Suicide prevention in australian aboriginal communities a review of past and present programs

Suicide and Life-Threatening Behavior 45 (1) February 2015 Š 2014 The American Association of Suicidology DOI: 10.1111/sltb.12121

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Suicide Prevention in Australian Aboriginal Communities: A Review of Past and Present Programs REBECCA RIDANI, BSC (HONS) PSYCH, FIONA L. SHAND, PHD, HELEN CHRISTENSEN, PHD, KATHRYN MCKAY, PHD, JOE TIGHE, BSC (HONS) PSYCH, JANE BURNS, PHD, AND ERNEST HUNTER, MD

A review of Aboriginal suicide prevention programs were conducted to highlight promising projects and strategies. A content analysis of gray literature was conducted to identify interventions reported to have an impact in reducing suicidal rates and behaviors. Most programs targeted the whole community and were delivered through workshops, cultural activities, or creative outlets. Curriculums included suicide risk and protective factors, warning signs, and mental health. Many programs were poorly documented and evaluations did not include suicidal outcomes. Most evaluations considered process variables. Results from available outcome evaluations suggest that employing a whole of community approach and focusing on connectedness, belongingness and cultural heritage may be of benefit. Despite the challenges, there is a clear need to evaluate outcomes if prevention is to be progressed.

Approximately 2,500 Australians die by suicide each year, which accounts for 1.7% of all deaths. Between 2001 and 2010, the overall suicide rate for Aboriginal and Torres Strait islander1 peoples was twice that for non-indigenous individuals, with indigenous youth being most at risk. Age-specific suicide rates for males and females were highest among 15 to 19 year olds at 4.4 and 5.9 times the rate of their non-indigenous counterparts, respectively. Those aged 20 to

34 were between 2.3 and 5.4 times more at risk than non-indigenous individuals (Australian Bureau of Statistics, 2012).

Suicide rates for Aboriginal and Torres Strait Islander peoples vary across states, with the highest rates being reported in Queensland, Western Australia, and Northern Territory (Australian Bureau of Statistics, 2012). The past few years has seen the tragedy of Aboriginal and Torres Strait Islander suicides highlighted in national

REBECCA RIDANI, FIONA L. SHAND, and HELEN CHRISTENSEN, Black Dog Institute, Sydney, NSW, Australia; KATHRYN MCKAY, University of New England, Armidale, NSW, Australia; JOE TIGHE, Men’s Outreach Service Inc., Broome, WA, Australia, and University of New South Wales, Sydney, Australia; JANE BURNS, Young and Well Cooperative Research Centre, Melbourne, Vic., Australia; ERNEST HUNTER, Remote Area Mental Health Service, Cairns, Qld, Australia.

Address correspondence to Rebecca Ridani, Black Dog Institute, Hospital Road, Randwick, NSW 2031, Australia; E-mail r.ridani@unsw.edu.au 1 The term Aboriginal and Torres Strait Islander will be used throughout to refer to Australian peoples of Aboriginal or Torres Strait Islander descent. Where it aids in the flow of text for the reader, the term indigenous may also be used to refer to Aboriginal and Torres Strait Islander peoples. Note that most suicide prevention research in Australia is carried out within Aboriginal communities rather than among the Torres Strait islanders.

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policy and calls for its prevention have escalated to “high priority” (Australian Government, 2012). The Australian Government’s commitment to address suicide in these communities has resulted in the launch of the first National Aboriginal and Torres Strait Islander Suicide Prevention Strategy, which will attempt to address a number of key outcomes over the next 10 years (Australian Government, 2013).

Among the key outcomes is the need to increase the evidence base of effective interventions to inform targeted service delivery.

In this article we aim to provide an entry point for researchers and communities to work together in achieving this outcome.

Epidemiological and etiological differences are hypothesized to exist between indigenous and non-indigenous suicide (Elliott-Farrelly, 2004; Hunter, Reser, Baird, & Reser, 2001); however, risk factors and triggers appear to overlap between the two including, among others, chronic trauma, substance use, impulsivity, poverty, conflict, and relationship breakdown (Parker, 2010; Parker & Ben-Tovim, 2002; Reser, 2004; Silburn et al., 2007). What may help to account for the hypothesized differences are social, historical, and political considerations. The emergence of suicide among Aboriginal and Torres Strait Islander communities was not evidenced until 1980 (Hunter, 1993) and occurred amid a backdrop of major sociopolitical changes, including deinstitutionalization, the introduction of alcohol canteens, and the forcible removal of children (McKnight, 2002). The Stolen Generation resulted in interrupted parenting and mentorship processes and displaced Aboriginal and Torres Strait Islander peoples from their culture and spirituality (Tatz, 1999).

Although it remains unclear how these factors influence suicide, the widespread intergenerational trauma, dispossession, and rapid social changes may have impacted child development environments (Hunter & Milroy, 2006) and contributed to a collective loss of autonomy and cultural identity, thus increasing the risk factors for suicide (Barnett et al., 2010). The continuing influence

of Australia’s sociopolitical history on indigenous communities has propelled some to argue for an Aboriginal suicidology (ElliottFarrelly, 2004; Tatz, 1999) highlighting the need for interventions that bolster protective elements and target societal, interpersonal, and intrapersonal factors (Grant, 2011).

Indigenous communities are not a homogenous group internationally although shared similarities across suicide risk factors do exist (Middlebrook, LeMaster, Beals, Novins, & Manson, 2001). As such, overseas research may inform future interventions for Australian Aboriginal and Torres Strait Islander peoples. International studies suggest that community empowerment and cultural identity may be important factors in suicide prevention. Chandler and Lalonde (1998) found few to no suicides within Canadian indigenous communities that had a measure of control over six core markers of cultural continuity: self-government, land claims, education, health, police/fire services, and cultural facilities. A review of nine suicide prevention efforts in American Indian and Alaskan Native communities revealed that community involvement and cultural relevance are essential components of suicide prevention efforts (Middlebrook et al., 2001). Taken together, these studies suggest that suicide prevention programs that bolster a community’s involvement in their social and political destinies and maintain a connection to their cultural past may reduce suicide rates. Although the majority of programs were delivered by community members, no study looked at community connectedness at the outset. The greater social cohesion and solidarity of some communities may have mobilized them to take control and bring together different community sectors to address the problem.

Evaluations of suicide prevention efforts in the general population are faced with several challenges. Even in high risk groups, the incidence of suicide is low, presenting difficulties in achieving adequate study power, and interventions may take years to translate into lower suicide rate outcomes (Harrison, Miller, Weeramanthri,

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ET AL.

Wakerman, & Barnes, 2001). Randomized controlled trials, often noted to be the “gold standard” of research (Charlton, 1991), may be difficult to implement with these populations as the use of control groups may not be ethical or possible (Elliott-Farrelly, 2005).

These challenges are compounded within remote and marginalized Aboriginal communities and may not necessarily be appropriate to the indigenous experience in Australia.

Although attempts at documenting suicide prevention efforts for the general population have been made (see, for example, Headey et al., 2006; Mann et al., 2005), no such information exists specifically for strategies targeting Australian indigenous communities. The result is a lack of documented and rigorously evaluated suicide prevention programs for Aboriginal and Torres Strait Islander peoples. Indeed, a review of systematically evaluated suicide prevention efforts in Australia, New Zealand, Canada, and the United States found only three programs within Australia meeting inclusion criteria (Clifford, Doran, & Tsey, 2013). This dearth in evaluations may be related to insufficient funding, a paucity of services, and a lack of knowledge sharing (Krysinska, Martin, & Sheehan, 2009).

Some communities employing prevention efforts are seeing positive results (for an example, see McEwan & Tsey, 2009); however, little knowledge of these programs may exist outside of the communities involved.

An increase in knowledge may be facilitated by the transfer of information laterally between communities (Chandler & Lalonde, 1998). Attempts at facilitating such knowledge transfers have already begun in several Queensland-based Aboriginal communities (see Schindeler, 2009). In presenting an inventory of Aboriginal and Torres Strait Islander suicide prevention strategies and reviewing the evidence, we aim to further foster such knowledge sharing and simultaneously provide a guide for future interventions within this population.

The lack of peer-reviewed literature on Aboriginal and Torres Strait Islander suicide prevention is augmented by the gray

113 literature, namely documents produced by governments, academics, and businesses which are published in noncommercial form (Hopewell, McDonald, Clarke, & Egger, 2007). Examples include research reports, policy documents, and book chapters. Thus, to more accurately capture past and present prevention efforts, the inclusion of gray literature is warranted.

METHOD

Search Strategy The Informit list of databases (http:// search.informit.com.au) was used to identify relevant gray literature sources pertaining to Aboriginal and Torres Strait Islander peoples or mental health. Additional gray literature databases were sourced through search engines and by means of the resources section of relevant Web sites. A full list of databases searched is included in Table 1.

Databases were searched with the following key terms: “suicid*,” “self-harm,” “self-poisoning,” “trial,” “intervention,” “prevention,” “Indigenous,” “Aborigin*.” Web sites of all Ministries of Health and major indigenous organizations were included in the search. Where a Web site did not have a search facility, their published documents were hand searched. The reference list of all articles was also searched and a request for relevant papers were made to colleagues within the field. Documents were restricted to those published between 1998 and 2012 as TABLE 1

Databases Used Within Search Strategy AIATSIS ATSI Health Indigenous Australia APAIS-ATSIS RURAL APAFT CINCH-ATSIS Informit Health Collection

APAIS-Health Sociological abstracts APA-FT PsycEXTRA CogPrints ProQuest Dissertations and Theses OAIster Australian Indigenous Index (Koori Mail)

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no interventions that met our requirements were found to be documented before 1998.

Study Selection Any papers that made mention of suicide-related interventions were considered for inclusion. There was no restriction on the age of target participants, the intervention delivery method, or the primary outcome. To be included within this review, an intervention must have made mention of: (1) the intervention inception date; (2) the geographical locations covered; (3) a clear suicide-related project aim or a suicide prevention focus within its curriculum; (4) its target population as Aboriginal or Torres Strait Islander peoples; (5) the content and delivery method; and (6) the program impact. Interventions prior to 1998 were included if they were found to still be operational today. Interventions were excluded if the reduction of suicide rates or self-harm incidents was not a main aim, the content did not specifically mention suicide-related matters, or if indigenous populations were not included within their target group. Two reviewers (R.R. and F.L.S) independently assessed all potentially relevant articles and interventions for inclusion. Any disagreements about inclusion were resolved by discussion with a third review author (H.C.).

Analysis The analysis relied on information provided in projects’ proposals and reports.

To allow for systematic profiling, relevant information pertaining to the inclusion criteria was extracted for each intervention and entered into an Excel spreadsheet. Where an intervention was included in several papers, information from all sources was synthesized into a single record. Simple frequencies and percentages were calculated for quantitative data (e.g., age of participants, intervention location, method of administration), while qualitative information (such as project aims, content, and impacts) was manually recorded and coded for themes.

Although evaluative information was not available for all programs, documentation that made mention of program effectiveness was included, even if actual measures and evaluation processes were not described within the document. Most interventions were delivered to individuals or the community and were not administered as academic or scientific studies. Thus, it was beyond the scope of this article to provide a critical review of the projects or to determine which programs resulted in better outcomes than others. Instead, this review presents an inventory of strategies and draws on available documentation and information to highlight promising interventions that may inform evaluative projects in the future.

RESULTS

Description of Studies A total of 421 articles were retrieved; 319 of these were identified through electronic database searching and 102 through Web sites and hand searching. Eighty-seven were removed due to duplication and a further 156 were excluded on the basis of title or abstract. A total of 178 articles were retrieved for closer inspection, of which 132 were excluded, resulting in a total of 46 articles. From these articles, 72 individual interventions were identified. The eligibility criteria for inclusion were unable to be determined for five interventions, despite contact with authors and their departments, leaving a total of 67 studies that met the inclusion criteria. Of these, 17 were based in Queensland, 13 in Northern Territories, 10 in Western Australia, 5 in Southern Australia, 4 in New South Wales, 1 in Victoria, and 17 were administrated across multiple states. Information from across the programs is compared in Table 2.

A breakdown of the projects by target group and delivery method is provided in Table 3. Most programs were aimed at the entire community or youth, while a smaller

To instill an alcohol ban following a spate of alcohol-induced suicides

To engage young at risk men and women, especially those feeling depressed or suicidal, in counseling, mentoring, and peer-education

To reduce suicide and improve well-being by having students from the local university live within the community for 2 months

Alive and Kicking Goals!, The Kimberley (2007)

Gelganyem Youth and Community Well-Being Program, East Kimberley (2007– 2009)

Activities to address substance abuse, selfharm, and suicide risk in youth

Project Aim/ Mission

Restricted alcohol areas, The Kimberley (2007)

Western Australia Yiriman Project, The Kimberley (2001)

Name (Year)

Aboriginal youth

One off 2-day training (university students); camps, concerts, photography showcases, art workshops, writing, outdoor activities, storytelling

Mental health counseling, peer-education on suicide and suicide prevention delivered by indigenous peer-educators. Peereducation on nonviolence, anger management, self-esteem building. Cultural activities and bush camps to build resilience and reduce stress

Stopping the purchase of alcohol from local canteens

Whole community

Aboriginal youth 10–25 (support, mentoring, peereducation); indigenous/ non-indigenous clients (mental health counseling)

Bush trips, looking after the land, cultural activities

Delivery method

At risk indigenous youth 14–30

Target group

Alcohol; violence; suicide; cultural sharing; relationship building

Suicide; feelings; depression; healing from pain; relationship building; identifying others at risk and how to help them; peersupport; peer-education

Life skills; cultural awareness; leadership skills; relationship building; land management; community building; confidence; self-identity Alcohol

Content

Gelganyem Trust, University of Notre Dame

Marninwarntikura Women’s Resource Center (Fitzroy Crossing); Halls Creek Alcohol Management Group (Halls Creek) Men’s Outreach Services Inc. & The Broome Saints Football Club Alive and Kicking Goals steering group

Kimberley Aboriginal Law and Culture Center

Program administrator

Key Characteristics of Suicide Prevention Strategies for Australian Indigenous Populations Grouped by Jurisdiction

TABLE 2

ET AL.

(continued)

An evaluation in Fitzroy Crossing has shown positive effects on health and social outcomes, and alcohol-related behaviors after 12 months.

Other communities have not been systematically evaluated.

Preliminary evaluation found participants have learned how to recognize the signs that friends or family may be suicidal and have developed the skills and courage to help. This evaluation also highlighted the importance of a peer-education model where indigenous community members have taken responsibility for the project, its content and delivery.

No formal evaluation.

Anecdotal evidence suggests improvements in community health and well-being.

Reduced police incidents in Wyndham when university students present. No suicides in Oombulgurr since program inception.

✗

Describes evidence of efficacy

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To provide timely and helpful support to people bereaved by suicide

Active Response Bereavement OutReach Support Service, Perth (2007) Aboriginal and non-Aboriginal people

Aboriginal youth

Young indigenous atrisk males

Explore the role of indigenous ceremonies (kanyirninpa/holding) in suicide prevention and attempt to connect younger males with elders in the community Increase suicide awareness and helpseeking behaviors

Kanyirninpa— Holding Men, southeast Kimberly (2001–2004)

Hope for Life Photo Project, the Kimberley (2010)

Whole community

Target group

To build community resilience for suicide prevention and to assist in recognition and response of people at risk of suicide

Project Aim/ Mission

The Understanding and Building Resilience Project, southwest (2007)

Name (Year)

(continued)

TABLE 2

Home visits, counseling and peer support

Photos capturing hope and hopelessness

Activities such as sport, art

Workshops, camps

Delivery method

Grief, referral information; suicide bereavement

Hope; hopelessness; suicide; help-seeking; creative outlets for feelings

Supports relationships across and within generations; selfcontinuity; cultural continuity

Community resilience; connectedness; suicide warning signs and responses; referral information; media reporting guidelines; mental disorders; self-harm; selfcare; leadership

Content

Standby Suicide Response Service, Headspace Kimberley, Burdekin Youth in Action, and KinWay Anglicare WA ARBOR

✗

Injury Control Council of Western Australia; Ministerial Council for Suicide Prevention (MCSP); Aboriginal Healing Program (Waratah); and SouthWest Aboriginal Medical Service Palyalatju Maparnpa Aboriginal Corporation Health Committee

✗

(continued)

Qualitative research showed the social expression of kanyirninpa can also sustain important meanings for young men as they grow up.

It can protect them from high-risk behavior and selfharm. ✗

Describes evidence of efficacy

Program administrator

116 AUSTRALIAN ABORIGINAL SUICIDE PREVENTION: A REVIEW

Building Bridges (2007–2009)

To support leadership and collaboration, obtain life promotion skills, increase awareness and knowledge of suicide, foster community connectedness

To train, support, and employ community members as Family Life Promotion Officers and assist community members in crisis

To reduce the incidence of suicide and the prevalence of selfharming behaviors

Feeling Winyarn?

(2005)

Queensland Yarrabah Family Life Promotion Program—Family Well-being, North Queensland (1995)

To reduce the incidence of suicide and the prevalence of selfharming behaviors

Project Aim/ Mission

Aboriginal people working together to prevent suicide and self-harm (2005)

Name (Year)

(continued)

TABLE 2

Whole community

Introduction and development of Family Life Promotion Officers, closure of community alcohol outlet; community education and training programs; telephone crisis line; safe place 24 hours; counseling; postvention; relationship skill building Project officers established in each of the 4 communities and responsible for setting up knowledge-sharing events, and knowledgesharing toolkits with multiple resources

Pamphlet

Aboriginal youth

Whole community

Pamphlet

Delivery method

Aboriginal communities

Target group

Draft vision statement, action plan, and value statements; family well-being topics; risk factors for indigenous men’s health; how to protect health

Postvention; relationship skill building; suicide warning signs and risks

Risk and protective factors; warning signs; thoughts/ feelings of suicidal person; how to support suicidal persons; referral information Risk and protective factors; referral information; advice and information on drug and alcohol issues as well as mental health problems

Content

Center for Rural and Remote Mental Health Queensland

(continued)

Statistical data indicate reduction in number of suicides, reduced school truancy rates; increased number of young people graduating from university and returning to the community to work; decline in numbers of presentations of threatened or actual selfharm. ✗

✗

Ministerial Council for Suicide Prevention

Yarrabah community

✗

Describes evidence of efficacy

Ministerial Council for Suicide Prevention

Program administrator

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Improving awareness of suicide and build capacity in suicide prevention

Improving individual, family, and community awareness and understanding of suicide prevention

Aboriginal & Torres Strait Islander Mental Health First Aid Instructor Training (2009)

Natjul Theatre for Change (2009) Whole community and youth Performance with invitation from participants on solutions to social issues being acted out; workshops

5-day face-to-face training

2-day workshop

Whole community

Improve mental health literacy and reduce stigma surrounding mental illness

Aboriginal and Torres Strait Islander Mental Health First Aid Course (2009)

Nongovernmental organization staff and indigenous service agencies

Narrative, interactive touch screen approaches with audio feedback

Delivery method

Remote and Indigenous communities

Target group

To promote health and well-being in disadvantaged populations through new media information

Project Aim/ Mission

Buluru Yealamucka— Healing Spirit, Health Interactive Touch Screen (2001)

Name (Year)

(continued)

TABLE 2

Suicidal behaviors; anxiety disorders; acute stress reaction; schizophrenia; panic attacks; bipolar disorder; acute psychotic behaviors; substance use disorder; depression Depression; anxiety; psychosis; substance misuse; suicidal thoughts and behaviors; nonsuicidal selfinjury; panic attacks; traumatic events; severe psychotic states; severe effects from alcohol or other drug misuse; aggressive behaviors Suicide

Diabetes; drugs & alcohol; smoking; substance use; nutrition; suicide prevention; sexual health; child health

Content

Natjul Indigenous Performing Arts (NIPA); WIK Media; Aawuch Ngangk Kemp Min Aak (Aurukun Wellbeing Center)

ORYGEN Research Center

Queensland Health

National Health Interactive Technology Network (HITnet) Development Program

Program administrator

✗

✗

(continued)

The quantitative and qualitative evaluation of the pilot provided strong circumstantial evidence that touchscreens change community attitudes and intentions toward health. ✗

Describes evidence of efficacy

118 AUSTRALIAN ABORIGINAL SUICIDE PREVENTION: A REVIEW

Providing targeted suicide prevention activities; provide creative outlets for engaging youth Building individual, family, and community awareness and understanding of suicide prevention; develop a series of communication tools Develop a fact sheet of suicide prevention, and social and emotional well-being information

Pathways Through Resilience (2010)

St George P2R Suicide Prevention Project (2009)

Young, Strong & Proud (2009)

Improving awareness, understanding, and capacity in suicide prevention; increase community connectedness and foster cultural identity

Project Aim/ Mission

NAIDOC Week Celebrations (2009)

Name (Year)

(continued)

TABLE 2

Whole community

Young Aboriginal males presenting from the justice system Whole community and youth

Whole community

Target group

Life-promoting messages; importance of culture; language; dance; bush tucker; school work; smoking; alcohol; cannabis; pregnancy; help-seeking; crisis services; bullying Social and emotional wellbeing; suicide prevention; referral services

Song writing and recording workshops; DVD launch; bags with mental health relevant information (e.g., services)

Pamphlet

Happiness as central painting theme

Theme was honoring our elders, nurturing our youth

Content

Art workshops

Activities and exhibitions; youth disco; motivational speaker at schools

Delivery method

Brisbane Indigenous Media Association; Mornington Island Council; Queensland Health; Mark Bin Bakar (Mary G) Kunya Consultancy; Goondir Aboriginal and Torres Strait Islander Corporation for Health Services

Cunnamulla Aboriginal Corporation for Health; Cunnamulla NAIDOC committee; Queensland Health’s Southern Population Health Services Cunnamulla Aboriginal Corporation for Health

Program administrator

✗

✗

✗

✗

(continued)

Describes evidence of efficacy

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Enhance resilience and interconnectedness; provide youth with choices as to ‘Which Way’ to go for information, support, or help

Restore indigenous men’s rightful role in the community encompassing spiritual, mental, physical, emotional, and social aspects

Develop culturally appropriate, self-help resources for indigenous people in Yarrabah

Yaba Bimbie Indigenous Men’s Support Group (or Yarrabah Men’s Health Group) (1997)

Healing Our Way, Yarrabah (2005)

Project Aim/ Mission

Which Way? (2001)

Name (Year)

(continued)

TABLE 2

Weekly meetings, bonding experiences, hunting, fishing, movie nights, dinners, planning for employment opportunities, educational programs

Two pamphlets and a DVD containing culturally adapted evidence-based content

Whole community

A video documentary; a resource handbook for community sector workers

Young indigenous people, indigenous and non-indigenous community sector workers

Indigenous males in community

Delivery method

Target group

Auseinet, FNQ Suicide Prevention Task force Suicide risk factors; warning signs; help-seeking; selfharm; prevention; postvention

(continued)

Informal evaluation indicates increased skills, community commitment personal change among men. Combined with Family Life Promotion Program, suicide rates in Yarrabah have dropped from 3 to 4 yearly suicides (mid1990s) to a low of 2 suicides over the last 9 years. Injury rates also appear to have declined. Decline in the prevalence of each of the four most common types of offence in Yarrabah between January 2002 and February 2006. ✗

Qualitative evaluation found video and resource wellreceived. No evaluation of wider community outcomes.

Youth Suicide Prevention Network, West Moreton Health, Teen Care Indigenous Youth Service and the Murri Youth Council Yarrabah’s community controlled health service, Gurriny Yealamucka

Video: cultural and social circumstances faced by young indigenous people including suicide.

Handbook: drug and alcohol; police relations; legal issues; homelessness; mental health; help-seeking Strategy plan focusing on employment, education and training, tradition and culture, leadership and personal development; health services for men; business partnerships; alcohol and drugs; family dynamics; domestic violence; grief and loss; health

Describes evidence of efficacy

Program administrator

Content

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Provide peer support training for youth to encourage pro-social behavior as a way to prevent suicide

Improve awareness and understanding of suicide prevention; strengthening community postsuicide response; develop and make available a directory of health and social services in the Mt Isa region Aims to raise awareness of youth suicide and to assist and support young indigenous people at risk of suicide through sporting activities led by a trained and dedicated local indigenous person

Adolescent Peer Counseling Program (2007)

Health & Social Services Directory (2009)

Something better (1996)

Through community engagement, to create guidelines for referring suicidal persons

Project Aim/ Mission

Guidelines to Support People at Risk of Suicide (1998)

Name (Year)

(continued)

TABLE 2

Fridge magnet with attached booklet; Web site

Sport, camping, painting, cooking, workshops

Indigenous youth 8–16

Guidelines printed in color using three different types of language (English, traditional, and pictorial) Workshops

Delivery method

Whole community

Aboriginal youth

Whole community

Target group

Suicide risk factors; warning signs; help-seeking

Peer support through counseling skills including understanding and respecting differences, clarifying values, identifying and clarifying problems, exploring options, dealing with emotions Beyondblue, MoodGym, BluePages, Reach Out!, Lifeline, Suicide Call Back Service, Bush Crisis Line and Support Service, Just Ask Rural Mental Health Information and Referral Line

Risk factors; hints and signs; how to help individuals with issues; referral information

Content

Queensland PoliceCitizens Youth Welfare Association; Dr Edward Koch Foundation

Mt Isa Center for Rural and Remote Health

Centacare; Queensland University of Technology

The community

Program administrator

✗

✗

✗a

✗

(continued)

Describes evidence of efficacy

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Project Aim/ Mission

Suicide Story Training Project— Central Australian Life Promotion program (2010)

Central Australian Life Promotion program (1999– 2006)

To develop an interagency response to youth suicides and selfharm including bereavement support; to promote public awareness of mental health and suicide prevention; resource development; skilling up local workforce through training To provide an indigenous specific training resource that educates about suicide and the skills necessary to intervene when someone is at risk

Northern Territory (NT) MindMatters, Program modification for Anangu (2004) indigenous populations to educate about suicide and mental health awareness

Name (Year)

(continued)

TABLE 2

8 remote indigenous communities in NT; indigenous communities in Central Australia

Communities in NT

School students

Target group

DVD and 3-day workshop

Training workshops (ASIST, SafeTalk; Suicide Story DVD), resources (Suicide Story booklet; Yarnin about suicide audio project), healing ceremonies

In class discussions and activities

Delivery method

Suicide risk factors; signs of suicidality; barriers to helping; supporting people at risk of suicide

Nurturing pride in self and culture; building on strengths; optimism; literacy; connectedness; self awareness; self management; social awareness; relationship skills; responsible decision making; feeling deadly; bullying; racism; teasing; apology Suicide warning signs; how to respond to suicidal crisis; suicidal bereavement; spirituality

Content

Mental Health Association of Central Australia; Central Australian Life Promotion Program

Mental Health Association of Central Australia; Central Australian Life Promotion Program

Mindmatters

Program administrator

(continued)

Qualitative evaluation suggested that the DVD increased trainees’ knowledge and confidence to respond to someone at risk of suicide.

No formal evaluation but interventions have been seen to defuse the likelihood of contagion.

✗a

Describes evidence of efficacy

122 AUSTRALIAN ABORIGINAL SUICIDE PREVENTION: A REVIEW

Raise community awareness on issues relating to suicide and to provide crisis intervention, family mediation, and 24-hour suicide watch

Help spread awareness of suicide impacts in NT; educate community on suicide warning signs and help-seeking for atrisk youth Open up discussion about youth suicide in a community in Wales following a 2-year spike in youth suicides

Galupa Marngarr Suicide Prevention Group—Wesley LifeForce, Arnhem Land (1996)

Roper Gulf Shire Council Youth Services Programs, Katherine (2012)

Darwin Community Arts (2011)

GPs refer at-risk patients to a psychologist, who contacts client within 24 hours; this project aims to help patients at medium to low risk of suicide or self-harm for the crisis period only

Project Aim/ Mission

Suicide prevention service, Darwin (2008)

Name (Year)

(continued)

TABLE 2

Camps; suicide awareness and SafeTalk workshops; theatre production about youth suicide

Play performed by community youth, adapted from a popular contemporary novel with suicide as a major theme.

The performance was followed by a facilitated discussion on the topics raised and the situation in the community

Whole community

Suicide

Darwin Community Arts

Roper gulf Shire Youth services team; IS Australia

✗

✗

(continued)

No formal evaluation but signs of reduced incidence of completed suicides.

Galupa Marngarr Suicide Prevention Group

Crisis intervention: 24-hour alert to chase down young people threatening suicide or missing; community education: family mediation and community discussion on issues such as domestic violence; postvention: culturally significant community gatherings and ceremonies Depression; alcohol and drug misuse; help-seeking; signs of suicidality; connecting individuals with referral sources

Self-harmers are taken to Galupa outstation and stay with the community for some time to be cared for

Aboriginal youth

No formal evaluation but referrals to service have increased resulting in more consumers receiving psychological services.

IM Concepts

Suicide warning signs; referral information

Referral, then face-to-face appointment

Describes evidence of efficacy

Anyone in Darwin community at risk of suicide (self harm, ideation, or attempt) and who visited a GP Yolngu community at Ski Beach

Program administrator

Content

Delivery method

Target group

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To assist communities in promoting mental health by developing resources to enable them to tackle issues surrounding suicide and self-harm; to provide guidance for future intervention projects

We Know our Strengths, Alice Springs Region (2007–2009)

Tiwi for Life, Darwin Region (2002)

Aims to provide community-based counseling and youth mentoring for those 12 –25 to address risks such as suicidal ideation and behavior, substance abuse, and violence To increase the likelihood of helpseeking behaviors and to treat mental illness, drug and alcohol abuse; suicide; and psychological problems

Project Aim/ Mission

Mt Theo, Yuendumu (1993)

Name (Year)

(continued)

TABLE 2

Whole community, especially indigenous men

Whole community

Warlpiri Aboriginal community of Yuendumu

Target group Counseling and mentoring service; cultural rehabilitation at outstation; youth development including education, training, mentoring and cultural activities; community outreach Training for mental health workers and community; development of community safety plan; fences around power poles; engaging elders to mentor the young; restriction of alcohol to medium and low strength; increased police presence; permanent psychiatric nurse; regular psychiatrist visits Cultural and family trips to local waterholes and other significant sites; health promotion activities; intergenerational male activities promoting family and community involvement; development of local suicide prevention and awareness resources

Delivery method

Resilience; connectedness; physical health; warning signs; referral information

Mental illness; drug and alcohol abuse; suicide; psychological problems

Counseling includes alcohol or other substance abuse, suicidal behaviors, sexual health, relationship breakdown, domestic violence, depression and grief, community and family engagement

Content

Waltja Tjutangku Palyapayi Aboriginal Association (Waltja)

✗

(continued)

No formal evaluation but rate of completed suicides dropped from 10 in 2002 to 2 in 2003, and while 4 suicides occurred in 2005, only 3 have occurred since 2006.

No formal evaluation but no completed suicides in area since program inception and reduced levels of petrol sniffing and suicide attempts.

Mt Theo Outstation; Jaru Pirrjirdi Project; Warlpiri Youth Development Aboriginal Corporation

Tiwi Health Board

Describes evidence of efficacy

Program administrator

124 AUSTRALIAN ABORIGINAL SUICIDE PREVENTION: A REVIEW

South Australia Sustainable Personal Development for Aboriginal Men, Port Pirie (2006)

Galiwin’ku Youth/ Parent/Worker Youth and Life Education Training Project (1995– 1999)

Well-being program, East Arnhem Land (2008)

Strong Spirit Strong Body Nauiyu Youth Program, Darwin Region (2009)

Name (Year)

(continued)

TABLE 2

To reduce the incidence of suicide

To decrease the incidence of suicide attempts and self-harm by increasing resilience of young people through local programs run by local young leaders To improve health and well-being through strategies targeting poor health outcomes, alcohol and other drug abuse, and the high rates of suicide in the Miwatj region To address issues related to at-risk youth including suicide, selfdestructive behaviors, kava drinking, violence, petrol sniffing, and gambling

Project Aim/ Mission

Healing camps; illustrated book; education workshops; artwork; film and narration of the films

Training provided to ‘Life Skills Workers’ (Community Education Team) and dissemination of these skills to wider community

Indigneous community

Indigenous community, particularly males and youth

Activities; workshops; intergenerational knowledge transfer; developing pathways to training and employment

Workshops; painting; ASIST training; MHFA training; diversionary excursions

Delivery method

Whole Yolngu community

Whole community

Target group

Centacare Catholic Family Services, Diocese of Port Pirie

(continued)

No formal evaluation but communities involved in project note that suicide is more easily discussed and help-seeking has increased.

✗

Galiwin’ku Community Council

Crisis work; counseling; debriefing; stress management; mediation; conflict resolution; parenting skills; mental health

Aboriginal history and culture; positive well-being; self-esteem; self-awareness; challenges faced by youth

✗

Yothu Yindi Foundation

✗

General Practice Network Northern Territory; Daly River Community

Depression; things that keep you strong; things that do not provide well-being; referral information

Alcohol and other drug use; volatile substance use; suicide prevention; traditional healing; cultural knowledge

Describes evidence of efficacy

Program administrator

Content

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125

Increasing the capacity of local service systems and the community to enter into partnerships that improve the quality of life and living outcomes for young Aboriginal men in the region

Riverland Young Indigenous Men Suicide Prevention Project (2006) Whole community

Warning signs; suicide risk; assisting at risk individuals; increasing safety; referral resources

Positive attitude; community pride; self-esteem; personal and community well-being

To celebrate community and create safe environments to talk about suicide

Wadninaka SelfEsteem and Resilience Program, Northern and Far Western Initiative (2006–2007) Community cultural development activities; workshops such as drumming, rap, dance, fashion design, traditional Aboriginal wood carving, community mural painting; Aboriginal traditional bush food and medicine Suicide prevention awareness program training workshops (ASIST), especially for police, mental health workers, and teachers

Suicide warning signs; how to help those at risk of suicide; connectedness; caring

Relationship building through consultation with community; half day suicide prevention workshop; counseling including 24/7 mobile support

Whole community, especially young indigenous men and their families

Provides counseling services for at-risk men and assists community members to recognize and support people who may be at risk of suicide and self-harm

No-one Walks Alone, Ngarrindjeri county (2006–2007)

Whole community

Content

Delivery method

Target group

Name (Year)

Project Aim/ Mission

(continued)

TABLE 2

Government of South Australia Social Inclusion Unit

✗

Suicide Prevention in Country SA initiative (SPICSA); Murray Mallee Community Health Service; Lower Murray Nungas Club Suicide Prevention in Country SA initiative (SPICSA)

(continued)

No formal evaluation but postworkshop surveys identified an increase in participant understanding, confidence, and skills, and most reported increased awareness of support services and comfort with referring to them.

✗

Describes evidence of efficacy

Program administrator

126 AUSTRALIAN ABORIGINAL SUICIDE PREVENTION: A REVIEW

New South Wales Life Matters, Western Riverina (2007)

Victoria Mildura H.O.P.E. (Hope, Opportunity, Purpose, Employment and Education) Shared Responsibility Agreement (2007)

Sustainable personal development for Aboriginal men, Port Augusta (2006)

Name (Year)

(continued)

TABLE 2

To improve community awareness and attitudes to suicide prevention in 14–25 year olds via the SPLASH program (Suicide-PreventionListening-AskingSafety-Help); to train community workers to better identify people at risk and provide support

To address the ‘complex interface between education and antisocial behavior’ by engaging young people at risk of suicide or self-harm in sporting teams and promoting positive alternatives to antisocial behavior

To reduce the incidence of suicide among indigenous men aged 15–45 years by equipping them with life skills, building resilience, and teaching coping mechanisms

Project Aim/ Mission

Koori people

Indigenous children and their parents

Aboriginal males in urbanized, semi-tribal and tribal communities with a strong emphasis on youth

Target group

Community education including ASIST for indigenous populations; surfing school program for children; art workshops

Parent/student workshops; organized sports and activities such as art and culture

Counseling; community and school workshops; group discussions; recreational activities; multimedia projects; healing camps; artwork; film and narration of the films

Delivery method

Cultural identity; optimism; child protection; child mental health; warning signs; strategies to feel comfortable when talking and listening to a person at risk; referral information

Connectedness; self-esteem, self-confidence; problem solving

Self-esteem; effective relationships; conflict resolution; anger management; separation; loss; grief; mental health

Content

Murrumbidgee Division of General Practice; Griffith Aboriginal Medical Service

Mildura Aboriginal Corporation

Centacare

Program administrator

✗

✗

(continued)

No formal evaluation but notice improved coping capacity and resilience from attending the Healing Camps; increase in helpseeking behaviors.

Describes evidence of efficacy

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127

Hunter New England Area Health Service Definitions; myths and facts; warning signs; risk and protective factors; tips for working with indigenous communities; identity and culture; referral information

2-day workshop

Aboriginal and non-Aboriginal workers

(continued)

✗

Bennelong’s Haven Family Rehabilitation Center

Treatment is delivered by AAmodeled personal sharing of life stories; culture; personal problem-solving for health, legal, and housing issues

30 acres of property with different programs including an Alcoholics Anonymous-based group; psychotherapy; recreation; food/rest; daily psycho-educational groups

Indigenous youth on drug- and alcohol-related charges with suicidal ideation or prior attempts

Provides an alternative to jail for young Aboriginal people facing drug- and alcohol-related charges who have high levels of suicidal ideation; outcome is for clients to increase their mental well-being To support workers to confidently recognize mental disorders and early signs of suicide risk

Bennelong’s Haven: Alternative to Gaol Program (established 1974)

Indigenous suicide prevention training package, Tamworth (2006)

Evaluation of the workshops demonstrated an increase in participants’ knowledge about suicide, greater confidence in identification of people who are suicidal, and high levels of intentions to provide help.

Fifteen of the 40 participants stated that they had helped someone at risk of suicide over the 2-year follow-up period. Intentions to help and confidence to identify someone at risk of suicide remained high.

All clients who completed 75 days of treatment significantly improved on the psychological indexes, indicating lower levels of depression, anxiety, and stress, and improvements in various psychological and physiological markers.

Describes evidence of efficacy

Illawarra Institute for Mental Health

Program administrator

Identifying suicidal behaviors; risk factors; myths and facts; statistics; communication skills; how to help; sources of help and how to gain access to them

Content

Eight 1-day workshops

Delivery method

Indigenous communities within the region

Target group

To increase the ability of the local community to identify individuals at risk of suicide, mobilize local informal helping networks, and facilitate help-seeking behavior

Project Aim/ Mission

Shoalhaven Aboriginal Suicide Prevention project (1999)

Name (Year)

(continued)

TABLE 2

128 AUSTRALIAN ABORIGINAL SUICIDE PREVENTION: A REVIEW

Family Well-being Empowerment Program (1993)

Multiple States Indigenous Hip Hop Projects—Building Bridges 2, Dalby, St George, The Kimberley (2007– 2010)

Name (Year)

(continued)

TABLE 2

A course designed by and for indigenous Australians to promote personal empowerment

Promote suicide prevention and social and emotional wellbeing; facilitate social change by addressing crime prevention and promoting community safety

Project Aim/ Mission Remote, regional, and urban indigenous communities; children and youth (primary and high school students); whole community Families and communities

Target group

Evaluation is based on qualitative information collected from participants.

Findings to-date indicate that program participation can significantly enhance feelings of control and responsibility for the conditions affecting one’s health and well-being.

Participants report increased levels of resilience, selfworth, and hope regarding the possibility of changing one’s situation, as well as enhanced problem-solving skills and ability to reflect on sources of problems.

The Indigenous Hip Hop Project; Center for Rural & Remote Mental Health Queensland

Exploration of issues in people’s daily lives; recognizing own strengths and resources; taking action to improve own situation; counseling skills; emotional health; violence; abuse; healing

Workshops, usually 4 hours per week over 40 weeks; handouts; brainstorming; group discussions; role-plays; visualization

(continued)

✗

Describes evidence of efficacy

Burdekin Youth In Action (Broome); beyondblue; Center for Remote and Rural Health

Program administrator

Mental health; suicide prevention; leadership; substance abuse reduction; crime prevention and community safety; cultural celebrations; depression; anxiety

Content

Dance; music; art; media workshops (in school and after school); community performances

Delivery method

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129

Deadly thinking (2011)

Applied Suicide Intervention Skills Training—ASIST (2009)

Marumali Journey of Healing (2000)

Name (Year)

(continued)

TABLE 2

To empower Aboriginal and Torres Strait Islander service providers in the provision of safe, appropriate, and effective support to survivors of removal and assimilation policies Targeted suicide prevention; improving awareness of suicide prevention; building resilience and capacity in sphere of suicide prevention Raise awareness, improve understanding, and provide strategies and pathways to help to address social, emotional, and mental well-being issues in a “whole person, whole community” context

Project Aim/ Mission

All community members and particularly elders, those with leadership roles, “natural helpers,” or those with an interest in promoting awareness and discussion about social and emotional well-being issues

Prisoners and Aboriginal and Torres Strait Islander people working to support survivors of forcible removal policies Whole community and long-term services staff

Target group

Participants learn to recognize the signs of suicide risk and respond in ways that increase safety and link people at risk with sources of professional help Mental health and well-being (stress, anxiety, substance abuse, depression, suicide); support networks; self-help techniques; help-seeking behaviors; change management skills and problem solving; pathways to care

1-day workshops

Silence and transgenerational effects of removal; identity, belonging, spirituality, and healing; managing suicide risk in survivors of removal policies

Content

2-day workshop

2-day workshop

Delivery method

✗

✗a

(continued)

✗

Winangali Marumali

LivingWorks auspiced

by Lifeline Australia; Cunnamulla Aboriginal Corporation for Health (CACH) Australasian Center for Rural and Remote Mental Health

Describes evidence of efficacy

Program administrator

130 AUSTRALIAN ABORIGINAL SUICIDE PREVENTION: A REVIEW

You Me—Which Way (2002)

To improve mental health for people bereaved by suicide; reduce negative health/ social outcomes; prevention of future suicides

Aboriginal and nonAboriginal peoples joining together to celebrate the sacredness of the earth and the sanctity of all life through trauma informed, trauma specific healing programs A trainer initiative to educate community members in how to be proactive to prevent somebody taking their life, or harming themselves

We Al-li (1993)

COmmunity REsponse to eliminating Suicide —CORES (2002)

Build community awareness of mental health and suicide prevention issues and services

Project Aim/ Mission

Yarnin about mental health (2010)

Name (Year)

(continued)

TABLE 2

Workshops; story mapping; sand-play; music; art therapy; movement and guided imagery

Team leaders encouraged to train 250 people over 12 months via a 1-day course; comprehensive training, mentoring, and support

Indigenous communities

Rural communities (some of which are indigenous or both indigenous and nonindigenous) Those bereaved by suicide; emergency and community responders; communities as a whole; indigenous and non-indigenous peoples 24-hour crisis telephone response; face-to-face counseling; workshops; storyboard consisting of a collection of magnetic images that pictorially describe experiences of grief and bereavement

Signs that a family member or friend may be at risk; help seeking; local support networks and services; stress; anxiety; postnatal depression; helplines; alcohol and drug use; depression; isolation; men’s groups Domestic violence; sexual assault; childhood trauma; suicide; self-injury; addictions

Radio broadcasts delivered over 6 months: monthly one 10-minute broadcast and six 1-minute broadcasts were produced. Each segment was broadcast an average of 12 times per month.

Cape York and other communities throughout Australia

Community attitudes toward suicide; suicide statistics; river of risk; funnel vision; signs and indicators; wallet card; assessing the level of risk; interventions; agreements; community resources and services Needs of indigenous communities in regards to grief and loss, particularly in relation to suicide bereavement

Content

Delivery method

Target group

United Synergies, Anglicare, Lifeline, Support Link Australia, CLS Inc, Pilbara Health Network

ET AL.

(continued)

Formal evaluation indicates that those receiving services from Standby within 2 years of a suicide are less distressed and have lower suicide ideation than those not receiving the service.

Qualitative evaluation suggests that program increases awareness of suicide, reduces social isolation, and possibly averted suicides from occurring.

✗

We Al-li

Kentish Regional Clinic

✗

Describes evidence of efficacy

Queensland Remote Aboriginal Media; Community Broadcasting Association of Australia (CBAA)

Program administrator

RIDANI 131

Helps young people talk about their own suicide risk after the suicide of a friend or loved one and promotes helpseeking behavior; also used as an educational resource

Toughin It Out (1998) Pamphlet utilized in indigenous health and youth services, schools in Queensland and NT, and during Applied Suicide Intervention Skills Training/Suicide Awareness workshops

Service provider workshops: latest research and bestpractice models of culturally appropriate service provision for Aboriginal clients, signs and symptoms of depression and suicidal behavior, risk indicators, basic counseling skills. Community member workshops: developing skills based on the “natural gatekeeper” model of prevention. Youth workshops: depression and suicide (and the relationship between the two), lifecoping skills (emphasizing managing difficult emotions).

Suicide; depression; negative thoughts; counseling services; referral information

Three forums (workshops): introductory, follow-up (6 months later), and skills consolidation phase (12 months postintroductory phase)

Service providers, community members, and youth in indigenous communities

To reduce the number of Aboriginal people attempting and completing suicide in rural and remote communities

Whole of Aboriginal Community Suicide Prevention Forums (2002)

Youth

Content

Delivery method

Target group

Name (Year)

Project Aim/ Mission

(continued)

TABLE 2

Simon Bridge

Indigenous Psychological Services

Program administrator

✗

(continued)

Pre- and poststructured questionnaires reported statistically significant gains on self-reported levels of skills and knowledge, and readiness to help a person at risk.

Describes evidence of efficacy

132 AUSTRALIAN ABORIGINAL SUICIDE PREVENTION: A REVIEW

Manual and workshops

Weekend workshop with a support person for each participant; participants encouraged to speak to others about how they resolved obstacles

Youth 12–18 (approximately 30% indigenous)

To enhance the young people’s self-esteem; increase school retention; reduce drug and alcohol abuse; reduce youth suicide; and to reduce violence, crime, and abuse in young people

Youth Insearch weekend programs (founded 1985)

Delivery method

Shoalhaven and Yarrabah communities

Target group

To train as many members of the community in suicide prevention skills as possible

Project Aim/ Mission

Suicide Awareness for Aboriginal Communities (1995)

Name (Year)

(continued)

TABLE 2

Definition of suicide; misconceptions about indigenous history; incidence of indigenous suicide; myths and facts; risk factors and warning signs; understanding needs, intention, level of danger and distress of a suicidal person; helping and first aid for the suicidal person; helping those bereaved by suicide; understanding and helping high-risk groups; suicide prevention in communities Family breakdown; domestic violence; sexual abuse; bullying; effects of drug and alcohol abuse; suicide and grief

Content

✗

(continued)

Informal evaluation 12 months after program administration to estimate the number of people using the acquired skills and the manual, and to ascertain further needs of the community. There was positive feedback from workshop participants and encouraging long-term outcomes, including development of support services and resources in the community.

Shoalhaven Suicide Prevention Network (NSW)

Youth Insearch

Describes evidence of efficacy

Program administrator

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To deliver suicide prevention messages through dance, music, and sport; restore pride in culture and build self esteem; link youth with local Aboriginal-led community organizations and services To help indigenous people bereaved by suicide deal with their grief

To promote social and emotional well-being and reduce community distress and suicide

Mokoi/Vibe Australia (2012)

Empowerment (2011)

Expected feelings after suicide; strategies to deal with grief; what to expect during and after the funeral; signs of not coping well; suicidal ideation; referral services Protective factors; barriers to well-being; cultural integrity; resilience; social cohesion; connection to land, culture, spirituality, and ancestry

Dance, music, sport

Information booklet

Young indigenous people

Indigenous bereaved by suicide

Indigenous communities

Phase 1: community consultations. Phase 2: mentorship; training; empowerment, healing and leadership workshops

Suicide awareness and prevention; collection of baseline data; provision of clinical support; helping community members identify and intervene with young people at risk; crisis intervention skills and adolescent mental health; community-based risk factors Pride in culture; self-esteem; suicide and its impact on spirit, family, and community

Primarily networking between service agencies, workshops, committee meetings, group forums

Community members in Tiwi Islands, Bourke, Atherton, Oatlands, Millicent

Content

Delivery method

Target group

Indicates that evaluation for non-indigenous version of the program exists.

a

Grieving Aboriginal Way (2001)

To trial and evaluate the effectiveness of state, territory, or regional networks in supporting rural or remote communities to prevent and respond to suicide attempts by young people

Project Aim/ Mission

Support to Rural Communities (1995 –1999)

Name (Year)

(continued)

TABLE 2

University of Western Australia

Indigenous Psychological Services

Vibe Australia

Charles Sturt University

Program administrator

Qualitative evaluation indicates empowerment programs are an effective strategy for enhancing social and emotional well-being and addressing suicide risk factors, especially among young people.

✗

✗

✗

Describes evidence of efficacy

134 AUSTRALIAN ABORIGINAL SUICIDE PREVENTION: A REVIEW

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135

TABLE 3

Projects by Target Group and Delivery Method

Delivery method Training and educational workshops Creative means Pamphlets/resources Counseling Peer support/mentoring DVD Closure of alcohol outlet Restriction of alcohol strength for sale Restriction of access to means Radio broadcasts Interactive touch technology

Whole community (n = 45)

Youth (n = 23)

Males (n = 7)

Service providers (n = 7)

Families/ Children (n = 3)

26

10

3

6

3

16 6 7 3 2 2 1

14 3 2 2 2 0 0

6 0 2 1 0 0 0

1 1 1 0 1 0 0

1 0 1 0 0 0 0

1

0

0

0

0

1 1

0 0

0 0

0 0

0 0

Note: Some programs targeted multiple groups and used several delivery methods thus the total exceeds 67, and the sum of programs over a delivery method exceeds the number within that group.

number were aimed at males, service providers, or families. The majority were delivered through multiple channels with many employing training and educational workshops. Creative means was another main delivery method and consisted of art, photography, sporting activities, performances, and camps. Other means of delivery included pamphlets, counseling, peer support, DVDs, radio broadcasts, interactive touch technology, closure of liquor outlets, and reducing access to means.

Almost all programs covered several topics within their content. Most interventions (n = 38) addressed suicide risk factors and warning signs, such as hopelessness, impulsivity, and aggression. Others looked at mental health or injury (n = 21), which included depression, anxiety, psychosis, and domestic violence. Eleven programs specifically covered alcohol and substance abuse.

Thirty-one programs looked at protective factors such as health and well-being, hope, creative outlets for feelings, resilience, and connectedness. Culture was specifically part of the curriculum for 14 programs. Ten programs looked at relationship building

skills, and seven discussed bereavement, loss, or grief. Many programs (n = 23) also addressed issues connected to help-seeking and local referral services.

Of the 67 programs, the majority (n = 38) were run by Aboriginal organizations or members of the communities in partnership with external organizations such as universities or mental health services (as indicated in Table 2 column “Program administrator”). These included programs in which Aboriginal people had contributed significantly to the creation of the content.

A further 21 programs were wholly owned and run by Aboriginal organizations. Eight programs were neither Aboriginal owned nor run and no outcome measures (as indicated in Table 2 column “Describes evidence of efficacy”) were found for these eight interventions. Programs wholly or partly Aboriginal owned used creative means of delivery and included culture and protective factors within their curriculum.

Programs that were not Aboriginal owned or run tended to use workshops as their delivery method, focused on the whole community or service providers, and

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AUSTRALIAN ABORIGINAL SUICIDE PREVENTION: A REVIEW

included mental health, warning signs, and referral information within their curriculum. The length of time that programs were run for varied. Many are still ongoing today (31%), although a large portion of the programs was only implemented for 12 months or less (54%). Seven percent of programs were implemented for a maximum duration of 2 years, 3% were implemented for 3 years, and 3% were implemented for 4 years. Only one program was run for a length of 7 years.

The majority of programs (63%) made no mention of program outcomes or had only process evaluations detailing the success of their implementation strategies (e.g., the number of workshops run, the number of participants attending). Evaluation results outlined in Table 2 are those that pertain specifically to suicide or selfharm-related variables. Of the 25 programs that mentioned outcome information, 32% conducted qualitative evaluations, 16% conducted quantitative evaluations, 12% combined qualitative and quantitative evaluation, and 40% had informal evaluations indicating observed improvements in outcome data over a period of time. Improvement in suicide awareness and readiness to help a person at risk occurred for 28% of evaluated programs. Twenty-four percent of evaluated programs outlined improvements in protective factors such as resilience, whereas 20% indicated improvements in help-seeking behavior. Twenty-eight percent of evaluated programs made mention of observed changes in suicide rates over time, although these changes were not systematically evaluated. Only one program, “You Me—Which Way� measured and reported reduced suicidal ideation for individuals within the intervention group.

DISCUSSION

Implementation of Interventions The current study provides an overview of suicide prevention projects targeting

Aboriginal and Torres Strait Islander communities. These programs have adopted various delivery approaches and covered both risk (such as the harmful effects of drugs and alcohol) and protective (such as the importance of healthy relationships) factors. Programs aimed at the community or youth have been particularly dominant, as have those that are run by indigenous organizations in partnership with non-indigenous organizations. In line with statistical data reflecting the highest state-based suicide rates (Australian Bureau of Statistics, 2012), most programs were conducted in Western Australia, Queensland, and Northern Territory. This may be reflective of program necessity (i.e., higher suicide rates for those states) or demographics (i.e., higher proportion of Indigenous populations in those states). Alternatively, it may reflect the evolution of funding allocations. Initial allocations were arbitrary but have changed over time so that funding is now driven by frameworks and strategies (e.g., the recently released Australian Government, National Aboriginal and Torres Strait Islander Suicide Prevention Strategy, 2013).

Programs that were wholly or partly indigenous owned employed creative means of delivery including art classes, dancing events, theatrical showcases, cultural camps, and community activities. Those programs not owned or run by Aboriginal corporations tended to use workshops as their main delivery method. This suggests that non-indigenous run interventions are individualistic and treatment oriented, whereas indigenous run interventions are more community minded and holistic. Indeed, findings from this review indicate that many programs included cultural activities that fostered a sense of community connectedness and cultural pride, both considered potent protective factors (Chandler & Lalonde, 1998; Dudgeon et al., 2012).

Restoring a sense of stable identity is particularly important considering its construction has been significantly impacted by a range of sociohistorical forces, including state-sanctioned processes of removal and

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family disruption, and substance abuse in areas of endemic welfare dependence. In a bid to design programs targeting the unique needs of indigenous individuals, it appears that suicide prevention efforts are amalgamating research findings with social, political, and historical considerations to design culturally appropriate prevention programs. Although challenging, systematic evaluations of these programs are necessary not only to help identify effective interventions and refine effort, but also to highlight programs that may be potentially detrimental.

Program sustainability was an issue in many communities, with many projects only receiving funding for one off community or training events. The majority of programs were run for no more than 12 months. Some programs managed to secure longer-term funding and were operational for a few years. However, program longevity appeared to be linked to community ownership. Programs still operational today (e.g., Yarrabah, Mt Theo) started small, were wholly owned and run by the communities in which they originated, and were located within a larger set of political and service developments. These programs were also implemented through several channels, including education, counseling, mentorship, crisis intervention, and reduced access to means (such as fences around power poles). Indeed, the sustainability and multipronged approach of these programs allowed for longer-term trends to be noted, with observed patterns indicating reduced suicide rates, fewer self-harm incidents, and fewer disruptive behaviors. However, without adequate evaluations, it remains difficult to determine whether a drop in suicide rate is attributable to the program, and whether changes are sustained and statistically significant or merely nonstatistically significant fluctuations. The multipronged approach of many programs also makes it difficult to determine which component, if any, was most influential. Nevertheless, in line with previous research (Dudgeon et al., 2012), the findings of this review suggest that whole of

137 community investment and involvement is essential in indigenous suicide prevention efforts.

Performance of Interventions Interventions were numerous, although outcome evaluations were sparse. Many programs conducted documented process evaluations, which included measures of program delivery satisfaction. However, few documented outcomes related to suicidality, such as suicidal behavior, desire, thoughts, or death by suicide. Although there does appear to be a growing body of information, knowledge regarding program impact is limited and improvement undocumented.

Social and emotional well-being (SEWB) is believed to be a common sensemediating factor of suicide and many interventions aim to increase the SEWB of indigenous populations. While suicide rates may be a disturbing indicator of poor SEWB, a sound evidence-based linking SEWB with suicidal outcomes is lacking.

While several interventions within this review made mention of SEWB outcomes (such as depression, psychological distress, anxiety, community connectedness, social cohesion), only one attempted to link it to suicidal ideation. Since SEWB has become the focus of a range of social, population, and mental health policies (see, for example, Australian Government, 2013), building a knowledge base of links between SEWB and suicidal outcomes will simultaneously contribute to our evidence base and may aid in obtaining funding for program expansions. Should SEWB be found to be a mediating or protective factor, it raises the possibility of its use in measuring the impact of interventions.

Recommendations and Improvements To increase our knowledge base of program impact it is imperative that programs measure outcomes. Given the low base rate for suicide and considering rates may take many years to shift, alternative

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AUSTRALIAN ABORIGINAL SUICIDE PREVENTION: A REVIEW

outcome measures are required. Within the general population, 60% of transitions from ideation to plan and attempt occur within the first year after ideation onset (Nock et al., 2008). Therefore, suicidal ideation may be a viable outcome measure, along with suicidal attempts and self-harm, as all are strongly predictive of suicide completion (Christiansen & Jensen, 2007; Tidemalm, L! angstrâ‚Ź om, Lichtenstein, & Runeson, 2008).

It should be noted, however, that the trajectory from ideation to suicide may not necessarily hold for indigenous experiences and further research is needed to determine whether findings from non-indigenous populations similarly apply to indigenous groups. The challenges of utilizing suicide and self-harm rates as outcomes within indigenous populations has prompted some to investigate alternate outcomes. Based on the work by Chandler and Lalonde (2009) and colleagues (Chandler, Lalonde, Sokol, Hallett, & Marcia, 2003) demonstrating clear links between social control factors and completed suicides, Hunter (2013) has argued that prevalence of psychosis may help to unpack vulnerability to suicide as a function of developmental and environmental factors.

Summary and Future Directions Many studies included within this review lacked systematic outcome evaluations, thus a limitation of this article is that no conclusive recommendations can be made. However, by combining the limited evidence base with results from overseas research, some promising avenues are suggested.

Overseas evaluations of indigenous suicide prevention efforts (Middlebrook et al., 2001) indicate that communities who wholly initiate, back, and run their programs have lower suicide rates. This suggests that Australian indigenous suicide prevention efforts must be community generated and garner community approval. Any implementation or evaluation of prevention efforts must be done so in partnership with

local members (Dudgeon et al., 2012). To foster true partnerships, researchers must empower individuals involved in program development by helping them to work toward principles of best practice in both process and outcome evaluative efforts.

The lack of formally documented and easily accessed suicide prevention efforts, particularly for remote communities, likely means that communities at large are uninformed about what is occurring in other communities. This may be exacerbated by programs that are implemented at present but without any accompanying documentation. Several projects (e.g., Building Bridges) have attempted to encourage lateral knowledge sharing between communities, a process vital in empowering communities to help each other (Chandler & Lalonde, 1998).

Communities in which suicide rates are low are especially likely to possess knowledge of potential benefit to other communities, and can work together to develop strategies, share or optimize limited resources, and monitor the impact of interventions. For those communities who may not necessarily be aware of the factors behind their low suicide rates, partnerships with researchers may help to unlock this knowledge.

As we are far from understanding what strategies work, for whom, and when, sound evaluations within this high-risk group are necessary. While randomized controlled trials are not always possible or ethical in suicide research, alternatives such as multiple baseline approaches may be used (Hawkins, Sanson-Fisher, Shakeshaft, D’Este, & Green, 2007). These have the advantage of requiring as few as two groups, and the added benefit of the community acting as their own control group.

Other culturally appropriate research methods include feedback from discussion groups, surveys/questionnaires, observation, and face-to-face interviews (Elliott-Farrelly, 2005). Researcher partnership with communities will ensure that evaluative efforts conducted within this field will allow us to move to a judicious evidence-based understanding of what works.

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A strategic approach targeting indigenous suicide prevention has only recently been employed (Australian Government, 2013). This provides a framework detailing the multipronged approach of prevention efforts. Recommended intervention target areas are similar to those proposed by Grant (2011), who argues that suicide prevention in indigenous communities is about reducing family violence, restricting access to means, educating youth, rebuilding language and culture, providing accessible employment, parenting education, affordable hous-

139 ing, and effective mental health systems.

Many of the reviewed prevention efforts included several of these areas within their content delivery; however, systemic, rather than individual change, may be the biggest challenge facing these communities. Piecemeal and ad hoc approaches are unlikely to be effective and near impossible to evaluate.

Perhaps the challenge moving forward will be to determine how we can coordinate intervention efforts so that they not only have an effect, but they also demonstrate it.

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Suicides, Australia, 2010. Retrieved from http:// www.abs.gov.au/ausstats/abs@.nsf/Latestproducts/ 3309.0Main%20Features12010?opendocument& tabname=Summary&prodno=3309.0&issue=2010 &num=&view Australian Government. (2012). A contributing life: The 2012 national report card on mental health and suicide prevention. Sydney, NSW: National Mental Health Commission.

Australian Government. (2013). National aboriginal and Torres Strait islander suicide prevention strategy. Canberra, ACT: Department of Health and Ageing.

BARNETT, L., KENDALL, E., MCKAY, K., MCINTYRE, M., KOLVES, K., & DE LEO, D. (2010). Suicidal behaviours in indigenous communities in Queensland: Evaluation and development of baseline data. Queensland: Griffith University.

CHANDLER, M., & LALONDE, C. (1998).

Cultural continuity as a hedge against suicide in Canada’s First Nations. Transcultural Psychiatry, 35(2), 191–219.

CHANDLER, M., & LALONDE, C. (2009).

Cultural continuity as a moderator of suicide risk among Canada’s First Nations. In L. J. Kirmayer & G. G. Valaskakis (Eds.), Healing traditions: The mental health of Aboriginal peoples in Canada (pp.

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Manuscript Received: May 2, 2014 Revision Accepted: May 15, 2014