Effective Suicide Prevention
Aboriginal and Torres Strait Islander peoples embrace a holistic concept of health, which inextricably links mental and physical health within a broader concept of social and emotional wellbeing which recognises the interconnectedness of physical wellbeing with spiritual and cultural factors and connection to the land, community and traditions as fundamental to wellbeing. The adverse and lasting impacts of colonisation has resulted in many people experiencing intergenerational trauma and social and economic disadvantage at individual, family and community levels. This can result in complex and interrelated issues and multiple stressors such as poor quality, overcrowded housing, poverty, trauma, abuse and loss placing unacceptable burden on Aboriginal and Torres Strait Islander people’s lives that can challenge their mental and physical health and wellbeing. A key aspect of suicide prevention then requires addressing the social determinants that impact adversely on the social and emotional wellbeing of individuals, families and community level and to provide culturally responsive services for early identification and treatment of mental health issues at the individual level.
In developing an understanding of suicide in this context, it is important to understand the definition of health as holistic and the distinctive notion of social and emotional accorded mental health.
The concept of mental health comes more from an illness or clinical perspective and its focus is more on the individual and their level of functioning in their environment.
The social and emotional wellbeing concept is broader than this and recognises the importance of connection to land, culture, spirituality, ancestry, family and community, and how these affect the individual. Social and emotional wellbeing problems cover a broad range of problems that can result from unresolved grief and loss, trauma and abuse, domestic violence, removal from family, substance misuse, family breakdown, cultural dislocation, racism and discrimination and social disadvantage. (Social Health Reference Group, 2004, p 9).
Suicide is the leading cause of death from external causes for Indigenous people who also experience relatively high rates of intentional self-harm (Dudgeon & Holland, 2016). The Indigenous suicide rate is the highest in 15 to 39 years age group (ATSISPEP, 2016). Trauma, grief and loss as well as alcohol and substance use have been found to be key factors in suicide deaths. The recent ATSISPEP research findings and Report (2016) confirm the need for:
- interventions focused on strengthening all domains of social and emotional wellbeing, including culturally based healing programs that connect people with cultural traditions;
- early interventions to address alcohol and substance use;
- prevention efforts that are evidence based, relevant and address the range of systemic issues that reduce people’s capacity to make positive choices to enhance their health, mental health and wellbeing; and
- greater focus on supporting and restoring protective factors, such as community connectedness, strengthening the individual and rebuilding family.
Policy responses to promote social and emotional wellbeing need to be multidimensional and involve a wide range of stakeholders including families and communities, the health sector, housing, education, employment and economic development, family services, crime prevention and justice, and Aboriginal Community Controlled Health Services (ACCHS). Strategies that build on the strengths, resilience and endurance within Indigenous communities and recognise the important historical and cultural diversity within communities are also recommended (SHRG, 2004). There is also a demonstrated need to increase Indigenous community capacity and mainstream workforce capacity to understand, cope with, and respond to, people experiencing trauma, loss and grief. This involves developing skills such as conflict mediation, suicide prevention, mental health first aid and lateral violence prevention to build a trauma-informed workforce (Healing Foundation, 2014).
A systematic review by Dudgeon et al. (2014), and the ATSISPEP report (2016) examined the quality and outcomes of programs which aim to strengthen social and emotional wellbeing and mental health of Aboriginal people. The table below summarises success factors for Indigenous suicide prevention (more detail is provided in Appendix 1 of the ATSISPEP report). The most promising programs and services for strengthening Indigenous social and emotional wellbeing were those that promote the guiding principles outlined earlier.
The following was highlighted:
- effective, culturally responsive service delivery also requires partnerships with Aboriginal Community Controlled Health Services (ACCHs) and local communities;
- that take a interdisciplinary approach that provides outreach services and transport;
- participatory action research approaches provide an effective mechanism for involving Indigenous families and communities in developing, implementing and evaluating programs. Programs that adopt participatory action research (PAR) tend to be more culturally responsive to local contexts and foster a culturally safe environment for program participants; and
- engaging in cultural activities is an indicator of positive cultural identity that is associated with better mental health among Indigenous Australians.
These key findings have informed the development of the CBPATSISP Evaluation Framework and aims to ensure the effective and culturally responsive implementation of the Fifth National Mental Health and Suicide Prevention Plan, which recognises the need and importance of community-focused, holistic and integrated approaches to suicide prevention that sit alongside intervention strategies that reduce the likelihood of suicide and related problems over the life-span.
The National Review of Mental Health Programmes and Services (2014) examined a range of influences relevant to Indigenous suicide prevention initiatives and services. These influences included efficacy and value, duplication and gaps in services and programs, and the specific challenges of service access for Indigenous peoples living in regional, rural and remote Australia. The report identifies the value and importance of systemic, community-based approaches to suicide prevention that involves initiating multi-level and multi-sectoral prevention models in communities in collaboration with the key stakeholders in those communities. Finally, the report recommended bolstering the availability and capacity of both community and culturally responsive primary health care services to support and respond to the mental health and social and emotional wellbeing needs of individuals, families and communities.
In addition, the findings from the Australian Institute of Health and Wellbeing review (AIHW, 2013) confirm that clinical approaches that have proved to be effective in reducing suicide rates include:
- Community programs that focus on the social, emotional, cultural and spiritual underpinnings of community wellbeing; and,
- Culturally responsive brief interventions comprising motivational care planning.
Programs and services that are not culturally competent and do not have a high level of Indigenous ownership and community support are unlikely to be effective in responding to the diverse and particular needs of Indigenous people in addressing suicide (AIHW, 2013).
Increasingly over the past fifteen years a number of Australian studies have established the need for a culturally responsive evaluation framework (Walker & Scrine, 2016). All of these studies highlight the problems with applying conventional health and social indicators and the need to take into account Indigenous community goals and social and community contexts in planning, implementing and evaluating community-based prevention efforts. For instance, Walker et al. (2003) highlighted the need for:
…a substantial reframing of evaluation approaches to encompass these other policy parameters to gauge how well governments are successfully working towards Indigenous self-determination by maintaining partnerships, engaging in dual accountability and implementing effective program linkages.
Specific approaches to conducting and evaluating significant, complex multi-agency projects with Indigenous remote communities in Australia to bring about positive social and inter-cultural change are outlined by Kania and Kramer (2011). The key principles and values identified as crucial in these Australian studies are also echoed in international suicide literature and have informed the development of this Evaluation Framework.
This CBPATSISP Evaluation Framework incorporates Indigenous determined, innovative evaluation approaches and indicators as measures for programs and interventions and Indigenous standards, values and priorities. The Framework also supports Indigenous cultural needs and aspirations to strengthen social and emotional wellbeing and reduce suicide and self-harm.
The Policy Context
The NATSISPS was developed by the Australian Government in response to the recommendations of the Inquiry into Suicide in Australia by the Senate Community Affairs References Committee, The Hidden Toll: Suicide in Australia. The inquiry was conducted in recognition of the high rates of suicide among Indigenous peoples, differences in the pattern of suicidal behaviour and its disproportionate impact on families and communities. The report recommended that NATSISPS, and its implementation, should:
- develop the capacity of communities and community organisations to provide local leadership and resources to enable Aboriginal and Torres Strait Islander peoples to take on the challenge of preventing suicide;
- provide postvention support to families and communities bereaved through suicide;
- be based on evidence and should provide professional support for effective practice; and
- be supported by the resources of all levels of government and across the whole of government.
The strategy goals and principles which underpin NATSISPS also underpin the CBPATSISP Evaluation Framework.
NATSISPS complemented both the National Suicide Prevention Strategy (NSPS), which provided the platform for the national policy on suicide prevention, and the Living is For Everyone (LiFE) Framework, a key component of the NSPS, which outlines the vision, purpose, principles, action areas and proposed outcomes for suicide prevention in Australia. The LiFE Framework sets out an evidenced based population approach to suicide prevention and resources to assist researchers, policy makers, professionals and community members in developing and implementing suicide prevention initiatives.
The NATSISPS was subsumed into the Fifth National Mental Health and Suicide Prevention Plan in 2017.
The Fifth National Mental Health and Suicide Prevention Plan (Fifth Plan, 2017) approaches Aboriginal and Torres Strait Islander people as consumers of mental health and suicide prevention services as well as peoples with collective human rights. As consumers, the Fifth Plan provides clear guidance to ensure that:
Governance and implementation of the Fifth Plan reflect the intent of the National Mental Health Policy regarding consumer and carer participation—that is, ‘Nothing about us, without us’.
Further, the Fifth Plan defines consumers and carers as:
people with lived experience… who identify either as someone who is living with (or has lived with) mental illness or someone who is caring for or otherwise supporting (or has cared for or otherwise supported) a person who is living with (or has lived with) mental illness…
For Aboriginal and Torres Strait Islander consumers, lived experience includes the cultural, historical and social context in which Aboriginal and Torres Strait Islander mental health difficulties and suicide are occurring (and as discussed above), in addition to a range of cultural and other barriers for engaging in effective treatment.
The value the Fifth Plan places on lived experience provides a further rationale for ensuring Indigenous governance of suicide prevention activity in communities and the full involvement of Aboriginal and Torres Strait Islander consumers with lived experience of the mental health system and of suicide in suicide prevention design and implementation processes. This should also be considered as a contributor to risk management by helping PHNs avoid common pitfalls that have the potential to result in harm, such as assuming that what works in one Aboriginal and Torres Strait Islander community will work in another, or by imposing integrated approaches, elements or interventions intended for non-Indigenous settings. The text box below provides an excerpt of the executive summary of the NATSISPS.
As set out in the Fifth Plan Appendix A, the five themes of the Gayaa Dhuwi (Proud Spirit) Declaration, set out below, are central to the development and implementation of actions in the Fifth Plan. They are:
- Aboriginal and Torres Strait Islander concepts of social and emotional wellbeing, mental health and healing should be recognised across all parts of the Australian mental health system, and in some circumstances support specialised areas of practice.
- Aboriginal and Torres Strait Islander concepts of social and emotional wellbeing, mental health and healing combined with clinical perspectives will make the greatest contribution to the achievement of the highest attainable standard of mental health and suicide prevention outcomes for Aboriginal and Torres Strait Islander peoples.
- Aboriginal and Torres Strait Islander values-based social and emotional wellbeing and mental health outcome measures in combination with clinical outcome measures should guide the assessment of mental health and suicide prevention services and programs for Aboriginal and Torres Strait Islander peoples.
- Aboriginal and Torres Strait Islander presence and leadership is required across all parts of the Australian mental health system for it to adapt to, and be accountable to, Aboriginal and Torres Strait Islander peoples for the achievement of the highest attainable standard of mental health and suicide prevention outcomes.
- Aboriginal and Torres Strait Islander leaders should be supported and valued to be visible and influential across all parts of the Australian mental health system.
NATSILMH has produced a Health in Culture – Gayaa Dhuwi (Proud Spirit) Declaration Implementation Guide, to assist Australian governments, mental health commissions and various parts of the Australian mental health system implement the Declaration.
Published separately as a companion document is a Health in Culture Policy Concordance of national policy documents relevant to Aboriginal and Torres Strait Islander social and emotional wellbeing, mental health and suicide prevention including the Gayaa Dhuwi (Proud Spirit) Declaration, the Fifth Plan and other key documents.
See the NATSILMH website: http://natsilmh.org.au.
In conclusion, the Fifth Plan implementation in Aboriginal and Torres Strait Islander communities is intended to be guided by a range of strategic documents, in particular the National Strategic Framework for Aboriginal and Torres Strait Islander People’s Mental Health and Social and Emotional Wellbeing 2017–2023; and the 2013 National Aboriginal and Torres Strait Islander Suicide Prevention Strategy.
Like the Cultural Respect Framework and the Gayaa Dhuwi (Proud Spirit) Declaration, these strategic documents emphasise the importance of Indigenous governance across their subject matter areas.
National Aboriginal and Torres Strait Islander Suicide Prevention Strategy
Executive Summary (extract). Available online at: http://www.health.gov.au/internet/main/publishing.nsf/content/mental-pub-atsi-suicide-prevention-strategy
The suicide rates of Aboriginal and Torres Strait Islander peoples for the period 2001–2010 were twice that of non-Indigenous Australians (ABS, 2012). The high rates of suicide among Aboriginal and Torres Strait Islander peoples are commonly attributed to a complex set of factors which not only includes disadvantage and risk factors shared by the non-Indigenous population, but also a broader set of social, economic and historic determinations that impact on Aboriginal and Torres Strait Islander social and emotional wellbeing and mental health.
In June 2010 the Senate Community Affairs References Committee recommended, in its report into suicide amongst Aboriginal and Torres Strait Islander peoples, that “…the Commonwealth government develop a separate suicide prevention strategy for Indigenous communities within the National Suicide Prevention Strategy…” (SCARC, 2011).
In response the Australian Government agreed to develop Australia’s first national Aboriginal and Torres Strait Islander Suicide Prevention Strategy and established the Aboriginal and Torres Strait Islander Suicide Prevention Advisory Group (the Advisory Group) to guide its development. A list of the members for the Advisory Group can be found at Appendix 1.
The Strategy has been informed by extensive community consultation across Australia and by the Aboriginal and Torres Strait Islander peoples’ holistic view of health that encompasses mental health, physical, cultural and spiritual health. Participants at the community consultations consistently called for community-focused, holistic and integrated approaches to suicide prevention with an emphasis on investment in “upstream” prevention efforts to build community, family and individual resilience and on restoring social and emotional wellbeing.
The overarching objective of the Strategy is to reduce the cause, prevalence and impact of suicide on individuals, their families and communities.
Six goals underpin this objective:
- Reduce the incidence and impact of suicide and suicidal behaviour in the Aboriginal and Torres Strait Islander population and in specific communities affected by suicide.
- Ensure that Aboriginal and Torres Strait Islander communities and populations are supported within available resources to respond to high levels of suicide and/or self-harming behaviour with effective prevention strategies.
- Implement effective activities that reduce the presence and impact of risk factors that contribute to suicide outcomes in the short, medium and long term and across the lifespan.
- Build the participation of Aboriginal and Torres Strait Islander peoples in the workforce in fields related to suicide prevention, early intervention and social and emotional wellbeing through the provision of training, skills and professional qualifications at all levels.
- Build the evidence base to support effective action and to evaluate the outcomes of suicide prevention activity at local, regional and national levels.
- Make high quality resources, information and methods to support suicide prevention for Aboriginal and Torres Strait Islander peoples available across all contexts and circumstances.
The objectives and goals will be achieved through the six action areas of the Strategy, which set out how these will be achieved in terms of areas of need, intervention and expected outcomes.
The action areas focus on early intervention and building strong communities through more community-focused, holistic and integrated approaches to suicide prevention. In implementing the activities listed under the action areas the focus should, where possible, be on providing the widest possible benefit to Aboriginal and Torres Strait Islander peoples, with additional effort focussed on those at greater risk or disadvantage. Each action area is supported by a number of outcomes and associated strategies through which the outcomes are intended to be achieved.
The CBPATSISP has developed an Indigenous Governance Framework that incorporates the above work and provides in-depth discussion of the principles and importance of Indigenous governance in the context of suicide prevention programs and services and of their evaluation. Click here to access the Framework.