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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.

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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 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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 ChildrenandYoungPeople’,p.4.66Above,p.3.36.Referringto:SubmissionNo.14fromBeyondBlue,13May2016,p.8. 67Above,p.3.36.Referringto:SubmissionNo.12fromAustralianHumanRightsCommission,13May2016,AttachmentA: Mitchell,M.andGooda,M.,‘SelfHarmandHelp-SeekingAmongAboriginalandTorresStrait ChildrenandYoungPeople’,p.4. 68ClosingtheGapClearinghouse(2014).Fetalalcoholspectrumdisorders:areviewofinterventionsforpreventionandmanagementinIndigenousCommunities.ProducedbytheClosingtheGapClearinghouse.Resourcesheetno.36,AustralianInstituteofHealthandWelfare,Canberra;AustralianInstituteofFamilyStudies,Melbourne.69LegislativeAssembly,ParliamentofWesternAustralia(2016).Above,p.3.38.Referringto:DrMurrayChapman,ClinicalDirector,KimberleyMentalHealthandDrugService,TranscriptofEvidence,7June2016,p.8. 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