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What are the causes of Indigenous suicides?

Madelaine Dickie -
: Dr Tracy Westerman is a proud Njamal woman from the Pilbara region of Western Australia. Tracy is the Western Australia’s Australian of the Year for 2018, recognised for spending over two decades working to reduce the burden of mental ill health and suicide in Aboriginal communities.  As an Indigenous clinical psychologist who has spent the better part of the past twenty years working solidly in Aboriginal suicide, I keep getting asked "What are the causes of Indigenous suicides?" ANSWER: I have long been concerned by public commentary on the causes of suicide & the impacts of this in finding evidence-based solutions. Simply put, suicide risk factors are being incorrectly and consistently stated as CAUSES of suicide. So:
  • Alcohol is not the cause of suicide, nor is foetal alcohol syndrome
  • Poverty is not the cause of suicide
  • Abuse is not the cause of suicide
They are all very likely risk factors, but they are not CAUSES. We need to better understand this distinctionIf we have clear evidence of the causes, this will ensure that programs are better focused on suicide reduction. So, for example, what separates person A who has been abused and becomes suicidal from person B who does not? Is it that the abuse has manifested as depression for Person A, compared to person B who is not at suicide risk? While this is an essential question - we currently do not have clear evidence of such causal relationships. This is staggering given we have the highest rates of child suicide in the world!!! What is the value of better understanding suicide causes? Research amongst non-Aboriginal populations has depression as an established causal pathway to suicide in around 50% of cases of suicide. Research then further indicated that if we could eliminate depression from the suicide equation by determining treatments of best practice for depression, we can effectively reduce up to 50% of suicide deaths!!!! See how important causal pathways are! Unfortunately, we have limited evidence on Indigenous-specific suicide risk factors and therefore no evidence establishing causal pathways. Therefore best practice treatments cannot be established with Aboriginal people (see how these things have a knock-on effect?). Is there a different nature to Aboriginal suicide?  My PhD research determined a different set of risk factors to Indigenous suicide finding, amongst other things, that up to 60% of suicide risk is accounted for by impulsivity. Mostly the impulsivity is a reaction to conflict; an absence of self-soothing capacity comes into play, alcohol and drugs are used as an enabler (in most, but not ALL cases) and then suicide attempt/death occurs. This pattern is often the case with those who have trauma and attachment related issues (racism impacts in the same way as trauma so this is also an important contributor to impulsivity). Whilst impulse control can be addressed as a focus of treatment, if the underlying cause of the impulsivity is not determined then treatment effectiveness is limited. The Westerman Aboriginal Symptom Checklist for Youth (WASC-Y) and Adult version (WASC-A) enables clinicians to undertake thorough risk assessments to determine this better and have focused treatment, capable of tracking client outcomes. This is a world first and I have personally trained over 25,000 individuals in its use. However, we need this to be a uniform measure across this country and particularly into high risk areas. It enables us to screen for early risk and target treatment accordingly. Why do we keep confusing risk factors and causes?  The diplomatic (and painfully simple) answer to this is that the data has just not been analysed to clearly establish causal pathways. The less diplomatic one is that those deciding on funding want simple, linear causes and it seems that ‘blaming’ victims for their circumstances has always been popular. Starting a few decades ago alcohol was reported as the CAUSE of suicide ... If it was a cause, everyone who drinks to excess would be at suicide risk. You get the drift! It is also of note that Aboriginal people are up to 8 times more likely than non-Indigenous people to be non-drinkers. Go figure! Alcohol is a strong RISK factor, or enabler to suicide not a CAUSE. So, taking this example, the government decided to SOLVE suicides by eliminating alcohol through establishing dry communities and restricting alcohol. There has not been a decrease in suicide in many alcohol restricted communities, in fact the opposite is true. Let's look instead at some obvious societal contributors to Indigenous suicide Firstly, racism impacts on Aboriginal people in the same way as a traumatic event with at least 30% of depression being accounted for by racism alone. For example, in the 10 years since the NT Intervention the average birth weight of an Indigenous child has DECREASED overall by 600 grams. This is staggering given that infant mortality rates were already higher than many third world countries. Research has shown that racism impacts in-utero disrupting the basic brain stem development. Why? Because racism impacts on Aboriginal people in the same way as a traumatic event. We have established this as ‘acculturative stress’ and it is a significant contributor to suicides based upon my extensive experience assessing Aboriginal people. This is because policies that restrict human choices contribute to established risk factors for suicide, being hopelessness and helplessness – a negative attributional style about prospects for the future – leads depressed individuals to view suicide as the only way out of insoluble problems. Secondly, the WA corner's inquest into the suicide deaths of 13 Indigenous children in the Kimberley made the stunning conclusion that NONE of these children had a mental health assessment. I am angered and frustrated that these children were not even afforded the basics that ANY Australian child has the right to and particularly given that I have dedicated my life’s work to training practitioners in this highly complex area of suicide risk assessment with Aboriginal people. Universities do NOT require minimum standards of cultural competence as pre-requisites in the degrees undertaken by those in the 'helping professions'. I have developed a normed Aboriginal Mental Health Cultural Competency Profile which provides enormous capacity to measure, support and improve cultural competencies. This is hard-nosed as it is objective and measurable – as cultural competencies should be! Finally, with less than 10% of Aboriginal victims reporting crimes to police, under-policing is a significant contributor. When people do not respond to your victimisation you stop asking for help. We need to look outside of the 'blame the victim' mentality and look at the role society must play in ongoing suicides of our young people. We are living in a world in which Aboriginal people have effectively had to 'help themselves” while government continues to fund solutions that restrict human rights and choices, that blame victims and have no evidence of reducing suicides. Results of confusing risk factors with causes 1. The media, general public, become ill informed about the complexity of suicide. 2. Public policy gets directed in a way that is focused on “eliminating the cause” and contributes to the intergenerational cycle of suicide and poor health and mental health outcomes. 3. Research is not undertaken to provide evidence of what accounts for suicide risk and establish causes to better inform best practice and clinically and culturally competent assessment of at risk Aboriginal people. 4. We fail to provide a range of early intervention and prevention programs into high risk communities or accumulate evidence of what works. 5. Suggesting abuse and /or alcohol is the cause of suicides further stigmatises Aboriginal people inferring that most, if not all, Aboriginal people are victims of abuse or, worse, that all Aboriginal people are perpetrators or alcoholics. 6. Perpetuating such stereotypes contributes to a general lack of empathy for Aboriginal people who are bereaved by suicide and increases any potential risk to them through greater levels of complicated grief. It is a sort of "they did it to themselves” mentality that is not only inaccurate, but unhelpful and unkind.” I am often dismayed that when non-Indigenous children suicide we RIGHTLY look for deficits in society or systems. When Indigenous children suicide we look for deficits in their families, in their culture. When are we going to have a more empathetic view of Indigenous child suicides and for Indigenous families bereaved by suicide? What are we doing to determine causal pathways to Indigenous suicide? I have recently made a request to Minister Ken Wyatt for access to the suicide morbidity data in perpetuity in partnership with Curtin University and Aarnja Ltd in the Kimberley. We are hopeful that we will be able to gain access to this soon. The spatial distribution of suicide informs suicide determinants and evaluation of the effectiveness of suicide prevention programs. With data on suicide deaths, causal pathways could be established and inform the focus of evidence-based interventions, clinical best practice and many other gaps in our knowledge on Indigenous suicide prevention. This would lead to public spending concerning the issue being appropriately-targeted to maximise outcomes. This will change the paradigm of this area and this is being done at NO cost to the government. Let me explain in (hopefully) the most simple terms I can. Ultimately, the big picture thinking here is, it will then be possible use the continuous suicide data (suicide risk factors that move and change) that has been and continues to be gathered by the Westerman Aboriginal Symptom Checklist – Youth (WASCY) and Adults (WASC-A) to determine causal pathways and co-variates (i.e. impulsivity; depression and suicide risk) and determine whether a reduction in these factors reduces the overall suicide death rate (this is what we need the morbidity data for). This is complex but these two data sets will enable us to determine what risk factors are reducing the suicide death rate in more of an immediate, measurable and responsive way. Hopefully you are still with me ... These are the things that are needed to better inform prevention, early intervention and measure the impacts of suicide prevention activities. Hopefully access to this data will come soon! By Dr Tracy Westerman   


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