the contexts and causes of suicide among indigenous ... · major public health concern in both the...
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ThecontextsandcausesofsuicideamongAboriginalandTorresStraitIslanderpeopleProfessorPatDudgeonandChrisHolland
1. IntroductionWithinaweekoftheNovember2016launchoftheAboriginalandTorresStraitIslanderSuicidePreventionEvaluationProject’s(ATSISPEP)SolutionsThatWorkreport,theWesternAustralianParliamentaryEducationandHealthStandingCommitteereleaseditsLearningsFromtheMessageStickreportonAboriginalyouthsuicideinWAremoteareas.1
TheWAreportcontainedachaptertitledAboriginalSuicideIsDifferent,areferencetothetitleofthe1999TatzstudyonAboriginalyouthsuicide.2ThebookendingofalmosttwodecadesofinvestigationbyreportsthatemphasisethedifferenceinAboriginalandTorresStraitIslandersuicidecomparedtoothersuicideswassignificant.
Thattherearedifferencesisimportanttorecognise.Mostobviousare:
• Thedifferencesinmethods.A2016analysisof102AboriginalandTorresStraitIslander
suicidesintheKimberleybetween2005and2014foundthathanging(asphyxiationbyligature,notusuallyinvolvingthebreakingoftheneck)wasthemethodusedin93percentofcases.3
A2011studyof478AboriginalandTorresStraitIslandersuicidesandacomparator8425non-IndigenoussuicidesinQueenslandover1994and2006,includingbyanalysisofcoronialinquestreportsand‘psychologicalautopsies’4(hereon‘2011Queenslandstudy’)isaparticularlyusefulsourceofdataaboutAboriginalandTorresStraitIslandersuicideandwillbereferredtoagaininthispaper.Thisreportedhangingtobethemethodinaround90percentofAboriginalandTorresStraitIslandercases,farhigherthaninthenon-Indigenouspopulationwhere,nonetheless,hangingwasthemostusedmethodofsuicide(about40percentofcases).5Therewasalsosignificantcontrasttothemuchgreatervarietymethodsofsuicideobservedinthenon-Indigenousgroup.6
Suicideisabehaviouroraction,notadistinctpsychiatricdisorder.Likeanybehaviour,itresultsfromtheinteractionofmanydifferentpersonal,historical,andcontextualfactors.Suicidemaybe
associatedwithawiderangeofpersonalandsocialproblems,andhavemanydifferentcontributingcausesinanyindividualinstance.Infact,suicideisonlyoneindexofthehealthandwellbeingofa
population,anditisimportanttoviewsuicideinthelargercontextofpsychologicalandsocialhealth,andwellbeing.Suicideisnevertheresultofasinglecause,butarisesfromacomplexwebof
interactingpersonalandsocialcircumstances.
ExcerptfromtheExecutiveSummaryof:KirmayerL,BrassG,HoltonT,etal.(2007).SuicideAmongAboriginalPeopleinCanada,AboriginalHealingFoundation,Canada.
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• ThedifferenceandrapidincreaseintheratesofsuicidereportedbetweentheAboriginalandTorresStraitIslanderandnon-Indigenouspopulation.Amongtheformer,suicideisarelativelyrecentphenomenonwithfewprecedentspriortothe1960s.7Yetfiftyyearslater,theAboriginalandTorresStraitIslandersuiciderateistwicethatofnon-Indigenouspeople.8
• Thedifferencesinagegroupswhoareattemptingandcompletingsuicides.Suicideisa
majorpublichealthconcerninboththeAboriginalandTorresStraitIslanderandnon-Indigenouspopulations. Overallin2015,suicidewastheleadingcauseofdeathamongallpeople15-44yearsofage,andthesecondleadingcauseofdeathamongthose45-54yearsofage.9 ButthepeakageofAboriginalandTorresStraitIslandersuicideis30-34yearsformalesand20-24yearsforfemales;10 andthisisthreetimestheratefornon-Indigenouspeopleofthesameages.11Incontrast,thehighestproportionofsuicidedeathsofnon-Indigenousmalesoccursamongthose40-44yearsofage,whileforfemalesitisthe45-49yearagegroup.12
Further,whenconsideringthesuicidedeathsofallAustraliansunder18years,AboriginalandTorresStraitIslanderpeopleaccountedfor30percentofdeathsover2007-2011despitecomprisingonlythreetofourpercentofthetotalagegrouppopulation.13AboriginalandTorresStraitIslander15-24yearoldsareoverfivetimesaslikelytosuicideastheirnon-Indigenouspeers.14
However, the focuses of this paper are, first, the underlying historical, culturalpolitical,socialandeconomiccontextofthesituationofAboriginalandTorresStraitIslanderpeopleincontemporaryAustraliathatcontributetomanyoftheabovedifferences.Thesemanifestmostobviouslyatthecommunitylevel.ThesecondfocusisthecausesoreventsassociatedwiththesuicideofAboriginalandTorresStraitIslanderindividuals.Inrelationtothesefactors,muchoftheliteratureonsuicideinthegeneralpopulationisrelevanttotheexperienceofAboriginalandTorresStraitIslanderpeoples.Butaswillbediscussed,theunderlyinghistorical,culturalpolitical,socialandeconomiccontextisnot,inpractice,separablefromthesecausesoreventsandthatcontributetotheotherpatternsofdifferencediscussedabove.
ThispapercomprisesfouroverlappingpartsthatconsiderthefollowingcontextualandcausalfactorsthatcontributetosuicideamongAboriginalandTorresStraitIslanderpeoples:
• Part1considersthehistoryofcolonisationandthesubsequentinteractionsofAboriginal
andTorresStraitIslanderpeopleswiththesocialandpoliticalinstitutionsofAustraliansocietythathavenegativelyimpactedonAboriginalandTorresStraitIslandercommunitylifeand,inturn,keypopulation-levelprotectivefactorsagainstsuicide.
• Part2,relatedtotheabove,considersthespecificriskfactorsthatariseinimpacted
communitieswithspecificrisksattheindividuallevel–thisincludesalcoholanddruguse,impulsivityandchildneglectandabuse.
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• InPart3,thecumulativeimpactofstressorsisconsidered,andalsotheevidencefortheimpactofspecificstressors:familyandrelationshipbreakdown,acriminalhistory/pendinglegalmattersandunemployment.
• Part4looksatmentalhealthandtheaccessibilityoftheAustralianmentalhealthand
suicidepreventionservicestoAboriginalandTorresStraitIslanderpeopleatriskofsuicide.
Fromthestarthowever,itshouldbeunderstoodthatthispaper’sfour-partstructureisanartificialconstruct,designedtoteaseoutthecomplexandinter-connectedcontextsandcausesofsuicideforanalysis.Inpractice,allorsomeinvariouscombinationsandwithvaryingemphasismightcontributetothesuicideofAboriginalandTorresStraitIslanderindividual.
Part1–ColonisationandCommunity
Thebroadcontextoftoday’shighAboriginalandTorresStraitIslandersuicideratesisthetraumaticdisruptingeffectofcolonisationanditsaftermathoncommunities.Itisnoteworthythatpriortothe1950sand1960stherearefewifanyreportsofAboriginalandTorresStraitIslandersuicide.15Itsemergenceasapopulationhealthissuehasbeenconnected,inparticular,totheclosingofreserves,andtheendofformallegallyencodedracialdiscrimination.
Sowhywouldthisresultinincreasedsuicide?First,becauseinpracticetheliftingoflegaldiscriminationwasnotenoughtoredressthedeeppovertyandlackofevenbasichealthandassociatedservicesthatcharacterisedlifeonthereserves.Inshort,AboriginalandTorresStraitIslanderremainedsociallyexcludedfromthebenefitsofpolitical,socialandeconomiclife16(asdiscussedinPart2).Second,becausethisenabledAboriginalandTorresStraitIslanderpeoplestoaccessbothwelfareandalcoholwithoutrestriction.HunterandMilroy(2006)contendthisledtowidespreaddysfunctioninmanycommunitiesleadingtoaperiodof‘normativeinstability’compoundedbyalcoholabuse.17 Theyalsoexplaintheunderlyingpsychologicalprocessesthroughwhichbroaderhistorical,socio-economicandcommunityfactorsmaybecomeinternalised,arguingthatAboriginalandTorresStraitIslanderself-destructivebehavioursreflectvulnerabilitystemmingfrominternalstatesinformedbybothindividualexperienceandcollectivecircumstance.18
ParticularlyinfluentialinexplainingtherelationshipbetweenthecollectivefunctioningofIndigenouscommunitiesandsuicideratesinthemaretwostudiesbyChandlerandLalondeamongBritishColumbian(Canadian)FirstNations’youngpeople.Thesefocusedoncommunity-levelprotectivefactorsagainstsuicidalbehaviours:inparticularcommunityempowermentandculturalcontinuityas,inpractice,inseparableprotectivefactors.19Intheirfirststudy(1987–1992)culturalcontinuitywasdefinedaccordingtosixkey
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interconnectingindicatorsofself-governanceandculturalmaintenance:• achievementofameasureofself-government;• havelitigatedforAboriginaltitletotraditionallands;• accomplishedameasureoflocalcontroloverhealth;• accomplishedameasureoflocalcontrolovereducation;• accomplishedameasureoflocalcontroloverpolicingservices;and• hadcreatedcommunityfacilitiesforthepreservationofculture.20
Inthisstudy,ChandlerandLalondemappedsuicidesinall197communitiesor‘bands’inBritish ColumbiaandfoundthatcommunitiesthatachievedallsixmarkershadnocasesofsuicideamongyoungFirstNationspeople.Conversely,wherecommunitiesachievednoneoftheseprotectivemarkers,youthsuicideratesweremanytimesthenationalaverage.21Asecondstudy(1993–2000)includedtwootherindicatorsandfoundsimilarresultstothoseofthefirststudy.Theadditionalindicatorswere:
• ameasureoflocalcontroloverchildwelfareservices;and• thattheyarecharacterisedbyhavingelectedbandcouncilscomposedofmorethan50
percentwomen.22CommunityempowermentandculturalcontinuityarenowconsideredinanAustraliancontext.
CommunityEmpowerment
InAustralia,colonisationrequiredtheexerciseofallformsofstatepowertocontrolthelivesofAboriginalandTorresStraitIslanderpeoplescombinedwithamassiveinfluxofnon-indigenouspeople.Today,AboriginalandTorresStraitIslanderpeoplescompriseathreepercentminoritywithinAustralia,withconcurrentlimitedpoliticalpower.23Therighttoself-determinationofIndigenouspeoples(includingAboriginalandTorresStraitIslanderpeoples)inpost-colonialsettingsisbroadlyunderstoodastherighttoself-governance.
Thishasbeenformallyrecognisedinthe2007UNDeclarationontheRightsofIndigenousPeoples,supportedbyAustraliain2009.24AboriginalCommunityControlledHealthServicesareemblematicoftheexerciseoftheaboverightwithinthehealthsystem,buttheconsistentapplicationoftheself-determinationprincipleintheoverarchingpoliticalandpolicy-developmentspaces,whichinvolvestheAustralianstatesharingpowerwith
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AboriginalandTorresStraitIslanderpeoplesindecision-makingthatimpactsuponthem,iscontested.25Atthecommunitylevel,thedisempowermentexperiencedatthenationallevelisoftenreflected.AsdiscussedbyTseyetal(2012),governancerefersto‘evolvingprocesses,relationships,institutionsandstructuresbywhichagroupofpeople,communityorsocietyorganisethemselvescollectivelytoachievethingsthatmattertothem.’26InAboriginalandTorresStraitIslandersettings,eachcommunityisdifferentandgoodgovernanceisdefinedbyculturallybasedvaluesandnormativecodesaboutwhatis‘therightway’togetthingsdoneintermsoflegitimacy,leadership,power,resourcesandaccountability.27Incontrast,poorgovernanceisidentifiedbyfactorssuchascorruption,favouritism,nepotism,apathy,neglect,redtapeandself-servingpoliticalleadersandpublicofficials.28DataonAboriginalandTorresStraitIslanderpeoples’experienceofcommunityandcommunitygovernancehasonlyjuststartedtobecollected.The2014–15AustralianBureauofStatistics(ABS)NationalAboriginalandTorresStraitIslanderSocialSurvey(NATSISS)reportedthatinremoteareas,onlyabouthalfofrespondentsfelttheirlocalcommunityhadstrongleadership.29Onlyone-quarter(26percent)reportedtheycouldhaveasaywithintheircommunityonimportantissues,allormostofthetime,while51percentfelttheycouldhaveasaywithintheircommunityalittleornoneofthetime.30Sixteenpercentofrespondentsfeltthattheircommunitywasaworseplacetoliveatthetimeofthesurveythanitwas12-monthspriortothesurvey.31
EmpowermentatboththeindividualandcommunitylevelhasbeencentraltoeffortstoreduceAboriginalandTorresStraitIslandersuicidetodate.Inparticular,theongoingNationalEmpowermentProject(NEP)thataimstoempowercommunitiesbyeducationinidentifyingandaddressingchallenges(includingthoseassociatedwithsuicide)andsupportingtheircapacityforself-governanceandorganisationtoaddressthosechallenges.32CulturalContinuityCulturalcontinuityisanimportantconceptinIndigenoussuicidepreventioninpartbecauseinherentintheconceptisthatyoungpeoplehaveasenseoftheirpastandtheirculturesanddrawprideandidentityfromthem.Byextension,youngpeoplealsoconceiveofthemselvesashavingafuture(asbearersofthatculture).33
WithreferencetotheAboriginalandTorresStraitIslandersocialandemotionalwellbeingconcept,culturallydefinedfamilyandkinrelationships;communityrelationships;theroleofElders,culturalpractice;connectiontocountry;andspiritualityandancestorsareconsideredaselementsofculturalcontinuityandthus–itcanbeextrapolated-protectivefactorsagainstsuicide.34[Thesocialandemotionalwellbeingconceptisotherwiseassumedknowledgeinthereader.]
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Assuchitisofconcernthatthereisevidencefor‘disconnection’fromtheseprotectivefactorsbeingexperiencedbyasignificantminorityofAboriginalandTorresStraitIslanderpeoplesbothincommunitysettingsandotherwise.Noteworthyisthat:• Socialcontact/communitysupport.TheNATSISS2014–15reportedthatabout17per
centofrespondents,frombothnon-remoteandremoteareas,didnothaveweeklyface-to-facecontactwithfamilyorfriendslivingoutsidetheirhousehold.35Further,thatabouteightpercentofrespondentssaidtheywereunabletogetsupportfromoutsidetheirhouseholdinatimeofcrisis.36
• Familyandfriends.TheNATSISS2014–15reportedabout18percentofoverall
respondentssaidtheywereunabletoconfideinfamilyorfriendslivingoutsidetheirhousehold:13percentofremotelivingpeopleand35percentofnon-remotelivingpeople.37
• Removalfromfamily.In2012-2013intheABSAustralianAboriginalandTorresStrait
IslanderHealthSurvey,justoverhalf(54percent)ofrespondentsaged15yearsandoverreportedthattheyand/orarelativehadbeenremovedfromtheirnaturalfamily.Thosewhowereremovedfromtheirfamilyweremorelikelytohavehighlevelsofpsychologicaldistress(35percent)thanthoseneveraffectedbyfamilyremovals(26percent).38
• InfluenceofElders.TheNATSISS2014–15reportedabouthalfofAboriginalandTorres
StraitIslanderchildrenaged4–14yearswerenotincontactwithaleaderorelderonweeklybasis.Thecorrespondingproportionsinnon-remoteareaswereaboutthreequartersofchildrenaged4-14.39Onlyabouthalfofadultrespondentsagreedthatleadersinthecommunityhadtimetolistenandgiveadvice(52percent).40
Inrelationtothelatterpoint,Niezen’saccountofasuicideclusterinCanadianInuitcommunitiesrecognisedtheprotectiveandlifeaffirmingfunctionwhich‘culturalcontinuity’playsinstrengtheningyoungpeople’sself-identityandsenseofconnectednesswithfamilyandcommunity. Inparticular,heobservedthatpatternsofincreasinglyself-destructivebehaviourinyoungpeopleappearedtobemoreprevalentinthosecommunitieswheretherewasadisengagementofyoungpeoplefromoldergenerationsandtheabsenceofalmostanyopportunitiesforproductiveandcreativeactivity.41
Niezenobservedthatyoungpeopleincommunitieswhereindividualandcommunityidentitiesarefragile,andwheretheyarecutofffromthepositiveexampleandsocialpersuasionofoldergenerations,arelikelytogravitatetoapeergroupofsimilarlydisconnectedyouth.42Tatz’s(1999)studydiscussedthesenseofhopelessnessamongAboriginalandTorresStraitIslanderyoungmenheconsideredtobeatriskofsuicideandsuggestedasimilarpatternofdisconnectionfromguidance.43Already,inAustralia,theNEPplacesastrongemphasisonleveragingculturalstrengths,involvingEldersandsupportingacommunity’sculturalrenewalonitsowntermsasamajorpartofitsworkwithincommunities.44
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Whiletheimplicationsofculturalcontinuityasaconceptareyettobefullyexplored,includingtheirapplicationinAboriginalandTorresStraitIslandersettings,andinurbansettings,supportforculturalcontinuityisahighlyproductivelineofpolicydevelopmentinrelationtosuicideprevention(andmorebroadly,AboriginalandTorresStraitIslanderpeoples’mentalhealthandsocialandemotionalwellbeing)basedonculturalmaintenanceand,wherenecessary,reclamation.
SocialexclusionPartoftheaftermathofcolonisationisinterpersonalandotherformsofracismanddiscriminationandtherelatedconceptofsocialexclusionthatcontributetothebroadercontextofhighAboriginalandTorresStraitIslandersuiciderates.The‘sociallyincluded’havebeendefinedashavingtheresources,opportunitiesandcapabilitiestheyneedto:• Learn(participateineducationandtraining);• Work(participateinemployment,unpaidorvoluntaryworkincludingfamilyandcarer
responsibilities);• Engage(connectwithpeople,uselocalservicesandparticipateinlocal,cultural,civic
andrecreationalactivities);and• Haveavoice(influencedecisionsthataffectthem).45
Incontrast,socialexclusionisapositionofcollectiveorindividualpowerlessnessthatcanresultfromacombinationoflinkedproblemssuchasunemployment,discrimination,poorskills,lowincomes,poorhousing,highcrime,badhealthandfamilybreakdown.46
SocialinclusionconsideredasempowermentfollowstheexampleofAmartyaSenwhodefinespovertyintermsoflowcapabilitiesandfunctionings.Senarguesthatpovertyensueswhenindividualsorcollectiveslackcertainminimumcapabilities.Lowcapabilitiescantranslateintooutcomessuchasinadequateincomesoreducation,poorhealth,lowself-confidence,andultimatelyapersonalorcollectivesenseofpowerlessnessorhelplessness.47
In2013,theProductivityCommissionclassifiedAustralianpopulationgroupsusingaSocialExclusionMonitor.Thiscomprised29indicatorsacrosssevenkeylifedomainsincludingthosethatrelatedtopersonalpower:includingaccesstomaterialresources,employment,educationandskills,andhealthanddisability,toassesstheir‘deepandpersistentdisadvantage.’48
BetweenfiveandsixpercentofAustraliansenterincomepovertyinanygivenyear,andasimilarproportionexit.49Buttheriskofapersonremainingpersistentlyindisadvantageincreaseswithitsduration.Forexample,onaveragethelikelihoodofapersonexitingincomepovertywhohadexperiencedpovertyforsixormoreyears(inthepreviousnineyears)isaroundtwothirdslessthansomeonewhohadexperiencedincomepovertyforoneortwoyears.Notsurprisingly,employmentisacatalystformovingoutofdisadvantage.50
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TheProductivityCommissionassessedthatpeopleathighestriskofexperiencingdeeperormultipleformsofdisadvantagein2010includednotonlyAboriginalandTorresStraitIslanderpeopleassuch,butalsopopulationgroupsamongwhomAboriginalandTorresStraitIslanderpeopleareover-representedwhencomparedtonon-Indigenouspeople:thosewhoaredependentonincomesupport,thoselivinginpublichousing,unemployedpeople,peoplewithalong-termhealthconditionordisability,loneparents andpeoplewithloweducationalattainment.51
ForAboriginalandTorresStraitIslanderpeopleperseitwasassessedthatoverall10.8percentofthepopulationwereinastateofdeepandpersistentsocialexclusionbetween2001and2010.Attheendofthatdecade,in2010,9.1percentofAboriginalandTorresStraitIslanderpeopleswereestimatedremaininthatstate,52comparedtoapproximatelyfivepercentinthegeneralpopulation.53Thisrepresentsareductionofonly1.7percentoverthedecade.
Notonlydocommunity-wideissues(forexample,alcoholanddruguse)involveindividuals,butasdiscussedaboveandasHunterandMilroypropose,collectiveself-perceptionscanbeinternalisedbyyoungAboriginalandTorresStraitIslanderpeopleandprovideacontextforspecificriskbehavioursandotherfactorsassociatedwithsuicide.
Inpractice,thelinebetweencommunitylevelcontributorstosuicideandfactorsassociatedwithindividualsuicidescanbehard,ifnotimpossible,todrawwithanysenseofprecision.Indeed,socialexclusionprovidesacontextformanyoftheindividualriskfactorsandcausesdiscussedinParts2and3below.
Part2:Individualriskfactors
Alcoholanddruguse
The2011Queenslandstudyexaminedtoxicologyreportsfor216AboriginalandTorresStraitIslanderandabout3600non-Indigenoussuicidecasesfortheperiod1998–2006.54Thecommonestprescriptionmedicationfoundin7.4percentofAboriginalandTorresStraitIslandersuicidecaseswerebenzodiazepines55:withsedative,sleep-inducingandmuscle-relaxantproperties.Butcomparedtothedrugbeingreportedin27percentofnon-Indigenouscases,56usageassociatedwithsuicideisrelativelysmall.Likewise,opiates,withpainkillingandrelaxantproperties,werefoundinonly3.2percent ofAboriginalandTorresStraitIslandercasescomparedto16.4percentofnon-Indigenous.57Incontrast,alcoholwaspresentinalmost60percentofAboriginalandTorresStraitIslandersuicidecasesatalcohol-bloodlevelsexceeding0.5mg/100ml(thedrinkdrivinglimit),aboutdoubletherateofthenon-indigenouspersons(about30percentofcases);with25percentofAboriginalandTorresStraitIslandersuicidecaseshavingover0.2mg/100ml(fourtimesthedrinkdrivinglimit)intheirbloodattimeofdeath,comparedtosevenpercentofnon-indigenousdeaths.58
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ThehighalcoholusagefigurecouldindicatethatAboriginalandTorresStraitIslanderpeopleareusingalcoholasapartoftheirmethodofsuicide,inpartperhapsbecauseofloweraccesstoprescriptionmedications,oruseofalcoholovertheirlifetime.Incontrasttothe60percent(justundertwointhree)whosetoxicologyreportsfoundhighalcoholbloodlevelsatthetimeofdeath,so-called‘psychologicalautopsies’revealedthatonlytwoinfivehadareportedhistoryofproblematicdrinking.59Cannabiswaspresentin30percentofAboriginalandTorresStraitIslandersuicidecases;almostdoubletherateofnon-Indigenoussuicidecases.60LearningsFromtheMessageStick,reportedsuicideisthemostcommoncauseofalcohol-relateddeathsamongAboriginalmenandthefourthmostcommoncauseamongstAboriginalwomenincontrasttothenon-Indigenouspopulation.61 Further,itreportedhighlevelsofalcoholanddrugmisusehavealsobeennotedinalmostalldocumentedAboriginalsuicideclusters,withmanyoftheaffectedindividualsbeingeitherintoxicatedorinseverewithdrawal.62Therearetwowaysofinterpretingthisdata.Oneisthatalcoholandcannabisisbeingusedbyasignificantproportion(atleastuptohalf)ofthesecasesaspartofasuicidemethod.63Anotheristhatuseofthesesubstancesmightbecontributingtosuicide,includingthroughloweringprotectivefactorsagainstimpulsivesuicidalbehaviour.LearningsfromtheMessageStickreportedthatimpulsivenessisa‘distinctfeatureofAboriginalsuicidewhichiscommonlylinkedtoexcessivealcoholconsumption’.64Bythis,stressfuleventssuchasrelationalconflictorbreakdown(discussedbelow)maypromptanimpulsivesuicidalreactionundertheinfluenceofalcoholordrugs.65Impulsivity
AsreportedinLearningsfromtheMessageStick,insomecasesanimmediate“precipitating”stressortoasuicideisnotapparent,ormayappeartoberelativelyminor;66orasanacttogainattention.67 Further,thatimpulsivityanditsrelationshiptosuicidalbehaviourisacomplexissuethatcannotbesimplyattributedtoalcoholanddruguse.Itis,forexample,associatedwithFetalAlcoholSyndromeDisorders(FASD)andtraumaasdiscussedbelow.FASDisanumbrellatermtodescribe‘arangeofphysical,cognitive,behaviouralandneurodevelopmentalabnormalitiesthatresultfromtheexposureofafetustoalcoholconsumptionduringpregnancy’.68 ImpulsivenessisalsoacorecomponentofFASD,togetherwithlossofdecision-makingabilityandinabilitytopredicttheoutcomesofone’sactions.69
TheLililwanProjectisastudydesigned,inpart,toestimatetheprevalenceofFASDandassociatedfactorsinanAboriginalcommunity–theFitzroyValleyintheKimberley,WesternAustralia.70 About95percentofAboriginalchildrenbornover2002-2003inthecommunitywereinvolved.71FASorpartialFAS(pFAS)wasdiagnosedin13of108children,aprevalenceof120in1000,or12percent.72PrenatalalcoholexposurewasconfirmedforallchildrenwithFAS/pFASincluding80percentinthefirsttrimesterand50percent
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throughoutpregnancy.73LearningfromtheMessageStickreportcitedexpertswhoconcludedthatFASDwas‘absolutelylinked’withsuicideinKimberleycommunities.74Impulsivityhasalsobeenassociatedwithanindividual’slackofabilitytoself-sootheasaresultofuntreatedtrauma.75Traumaisnotamentalillnessbutreferstoexperiencesandsymptomsassociatedwithparticularlyintensestressfullifeeventsthatoverwhelmaperson’sabilitytocope.Forchildreninparticular,thesecanincludesexualabuse,asdiscussedbelow.WhatlimiteddataisavailablesuggestsrelativelyhighlevelsoftraumaintheAboriginalandTorresStraitIslanderpopulation.Post-TraumaticStressDisorder(PTSD)isonemanifestationoftrauma.A2008studyofAboriginalandTorresStraitIslanderprisonersinQueenslandreported12.1percentofmalesand32.3percentoffemaleswithPTSD.76Familyviolenceandchildabuse,childrenincare
Inhis2014,InvestigationintowaysthatStategovernmentdepartmentsandauthoritiescanpreventorreducesuicidebyyoungpeople,theWAOmbudsmenexaminedthedeathsof36youngpeoplebysuicideorsuspectedsuicideandfoundthat:
• 44percentweresaidtohaveexperiencedfamilyanddomesticviolence • 25percentwererecordedashavingallegedlyexperiencedsexualabuse • 22percentwererecordedashavingallegedlyexperiencedphysicalabuse,and • 33percentwererecordedashavingallegedlyexperiencedoneormoreelementsof
neglectduringtheirchildhood.77 Nationallyin2014-15,themostcommonreasonforsubstantiationforAboriginalandTorresStraitIslanderchildrenaged0–17yearswasneglect(38.3percent)followedbyemotionalabuse(37.7percent).78AsnotedinLearningsfromtheMessageStick:
Whileallformsofabusesignificantlyincreasetheriskofsuicidalideationandsuicideattemptsforyoungpeople,researchsuggeststhatthelinkisstrongestincasesofsexualabuse.Theriskofrepeatedsuicideattemptsisreportedlyeighttimeshigherforyoungpeoplewithasexualabusehistorythanforthosewithout.Ithasbeensuggestedthatsexualabusecouldbespecificallyrelatedtosuicidalbehaviourbecauseitiscloselyassociatedwithfeelingsofshameandinternalattributionsofblame(withoutreferences)79
Likewise,CashmoreandShackel’s(2012)meta-analysisThelong-termeffectsofchildsexualabuse,reportedthatsexualvictimisation,bothinchildhoodandbeyond,isasignificantriskfactorforsuicideattemptsamongbothmenandwomen.80
WhilsttheactualprevalenceofchildsexualassaultbyAboriginalandTorresStraitIslanderchildrenstatusisnotknown,datafromincidentsthatcometotheattentionof,andarerecordedby,policeareavailable.In2015,AboriginalandTorresStraitIslanderchildvictims
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(agedlessthan15years)ofsexualassaultaccountedfor48.4percent(NSW),54.5percent(Queensland),36.4percent(SA)and38.0percent(NT)ofsexualassaultvictimsineachjurisdiction.81LearningsfromtheMessageStickalsonotedthestrongassociationbetweenhighratesofsuicideamongyoungpeopleafterleavingcare.82 ItalsonotedthattheratesofchildprotectionintheKimberleyregionare,liketheratesofsuicideinthatregionextremelyhigh.83Exposuretosuicidalbehaviour
The2011QueenslandstudyreportedthatamongAboriginalandTorresStraitIslandersuicidecases,imitationappearstoplayanelevatedrolewhencomparedtotheevidenceforimitativebehaviorinnon-Indigenouscases.Intheformer,16.7percenthadexperiencedasuicideeventintheirsocialnetwork,comparedto8.8percentofnon-Indigenouscases.84This16.7percentamountedtoasamplegroupof71AboriginalandTorresStraitIslandersuicidedeathswithasuicideintheirsocialnetwork.85Ofthese,almost50percenthadexperiencedthesuicideofadirectrelative,40percentthesuicideofanotherrelativeorafriend,andaboutoneineighthadexperiencedmultiplesuicidesintheirsocialnetwork.86Andamongyoungpeople,therearereportsthatasignificantpercentageofallAboriginalandTorresStraitIslandersuicidesintheNorthernTerritorybetween1996and2005arethoughttohavebeenpartof‘suicideclusters’asaresultof‘copy-cat’behaviours.87Similarly,inthe2001-2002WesternAustralianAboriginalChildHealthSurvey,amongthe16percentof12-17yearoldswhoreportedsuicidalthoughtsrateswereelevatedamongthosewhohadafriendwhohadattemptedsuicide.88
Reasonsfor‘clustering’requirefurtherresearch.However,AboriginalandTorresStraitIslandersuicidesingeneral,andsuicideclustersinparticular,arecharacterisedbythesamechoiceofmethod(hanging,asdiscussedintheIntroduction)andoftenconcentratedingeographicallyisolatedareasasillustratedinDiagram1below.
Diagram1:ThenumbersofAboriginalandTorresStraitIslandersuicidesbypostcode,
2001-12
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AkeypatterninAboriginalandTorresStraitIslandersuicidedeathsinAustraliaistheirconcentrationinremoteareasasillustratedbyATSISPEP’smapofAboriginalandTorresStraitIslandersuicideover2001-12bypostcode.Thedarkerthecolour,themoresuicideshaveoccurred.89Mechanismsimpliedtoincreasetheriskofsuicideimitation(ornormalisation)areconsideredtoinclude:desensitisationofyoungpeopletowardsdeathandsuicide;thevisibilityofsuicidesoccurringinthecommunities;and/orcommunicationaboutthesedeathsviamediaorwordofmouth.90
Copy-catorimitativesuicidalbehaviorisnotuniquetoAboriginalandTorresStraitIslandercommunities.Internationally,ithasbeenestimatedthatbetweenoneandfivepercentofallsuicidesbyyoungpeopleoccurinthecontextofacluster.91WhilemostcommonlydocumentedinAboriginalandTorresStraitIslandercommunitiesinAustralia,itisalsooccurringamongthenon-Indigenouspopulation.92Part3:Specificcausesassociatedwithsuicide
Associatedwithsocialexclusionanddisadvantageisgreaterexposuretostressfullifeevents.ThemostfrequentlyreportedstressfullifeeventsreportedbyAboriginalandTorresStraitIslanderpeoplesinthe2012-2013AATSIHSwere:• deathofafamilymemberorfriend(reportedby37percentofrespondents);• seriousillness(23percent);• inabilitytogetajob(23percent);and• mentalillness(16percent).93
TheseeventsaresharedexperiencesbetweenAboriginalandTorresStraitIslanderpeoplesandthenon-Indigenouspopulation.However,thereisevidenceforAboriginalandTorresStraitIslanderpeoples’greaterandsimultaneousexposuretomultiplestressfulevents.Researchersreportthat1.9–2.6overlappingstressfullifeeventsareassociatedwithmildormoderatepsychologicaldistress,withbetween2.6and3.2eventsassociatedwithhighorveryhighpsychologicaldistress.94 Assuchitissignificantthatin2012–13,30percentofAATSIHSrespondentsover18yearsofagewereassessedwithhavinghighorveryhighpsychologicaldistresslevelsinthefourweeksbeforethesurvey.95Thatis,nearlythreetimesthenon-Indigenousrate.96 Inthesamesurvey,73percentofrespondentsaged15yearsandoverreportedthatthey,theirfamilyorfriendshadexperiencedoneormorestressfullifeeventsinthepreviousyear.97Thatrateis1.4timesthatreportedbynon-Indigenouspeople.98
A2009studyreportedthatthosewithhighandveryhighpsychologicaldistress(measuredbytheKesslerK-10scale)were21and77timesmorelikely,respectively,tobeexperiencingsuicidalideation.99Whenconsideringparticularindividualfactorsassociatedwithsuicide,the2011Queenslandstudy’isparticularlyuseful.Thisreportedthattwo-thirdsoftheentiresample(both
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AboriginalandTorresStraitIslanderandnon-Indigenouscases)hadrecordsofbeingexposedtoatleastonerecentstressfullifeeventpriortosuicide,withnosignificantdifferencesobservedacrossageorgender.
ItreportedthemostcommonstressfullifeeventsfoundtoprecedeanAboriginalandTorresStraitIslandersuicideare:• conflictwithpartners(relationshipconflict)andfamilymembers(familialconflict)or
otherpersons(interpersonalconflict);• pendinglegalmattersandcriminalhistory;and• lossofsignificantpersons(bereavement),withaparticularfocusonexposuretosuicide
inthesocialnetwork.100Therewerealsostrongassociationsnotedbetweensuicideandunemployment.
Relationshipbreakdownanddeathofsignificantpersons
The2011QueenslandStudyreportedthemostfrequenteventsprecedingallsuicidedeathswererelationshipproblems(eitherconflictwithapartnerorrelationshipbreakdown/separation),whichwerereportedin31.1percentofAboriginalandTorresStraitIslanderand29.6percentofnon-Indigenoussuicidecases–roughlythesameproportions.101However,thesecondmostcommonlifeeventreportedinAboriginalandTorresStraitIslandersuicideswereconflicts,eitherwithfamilymembers(familialconflict)orotherpersons,suchasfriends,neighboursandcolleagues(interpersonalconflict).Thiswasatanelevatedratecomparedtothenon-Indigenouspopulation(13.9percentvs.8.2percent).
Relevanttosuicidepreventionandtouchingoncommunityfunctioningis‘lateralviolence,’atermthatdescribesthewayoppressedpeople,covertlyorovertlydirecttheirdissatisfactionsidewaystowardeachother,towardthemselves,andtowardthoselesspowerfulthanthemselves.Itresultsinpeopleturningoneachotherasopposedtothesystemsthatexcludeandoppressthem.102Lateralviolenceisaspectrumofbehavioursthatinclude:gossiping,jealousy,bullying,shaming,socialexclusion,familyfeuding,intra-organisationconflictand,ultimately,physicalviolence.Whilenotnamedassuch,manyelementsoffamilyfeudingcanbeseentoconstitutelateralviolence.LateralviolencewasidentifiedinthereportsoftheNEPasasignificantproblemincommunities.103
The2011Queenslandstudyalsoreportedthatbereavement/lossofasignificantpersonwasmorecommonamongAboriginalandTorresStraitislandersuicidecases(11.5percent),comparedtonon-Indigenouscases(8percent).104Inparticular,11.7percentofAboriginalandTorresStraitislandermaleswerereportedtohavesufferedabereavementcomparedto7.5percentofnon-Indigenousmales.105Inparticular,theage-distributionofAboriginalandTorresStraitislanderandnon-
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Indigenousbereavedpersonswhosuicidedwassignificantlydifferent:about32percentofbereavednon-Indigenoussuicidecaseswereolderthan55years,whileinalmostfourinfiveofbereavedAboriginalandTorresStraitislandercasespersonswereyoungerthan34years.106CriminalhistoryandpendinglegalmattersInJune2015,AboriginalandTorresStraitIslanderpeoplescomprised27percentofallprisoners107despitecomprisingaboutthreepercentofthepopulation.Theage-standardisedimprisonmentratewas13timesgreaterthanfornon-IndigenousAustralians.108
Notoftenconsideredistheimpactthatimprisonmentmighthaveonsuiciderates.Inparticular,apotentialsubjectoffutureresearchisproposedtobethe2011Queenslandstudyreportofacriminalhistoryin32.5percentoftheAboriginalandTorresStraitislandersuicidecases.Thiswasmorethantwicethatrecordedinnon-Indigenouscases(15.8percent).109Pendinglegalissuespriortodeathwerealsoreportedinthe2011QueenslandstudyatelevatedlevelsintheAboriginalandTorresStraitislandersuicidedeathsamplewhencomparedtothenon-Indigenoussample:at11.5percentcomparedto7.5percentrespectivelyoverall,andamongmalesat13.7percentv8.4percentforthenon-Indigenous.110
Almosthalf(about50percent)oftheAboriginalandTorresStraitislandersuicidecasesofmaleswithpendinglegalissueswereofyoungmen–lessthan24yearsofage.Amongthenon-Indigenouscomparatorsample,only17.2percentofdeathswereinthatagegroup.111Unemployment/inabilitytogetajob
The2011QueenslandstudyreportedalmosthalftheAboriginalandTorresStraitsuicidecasesinitssamplewereunemployedatthetimeoftheirdeath,whichwasalmosttwicemorethaninnon-Indigenouscomparatorcases.112 Thismirrorssomewhattheunemploymentrateitself,atleastforAboriginalandTorresStraitIslanderpeopleaged15–24yearswhoareamongatthehighestriskofsuicide:• TheNATSISS2014–15reportedthattheunemploymentrateforAboriginalandTorres
StraitIslanderpeopleaged15yearsandoverwas20.6percent.113 Theratesandtheemployment‘gap’withthenon-Indigenous,werehighestamongAboriginalandTorresStraitIslanderpeopleaged15–24years(31.8percentcomparedwith16.7percentfornon-Indigenouspeople)114
• TheunemploymentratewashigherforAboriginalandTorresStraitIslanderpeopleaged
15yearsandoverinremoteareas(27.4percent)thaninnon-remoteareas(19.3percent).Bycomparison,theAboriginalandTorresStraitIslanderpeopleunemploymentrateinmajorcitieswas14.0percent.ThestateswiththehighestunemploymentrateswereWesternAustralia(26.4percent)andQueensland(25.1percent).115
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Part4:AccesstoservicesaccordingtoneedThefinalpartofthepictureisnotacausepersebutreturnsustothecontextualfactorsthatareassociatedwithAboriginalandTorresStraitIslandersuicideandultimatelyrelatetosocialexclusion.Inparticular,thatanAboriginalandTorresStraitIslanderpersonatriskofsuicideorwithamentalhealthproblemislesslikelytobeabletoaccesstheservicestheyneedthananon-indigenouspersoninthesameposition.Despitethepreviousdiscussionaboutimpulsivenessasariskfactorforsuicide,itisnoteworthythattheevidencesuggestsasignificantnumberofAboriginalandTorresStraitIslandersuicidesarepre-meditatedandinmanycasesthatintenthadbeencommunicatedpriortodeathandthatthesepeopleweretosomedegreeidentifiabletofriends,familyandmentalhealthandsuicidepreventionserviceproviders:
• The2011Queenslandstudyreportedthatofthe478AboriginalandTorresStrait
Islandersuicidesthatwerethesubjectofthestudy,43.3percentinvolvedthepersoncommunicatingsuicidalintentintheirlifetime,with39.1percentcommunicatingintentinthe12monthspriortodeath.Thisincludes25percentofthecaseshavingahistoryofprevioussuicideattempts;16percentintheprevious12-months.116
• Inthe2001-2002WesternAustralianAboriginalChildHealthSurvey,16percentof12-
17yearoldsreportedsuicidalthoughtsand39percentofthesereportedanattemptedsuicide(i.e.about7percentofthetotalsample)duringthe12monthspriortothesurvey.117
• Self-harmcanbeawayofcopingwithstressandakintoa‘cryforhelp,’118butdata
collectionsdonotdistinguishbetweenself-harmforthispurposeandattemptedsuicide.In2014-2015,AboriginalandTorresStraitIslanderpeopleswerehospitalisedforself-harmat2.6timestherateofnon-IndigenousAustralians.119Rateshaveincreasedby55.6percentsince2004-2005.120
• Suicideisalsostronglyassociatedwithdepression.Ingeneralpopulationsuicide
research,peoplewhohavealreadyattemptedsuicideareconsideredtobeatthehighestriskofsuicide(at40xincreasedrisk)thananyotherpopulationgroup.Furtherincreasedriskwasrelatedtotherecencyofapreviousattempt,thefrequencyofpreviousattempts,andisolation.121 Inthe2012–13AATSIHS,12percentofrespondentsreportedfeelingdepressedorhavingdepressionasalong-termcondition;compared9.6percentinthetotalpopulation.122Over2008–2013,depressionwasthemostfrequentlyreportedmentalhealthrelatedproblemmanagedbyGPsamongAboriginalandTorresStraitislanderclients.123The2014–15NATSISSaskedwhetherrespondentswerehappy‘all’,‘most’,‘some’,‘little’or‘none’ofthetime.Nationwide,9.2percentofAboriginalandTorresStraitIslanderpeoplereportedbeinghappylittleornoneofthetime.124
Yetthe2011QueenslandstudyreportedthefollowingevidencethatsuggestssignificantlymoreAboriginalandTorresStraitIslanderpeopleatriskofsuicidearenotaccessingthe
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supportand/orservicestheyneededpriortotheirdeathswhencomparedtonon-Indigenoussuicide:• 20.5percentoftheAboriginalandTorresStraitIslandersuicidecaseshadatleastone
reportedmentalillnessatthetimeofdeath,comparedwith2,514(40.4percent)ofnon-Indigenoussuicidecases;
• 23.3percentofAboriginalandTorresStraitIslandercaseshadreceivedtreatmentfrom
amentalhealthprofessionalintheirlifetime,comparedto42.3percentofnon-Indigenous;
• 10.1%ofAboriginalandTorresStraitIslandercaseswereseenbyamentalhealth
professionalinlastthreemonthspriortosuicide,comparedto25.6percentofnon-Indigenouscases;125
• 1.9%ofAboriginalandTorresStraitIslandercaseshadarecordeduseofanti-psychotics,
comparedto4.4percentofnon-Indigenouscases.126Whileusageisimproving,AboriginalandTorresStraitIslanderpeoplesand- itcanbeextrapolatedparticularlythoseatriskofsuicide-haverelativelylowaccessto/orarechoosingnottousementalhealthservices.
Inthe2012–13AATSIHS,onlyaboutoneinfour(27percent)ofadultswithhigh/veryhighlevelsofpsychologicaldistress,asdiscussedaknownriskfactorforsuicide,hadseenahealthprofessionalinresponseintheprevious4weeks.127128Primarymentalhealthcareisalsoparticularlyimportantfortreatingdepressionandcanbeagatewaytospecialistmentalhealthcareinseverecases.129AsmentalhealthandrelatedproblemsarereportedintheAboriginalandTorresStraitIslanderpopulationattwotothreetimestherateinthegeneralpopulation,twotothreetimestherateofusageofprimarymentalhealthservicesmightbeexpected.
Infact,over2008-2013,11percentofallproblemsmanagedbyGPsamongAboriginalandTorresStraitIslanderclientswerementalhealthrelated:1.3timestherateforotherAustralians.130In2012-2013,8percentofAboriginalandTorresStraitIslanderpeopleaccessedMedicaresubsidisedmentalhealthcareservices,(providedbyconsultantpsychiatrists,clinicalpsychologists,GPsandalliedhealthprofessionals):thesamerateasnon-Indigenouspeople,131despitethegreaterneed.Thereisevidencethatbecauseoflackofaccessto/oruseofprimarymentalhealthcareaccordingtoneed,AboriginalandTorresStraitIslanderpeopleswithmentalhealthproblemsareoverrepresentedinotherpartsofthehealthandmentalhealthsystem.Forcommunitybasedmentalhealthclinics,about9percentofcontactswereprovidedtoIndigenouspeoplesin2013-14:3.3timesthenon-Indigenousrate.132 In2012-13,IAboriginalandTorresStraitIslanderpeopleaccountedforadisproportionate9percentofmentalhealth-relatedEDoccasionsofservice.Theyaccountedfor4.9percentmental
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health-relatedhospitalisationsincludingspecialisedpsychiatriccarein2012-2013;and4.1percentofallepisodesofresidentialmentalhealthcarein2013-2014.133Culturalracismincludesactionsbyinstitutionsthatarenotovertlyracistorbelievethemselvestoberacistbutamountto‘theobservanceandadministrationofpolicies,rulesandproceduresthatpurporttotreateverybodyequally,butareunfairlyorinequitablyadministeredorappliedindealingswithpeoplebelongingtoaparticularracial,ethnic,religiousorculturalgroup’.134Whetherevidenceofculturalracismornot,theNATSISS2014–15reportedthatninepercentofrespondentsagreedthattheirowndoctorcouldnotbetrusted,35percentthathospitalscouldnotbetrusted.135The2012-13ABSNationalAboriginalandTorresStraitIslanderHealthSurvey(NATSIHS),reportedthat35percentofthosewhoreportedbeingtreatedbadlybecausetheywereAboriginaland/orTorresStraitIslanderusuallyrespondedbysubsequentlyavoidingthepersonorsituation.Suchisbackedupbyotherresearch.136AboutsevenpercentofNATSIHSrespondentsreportedthattheyhadavoidedseekinghealthcarebecausetheyhadbeentreatedunfairly.137CriticaltoaddressingculturalracismandimprovingaccesstohealthandmentalhealthservicesisthedevelopmentofAboriginalCommunityControlledHealthServicesandotherdedicated(ifnotcommunitycontrolledhealth)servicesaimedatAboriginalandTorresStraitIslanderpeoples.
YetonlyabouthalfofAboriginalandTorresStraitIslanderpeoplescanaccess/orchoosetousesuch.Atthetimeofthe2011Census,theABSestimatestheIndigenouspopulationtonumber669,900persons.138Intheir2015ServiceReports,the203AustralianGovernmentfundedIndigenousprimaryhealthcareorganisations(IPHCOs)report323,600AboriginalandTorresStraitIslanderpeoplesclients.139ThisincludesAboriginalCommunityControlledHealthOrganisations(ACCHOs)whoidentifyashavingabout255,060AboriginalandTorresStraitIslanderpeoplesclients.140ThissuggeststhatIPHCOshadapproximately48.3percentofthetotalIndigenouspopulationasclients,andwithinthatcohorttheACCHOsabout38percent.StudieshavefoundthatforAboriginalandTorresStraitIslanderpeople‘accesstoserviceiscriticaland,whereACCHOsexist,thecommunitypreferstoanddoesusethem.’141Withappropriateresources,anACCHOisabletoimplementaculturallycompetentandcomprehensiveprimaryhealthcaremodelbasedontheculturallyshaped,holisticconceptsofhealthunderstoodbythecommunitiestheyserve.142 However,inthe2015ServiceReports,ofthe203IPHCOs,includingACCHOs,55percentreportedservicegapsformentalhealthandsocialandemotionalwellbeing;and47percent-alcohol,tobaccoanddrugservicegaps.143
Wheresuchservicesdonotexist,AboriginalandTorresStraitIslanderpeopleareobligedtorelyongeneralpopulationhealthandmentalhealthservices.Assuch,itiscriticalthatsuchservicesareculturallysafeandthatitsstaff,andindeedtheorganisationitself,isculturallycompetenttoworkwithAboriginalandTorresStraitIslanderpeoples.[Theseconceptsareassumedknowledgeinthereader.]
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OneoftheimportantcontributionstheAboriginalandTorresStraitIslanderMentalHealthAdvisoryGroupmadetosuicidepreventionwastodevelopasetofOperationalGuidelinesAccesstoAlliedPsychologicalServicesProgram(ATAPS)AboriginalandTorresStraitIslanderSuicidePreventionServices.144Theseincludedqualityindicatorsforservicesto:
• provideculturallysafe,non-triggeringmanagement,treatmentandsupportto
AboriginalandTorresStraitIslanderpeoplesathighriskofsuicideorself-harmatacriticalpointintheirliveandtomitigatethereverberationsfromsuicideintheclient'scommunity;
• bestaffedbyadministratorsandcliniciansthataretrainedandunderstandmental
healthandsuicidepreventionculturalsafety;• establishmanagementprotocolsthatreflectthemultiplelevelsofdiversityfoundin
modernAboriginalandTorresStraitIslanderpopulations;and• bebasedonAboriginalandTorresStraitIslanderpeoples'definitionsofhealth,
incorporatingspirituality,culture,family,connectiontothelandandwellbeingandgroundedincommunityengagement.145
Theguidelinesestablishthatahighquality,culturallycompetentservicewillbemadeavailablebyensuring:• AboriginalandTorresStraitIslanderpeoplesthatareprovidingservicesshouldhavethe
appropriatelevelofskillsandqualificationstodeliverservices;• AboriginalandTorresStraitIslanderpeoplesandnon-AboriginalandTorresStrait
Islanderpeoplesareprovidedwithopportunitiestodeveloptheappropriatelevelofskillsandqualificationstodeliverservices;and
• non-Indigenousprofessionalsandadministratorshaveundertakenmentalhealth
culturalsafetytrainingthatperpetuatestheNationalPracticeStandardswithinasocialandemotionalwellbeingframework,andpromotestheappropriateskills,knowledge,andattitudesrequiredtooptimallydelivermentalhealthservicestoAboriginalandTorresStraitIslanderpeoples,includingthoseoftheStolenGeneration.146
TheseguidelinesholdgreatpromiseincludingbeyondtheATAPSscheme,whichisnowbeingmergedintothefundingpoolsofthePrimaryHealthNetworks.WhenappliedsuchguidelinescanensureaculturallyappropriateserviceattheverytimewhenavulnerableAboriginaland/orTorresStraitIslanderpersonislikelytoneeditmost.
ConclusionAsthispaperhassetouttodemonstrate,highAboriginalandTorresStraitIslandersuicideratesarisefromacomplexwebofinteractingpersonalandsocialcircumstances.
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Forthoseconcernedwithsuicideprevention,thecontributorstosuicidecanbethoughtofintermsofriskfactorsatthecommunityandcollectivelevelthatincreasethelikelihoodofsuicidalbehaviour,andprotectivefactors(culturalcontinuity,empowerment)thatreduceit.
Further,thatwhilethe‘causes’associatedwithsuicideamongAboriginalandTorresStraitIslanderindividualsareoftenthesameasthatinthegeneralpopulation,theprevalenceandinterrelationshipsamongthesefactorscandifferbecauseofwidercontextualfactors,nottheleastofwhichbeingcolonisationanditsaftermathandtheongoingimpactsoncommunities.
Infact,suicideisjustoneindicatorofdistressincommunitiesandcannotbemeaningfullydiscussedwithoutconsideringalcoholanddruguseandmentalhealthproblems.Allcanbeconsideredsymptomaticoftheneedforhealingatacollectivelevelamongothercultural,historical,andpoliticalconsiderations.
1.LegislativeAssembly,ParliamentofWesternAustralia(2016).Learningsfromthemessagestick,ThereportoftheInquiryintoAboriginalyouthsuicideinremoteareas,LegislativeAssembly.Committees.EducationandHealthStandingCommittee.Report11,ParliamentofWesternAustralia,Perth.
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2 TatzC(1999).AboriginalSuicideisDifferent,AboriginalYouthSuicideinNewSouthWales,theAustralianCapitalTerritoryandNewZealand:TowardsaModelofExplanationandAlleviation,AReporttotheCriminologyResearchCouncilonCRCProject25/96–7.Availableonline:http://crg.aic.gov.au/reports/tatz/tatz.pdf.[Verified12Dec2016.]3 McHughC,CampbellA,ChapmanM,etal.(2016).IncreasingIndigenousself-harmandsuicideintheKimberley:anauditofthe2005–2014data,TheMedicalJournalofAustralia,2016;205(1):33.4 DeLeoD,SveticicJ,MilnerA,etal.(2011).SuicideinindigenouspopulationsofQueensland,AustralianInstituteforSuicideResearchandPreventionNationalCentreofExcellenceinSuicidePreventionandWHOCollaboratingCentreforResearchandTraininginSuicidePrevention,AustralianAcademicPress,Brisbane,pp.32-33.5 Above,p.32.6 Above,p.32.7HunterE,MilroyH(2006).AboriginalandTorresStraitIslanderSuicideinContext,ArchivesinSuicideResearch;2006,10(2):141-157.8SteeringCommitteefortheReviewofGovernmentServiceProvision(2016).OvercomingIndigenousDisadvantage:KeyIndicators2016,ProductivityCommission,Canberra,p.8.42.9AustralianBureauofStatistics(2016).CausesofDeath,Australia,2015,ABScat.no.3303.0.Availableonline:www.abs.gov.au/ausstats/[email protected]/Lookup/by%20Subject/3303.0~2015~Main%20Features~Intentional%20self-harm:%20key%20characteristics~8.[Verified12 Dec2016.]10AustralianHealthMinisters’AdvisoryCouncil(2015).AboriginalandTorresStraitIslanderHealthPerformanceFramework2014Report,AHMAC,Canberra,p.59. 11SteeringCommitteefortheReviewofGovernmentServiceProvision(2016).OvercomingIndigenousDisadvantage:KeyIndicators2016,ProductivityCommission,Canberra,p.8.44.12AustralianBureauofStatistics(2016).CausesofDeath,Australia,Above.13NationalChildren’sCommissioner(2014).Children’s’RightsReport2014,AustralianHumanRightsCommission,Sydney,p.62.14AustralianHealthMinisters’AdvisoryCouncil(2015).Above,p.59.15Hunter,E,Milroy,H(2006).Above.16Above.17Above.18Above.19Above.20 ChandlerM,LalondeC(1998).CulturalContinuityasaHedgeagainstSuicideinCanada’sFirstNations.TransculturalPsychiatry;199835(2):191–219.Chandler,M.J.&Lalonde,C.E.(2008).CulturalContinuityasaProtectiveFactoragainstSuicideinFirstNationsYouth.Horizons--ASpecialIssueonAboriginalYouth,HopeorHeartbreak:AboriginalYouthandCanada’sFuture.10(1),68-72.21Above.22Above.23AustralianBureauofStatistics(2010).EstimatesofAboriginalandTorresStraitIslanderAustralians,June2011,Notes,ABScatno.3238.0.55.001(webpage)http://www.abs.gov.au/AUSSTATS/[email protected]/Lookup/3238.0.55.001Main+Features1June%202011?OpenDocument.[Verified12Dec2016].24UNGeneralAssembly(2007).UnitedNationsDeclarationontheRightsofIndigenousPeoples:resolution/adoptedbytheGeneralAssembly,2October2007,A/RES/61/295.25AustralianHumanRightsCommission(undated).RighttoSelfDetermination,(webpage)<https://www.humanrights.gov.au/right-self-determination>[Verified3March2016].26TseyK,McCalmanJ,BainbridgeR,etal.(2012).ImprovingIndigenouscommunitygovernancethroughstrengtheningIndigenousandgovernmentorganisationalcapacity,ClosingthegapClearinghouse,Resourcesheetno.10,ClosingtheGapClearinghouse,AustralianInstituteofHealthandWelfare,Canberra.27Above.28Above.29AustralianBureauofStatistics(2016).NationalAboriginalandTorresStraitIslanderSocialSurvey,2014-15,ABScat.no.4714.0(webpage)http://www.abs.gov.au/ausstats/[email 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57Above,p.60.58Above,p.57.59Above,p.56.60Above,p.58.61 LegislativeAssembly,ParliamentofWesternAustralia(2016).Above,p.3.35.Referringto:WilkesE.etal.(2014)'HarmfulSubstanceUseandMentalHealth'inP.Dudgeon,H.MilroyandR.Walker(eds.),WorkingTogether:AboriginalandTorresStraitIslanderMentalHealthandWellbeingPrinciplesandPractice,2ndedition,KulungaResearchNetwork,WestPerth,2014,pp129-130. 62Above,p.3.35.Referringto:Silburn,S.,Robinson,G.Leckning,B,etal.(2014).‘PreventingSuicideAmongAboriginalAustralians’inP.Dudgeon,H.MilroyandR.Walker(eds.),WorkingTogether:AboriginalandTorresStraitIslanderMentalHealthandWellbeingPrinciplesandPractice,2ndedition,KulungaResearchNetwork,WestPerth,2014,p.155. 63Above,p.56.64Above,p.3.36.ReferringtoSubmissionNo.17fromLifelineWA,13May2016,p.6. 65Above,p.3.36.Referringto:SubmissionNo.12fromAustralianHumanRightsCommission,13May2016,AttachmentA: Mitchell,M.andGooda,M.,‘SelfHarmandHelp-SeekingAmongAboriginalandTorresStrait 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70FitzpatrickJ,LatimerJ,CarterM,OscarJ,etal(2015).Prevalenceoffetalalcoholsyndromeinapopulation-basedsampleofchildrenlivinginremoteAustralia:TheLililwanProject,JournalofPaediatricsandChildHealth51(2015)450–457.71Above.72Above.73Above.74LegislativeAssembly,ParliamentofWesternAustralia(2016).Above,p.3.38.Referringto:DrMurrayChapman,ClinicalDirector,KimberleyMentalHealthandDrugService,TranscriptofEvidence,7June2016,p.8.75LegislativeAssembly,ParliamentofWesternAustralia(2016).Above,p.3.37.Referringto:DrTracyWesterman,ManagingDirector,IndigenousPsychologicalServices,TranscriptofEvidence,12September2016,p.3. 76HeffernenE,AndersenK,DevA,etal,PrevalenceofmentalillnessamongAboriginalandTorresStraitIslanderpeopleinQueenslandprisons.MedJAust2012;197(1):37-41.77LegislativeAssembly,ParliamentofWesternAustralia(2016).Above,p.3.41.Referringto:OmbudsmanWesternAustralia,InvestigationintowaysthatStategovernmentdepartmentsandauthoritiescanpreventorreducesuicidebyyoungpeople,OmbudsmanWesternAustralia,Perth,April2014,p.14. 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115Above.116DeLeoD,SveticicJ,MilnerA,etal.(2011).Above,p.54.117ZubrickS,SilburnS,LawrenceD,etal.(2005).Above,p.340.118KlonskyE(2006).Thefunctionsofdeliberateself-injury:areviewoftheevidence,ClinPsycholRev.2007Mar;27(2):226-39.Epub2006Oct2.119AustralianHealthMinisters’AdvisoryCouncil(2015).Above,p.59.120SteeringCommitteefortheReviewofGovernmentServiceProvision(2016).Above,p.8.42.121HarrisE,BarracloughB,(1997).‘Suicideasanoutcomeformentaldisorders.Ameta-analysis’,TheBritishJournalofPsychiatryMar1997,170(3)205-228;DOI:10.1192/bjp.170.3.205.(Notethattherewassignificantvariationsbetweencountries).122AustralianInstituteofHealthandWelfare(2015).ThehealthandwelfareofAustralia’sAboriginalandTorresStraitIslanderpeoples2015,Cat.no.IHW147.AustralianInstituteofHealthandWelfare,p.85.123AustralianHealthMinisters’AdvisoryCouncil(2015).Above,p.59.124AustralianBureauofStatistics(2016).NationalAboriginalandTorresStraitIslanderSocialSurvey,2014-15,ABScat.no.4714.0,Table8A.7.19Selectedindicatorsofpositivewellbeing,AboriginalandTorresStraitIslanderpeopleaged18yearsorover,byStateandTerritory,2014-15(a),(b),(c)(webpage)http://www.abs.gov.au/ausstats/[email protected]/Lookup/by%20Subject/4714.0~2014-15~Main%20Features~Social%20networks%20and%20wellbeing~4.[Verified12Dec2016.]125DeLeoD,SveticicJ,MilnerA,etal.(2011).Above,p.52.126Above,p.60.127AustralianHealthMinisters’AdvisoryCouncil(2015).Above,p.148.128Above.129WorldHealthOrganization(2015).‘Depression’(webpage)http://www.who.int/topics/depression/en/[Verified12Dec2016.].130AustralianHealthMinisters’AdvisoryCouncil(2015).Asabove,p.148.131Asabove.132AustralianInstituteofHealthandWelfare,(2015).’Characteristicsofpeoplewhousecommunitymentalhealthcareservices’,MentalHealthServicesinAustralia,https://mhsa.aihw.gov.au/services/community-care/client-characteristics/.[Verified29October2015.]133Asabove.134MarrieA,MarrieH(2014).AMatrixforIdentifying,MeasuringandMonitoringInstitutionalRacismwithinPublicHospitalsandHealthServices,Publishedonline:<http://www.avidstudy.com/wp-content/uploads/2015/08/Matrix-Revised-2-9-14.pdf.[Verified12Dec2016.]135AustralianBureauofStatistics(2016).NationalAboriginalandTorresStraitIslanderSocialSurvey,2014-15,ABScat.no.4714.0,(webpage)http://www.abs.gov.au/ausstats/[email protected]/Lookup/by%20Subject/4714.0~2014-15~Main%20Features~Social%20networks%20and%20wellbeing~4.[Verified12Dec2016.]136AustralianHealthMinisters’AdvisoryCouncil(2015).Asabove.137Asabove.138AustralianBureauofStatistics,EstimatesofAboriginalandTorresStraitIslanderAustralians,June2011,Notes,ABScatno.3238.0.55.001,http://www.abs.gov.au/AUSSTATS/[email protected]/Lookup/3238.0.55.001Main+Features1Junepercent202011?OpenDocument.[Verified12Dec2016.]139AustralianInstituteofHealthandWelfare(2015).AboriginalandTorresStraitIslanderhealthorganisations:OnlineServicesReport—keyresults2013–14.AboriginalandTorresStraitIslanderhealthservicesreportNo.6.IHW152.AustralianInstituteofHealthandWelfare,Canberra,p.24.140Asabove.141PanarettoK,WenitongM,ButtonSandRingI,(2014)‘Aboriginalcommunitycontrolledhealthservices:leadingthewayinprimarycare’,200(11)MedicalJournalofAustralia,200(11)649,p.650.142GeeG,DudgeonP,SchultzC,etal(2014).Asabove.143AustralianInstituteofHealthandWelfare(2015).AboriginalandTorresStraitIslanderhealthorganisations:OnlineServicesReport—keyresults2013–14.Asabove,p53,Table7.2.144DepartmentofHealthandAgeing(2012).OperationalGuidelinesfortheAccesstoAlliedPsychologicalServicesAboriginalandTorresStraitIslanderSuicidePreventionServices(unpublished)DepartmentofHealthandAgeing,Canberra.145Asabove,p.4.146Asabove,p.5.