team (SEWB) and has internal supports from a psychologist and visiting psychiatrist.
Research shows that a previous suicide attempt is one of the strongest predictors of a further attempt. In order to reduce the likelihood of a further attempt, a coordinated plan is required for those survivors of that initial attempt. This requires immediate intervention and individualised care and referral after discharge and throughout the next 3 months.
The consultation process2 revealed that the aftercare service needs to include:
a recognition of the importance of community
appropriate service funding, delivery availability and resourcing
implementation in a culturally safe manner including an evaluation of the design
recruitment of support staff who have trauma experience and lived experience
Ability to extend client care past 3 months to 6 months, to provide a culturally safe service where there is increased complexity in presentation.
traditional healers, social and emotional wellbeing support and Aboriginal leadership
recognition by Western medical practitioners and providers of the existing cultural expertise, mentoring and leadership within the Aboriginal community and,
the integration of medical, mental health and other services.
Additionally, the Aboriginal working group recommended2 that the design should include:
face to face contact while in the hospital emergency department
culturally respectful communication
the importance of cultural and spiritual factors when considering treatment options
involving family for background information and assistance in the assessment, care planning and treatment processes and,
providing social and emotional well-being support to family and community, inclusive of children.
The program has drawn upon the Black Dog Institute’s Guidelines for Integrated suicide-related crisis and follow-up care in Emergency Departments and other acute settings as a guide for developing the Aboriginal Aftercare Service Design.2 The working group recommend that these guidelines be reviewed after 12 months of service delivery, and adapted or changed to reflect new learnings. The Aftercare Service comprises seven non-hierarchical interventions. These are:
1. Brief contact interventions
This is a non-clinical intervention which uses minimal intrusion activities such as telephone calls, text messages to encourage help-seeking behaviours which are helpful in reducing the frequency of suicide attempts.
2. Coordinated assertive aftercare:
This intervention contains five distinct processes. These are:
face to face contact – during the stay in the emergency department, the person is met by the service provider
assertive follow-up – the person is met again by a service provider within 24 hours of discharge
ongoing risk assessment and planning – a safety plan is developed with the individual’s goals and encourages safety in daily life
encouragement and motivation to adhere to treatment – this is to reduce the barriers to further care where follow-up appointments are managed to ensure that the person connects with appropriate health and other social support services and,
problem solving and solution focussed counselling – this includes intensive contacts through face-to-face or electronic communications
3. Brief therapy combined with brief contact interventions
A more structured intervention consisting of narrative therapies to help the individual better understand the factors that have led to the attempt. This may be one to ten brief contacts with an appropriate person such as a counsellor or psychologist using a person-centred narrative therapy.
4. Combined clinical and non-clinical models of care
Using the individual’s family or other care givers, including friends, the brief contacts are to help the individual gain a sense of belonging in the community and with his or her family. This would include appropriate activities to help the person connect to culture, community and country.
5. Post-discharge plans and primary health care
Intensive follow-up plans are established along with a safety plan for the individual in conjunction with the person’s family and care givers. Established medical practitioners are also included in this intervention.
6. Coordinated support to utilise available services
A case manager ensures that the individual is able to access and attend culturally appropriate post-care services for health management as well as reconnect with friends, family and the community.
7. Providing support for caregivers and recognising their role
Friends and family of the individual benefit from ongoing support for chronic mental health issues. These people who are supporting the person receive culturally appropriate education, upskilling and capacity building.
Guidelines for Integrated Suicide-Related Crisis and Follow-Up Care.
A complementary document for the admitting hospital’s emergency department are the Guidelines for Integrated Suicide-Related Crisis and Follow-Up Care.4 These guidelines consist of six steps for urgent care, clinical assessment and discharge. Briefly, these are:
1. Triage and notification to the Suicide Response Team or Mental Health Team
This involves stabilising the patient and offering to notifying friends, family or carer.
2. Comprehensive Psychosocial Assessment
The Comprehensive Psychosocial Assessment (CPA) is a broad assessment of a person’s mental, physical and emotional health, as well as their ability to function in the community. It covers assessment of suicidality, medical/ mental health assessment and history, coping resources and support and the ability to recover in the community. Importantly, the CPA is an opportunity to build rapport and show compassion and understanding.
3. Treatment care plan – inpatient and/or outpatient
Draft of treatment plan prepared and the individual is informed of various options for care.
4. Arrange referral and follow-up services
Aftercare providers finalise the plan and gain consent from the individual for personal information to be shared with service providers. Referrals and appointments are then arranged for 24 to 72 hours after discharge.
5. Discharge Care Plan
This plan includes an explanation of the plan as well as recommendations for treatment and support, relapse prevention and emergency contact details. The patient is discharged with medications and service provider contacts. Aftercare staff arrange for client transport a referral to supporting services by telephone.
6. Follow-up care and case management
This step is described in the Aboriginal Aftercare Service Design which is briefly described above.
The project has produced two sets of guidelines – for use in the emergency department at Port Augusta Hospital and for the community mental health team. These are the Aboriginal Aftercare Service Design2 and the Guidelines for Integrated Suicide-Related Crisis and Follow-Up Care.4 Each offers a comprehensive staged approach to maintaining contact through admission and after discharge with a mix of psychosocial, clinical and healing approaches with a strong focus on family and community.
An unanticipated positive outcome has been greater collaboration between clinical and cultural workers across the spectrum of mental health services. Mental health plans and referrals overseen by the visiting psychiatrist now frequently include a recommendation for healing alongside other supports. Aftercare workers have been invited to participate in traditional healing on country with ngangkari. The Pitjantjatjara word ngangkari is defined as an Indigenous practitioner of bush medicine (see Further Reading). Hospital mental health staff similarly are reported to be more comfortable referring people post-discharge to social and emotional wellbeing services and GP services knowing that these services can draw on the expertise of the aftercare team. Ongoing clinical management including medication support now sits with the Pika Wiya Health Service and not the hospital which continues to build the capacity within the health service.
From December 2018 to June 2019, around 120 people have been supported with 13 to 20 referrals a month to the end of 2019. Three-quarters of referrals are from the emergency department while the remainder come directly from the ACCHO which demonstrates that the Aftercare Service is appropriately supporting the most acute needs. The Aftercare Service is also working with established postvention services that includes the National Indigenous Critical Response Service and Beyond Blue’s service, The Way Back.
The Aboriginal Aftercare Service is consciously based on ATSISPEP’s three levels of intervention5 that are:
Universal Interventions which attend to those factors that create dysfunction as well as creating an environment in which individuals and the community are able to seek help before suicide attempts.
Selective Interventions which focus on youth who are at higher risk of suicide.
Indicated Interventions which ensure that those who are a risk to themselves or have attempted suicide are assisted in their recovery.
The program has been managed by the Pika Wiya Health Service Aboriginal Corporation and the ACCHO which meets the recognised need for strengthening Indigenous governance. The use of the lived experience of Aboriginal and Torres Strait Islander people in Port Augusta through the workshops during the development of the design has established a community and cultural focus in the design. The design includes a broad, closely-integrated use of public health services and other services such as culturally-safe healing and reconnection to culture and country.
While the program managers are collecting data which will be used to improve services, no formal evaluation of the program has taken place. CBPATSISP recognises that this program is still developing however this program is demonstrating a commitment to recognised principles and therefore is recognised as a promising program.
Aboriginal Aftercare Service Design November 2019. Country SA PHN, Nuriootpa South Australia.
LifeSpan strategies and components. Black Dog Institute.
Guidelines for integrated suicide-related crisis and follow-up care for Aboriginal and Torres Strait Islander people in the Emergency Department in Port Augusta, South Australia November 2019. Country SA PHN, Nuriootpa South Australia. N/A
The HOPE Initiative will provide tailored, holistic support to people post a suicide attempt with the aim of supporting the person and their carers and families to identify and build the protective factors that reduce the risk of suicide attempt/completed suicide.
Contact: Program Coordinator for HOPE is Eileesh Diviney (DHHS), Senior Policy Officer Dept. of Health and Human Services Email:Eileesh.Diviney@dhhs.vic.gov.au
HOPE – Hospital Outreach Post-suicidal Engagement – initiative provides practical support for people across Victoria who have thought about suicide or made an attempt on their life, and need an intensive response in the months following. HOPE is part of the state government’s Victorian Suicide Prevention Framework 2016-25, a co-ordinated strategy to halve the state’s suicide rate by 2025.
HOPE was trialed at hospitals including Peninsula Health (Frankston Hospital), Alfred Health (The Alfred), St Vincent’s Health (St Vincent’s Hospital), Barwon Health (Geelong Hospital), Eastern Health (Maroondah Hospital) and Albury Wodonga Health (Wangaratta Hospital). The program has assessed and supported more than 500 people since 2018. The government funding will enable the program to be rolled out in an additional six hospitals and health services including Ballarat Health Services.
New sites were selected based on suicide and intentional self-injury data analysis; population demographics; and community profiles so that rural communities are able to have the same level of access and quality treatment and positive outcomes as the larger communities. HOPE is auspiced with PHNS to provide advise on where to best target the funding and resources to meet the different needs of different communities. Funding has been provided to appoint an Aboriginal Suicide Prevention Coordinator in Albury-Wandonga.
StandBy – Support after Suicide is a national program of United Synergies, established in 2002 to meet the need for a coordinated community response to supporting those who have been affected by suicide.
StandBy is an Australian nation-wide umbrella body that maintains a 24/7 telephone support line as well as being able to provide face-to-face support for those who have been bereaved or impacted by suicide. Using a decentralised model, StandBy is able to link local services to those who require assistance. StandBy has close links with the National Indigenous Critical Response Service and Thirrili in the Northern Territory which are specific services for Aboriginal and Torres Strait Islander people. StandBy ensures that those who have been assisted continue to have follow-up contacts up to two years after the initial contact.
StandBy provides a full library of support resources. Resources are available for children under 12 years and for teenagers as well as a full range of information sheets for adults in the English language. Some resources are also available in nine international languages and two in local languages for Aboriginal people in South Australia.
StandBy also delivers the YouMe~WhichWay Program (YM~WW). YM~WW was developed in 2012 as a cultural awareness training program addressing the impacts of grief, suicide, suicide attempts and self-harm on Indigenous people and communities. YM~WW aims to increase understanding about suicide and self-harm, the trauma and grief associated with suicide that was experienced by Aboriginal and Torres Strait Islander Indigenous and to increase the knowledge and skills to enable the development of appropriate approaches to trauma and self-care within an Indigenous community setting. YM~WW was named among 18 other ‘promising programs’ in the ATSISEP report ‘Solutions that work’ June, 2016.1
The original YM~WW program was developed by an Indigenous consultant employed by the National StandBy Response Services (StandBy) and piloted in five Indigenous communities across Queensland and Tasmania. In 2016, the Hunter Institute of Mental Health was in partnership with StandBy to undertake the renewal of the YM~WW Program which involved:
Undertaking a literature scan on best practice, effective and appropriate approaches to suicide, suicide prevention and bereavement in Indigenous communities
the establishment of a small short term YM~WW Advisory Committee, consisting of Indigenous representatives, community members and Indigenous Health professionals to provide cultural advice and contribute to the program content, delivery and evaluation, and
reviewing, updating and renewing the YM~WW Program.2
StandBy supports all Australians bereaved and/or impacted by suicide through its own capacity and through other organisations. This includes schools, workplaces and first responders. These services are provided free of charge at a time and place that suits the individual or group. StandBy also delivers training to those service providers involved with the aftereffects of suicide and suicide bereavement.
delivers direct support to people bereaved and/or impacted by suicide and training for emergency and community responders
conducts workshops to provide communities with the capacity to plan, lead and sustain strategies to promote community awareness around suicide and implement community suicide prevention plans
provides or identifies appropriate materials and resources to meet local needs of Indigenous peoples in diverse community settings
establishes links with local gatekeepers and ‘natural helpers’ monitoring communities with high levels of suicide and self-harm to facilitate a planned response
assists communities to plan and implement a comprehensive response to suicide and self-harm including both short-term and long-term early intervention and prevention activities, and
ensures the local mental health services and community organisations are able to provide appropriate postvention responses to support individuals and families affected by suicide.
The StandBy program has demonstrated3 that there is a positive outcome in the first 12 months for those who have been affected through suicide. The program is cost-efficient and those using the services are less likely to have suicidal ideation and less likely to suicide.4
Around two in five people accessing StandBy received a combination of support, almost one third received telephone support with the remaining third using outreach support or referral only. Ninety percent of those using the program indicated that they felt that the program should be used by those who have recently been bereaved through suicide.3
In 2018, YM~WW received funding from Country SA PHN to deliver workshops in five SA communities. United Synergies utilised their partner organisation, Centacare, to deliver the workshops and in 2020 it is funded by the Central Queensland, Wide Bay, Sunshine Coast PHN (CQWBSC PHN) to deliver four ‘train-the-trainer’ workshops in Gympie and Maryborough.
The 2020-2021 Federal Budget has allocated $10 million over two years from June 2021 to June 2022 for an initial expansion and continuation of existing StandBy sites of the StandBy Support After Suicide Service as a main-stream service.5 This will include Thirrili in the Northern Territory and the Kimberly Postvention Service in in Western Australia in collaboration with Thrrili, the Kimberly Aboriginal Medical Service and Anglicare. Furthermore, the founder of YM~WW, Travis Shorley, a Barbarrum man from west of the Wild River, Atherton Tablelands is a team member with Standby.
An evaluation3 was carried out of the StandBy program during 2018 using data from seven sites at the three and twelve-month follow-up contact and a control group of volunteers who had not used StandBy services.
The evaluators noted that within the Aboriginal and Torres Strait Islander community in the Kimberley region of Western Australia, a more culturally safe approach to collecting data was required and that it had not been sufficiently resolved during the period of the study. It is important to note that the StandBy services are delivered through the culturally safe Kimberley Postvention Service which includes the National Indigenous Critical Response Service (Thirrili) and the Kimberley Aboriginal Medical Service.
Within the mainstream population, who had used the StandBy services and received follow-up calls were significantly less likely to:
experience thoughts of suicidal ideation
not have social support in dealing with their reactions to grief
not experience loneliness
suffer adversely from poor mental health, and
lose social connections.
The recommendations from the evaluation suggest that:
social support and feelings of connectedness should be improved
client surveys need to be culturally appropriate and include qualitative methods, and
continued follow-up using a survey instrument after the 12 month period
The StandBy program provides demonstrated, evidence-based data of the cost effectiveness and efficacy of the program for mainstream participants. StandBy uses a network of service providers and may provide for the sharing of ideas and knowledge across the country. For example, Thirili and the Kimberly Aboriginal Medical Service as well as Aboriginal and Torres Strait Islander staff in remote areas.
Thirrili National Indigenous Critical Response Service
Thirrili Ltd is a not for profit organisation which aims to contribute to the broader social wellbeing of Aboriginal and Torres Strait Islander people. Thirrili offers a range of programs which are designed to address fully the systemic and long standing causal issues for which solutions have eluded us for too long. We stand ready to partner with governments, academia and the broader service system to tackle these issues.
Thirrili was established in 2017 and is a Bunuba word meaning power and strength. It provides postvention assistance and support after suicide for Aboriginal and Torres Strait Islander people. Using a strength-based approach, Thirrili provides telephone and face-to-face assistance. The organisation uses a decentralised staffing model as well as using other postvention support networks to provide support in all Australian states and territories.
Thirrili works with communities that have experienced suicide or are currently experiencing trauma as well as communities who have recognised that increased governance and community capacity building are important to strengthen postvention.
Using a four-step Response Assessment Process2, Thirrili ensures that it uses local resources where appropriate. The four steps are:
Receipt of a notification of an incident
Verification of the person who has died or has been injured
Seeking client or family consent to obtain personal details and a description of the incident and to assess the most appropriate response, and
To work with local service providers and explore their ability to respond to family members and help structure a response.
Critical Response Support Advocates consider the throughcare plan and how this plan will assist the individuals’ physical and mental health, social and emotional wellbeing and the benefits to cultural, spiritual and community health. A key part of the plan is to help develop capacity and governance within the community. Follow-up contacts are made to ensure that the community and families are building resilience and are continuing to heal.
This may involve an advocate attending the location (or using a local service provider) to assist with the grieving process, liaising with the family to arrange a funeral or other culturally-appropriate interactions. The advocate would also assist the family in dealing with perhaps physically-distant government agencies or financial institutions that are involved after a suicide.
Using an evidenced-based model, Thirrili recognises that Aboriginal and Torres Strait Islander people grieve differently to non-Indigenous people in a number of significant ways (that is, sometimes greater time is required for recovery and the need to observe cultural obligations) as a result of strong, closely-linked family circles and community bonds. Additionally, Aboriginal and Torres Strait Islander people have experienced trauma from historical cultural dislocation, family separation and disruption to community values.1
Thirrili demonstrates best practice in providing services to the Aboriginal and Torres Strait Islander community. The Model of Care ensures that the community and the family are cared for after a suicide in a way that is culturally safe and respectful. This Model of Care allows for the community and the family to determine who delivers the care and the time of the care which includes advocates who are often familiar with the community. The program allows for the development of capacity of the community in dealing with the trauma associated with the recent loss as well as to begin to address the wider grief and loss and transgenerational trauma that is experienced. The Thirrili program includes follow-up on a three-monthly basis.
National Indigenous Critical Response Service (NICRS)
The National Indigenous Critical Response Service supports individuals, families, and communities affected by suicide or other significant trauma.
A Critical Response Support Advocate can be contacted 24/7 by calling 1800 805 801
The telephone service is usually answered by one of our Critical Response Support Advocates. If for some reason the call is diverted to message bank, callers are asked to leave a message with their best contact number and the Support Advocate will call them back as soon as possible.
If you or someone you know is suicidal
If you are looking for help, please call one of the following national helplines:
Lifeline Counselling Service: 13 11 14
Suicide Call Back Service: 1300 659 467 (cost of a local call)