Strategic Framework for Suicide Prevention in NSW 2018 ... · beautiful colours of nature are...

From consultations with people, communities and service providers across NSW

Strategic Framework for Suicide Prevention in NSW 2018-2023

Consultation paper – Aboriginal perspectives

Thank you We would like to thank everyone who participated and contributed to the development of this Framework. In particular, we acknowledge the strength, courage and generosity of those who shared their personal stories and journeys with us.

We encourage everyone to have open, safe and honest conversations about suicide and for those in distress to put up their hand and ask for help.

DedicationThis Framework is dedicated to those who have died by suicide, those who have made an attempt on their own life and those who are bereaved by suicide.

Cover image

Waiting for the Sun

Acrylic painting by Owen LyonsOwen Lyons is a Wiradjuri man and was born in Narrandera, southwestern NSW. He is the second youngest in a family of 10 children (five girls and five boys) to a shire council labourer and a stay at home mum. Owen is married to Shay, and they have three children - Brooke, Josh and Lexi. Mental illness has had a great effect on Owen and his family. After a family member’s battle with mental illness, Owen hoped that by creating this painting he could help to raise awareness about suicide prevention.

Owen has been involved in Aboriginal art for most of his life, learning his craftsmanship and artwork early on from his father, and in later years his elder brother Michael. Like many other artists from this area in Wiradjuri country, Owen’s style has been derived from Michael’s. Owen has only to step outside his front door to get inspiration from his surroundings. The river is just down the road, wildlife abounds and the beautiful colours of nature are everywhere. Owen paints a variety of landscapes, animals and symbols, using the dotting method.

“Waiting for the Sun” tells the story of a person emerging from a dark place and being connected back into their community. The scar tree shows that even though it has been scarred, it still stands strong and proud with deep roots connected to its country.

The painting also illustrates pathways to services and supports available to help people get back on track. It shows people that there really can be a brighter future. You just need to ask for help. There’s no shame in that. Most importantly, there are people in our communities who do care about mental health and suicide prevention. We will work with these beautiful people to help others return to fulfilling lives.

Mental Health Commission of NSW (2020). Consultation paper – Aboriginal perspectives

© State of NSW 2020 ISBN: 978-0-6488428-1-1

nswmentalhealthcommission.com.au

ContentsOverview ................................................................................................. 2Purpose ................................................................................................................................................. 3

Context .................................................................................................................................................. 3

Audience ................................................................................................................................................ 3

Approach ............................................................................................................................................... 3

Language ............................................................................................................................................... 3

What we heard: At a glance ..................................................................... 4Inclusion of people with lived experience ............................................................................................. 5

Building community resilience and wellbeing ....................................................................................... 5

Supporting excellence in clinical services ............................................................................................. 5

Enhancing coordination and integration ............................................................................................... 5

Enhancing capacity to respond to suicide ............................................................................................. 5

Supporting and promoting evidence-based practice ............................................................................ 5

Summary: Feedback on what is working well and areas for improvement ..................................................................... 6

What we heard: In detail.......................................................................... 9Inclusion of people with lived experience ........................................................................................... 10

Building community resilience and wellbeing ..................................................................................... 11

Supporting excellence in clinical services ........................................................................................... 13

Enhancing coordination and integration ............................................................................................. 14

Enhancing capacity to respond to suicide ........................................................................................... 16

Supporting and promoting evidence-based practice .......................................................................... 18

Appendix 1: About suicide and Aboriginal communities ........................ 19Risk factors .......................................................................................................................................... 20

Protective factors ................................................................................................................................ 21

Cultural safety ..................................................................................................................................... 21

Limited evidence about Aboriginal suicide prevention ....................................................................... 22

Common elements for successful approaches .................................................................................... 22

Continuum of care and support needed to prevent Aboriginal suicide .............................................. 23

Appendix 2: The consulation process ..................................................... 24

1Strategic Framework for Suicide Prevention in NSW 2018-2023

Contents

Overview

2Consultation paper – Aboriginal perspectives Overview

Purpose This report records the experiences and insights of Aboriginal people with a lived experience of attempted suicide, those who have been bereaved by suicide and those people who are concerned about or working to prevent suicide in their communities.

The Mental Health Commission of NSW gratefully acknowledges the honesty, openness and courage of all those who contributed to the consultation process. It is only through listening to these community and service-level stories and experiences that better outcomes can be achieved.

Context In 2018, the Minister for Mental Health tasked the Mental Health Commission of NSW with developing a framework for suicide prevention in NSW in partnership with the NSW Ministry of Health. The Strategic Framework for Suicide Prevention in NSW 2018-2023 (the Framework) was launched on 17 October 2018 by the Honourable Gladys Berejiklian, Premier of NSW. View the Framework on the Commission’s website.

In developing the Framework, over 1,500 people participated in a series of consultations held in communities across NSW between March and July 2018. Aboriginal consultations were held in Wollongong, Lismore, Dubbo and Wagga Wagga. Aboriginal people also participated in the general community and stakeholder consultations that took place in Taree, Port Macquarie, Cootamundra, South Western and Northern Sydney. Targeted consultations were also held with other population groups known to be at greater risk of suicide, including young people, LGBTIQ+ people and people living in rural and remote areas. See page 34 for more information on the consultation program.

AudienceAboriginal people from across NSW, service providers and the broader community contributed to the material in this report. We hope they will see their views and experiences reflected here.

There are many people and organisations that support the social and emotional wellbeing of Aboriginal people in NSW. This report provides a snapshot of Aboriginal experiences of suicide and trauma, as told by those with lived experience. Service providers, clinicians, advocates, planners and policy makers may also find this report useful for their work.

Approach Six guiding principles were developed by the NSW Suicide Prevention Advisory Group to guide the development of the Framework and the consultation process. They are:

• inclusion of people with lived experience• building community resilience and wellbeing• supporting excellence in clinical services• enhancing coordination and integration• enhancing capacity to respond to suicide• supporting and promoting evidence-based practice.

This report presents Aboriginal people’s views of what is working and what challenges and gaps exist in suicide prevention, as measured against these principles.

Language This report uses the terms ‘Aboriginal’ and ‘Aboriginal peoples’ to refer to the traditional owners of the land in NSW, in line with Communicating Positively – A Guide to Appropriate Aboriginal Terminology1, developed by the Centre for Aboriginal Health and the Aboriginal Health and Medical Research Council of NSW. While Australia is privileged to have two distinct Indigenous cultures, only Aboriginal peoples are the traditional owners of the lands, seas and waterways of NSW. The Mental Health Commission of NSW recognises this reality and respects Aboriginal cultures and communities in this State.

This document also uses the concept ‘social and emotional wellbeing’ in line with the Gayaa Dhuwi (Proud Spirit) Declaration2 developed by the National Aboriginal and Torres Strait Islander Leadership in Mental Health group (NATSILMH). The Declaration promotes the importance of recognising Aboriginal and Torres Strait Islander concepts of social and emotional wellbeing, mental health and healing in practice, and calls for strengthened Aboriginal leadership and influence.

1 https://www1.health.nsw.gov.au/pds/ActivePDSDocuments/GL2019_008.pdf2 https://natsilmh.org.au/sites/default/files/gayaa_dhuwi_declaration_A4.pdf


Overview

https://nswmentalhealthcommission.com.au/resources/strategic-framework-for-suicide-prevention-in-nsw-2018-2023

What we heard: At a glance

4Consultation paper – Aboriginal perspectives What we heard: At a glance

Inclusion of people with lived experience • ‘Nothing about us, without us’ –

Strategies for preventing suicide must be developed in meaningful partnership with Aboriginal people, service providers, volunteers and peers.

• Experience with suicide is personal and repeated The high rates of suicide across Aboriginal families and communities means that many Aboriginal people have had personal and repeated experiences with suicide. Such direct experience with recent and traumatic suicide attempts, coupled with the communal grief they cause, have created an all too familiar sense of dealing with repeated loss and trauma for Aboriginal people.

• For some the sheer prevalence of suicides in the community and unrelenting ripple effects lead to feelings of helplessness and weariness as well as a strong drive to prevent future occurrences.

Building community resilience and wellbeing• Building capacity within and across communities

is vital – Training opportunities need to continue to be provided to health professionals and the broader community.

• Responses must recognise the ‘cycle of trauma’ – Suicide, in many cases for Aboriginal families in NSW, is not a one-off, stand-alone, clinical event. It is a result of a continuous cycle of repeated trauma and this fact must inform responses of clinicians, services and systems.

• Safe and supportive environments are key – Aboriginal communities want to be able to discuss and raise suicide as an issue in a safe and supportive environment.

Supporting excellence in clinical services• Developing culturally appropriate partnerships –

“Mainstream” and “broader community” services and support networks must engage in culturally appropriate partnerships to afford a broad range of preventative and support options.

Enhancing coordination and integration• Ensuring there is ‘no wrong door’ –

The principle of ‘no wrong door’ must be married with supported advocacy and partnership to move beyond ‘warm referrals’. It means moving towards greater community and service accountability, supporting people through difficult journeys and providing practical assistance in navigating limited service options.

Enhancing capacity to respond to suicide• Services need support to meet demand –

Community members told us that services do not have the capacity to meet demand and there are significant barriers to accessing care.

• There is a need for more staff (that are better supported) – Many communities do not have Aboriginal staff and few Aboriginal staff are in clinical roles. It is important to recognise that the work days of Aboriginal staff do not stop at 5pm and more must be done to prevent burnout.

Supporting and promoting evidence-based practice• Enhancing Aboriginal training and support –

Training, supporting and resourcing Aboriginal people to develop and implement suicide prevention strategies is vital and must include their involvement in all levels of design, implementation and evaluation.

• Services need to be both culturally and trauma informed – Service providers must embrace culturally-informed advocacy, trauma-informed practice and relationship-based service delivery.


What we heard: At a glance

Aboriginal people, service providers and community leaders were consulted across metropolitan, regional and rural NSW in 2018

Inclusion of people with lived experience

What is working well Areas for improvement

• Services that go out to the community to see the local experience and context

• Respecting cultural practices and protocols, such as not naming or showing images of those who are deceased

• Using lived experience to intervene early with young people, including using story telling from past students in schools

• Putting lived experience into practice and promoting it widely, rather than just in mental health services.

• Promoting the stories of survivors rather than the problems of communities

• Supporting people with lived experience to educate others (including professional staff) and encourage others who have made suicide attempts to access services

• Valuing stories and translating them into data and evidence

• Conducting more research on family experiences.• Better supports available for grieving families

and communities • Forming and promoting survivor groups with

the key message of “you will regret the decision”.

Summary: Feedback on what’s working well

6Consultation paper – Aboriginal perspectives Summary: Feedback on what is working well

Building community resilience and wellbeing


• Mental health promotion through awareness days, public forums and networking groups, local heroes, community awards and other events (such as football presentations)

• Awareness raising and support through community groups, Elders, families and yarning circles

• Basic training for the broadest possible spectrum of community members and leaders

• Cultural initiatives that connect people with Country and waters, and healing councils and healing lodges that provide connection and cultural support

• Mental Health First Aid (MHFA), especially if it is delivered by Aboriginal practitioners with significant cultural knowledge and awareness.

• Providing more stable, long-term funding for community-led programs and initiatives

• Managers, service providers and policies need to respect cultural practices and grieving needs such as ‘Sorry Business’

• Approaches to suicide prevention and concepts around wellbeing need to be more culturally appropriate and meaningful to local people

• Providing more support for women to rent and purchase their own homes to provide family stability and role-modelling for others

• Creating more safe spaces to have conversations• Supporting communities and services to raise issues

around suicide, to respond in difficult situations and to have preventive conversations

• Creating links between housing options and mental health care providers.

Supporting excellence in clinical services


• Engaging community Elders in local solutions, including identification of needs, community education and as advisors to clinical services

• Using outdoor and community venues rather than hospitals

• Coordination roles are valuable (but they need support).

• Establish better ways for people to give feedback on mental health services and for mental health programs to be transparent and held accountable with deliverables

• Improving relationships and building trust between service providers and the community

• Primary healthcare providers require defined referral pathways to clinical and other support services

• Training must be linked to on the ground realities of services and help health professionals understand the barriers and risks that Aboriginal people face.

Enhancing coordination and integration


• Working with communities as partners ensures decisions are guided by the principle of self-determination

• Coordination by local initiatives, not-for-profit organisations and community groups in partnership with local leaders, including suicide prevention working groups

• Services that are flexible and able to respond to need where and when it arises

• Service partnerships and co-location that bring clinical services to the organisations and are connected to the community

• Neighbourhood and youth centres acting as hubs for service delivery

• Aboriginal staff leading and expanding local groups, such as youth groups.

• Embracing the principle of ‘no wrong door’ and providing practical assistance to help navigate the mental health system

• Developing a ‘safe person program’ in schools and communities for children to feel comfortable discussing issues and confident in accessing help

• Services should be structured as a ‘one stop shop’ • More services must operate in communities

(rather than requiring travelling to them)• Improving the continuity of care via handovers,

collaboration and referrals • Improving visibility and accessibility of existing services,

community organisations and education programs • Providing specific integrated services for

domestic violence.


Summary: Feedback on what is working well

Enhancing capacity to respond to suicide


• The Aboriginal workforce is being strengthened by attracting, developing and sustainably supporting more Aboriginal people

• Having serious conversations about suicide directly with families

• Seeing mental health issues as a whole of community issue and encouraging services to view it as ‘everyone’s business’

• Community networks helping to protect staff through the challenges and trauma of their work

• Training in Mental Health First Aid and ‘Question, Persuade, Refer’ are helpful and should be expanded to all service sector staff.

• Expanding service provision and capacity • Providing greater access to transport • Improving community knowledge of services and

ways of identifying the people who need support• Investigating new models of response such

as a community ‘toolkit’, telehealth options and formalised response teams

• Better support of staff wellbeing, professional development and access to clinical supervision

• Providing orientation for students each year around local mental health support services.

Supporting and promoting evidence-based practice


• Support services that work in a way that is culturally appropriate, trauma-informed and relationship-based

• Training programs exist that support basic skills and build confidence in identifying risk behaviors and supporting those at risk.

• More clinical services need to shift their approach to one that understands cultural knowledge and responds to the communities in which they work

• Better promotion of training programs that support those at risk is required

• Making service policies and procedures more culturally appropriate and trauma-informed

• Addressing consumer privacy concerns and making service policies culturally appropriate

• Improving identification of people who are at risk or need support, and identifying better ways of sharing information about services

• Resourcing the NSW Coroner to share information that enables identification and analysis of local issues

• There is still limited evidence about what works in Aboriginal suicide prevention.

8Consultation paper – Aboriginal perspectives Summary: Feedback on what is working well

What we heard from Aboriginal people, communities and service providers

Aboriginal people, communities and services involved in consultations provided a comprehensive assessment of the major gaps and challenges for suicide prevention in their local communities and for Aboriginal people in NSW. These are summarised below through the lens of the six guiding principles which shaped the consultation process and now underpin the Strategic Framework for Suicide Prevention in NSW 2018-2023:

• Inclusion of people with lived experience• Building community resilience and wellbeing• Supporting excellence in clinical services• Enhancing coordination and integration• Enhancing capacity to respond to suicide• Supporting and promoting evidence-based practice

What we heard: In detail

Listen, listen, listen…

Why don’t mainstream services learn from us as a resilient people?



Inclusion of people with lived experienceWe heard about recent and ongoing experiences with suicide:

• Many communities have had suicides recently. Some communities have had multiple suicides, such as Brewarrina which has had four and Coonamble which has lost several young people. Members of one community described how five Aboriginal people have died by suicide recently, including young people and a young mother.

• Communities told us that local media coverage and discrimination are major issues. An example was given of how media reported on young people who were missing but excluded the Aboriginal child from the coverage.

We heard about the trauma and shame associated with suicide:

• We heard that the trauma and grief caused by suicide is widespread, and that it impacts on both the family and the community. We heard about repeated trauma and the retriggering of trauma, such as when a community member died by suicide 12 months after another community member of the same age died, retraumatising the whole family and community.

• We heard that feelings of worthlessness, shame and stigma and being charged with criminal offences often contribute to the circumstances that lead to suicide. We also heard that feelings of shame are often associated with suicide and experiences of self-harm.

• We heard that mental health issues are often connected with a developmental disability and other disadvantage, either individually or within a family.

We heard that cultural practices must be respected, and that grieving families and communities need to be supported:

• We heard that taboo issues such as cultural practices determining the naming or the use of images of deceased individuals are of importance. These are basic respectful practices but the diversity of Indigenous cultural practice and experience in Australia means that care must be taken when dealing with an individual who has suicided, who has attempted suicide or who is impacted by suicide.

• There are specific media and reporting guidelines surrounding the naming of deceased individuals in most media and health arenas. These guideline should be followed to prevent retraumatising families and communities and ensure adherence to fundamental cultural respect protocols.

We heard that learnings from people’s lived experience must be valued and put into practice:

• We heard that people’s narratives need to be valued. Communities want learnings from lived experience to be put into practice and promoted widely rather than just in mental health services.

• People with lived experience should be supported to educate others, including professional staff, through workshops and presentations. They should also be supported to educate others who have made a suicide attempt, encourage people to access services and work with young people, including story telling from past students in schools.

• We heard that the stories of survivors should be promoted rather than the problems of communities. Survivor groups with a key message of ‘you will regret the decision’ should be formed and supported. ‘Hearing Voices’ style groups for people with suicidal ideation and new communication tools for promoting lived experience inclusion are also supported.

• We heard that there is a need to improve how stories are translated into data and evidence. More research needs to be done on family experiences.

‘promote the stories of survivors rather than the problems of communities.’

10Consultation paper – Aboriginal perspectives What we heard: In detail

We heard about the distinct challenges facing Aboriginal young people:

• We were told that using lived experience is important when working with young people. This included past students telling their stories in schools. Intervening early and reducing stigma around mental health and suicide using lived experience was a strong message.

• We heard that communities are concerned about their young people but that children do not open up about problems occurring at home. Community members said that for some kids, it is safer to be on the street than at home and that juvenile detention has become a ‘cycle’ for many children. They noted that there is a lack of emergency accommodation for kids who are at risk. In Dubbo, for example, there is no youth hostel and the Doorways Service is always full. We heard that issues of self-esteem, bullying at school and the quality of education are concerns of Aboriginal communities. We heard that in places like Brewarrina, Condoblin and other remote communities, community members feel that the quality of education is impacted by teachers that are perceived to be ‘biding their time until they can leave’.

• We heard that governments need to increase access to psychological support services that can work closely with schools. A ‘safe’ or trusted person who is easy to access should be present in every school and community for children to discuss their issues with.

• We heard that communities want Mental Health First Aid (MHFA) training to be given to all school students and teachers, and mental health, wellbeing, suicide prevention as standard school subjects.

Building community resilience and wellbeingWe heard about family-wide and community-wide trauma:

• Suicide is not a one-off event for most Aboriginal families in NSW. Rather, it is part of a continuous ‘cycle’ of repeated trauma and this must inform responses of clinicians, services and systems. It cannot be neatly managed as a stand-alone clinical event. A concerted, long-term effort will be required to break the ‘cycle’ of trauma.

• All sections of the Aboriginal communities we heard from consistently told us that past experiences of trauma have resulted in suicides, self-harm and significant concern for community members and loved ones. This includes people with lived experience, surviving family members, other family members, service providers, peer workers, and, most significantly, Elders and senior community leaders.

• Elders and senior community leaders reported significant distress in their communities and highlighted limited community capacity to continue responding to suicide.

We heard about the importance of community conversations and mental health as a shared issue:

• People told us that they want mental health to be seen as a whole of community issue. This includes greater awareness of community organisations, networking groups and community education programs.

• Communities told us that awareness days need to be promoted rather than trivialised. Other suggested promotional activities included the use of local heroes, community awards and mental health advertisements during football presentations and shows.

• The community in Grafton spoke about the need for more knowledge about how to respond in difficult situations and have preventive conversations following several recent suicides in the area.

• We heard that communities and services need to be supported to have conversations and raise issues around suicide and suicide prevention. This might take the form of broader community forums, as well as groups and shared activities, especially in smaller towns. Sports clubs and sporting events are also opportunities for engagement. It is also important to include ‘little’ celebrations for the community.

• We were told that all Parliamentarians should do Mental Health First Aid (MHFA) training.



We heard about the value and need for ongoing training across the community:

• Communities told us that it is essential that basic training opportunities continue to be provided to the broadest possible spectrum of community members and leaders. This included mental health and Social and Emotional Well Being (SEWB) workers, general community members, family members, and community service providers including alcohol and drugs services, domestic violence services, child and maternal health, men’s health, women’s health, sporting and cultural groups.

• Many Aboriginal people feel that more can be done to protect loved ones and community members, but this desire has not been matched by training. They advocated for a common sense approach to training that focused on ensuring the fundamentals surrounding suicide and suicide prevention (specific to Aboriginal communities and cultural life in NSW) are understood. They also strongly supported more in-depth training courses such as mental health first aid, especially if it is delivered by Aboriginal practitioners with significant cultural knowledge and awareness.

We heard that communities want self-funded initiatives:

• We heard that funding of community initiatives is a challenge, especially with respect to funding instability. One solution put forward is self-funded foundations, free of government requirements and restrictions. We also heard that funding for programs and initiatives needs to be made with longer-term arrangements in place, and based on achievement of positive outcomes.

• One area of support identified is to increase support for women to rent and purchase their own homes. This would provide stability, role modeling and strong foundations for younger generations.

We heard about the challenges associated with suicide and the practice of Sorry Business:

• Many Aboriginal and Torres Strait Islander people mourn the loss of a family member or loved one by following traditional practices and ceremonies which are often collectively known as ‘Sorry Business’. In cases involving suicide and other trauma, there are major challenges with this including those relating to burial, cause of death notification, advice to wide kinship networks, release for burial, institutional arrangements, coronial timelines, and inquest procedures.

• ‘Sorry Business’ is a period of mourning and grieving that incorporates various responsibilities and obligations. It might include attendance at funerals, participation in cultural events or activities and other ceremonies involving the community. Most Aboriginal and Torres Strait Islander people have clear cultural obligations to be involved in ‘Sorry Business’ resulting from the loss of a family member, extended family, those with kinship ties or wider community relationships. However, the mourning process for each person will be unique. There is no set length of time for ‘Sorry Business’ with different communities and cultural groups following longstanding practices and ceremonial responsibilities which extend well beyond a single funeral event.

• We were told that managers and service providers need to understand cultural practices and grieving needs.

We heard about the importance of spirituality and social and emotional wellbeing:

• The concepts of spirituality and social and emotional wellbeing underpin many of the approaches to holistic Indigenous mental health and wellbeing practiced by community-based health services and other culturally responsive services. Spiritual wellbeing is essential because it directly connects past, present and future for many Aboriginal and Torres Strait Islander people. It is an inherent cultural aspect for many people which is both ancient and evolving. Spiritual traditions and practices are entwined with many contemporary approaches to wellness, resilience and identity. This broadly-based concept of wellbeing within an Indigenous context incorporates diverse traditional and contemporary Dreaming understandings, spiritual beliefs, stories, dance, painting, medicinal and healing practices and practitioners.

We heard that the language and measures around wellbeing need to be culturally appropriate:

• The definitions, measures and assessments of wellbeing need to be refined to be more culturally appropriate and should be tailored to specific groups. The language and terminology used must be accessible and useful to local people.

• We were also told that there needs to be a language specific to suicide prevention. This would be a standardised and holistic approach with agreed benchmarks, but with appropriate local cultural and community adaptions available.


Supporting excellence in clinical servicesWe heard that engaging community Elders in local solutions is crucial:

• Community Elders should be engaged to help develop plans to increase awareness of and identify training needs. It is important to engage them before rolling out any programs.

• Clinical services should include Aboriginal advisors in their work to prevent silos and professional bubbles and improve the balance between theoretical approaches and on the ground practice. Elders must be included in work with communities.

• The idea of an ‘Aboriginal Lifeline’ was put forward. This would be a local team made up of local Elders and other senior community members who could be contacted to assist families and service providers.

We heard about poor experiences with services:

• Some people don’t call Triple Zero (000) because of poor responses in the past. Greater trust and improved relationships between the community and service providers is essential. In one area, an experience was that an ambulance would not go out without a police escort.

• For many people, the general Suicide Callback Service (1300 659 467) does not work due to waiting times, access to technology or delayed and non-returned calls. People also reported frustration at not being able to access other helplines such as Lifeline 131 460 in a timely manner. Staffing levels are felt to impact a crisis call even being answered.

• We heard the story of one young father in Wellington who was experiencing complex mental health and relationship issues. We were told that he attended the local Aboriginal Medical Service and waited for two and a half hours and was not asked a single question in reception. As a result, he left the service and suicided.

We heard suggestions for improving services and greater accountability:

• There needs to be greater focus on training to ensure that clinical excellence expands from metropolitan areas into rural and remote NSW, including streaming and online options.

• Care should be provided by multidisciplinary teams through partnerships between community services and quality clinical services. Local protocols need to be followed. We also heard that coordination roles are valuable and need support and the participation of people with lived experience should be promoted.

• We were told that primary healthcare providers need to be specific around referrals and pathways to clinical and other support services.

• Communities told us that there must be a vehicle for people to provide overall feedback regarding the mental health system. We also heard that programs addressing suicide prevention and responses to suicide must be made accountable.

We heard that clinicians need to familiar with the communities in which they work:

• We heard that training must be linked to on ground delivery and evaluation of services. Health professionals need to have direct experience of the common barriers and risks that Aboriginal people face, including the unique challenges faced in remote communities. General Practitioners need to be familiar with specific crisis intervention options that are relevant locally and acknowledge existing infrastructure and resources to prevent false expectations.

• We were told that health professionals could be linked in to local community groups, including community service providers, to act as ambassadors.

• We also heard that promotion and career development pathways are linked to regular activity with Aboriginal partners and communities.

We heard that there are barriers to early intervention:

• We heard that access to welfare and early intervention support is not possible for many as there are too many “hoops to jump through”.

• We were told by one community member that “for some people, getting locked up is the only way to get help”.



Enhancing coordination and integrationWe heard that the principle of ‘no wrong door’ must guide improved integration:

• The principle of ‘no wrong door’ must be married with supported advocacy and partnership to move beyond ‘warm referrals’. We were told that this involves moving towards greater community and service accountability. It also means supporting people through difficult journeys and providing practical assistance in navigating limited service options.

• We heard that structural factors contribute to confusion and fragmentation. For example, most emergency and triage services for mental health in NSW sit outside the community sector and it will take a concerted effort to develop and integrate them. Greater integration would improve the use of scarce resources.

• It was suggested that flow charts should be developed to guide people through the system and service choice.

• We also heard that acute in-patient units must accept referrals rather than send people away. At present this is often done on a regional basis which precludes support.

We heard that communities should be treated as partners:

• Efforts to enhance coordination and integration should be guided by the principle of self-determination. We heard that there should be a focus on empowering communities through tools, groups and knowledge. Education can empower partners to change the conversation with kids.

• This also means identifying the right committed people in communities, developing relationships with them and improving trust. Local protocols for navigating community and cultural relationships should be used and traditional dance, art, weaving and other activities should be included in these partnerships.

• Individuals, families and carers must be involved in the whole process. Family and parental support is vital.

We heard that coordination is a major challenge, particularly in regional and remote areas:

• We heard that there needs to be a coordinated approach to service provision that ensures consistency. For example, community members from one area told us that there are over 28 care agencies locally, making coordination a major challenge. Different support options and reinforcing collective aims should be the focus, rather than competition for resources and funding.

• The linkages between mental health support and other social services, especially housing, are critical. We heard about the important role of community and service providers in this area, and how there is no provision for healing or supporting caregivers. Without appropriate (or in many cases, any) housing support or options, counseling and recovery-oriented approaches are difficult to establish or maintain.

• We heard that opportunities for working together are limited by barriers to access and funding restrictions.

• Community members noted the challenge of social and geographical isolation.

We heard about service gaps, particularly in smaller regional communities:

• We heard that there is a lack of services in many smaller communities, including Aboriginal-specific services. We heard that community members would like to see more early intervention, better coordination, and greater acute service options and psychological services.

• Many of the clinical services that exist operate on a fly-in and fly-out basis. This is a major constraint on access, partnership arrangements, and notifications of available appointments.

• Phone support options such as the Mental Health Access Line now seem to operate as more of a triage service rather than a counselling line.

• Community members wanted appropriate options operating in their communities, rather than having to travel to access them. In Dubbo, we heard about the challenge of geography and service access across distance or what was described as “the big sandstone curtain called the Blue Mountains”.


We heard that communities want a service that is flexible, responsive and a ‘one stop shop’:

• We were told that people want support services to be structured like a ‘one stop shop’ in the same way that Service NSW has been. This would improve the identification of those people and families in need of support, and importantly mean that each person must only tell their story once.

• We heard that services need to: > be flexible enough to respond to the need

when and where it is needed, including being able to go out to the community to respond and being available 24 hours a day

> be culturally safe and staffed by people who use simple language and local community terms rather than clinical jargon, and

> avoid speaking about ‘appropriate referrals’ as this only isolates people from service providers. In-patient units must also accept referrals rather than send people away (often on a regional basis which precludes support).

• Competition for resources and funding prevents a focus on the collective aim of providers.

• Those who have self-harmed should be given follow up support (aftercare) after they have been discharged, along with community mental health.

“We need to find out where we are heading as we often gather to talk and don’t seem to do anything.”

“What happens to families and the community after we shut at 5 PM?”

“Sometimes it feels like you are working with a different mob each time in services and programs.”



Enhancing capacity to respond to suicide We heard that there are significant issues related to service provision and capacity:

• Community members communicated that services do not have the capacity to meet demand. In Dubbo, we were told that there are not enough beds to meet the needs of the local community, let alone communities such as Brewarrina and Condobolin. In the past, a non-government organisation ran a community-based six-week program as a starting point for pre-crisis approval in the area but because it lost its funding, the program is now only available through the hospital.

• Other important social services are also limited by funding. For example, in one community the night patrol bus provides a service but is limited by funding to four nights per week.

• Aftercare follow up with people who have self-harmed after discharge (with community mental health) needs to be offered.

We heard about barriers to accessing services:

• One community told us that there are lots of mental health issues in their town of 2,500 people but a lot of people do not access services, and this increases reliance on welfare. Common reasons include a lack of Aboriginal staff, poor relationships with service organisations, negative experiences at service venues or institutions, perceptions of racism and judgement, short-term funding of initiatives, funding withdrawals and a fundamental lack of trust.

• Access to programs and innovative approaches depends on the sector and community location. For example, the Clontarf Girls Academy and Language Hub was originally run by a non-government organisation and open to kids, but now that it is managed by TAFE there is limited access for young people. In many communities, access to programs and preventive opportunities are only available to ‘people with connections’.

• We were told that there are complexities in applying for the NDIS to access any support service which means that some people are not receiving the support to which they are entitled. However, it was identified that at times there is no service to access even if they do have a package to purchase.

• A severe lack of transport was identified as a gap that needs to be addressed.

• One solution that was put forward is school and university students being given a mandatory orientation at the commencement of each year that addresses mental health services on campus and in local communities.

• It is important to address the underlying belief in many local communities that if you need help the only place you will get it is in jail. There is a cycle between school to jail to hospital to mental health services and back again that needs to be broken.

We heard that communities want practical responses and clear options:

• The idea of a ‘toolkit’ that outlined practical solutions was put forward. It would include guidance about how to respond along the lines of ‘if you see this then do that ’ and suggestions about reducing stigma, including simple language to use.

• The question “where do we go when I or someone I know is in crisis or at risk?” must be clearly addressed. This might involve flow charts to guide people through the system and service choice and more awareness and promotion through advertising. This should fully include local and regional service providers and support options including primary health networks, Headspace centres, the Mental Health Access Line, emergency departments and general practitioners.

• We also heard that education about mental health and how to direct and support people should be offered to staff in all sectors, including justice, health and education. Mental Health First Aid and Question, Persuade, and Refer (QPR) training is also supported.

• The idea of dedicated tele-health service to increase rural and remote access and capacity to respond quickly to emerging needs was put forward. We were told that ‘copycat’ suicide does happen in communities and must be considered in comprehensive response and support programs.

• The idea of a formalised Aboriginal response team was put forward.

• Aboriginal communities told us that suicide is a challenge, and that the response must be patient and methodical. Do it slowly, build relationships, chip away at it.


We heard about the relationship with police:

• Police relationships with Aboriginal communities are often strained and this results in people not calling for help simply because of fear of incarceration.

• Community members want Police officers to receive specific training in suicide prevention. Currently Aboriginal Community Liaison Officers are getting trained but they are not the police. They also want police to prioritise engagement with local programs and Elders.

• Community members suggested that we learn from models such as those in Queensland where a mental health nurse is also in attendance when police receive a call.

We heard that there needs to be more staff:

• We heard that there needs to be more Aboriginal staff. Some areas do not have Aboriginal-specific workers and few Aboriginal staff are in clinical roles. In one instance, we heard that trainee mental health pathways positions had been transferred laterally to mainstream positions.

• Retaining workers, including those who are living off country, is essential. Ensuring continuity of knowledge is also important.

• We were told that there needs to be more youth workers, male workers (especially clinicians) and peer workers. There are gaps in staffing in rural and remote areas that must be filled by qualified, experienced people. Often these positions are made available but are not filled due to lack of incentives.

We heard about the challenges facing workers and that staff need greater support:

• We heard that trauma ‘sneaks through the cracks’ for many staff through experiences of vicarious trauma and intergenerational trauma. Community networks act as a protective blanket for workers who are constantly bombarded with trauma and challenges in their work.

• In doing their work, Aboriginal staff working in complex and sensitive areas must often negotiate family and community issues and tensions.

• We were told that it is important to recognise that the ‘work’ days of Aboriginal workers do not stop. Their wellbeing needs to be better supported, with a focus on addressing and preventing burnout.

• We heard that Family and Community Services (now NSW Department of Communities and Justice) provide support for self-care for workers, but that it is only available in Sydney. Some professional development programs have only supervision visits or include significant online content which is not appropriate.

• We heard that all care and support providers should have a system of clinical supervision in place. In addition, people believe that all workplaces should have Employee Assistance Programs (EAP) in place.



Supporting and promoting evidence-based practiceWe heard about the importance of trauma informed, culturally safe service options:

• For many Aboriginal people suicide is not best addressed through Western mental health models or approaches but through embracing culturally-informed advocacy, trauma-informed practices and relationship-based service delivery.

• We heard that cultural knowledge is not being considered and cultural protocols are not being followed. Most services are not operating in a trauma-informed model.

• Clinical services need to shift from a predetermined concept to an approach based on the reality of the communities in which they work. There is a perception that they take a ‘tick and flick’ approach and Aboriginal people told us that this should be avoided.

We heard that there is a need for improved data and information gathering:

• We heard that there is a need to build a greater body of evidence of what works. There is also a need to better demonstrate what services and evidence already exists.

• There is also a desire for improved ways of identifying those people who are at risk or need support, and for better ways of sharing information about services.

• Data that is gathered must be meaningful, recognise priority populations and be understood with knowledge of historical context and trauma in mind.

• We were told that the NSW Coroner needs to be resourced to share information. This would enable identification and analysis of local issues. A NSW Suicide Register should also be developed.

We heard about the need to promote existing programs that build skills:

• Aboriginal communities told us that there is a need for basic skills and greater confidence in identifying risky behaviours and supporting those at risk, especially young people.

• Many community members suggested that there is a lack of awareness of training and information. We heard that it is difficult to know what training is available, even when it is being provided. One example was that more community members needed to know about their local area alcohol, drug and mental health plan.

We heard about problems with confidentiality, and when service policies clash with culture:

• We were told that improving the confidentiality of consumers and clients when accessing services needs to be a priority.

• We heard that the policies and procedural pathways set up by services might not be culturally appropriate, either in a general cultural sense or a local aspect.

• Stated policy goals or principles are not always apparent in how services are delivered or in the lived experience of consumers and family members. We heard that organisational and staff culture is more important than overarching policy statements. For example, there is considerable concern about how difficult it can be to access basic services, how admissions occur and the range of “confusing” discharge practices.

• Service workers told us that taking people through the medical model and explaining what is happening is challenging.

We heard about challenges with funding and accessibility:

• Service providers spoke about how funding is short-term and episodic. Eligibility for some programs such as Mighty Hands is often age based, and prevents some people attending and gaining support.

• We heard that Applied Suicide Intervention Skills Training (ASIST) training is seen as very ‘Canadian’. It is important that whatever options are offered, they are relevant to local communities.

• Local initiatives like weaving circles are self-funded, and difficult to support because the benefits are hard to measure.


Appendix 1: About suicide and Aboriginal communities

The reality of suicide and associated trauma facing many Aboriginal individuals, families and communities in NSW has been well documented over the past decades as rates have increased. It is nevertheless important to look clearly at the contextual factors influencing suicide and prevention activities for Aboriginal peoples. The purpose of this is two-fold. Firstly, there is a significant database of and awareness concerning Aboriginal suicide rates and factors which must inform prevention framework strategies. Secondly, there remains a lack of specific evidence-based suicide prevention strategies for Aboriginal people.


Appendix

The Centre of Best Practice in Aboriginal and Torres Strait Islander Suicide Prevention outlines the challenge:

“ In 2017, suicide remained the leading cause of death for both Aboriginal and Torres Strait Islander and non- Indigenous children and young people, accounting for 40% of all Indigenous child deaths. Those aged 15-17 contributed to 94.4% of all suicide deaths in young Indigenous people. When considering gender differences, 91.6% of Indigenous male youth suicides were aged 15-17. There were no female Aboriginal and Torres Strait Islander suicide deaths under the age of 15 in 2017.3”

Risk factorsDuring the consultations people spoke about risk factors for suicide. The following list is drawn from resources published by Beyond Blue, Black Dog Institute, headspace and Mental Health First Aid and reflects what we heard during consultation. Risk factors include:

• having a mental health issue• history of mental health conditions –

depression, anxiety, bipolar, PTSD• had bad things happen recently, particularly

with relationships or their health • attempted suicide or harmed themselves

in the past • been physically or sexually abused as a child • having been recently exposed to suicide by

someone else• losing a family member or friend to suicide• history of substance abuse or self-harming

behaviours• relationship problems – conflict with parents

and/or romantic partners• family relationship crises including child removals,

interactions with the child protection and justice systems, unsuccessful restoration attempts

• poor physical health and disabilities • legal or disciplinary problems• access to harmful means such as medication

or weapons

• ongoing exposure to racism and racist behaviours (including lack of cultural safety and structural racism), and

• ongoing exposure to bullying behaviour including cyberbullying.

The level of risk, the need for vigilance and the urgency for coordinated support and response can appear overwhelming when placed within the context of Aboriginal communities that endure poorer resourcing, service delivery options, access to services of choice and underlying social and economic capacity. Yet it is important to highlight that Aboriginal communities, organisations and service providers have not given up, despite understandable levels of fatigue and concern for their families. They continue to manage complex and challenging situations for their families and communities using whatever resources and collaboration is available.

3 (Statistics, 2018)

20Consultation paper – Aboriginal perspectives Appendix

Protective factors During the consultations people spoke about protective factors around social and emotional wellbeing for Aboriginal people. The following list is drawn from resources published by Beyond Blue, Black Dog Institute, headspace and Mental Health First Aid and reflects these conversations. Protective factors include:

• strong, positive relationships with parents, family members, guardians and extended kinship networks (feeling secure and supported)

• connections to other non-parental adults and closeness to caring friends and social support networks

• school safety and academic achievement • feeling a sense of belonging to something bigger than

themselves – community, culture, religion, sports• neighbourhood safety, and• awareness of and access to local health services.

At a community level these protective approaches may include:

• addressing community challenges such as poverty and other social determinants of health

• promoting cultural elements, building identity, Social and Emotional Wellbeing (SEWB) and healing

• connecting to culture, Country and Elders• reduction of alcohol and drug use • gatekeeper and service provider training (this must be

Aboriginal-specific and community-specific)• awareness-raising programs about suicide risk• promotion of opportunities to ‘have the discussion’

about suicide without it always being a response to an incident (i.e. preventive and open discussions)

• use of multimedia and visual communications with no assumption of literacy or understanding of service jargon and acronyms

• reducing access to lethal means of suicide• training of frontline staff, allied health workers and

GPs in detecting depression and suicide risk• e-health services, internet access, crisis call lines

and chat services (including online and social media mechanisms for support and engagement)

• responsible suicide reporting by the media• school-based peer support and mental health

literacy programs

• culture being taught in schools (generalised information linked with local knowledge, history, current practice and engagement with Elders and community stakeholders)

• peer-to-peer mentoring and education and leadership on suicide prevention

• programs to engage and divert – sport, capacity building, access to driving licenses, arts and craft, drama, media and storytelling (including digital storytelling and cultural yarning), and

• providing hope for the future and education – preparing for employment, family life, educational opportunities, carer roles, cultural engagement and connection.

Cultural safety The relatively new concept of cultural safety is now informing practice around the world. Originally developed in New Zealand under Maori Nursing principles the following definition provides a context for its relevance to suicide prevention:

“ Cultural safety extends beyond cultural awareness and cultural sensitivity. Cultural safety is about consumer, patient, practitioners and services working to enhance rather than diminish individual and collective cultural identities, and empower and promote individual, family and community wellbeing. Culturally safe service delivery is crucial in enhancing individual and collective empowerment and more effective and meaningful pathways to Aboriginal self-determination.4”

It is crucial to understand that cultural safety is about the experience of the person, and not about service quality, appropriateness or relevance. In the Australian Indigenous context, Professor Dennis McDermott describes cultural safety as: “…the awareness, knowledge, understanding and sensitivity to other cultures combined with a proficiency to interact appropriately with people from those cultures.”5

4 (Telethon Institute for Child Health Reserach/ Kulunga Reserach Network, University of Western Australia, 2014)5 (Report of IHEAC Annual Conference 2007, p5)


Appendix

6 https://www.atsispep.sis.uwa.edu.au/__data/assets/pdf_file/0006/2947299/ATSISPEP-Report-Final-Web.pdf7 (Statistics, 2018)

Limited evidence about Aboriginal suicide prevention Unfortunately, there is still limited evidence about what works in Aboriginal suicide prevention. The Aboriginal and Torres Strait Islander Suicide Prevention Evaluation Project Report (ATSISPEP) Solutions that Work Report (2016)6 provides a summary of the current state of affairs:

• There is little evidence about what works in general population suicide prevention, let alone an Indigenous-specific prevention. In 2013, following an extensive literature review, the National Mental Health Commission (NMHC) noted in its National Report Card on Mental Health Services and Suicide Prevention that, “in terms of what works for suicide prevention, Closing The Gap Clearinghouse’s Strategies to Minimise the Incidence of Suicide and Suicidal Behaviour, which focused on Indigenous suicide prevention programs, showed that few programs had been suitably evaluated”. The publication concluded that there was a need for significant further research.

• Aboriginal suicide is a significant population health challenge for Australia. Suicide has emerged in the past half century as a major cause of Indigenous premature mortality and is a contributor to the overall Indigenous health and life expectancy gap. In 2014 it was the fifth leading cause of death among Indigenous people, and the age-standardised suicide rate was around twice as high as the non-Indigenous rate.

• Indigenous children and young people are particularly vulnerable, comprising 30 per cent of the suicide deaths among those under 18 years of age. Over the 5 years from 2013 to 2017, Aboriginal and Torres Strait Islander children and young people accounted for more than a quarter of all suicide deaths in this age group (93 of 358 deaths, 26.0%)7. ‘Suicide clusters’, or a series of suicide completions and/or self-harming acts that occur within a single community or locale over a period of weeks or months is also a significant concern, particularly among younger people.

• As males represent the significant majority of completed Indigenous suicides, gender can also be understood as a risk factor. However, the number of suicides and increasing self-harm among Indigenous females is an ongoing concern.

These challenges are long-standing and will only be addressed through effective partnership, collaboration and a commitment to a true understanding of the cultural and socio-economic influences on Aboriginal suicide in NSW.

Common elements for successful approachesRegardless of location, successful approaches need to include:

• community empowerment, development and ownership (based on the principles and practice of community-specific or place-based responses)

• involvement and connection with Elders• cultural frameworks informing practice• partnerships with community organisations

(including Aboriginal Community Controlled Health Services, Aboriginal volunteer and peer networks)

• employment and training of community members and peer workforce

• development of appropriate and meaningful indicators for evaluation

• cross-agency collaboration• data collection (with appropriate privacy and

confidentiality settings), and• dissemination of learning and commitment to

continual improvement.


https://www.atsispep.sis.uwa.edu.au/__data/assets/pdf_file/0006/2947299/ATSISPEP-Report-Final-Web.pdf

Continuum of care and support needed to prevent Aboriginal suicideThe below flow chart was designed to capture the essential care elements that were consistently raised across the consultation and engagement sessions.

The ‘continuum of care’ approach works well in holistic Indigenous health models and reflected community members expressed desire for suicide prevention to be managed with a broader awareness.

Below is an illustration of the ‘continuum of care’ that captures the key thematic elements and priority care needs and to represent the continuum rather than a linear list of service types or delivery options.

Aboriginal communities and families (general

community environment) awareness, engagement

and access to skills and supports

Specific children-focused

conversations, skills and resilience

Specific adolescent-focused

conversations, skills, resilience and

support options

Post-vention support, debriefing, trauma-informed for individuals, families,

surrounding people and broader community (long-term support

and relationship-based options)

Crisis-level response and

management to protect and support the individual

and surrounding people (families, peers, friends,

colleagues)

Concern-level support and

engagement for individuals and supports (family, peers, friends)


Appendix

Appendix 2: The consulation process


14 March 2018 Wollongong – Aboriginal consumer and stakeholder forum

15 March 2018 Wollongong – General community and stakeholder forum

15 March 2018 Kooloobong Village – University of Wollongong youth forum

20 March 2018 Liverpool – General community and stakeholder forum

28 March 2018 Lismore – Aboriginal consumer and stakeholder forum

29 March 2018 Lismore – General community and stakeholder forum

4 April 2018 Dubbo – Aboriginal consumer and stakeholder forum

5 April 2018 Dubbo – General community and stakeholder forum

18 April 2018 Wagga Wagga – Aboriginal consumer and stakeholder forum

18 April 2018 Wagga Wagga – General community and stakeholder forum

9 May 2018 Sydney – LGBTIQ+ communities forum

10 May 2018 Sydney – LGBTIQ+ stakeholder and service provider forum

30 May 2018 Port Macquarie – General community and stakeholder forum

1 June 2018 Taree – General community and stakeholder forum

27 June 2018 Cootamundra – General community and stakeholder forum

6 July 2018 Sydney – Agencies and service providers forum

Four forums focused on Aboriginal community and service provider participation.

Aboriginal people with a lived experience of mental health issues and caring, families and kinship groups, and service providers participated in all forums. Many Aboriginal people also attended general community forums, and the breadth and depth of their perspectives and experiences shaped those discussions. This was important when considering issues such as clinical service provision, access and coordination given many services in regional and metropolitan NSW use a mainstream or generic service provider model.


Appendix

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