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
- 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
- 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
- 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.