This article was first published in The Australian on the 19th April as ‘Sick Heart of a Generation’. It has been republished here with the permission of Dr Tracy Westerman. Dr Tracy is a proud Njamal woman from the Pilbara region of Western Australia who is widely recognised for spending over two decades working to reduce the burden of mental ill health and suicide in Aboriginal communities.
The Federal Minister for Indigenous Affairs recently shared that the Federal Government has allocated $134 million into “Indigenous suicide prevention”. This crudely translates to $248,000 per suicide death based upon the suicide mortality rate – without adding state funding into the mix.
Despite this, and as a country facing this growing tragedy of inter-generational Indigenous child suicides, we still have no nationally accepted evidence-based programs across the spectrum of early intervention and prevention activities.
Staggeringly, funded programs are not required to demonstrate evidence of impact, nor are they required to demonstrate a measurable reduction in suicide risk factors.
Given this, governments cannot actually claim they are funding suicide prevention.
You can’t claim prevention if you aren’t measuring risk. It’s that simple.
Restrict alcohol if communities want that, but don’t call it suicide prevention. Employ youth mentors, but don’t call it suicide prevention. Funding football programs is not suicide prevention. Sending high risk kids to elders is not suicide prevention.
I have spent 21 years evaluating the impacts of all my programs and tools and this is with $0 in government funding. It isn’t even ‘best practice’, it is basic clinical practice. I do not understand why substantially funded programs are not evaluating the impacts of their work and why governments aren’t doing their due diligence and insisting on it.
In an area as complex as Indigenous suicide, it is crucial that funding decisions unsupported by clinical and cultural expertise are challenged and redirected in the best way possible. Toward the evidence. Report after report has pointed to the need for ‘evidence-based approaches’ – we must question why it continues to remain elusive while our child suicides escalate.
Perhaps we need to start with what constitutes evidence. It doesn’t mean attendance. This is not evidence of impact. It means measurable, outcome evidence – a reduction in suicide risk factors attributable to the intervention provided.
Without measurability there is no accountability.
Without measurability we are failing to gather crucial evidence of what works to better inform current and future practitioners struggling to halt the intergenerational transmission of suicide risk.
What it’s like as a clinician to have a lack of evidence
Up to 30% of clinicians will experience the suicide death of a client in our clinical lifetime. It is complex, it is scary and very few of us understand what it is like to feel as though you are holding someone’s life in your hands. I can tell you that despite extensive training, suicide prevention challenges you at every level. It challenges your core values about the right of people to choose death over life; it stretches you therapeutically despite your training in best practice; and it terrifies you that you have missed something long after you have left your at-risk client.
The nature of suicide risk is that it changes. Being able to predict and monitor it takes years of clinical expertise and well-honed clinical insight and judgement. Throw culture into the mix and this becomes a rare set of skills held by few in this country.
As psychologists we are heavily trained in the scientist-practitioner model – we rely on the science to inform our practice. However, to date, there has not been any published research with cohorts of at-risk Indigenous people to determine treatments of best practice. Aboriginal people are therefore invisible in all the training provided to practitioners.
Indeed, back-to-back coronial inquiries, a 2016 Parliamentary Inquiry and 2018 Senate inquiry all concluded that not only are services lacking in remote and rural areas of Australia, but culturally appropriate services are often non-existent with most deceased children experiencing ‘system failure’.
So where does the focus need to be?
First, we need to recognise the significant societal contributors to child suicides, and this must start with changing the narrative on Indigenous suicides.
The core driver is that Indigenous suicide is badly understood and myths about the ‘causes’ of suicide are portrayed as if they exist as a direct linear relationship. Suicide risk factors are being incorrectly stated as causes. Why is this significant? Let me explain why.
If you eliminate a ‘cause’ you eliminate suicides, so having a national dialogue that consistently refers to alcohol, poverty, abuse, Foetal Alcohol Spectrum Disorder, colonialisation as causes is clinically incorrect. These are not causes. They are risk factors, not causes.
To understand this difference is the first step towards better and more targeted prevention efforts. There are many people who are exposed to the risks outlined above. So what separates person A who becomes suicidal, from person B who does not? We don’t currently have clear evidence of these critical causal pathways.
Once we determine a causal pathway, we can focus on determining treatments of best practice that will support clinicians to focus on eliminating established causes.
Some risk factors will be static, meaning that they cannot be changed: You cannot change someone’s date or place of birth for example, or whether they are Aboriginal or not. Other risk factors will be dynamic and changeable.
We can work on changing anxiety and responses to trauma.
Presenting poverty and colonialisation as causes offers little assistance to clinicians in identifying what is alterative and treatable in clients; we cannot undo what has been done.
It also distracts us from ascertaining the true causes of Indigenous suicide and which enable a genuine opportunity for prevention.
Our people are not killing themselves because they are poor. They are killing themselves because of racism, trauma, most likely co-morbid with risk factors of depression and alcohol and drug use, isolation and a lack of access to culturally competent clinicians and evidence-based programs.
It has often been claimed that addressing poverty in Aboriginal communities will prevent further suicides. Numerous studies have controlled for socio-economic status as a risk factor for suicides and shown that poverty does not play a ‘causal’ role. It is illogical to suggest that only children from poor families commit suicide—identifying poverty as a cause is not supported by the evidence … or common sense.
A further danger in confusing causes with risk factors is that it informs government responses.
So, taking the example of alcohol, the government decided to ‘solve’ suicides by establishing dry communities. There has not been a decrease in suicide in alcohol restricted communities, in fact the opposite is true because alcohol is an enabler or risk factor for suicide, not a cause.
The recent Fogliani Coronial Inquiry into Aboriginal suicides was another example where assumptions about Aboriginal people, rather than the evidence, shaped the findings.
“I have not found any of the children had FASD and none had been diagnosed with FASD”.
Yet Foglianis’ first six recommendations are related to FASD and 9/42 recommendations relate to FASD and alcohol restrictions. Someone point me to research that establishes FASD as a cause of suicide and the highest priority issue in Indigenous suicide prevention because I am confused?
Let’s look at where the focus should have been.
None of the children had mental health assessments, yet only 1/42 recommendations addressed improving access to culturally competent assessment. So Australian children are dying without being provided with basic mental health care and yet it is little more than a foot note in a coronial inquiry.
Suicide is so multi-dimensional and multi-faceted that unless you can undertake rigorous assessment, there is going to be an endless cycle of risk that is only ‘predicted’ once a child dies by suicide.
The most distressing outcome of failing to understand suicide causes is that it further stigmatises bereaved Aboriginal parents, inferring that most, if not all, are perpetrators or alcoholics. Perpetuating such stereotypes contributes to a general lack of empathy for Aboriginal people bereaved by suicide. It reflects a ‘they did it to themselves’ mentality that is not only inaccurate, but unhelpful and unkind.
When non-Indigenous children die by suicide, we rightly look for deficits in society or systems and how we need to ‘do better’ as a society.
When Indigenous children die by suicide, why is it that we look for deficits in their families, in their culture? Why don’t we have a more empathetic view of Indigenous child suicides and for Indigenous families bereaved by suicide?
What are the answers?
Unfortunately, the gaps are obvious and have been for decades.
First, universities need to set minimum standards of cultural competence in the degrees undertaken by those in the ‘helping professions’. Most would be lucky to have an hour of cultural training and are then sent out to Indigenous communities where cultural barriers render the most gifted clinicians paralysed.
I have developed a normed Aboriginal Mental Health Cultural Competency Profile which has demonstrated the capacity to measure, support and improve cultural competency development. This is objective and measurable and provides a useful method for educational institutions in order for them to set minimum standards.
Secondly, we need to assess and screen for early risk.My PhD resulted in the development of the Westerman Aboriginal Symptom Checklist – Youth (WASC-Y) – a culturally validated psychometric test to screen youth at risk. Despite this, we do not have a widely accepted methodology to assess for suicide risk in Indigenous people.
Whilst the WASCY and adult version, the WASC-A have been around for two decades and over 25,000 clinicians have chosen to be accredited in it, access into high risk areas is limited by the lack of wide scale government roll out of the tool.
The WASCY also enables clinicians to determine treatment impacts and best practice approaches in reducing suicide which are currently absent from the research.
Third, we need to understand the causes of Indigenous suicide. The priority needs to be to analyse the suicide death data to firmly establish causal pathways to suicide. If the suicide data were analysed in a way that determined ‘causal’ pathways it would quite simply change the paradigm of this area.
The big picture thinking is to use continuous suicide data (suicide risk factors that move and change) gathered by the WASCY and Adults (WASC-A) to determine causal pathways and co-variates (i.e. depression and suicide risk) and determine whether a reduction in these factors reduces the overall suicide death rate.
This is complex but these two data sets will enable us to determine what risk factors are contributing to the suicide death rate in more of an immediate, measurable and responsive way. Access to this data will likely take many months to pass through ethics committees, but we will self-fund this to fast track this vital information and to speed up crucial gaps in our knowledge in this area.
Fourth, we need to determine whether Indigenous suicide is different.The WASCY has determined a different set of risk factors for Indigenous suicide finding, amongst other things, that up to 60% of suicide risk is accounted for by impulsivity. Those with impulse-control issues are more likely to have limited coping mechanisms that would otherwise enable self-soothing specific to interpersonal conflict. This pattern often occurs with those who have trauma and attachment related issues the origin of which for Aboriginal families often lying in the forcible removal from primary attachment figures.
With the increasing evidence of the impacts of race-based trauma there is a need to address societal contributors to Indigenous suicides. Bryant-Davis and Ocampo (2005) amongst others, have noted similar courses of mental illness between victims of violent crime and victims of racism.
In Australia, Paradies (2016) has found that racism explains 30% of depression and reduces Aboriginal life expectancy more than smoking!
Just as trauma frequently becomes a central organising principle in the psychological structure of the individual, trauma has become a central organising principle in the psychological structure of whole communities. This is known as ‘repetition compulsion’ meaning those individuals who have had a previous traumatic event are at increased risk for future trauma experiences. Suicide ‘clusters’ are an obvious and common consequence of trauma repetition compulsion.
From a suicide prevention perspective, racism manifests as a sense of hopelessness and helplessness which has consistently been implicated in suicide risk. When the origin of this lies in racial identity it seems inherently ‘untreatable’ as a core risk factor and unchallengeable as a core driver when a suicidal individual develops thought processes based upon a belief that they don’t matter. When those within the ‘system’ and broader community show no visible sign of caring this cognition then becomes increasingly engrained through daily reinforcement.
The best I can do as a clinician is to assist my clients to develop healthy and robust cultural identity and acquire the skills and resilience to manage racist events. The WASCY provides a cultural resilience assessment which enables clinicians to ‘treat’ those factors that have been demonstrated to moderate or buffer suicide risk. This is crucial to prevention.
Epigenetics tells us that racism impacts on Aboriginal people in the same way as a traumatic event. The fact that most of our suicides are so impulsive makes absolute sense from a trauma perspective.
We need evidence-based suicide intervention programs. We are also about to publish an article on the impacts of a whole of community suicide intervention in relation to Indigenous suicides. This is the first evidence-based program which has demonstrated a measurable reduction in suicide risk factors. Whilst it is crucial that these programs are widely available in high risk communities the absence of funding negates this possibility.
Finally, we turn to our political leadership. We look for guidance in what resonates in the conscience of our nation. I wrote recently about the silence of our political leaders during the Fogliani coronial inquiry into these 13 deaths of Indigenous children in the Kimberley.
Not a single question in the Lower House of the WA Parliament has been asked about the coroner’s report, nor what was going to be done about it. The ABC reported only 9 of the 95 Members of Parliament have brought up the inquest, in either chamber, in any way this year.
Studies support that there exists a ‘hierarchy of newsworthiness’ in which ‘cultural proximity’ to the audience plays a crucial role in the extent of empathy generated for victims (Dowler, Fleming & Muzzatti 2006; see also Meyers 1997). The more the audience relates to victims, the greater the newsworthiness. If the broader community can’t connect in a ‘this could happen to me or my family’ manner, then there is less community outcry and significantly less pressure on politicians to respond because, ultimately, they are very aware that there will be little to no backlash.
When those who are mandated to care fail to respond your trauma becomes magnified.
The silence of our political leaders has served to magnify the trauma of these families and in effect has become systemically perpetuated by them.
By Dr Tracy Westerman