Suicide is the fifth leading cause of death for Aboriginal and Torres Strait Islander peoples, compared to the 14th among non-Indigenous people.2 The 2013 Aboriginal and Torres Strait Islander suicide rate is 2.1 and 2.4 higher for males and females respectively when compared to the rate among non-Indigenous people.3 In particular, 15-24 year olds are over five times as likely to suicide as their non-Indigenous peers.4 Aboriginal and Torres Strait Islander children and young people under 18 years of age accounted for 30 per cent of the suicide deaths in that age group over 2007-20115 despite comprising three to four per cent of the population.
Suicide is a complex behaviour with many causes. For Aboriginal and Torres Strait Islander peoples there are specific cultural, historical, and political considerations that contribute to the high prevalence, and that require the rethinking of conventional models and assumptions.
How to prevent suicide is poorly understood for both the general population and Aboriginal and Torres Strait Islander peoples. As noted by the National Mental Health Commission in its 2013 National Report Card on Mental Health Services and Suicide Prevention, there is in fact ‘surprisingly little evidence about what works in suicide prevention.’ They conclude, ‘in terms of what works for suicide prevention, we are only just starting to scratch the surface.'5
In particular, few formal evaluations of Aboriginal and Torres Strait Islander suicide prevention programmes have occurred, and those that have are inconclusive. These are summarised in the 2013 Close the Gap Clearinghouse report Strategies to minimise the incidence of suicide and suicidal behaviour.7 However, these do not amount to an evidence base for best or promising practice.
The Aboriginal and Torres Strait Islander Suicide Prevention Evaluation Project (ATSISPEP) currently being undertaken should enable a much clearer picture as to what amounts to best or promising practice to emerge (see www.atsispep.sis.uwa.edu.au for more details on the project).
It is, however, possible to discuss emerging best or promising practice based on expert opinion and other research. This includes best or promising practice across three levels of intervention.
For those at immediate risk of suicide
One of the important contributions the Aboriginal and Torres Strait Islander Mental Health Advisory Group made to suicide prevention was to develop a set of Operational Guidelines for the Access To Allied Psychological Services (ATAPS) Program for Aboriginal and Torres Strait Islander Suicide Prevention Services (2012). 1 This included quality indicators for services to:
- Provide culturally safe, non triggering management, treatment and support to Aboriginal and Torres Strait Islander peoples at high risk of suicide or self-harm at a critical point in their lives and to mitigate the reverberations from suicide in the client's community;
- Be staffed by administrators and clinicians that are trained and understand mental health and suicide prevention cultural safety;
- Establish management protocols that reflect the multiple levels of diversity found in modern Aboriginal and Torres Strait Islander populations; and
- Be based on Aboriginal and Torres Strait Islander peoples' definitions of health, incorporating spirituality, culture, family, connection to the land and wellbeing and grounded in community engagement.9
These guidelines for suicide prevention services for people who have attempted, or are at risk of, suicide hold great promise including beyond the ATAPS scheme. This is because they ensure a culturally appropriate service at the very time when a vulnerable Aboriginal and/or Torres Strait Islander person is likely to need it most.
Training Aboriginal and Torres Strait Islander peoples to provide such services is one way to achieve this; ensuring non-Indigenous workers are culturally competent is another. Services should be delivered through Aboriginal Community Controlled Health Services where possible.
For at risk groups, particularly young people and adults
In a preventative approach, the developmental factors that can pre-dispose a person to suicide must be addressed at a relatively early age. As noted in the National Aboriginal and Torres Strait Islander Suicide Prevention Strategy:10
Preventive responses should include parenting programs and therapeutic interventions for high risk families and children, and a mix of therapeutic, supportive and competency-building or “life skills” interventions for youth in schools or in post-secondary training, as well as for those who are unemployed or entering the workforce. In many contexts, young people leaving school struggle to undertake further training or to stay in work and are in need of counselling and support... it is increasingly important that prevention policies focus on their common precursors in human development. There needs to be a shift towards collaborative, cross-sectoral approaches to treatment and prevention to treat both current risk and its developmental precursors.11
For whole communities
Building on cultural strengths and supporting self-determination is likely to be a core component of any suicide prevention program at this level. Importantly, the content, design and delivery of programs need to have legitimate community support, and be culturally appropriate, locally based and relevant to people’s needs. This requires engagement and partnerships with communities.
Aboriginal and Torres Strait Islander peoples describe their physical and mental health as having a basis of ‘social and emotional wellbeing’ originating in a network of relationships (or connections) that includes between the individual and their community, traditional lands, family and kin, ancestors and the spiritual dimension of existence.12 Life is understood in holistic terms: with the health of individuals and communities evident not simply by the absence of disease but linked to their ‘control over their physical environment, of dignity, of community self-esteem, and of justice’.13
Social and emotional wellbeing can be thought of as a protective factor and a source of resilience against the challenges of life, including those that impact on mental health. Challenges to social and emotional wellbeing can undermine resilience and leave individuals and communities exposed to distress and trauma without a countering protective force.
The National Empowerment Project’s Hear Our Voices’ Report (2012) reported that Aboriginal people have particular conceptions and understanding of healing, empowerment and leadership based on their historical, political and social experiences and cultural values and that there is a high level of need for a range of culturally appropriate and locally responsive healing, empowerment and leadership programs and strategies.14
The following principles are suggested as critical to the success of empowerment based suicide prevention programs operating at the community level:
- Community control and empowerment: projects should be grounded in community, owned by the community, based on community needs and accountable to the community.
- Holistic: based on Aboriginal and Torres Strait Islander definitions of health incorporating spirituality, culture and healing.
- Sustainable, strength based and capacity building: projects must be sustainable both in terms of building community capacity and in terms of not being ‘one off’; they must endure until the community is empowered.
- Partnerships: projects should work in genuine partnerships with local Aboriginal and Torres Strait Islander stakeholders and other providers to support and enhance existing local measures not duplicate or compete with them.
- Safe cultural delivery: projects should be delivered in a safe manner.
- Innovation and evaluation: projects need to build on learnings, try new and innovative approaches, share learnings, and improve the evidence base.
Professor Michael Chandler’s research among Canadian Indigenous communities shows in communities with ‘cultural continuity’, young people have a sense of their past and their traditions and draw pride and identity from them. By extension, young people also conceive of themselves as having a future (as bearers of that culture).15 Such communities also have significantly lower rates of suicide.
Conversely, poor cultural continuity can result in communities where young people are at a much higher risk of suicide.16 While the implications of this research are yet to be fully explored, including their application in Aboriginal and Torres Strait Islander settings, and in urban settings, the research suggests a highly productive line of inquiry and potential policy development in relation to suicide prevention (and more broadly, Aboriginal and Torres Strait Islander peoples’ mental health and social and emotional wellbeing) based on cultural maintenance and reclamation.
Cultural continuity can be understood in broad terms as self-determination and cultural maintenance.17 In Professor Chandler’s work a range of cultural continuity indicators were identified. These included: self-government; land claims; community controlled services, (including police and fire services, health services, child protection and education services); knowledge of indigenous languages; women in positions of leadership; and facilities dedicated to cultural purposes. The number of indicators present correlated to decreased suicide rates in communities.18
All communities have the potential for cultural maintenance and cultural continuity. While many are under pressure, they will have cultural strength that needs to be built upon. Adequate resources should be devoted to promoting cultural continuity in addition to, and as a part of, allocations to suicide prevention and mental health and social and emotional wellbeing services.
As noted, for Aboriginal and Torres Strait Islander peoples there are specific cultural, historical, and political considerations that contribute to the high prevalence of suicide, and that require the rethinking of conventional models and assumptions in suicide prevention. Policy makers should work in partnership with Aboriginal and Torres Strait Islander peoples, and accept their leadership, in order to ensure our peoples are able to benefit from both the best of clinical and culturally-informed practice in efforts to prevent suicide. This is particularly so at the population level where communities must be placed at the centre of strategic responses.
The first author can be contacted at [email protected]