Highest risk groups to suicide

In recent years Australians have been learning that suicide is a leading cause of death and they have been discovering the hidden toll of suicide and of its impacts on those left behind. However what have we learned of the ways forward in suicide prevention and in improving the levels of emotional and mental health wellbeing for those who are vulnerable? Are some people more vulnerable than others and if so, why? Who are those most at risk?

Suicide is a leading cause of death for teenagers, for Indigenous peoples in countries with relative recent colonial oppressor history, for Lesbian, Gay, Bisexual, Queer, Transgender and Intersex. These are among the highest risk groups and for them it still appears that the suicide trends will get worse, that more lives will be lost. Despite 28 countries claiming that they have established national suicide prevention strategies little has been achieved. The suicide prevention strategies are effectively just troves of paper. Generalised frameworks with very little that is tailor made. The highest risk groups are being missed altogether. Australia is one of the 28 nations with a suicide prevention strategy but for those of us in the suicide prevention space we know that it is paper heavy, generalised, weak and ineffective, maybe dangerous and not just because of its omissions but also by what it applies. These generalised frameworks sponsor only ad hoc funding that remains forever inadequate. Sadly, lobbying determines funding, not what works in suicide prevention. Australia has failed to prioritise suicide prevention and failed to deliver authentic responses. Yet, suicide takes more Australian lives than the road toll, two and half times.

Because suicide prevention has been failed as dedicated space, what little funding is made available is competed for by tiers of unrelated mental health and research groups. Many stakeholders badged as suicide prevention experts and who draw relative significant funding only posit papers and in some cases to facilitate pricey workshops are not the leaders or experts. In my book, they are carpetbaggers. The only leaders in suicide prevention I have met are at the coalface, talking down suicidal individuals, responding to suicide related trauma, talking to families and communities and working alongside them to reduce distress levels and helping to steer them to positive pathways. The top end of town experts have long lost the plot but fill the government boards and national steering committees.

In Australia, it will soon be known that the highest risk groups to suicide are former prison inmates and individuals who as children were removed from their families and into the care of the state. The research is unfolding. Children who have been in care are three times more likely to finish up in prison. The national suicide rate has increased to 12.2 suicides per 100,000 people. The Kimberley’s Aboriginal and Torres Strait Islander peoples’ suicide rate is nearly 80 per 100,000, the highest in the nation. Greenland’s Inuit peoples have long endured the world’s highest suicide rate. Greenland’s overall suicide rate is 92 per 100,000. The world’s highest national suicide rate belongs to Guyana, 44 per 100,000. I estimate that the suicide rate for Australians who as children were removed into state care is in excess of 300 per 100,000. That is nearly four times the highest demographical suicide rate in the nation, that of the Kimberley’s tragic Aboriginal and Torres Strait Islander suicide toll..If we do not disaggregate to children in care, to foster children, to former inmates, to LGBQTI, to migrants, to cultural groups then we make them invisible, we discriminate. I estimate that the suicide rate for Australians who have been to prison is in excess of 250 per 100,000 and possibly more than 300 per 100,000. I hope to be proven wrong but thus far I have been right about nearly all my research, disaggregating, estimations.

Suicide is a leading cause of death among the nation’s teenagers, of young adults but more so among Aboriginal and Torres Strait Islander peoples and then very likely next highest among Australian children who were born overseas or of parents born overseas. Aboriginal and Torres Strait Islander children are removed from their families and into the care of the state at alarming rates. One in ten of NSW’s Aboriginal children have been removed from their families. Nationally, the rate is thereabouts one in 15 Aboriginal and Torres Strait Islander children. More than 16,000 Aboriginal and Torres Strait Islander children are currently removed. I estimate that since the turn of the century thereabouts 50,000 children have been removed. The Aboriginal and Torres Strait Islander population is 730,000. Nearly half the Aboriginal and Torres Strait Islander population is comprised of children (aged 18 years and less).

The high suicide toll of Greenland’s and Canada’s First Peoples are predominately of young people, and the median age for suicide is tragically getting lower. The majority of the suicides had either a history of child removal or of their families displaced from their communities and into regional and urban masses. Australia’s outrageously high removal rate of Aboriginal and Torres Strait Islander children – the world’s highest – and the concomitant increase of the Aboriginal and Torres Strait Islander prison population and the Aboriginal and Torres Strait Islander suicide rates cannot be coincidental.

We find ourselves without a clear picture of Australia’s mental health, only snapshots. We need to diversify the research, to disaggregate so we can respond with tailor made responses.

Suicidal behaviour does not mean that someone wants to die, this is a dangerous myth. Suicidal behaviour is a scream for help – people need people. It is a fallacy to presume ‘self-responsibility’ as a way forward for someone in a dark place. People need people to strengthen their resolve to the ways forward. Suicidal behaviour is destructive behaviour that can lead to impulsive actions such as a suicide attempt.

Access to emotional support can save lives. It may never be realised this was the case but person to person support is a huge factor in the improving and saving of lives. Resilience and empowerment are gradually accumulated over time, to the point there comes a times that there is no looking back. It is not true that once someone has exhibited suicidal behaviour that they are forever trapped in the heightened vulnerability to recurring suicidal behaviour.

It is true that a strong indicator to future risk of suicide is a prior suicide attempt however this does not mean that the heightened risk shall be there for life. Indeed, with the coming together of emotional wellbeing and meaningful contexts, there develops resilience within the individual that can make one stronger than before. With the right sort of support, protective factors can guard people against the risk of suicide. But the support may need to be tailor made to address underlying issues and trauma that maybe unique to a certain group.

Suicide prevention should not be focused alone on reducing risk factors but just as focused, if not more so, on increasing protective factors. The strongest protective factors include building a connectedness with other people. This connectedness with other people should include the types of engagements that allow the individual to directly and indirectly draw information about wellbeing, about navigating ones journey through society, and therefore predominately focus on self-worth, identity and conflict management.

Most importantly, healthy relationships will contextualise a meaningful life, an honest life, and this in itself is a relief from the conflict and discord that arise from unhealthy levels of expectations. Personal relationships are important, where the support person can understand that they are about support and not about any particular targeted responsibility to the individual. More research needs to be disaggregated on suicidal behaviour and mental disorders, but it appears the majority of suicidal behaviour is not linked to mental disorders and rather to a sense of deep unhappiness. Therefore families and communities can contribute significantly to the improving of the life understandings of a troubled person. Supporting families to support a family member who has been incarcerated or recently released from prison is imperative and national strategies should focus on this. In Western Australia and the Northern Territory, one in 6 of all Aboriginal and Torres Strait Islanders has been to prison. There need to be awareness-raising of the issues and tailor made responses to vulnerable individuals who as children have been removed from their families. Ideally, more needs to be done to assist families to stay together instead of removing the children which elevates the propensity for psychosocial and psychological degeneration and to lives ruined deep in a constancy of traumas.

The risk of suicidal behaviour increases when individuals suffer various discord – such as a relationship conflict or from a sense of loss or from a sense of failure. People need people. Isolation is dangerous. Emotionally, former inmates and individuals who as children were removed from their families are likely to internalise a sense of isolation. Those best placed to support someone are found in ones immediate circle. They are who are present 24/7. In terms of protective factors, these are strengthened from the development of ones context of meanings and these too are contributed to and significantly validated by ones social circle.

There may have been childhood trauma, interrupted childhood development – a series of emotional instabilities and turmoil that have affected personality traits which have given way to unhappiness and suicidal risk factors. But good self-esteem and protective wellbeing factors will come from people coming together with the troubled individual at whatever point in time. These development interruptions, life stresses and unhappiness are not mental disorders that require specialist health practitioner support.

Rather this is all about people coming together to secure healthy and positive relationship building, to patiently assist one with their self-esteem, to contextualise the path to positive self-identity and the pathway to positive outlooks. Attitude is imperative but it is something shaped by the individual and by those around the individual. People do listen; they listen to the negative and the positive. Positive adaptive outcomes must be patiently but relentlessly educated and shaped, and the familial and community support self-evident and generous. Once positive attitudes and positive coping understandings settle in as personality traits, the formerly troubled individual is effectively ‘safe’.

There needs to be in society greater onus on shared understandings of contextual meanings of what it takes to shape positive coping strategies in overcoming childhood adversity – abuse, maltreatment, of exposure to domestic violence, of parent mental disorder. There should be less focus and judgment on the fact of any difficult past; it should not be the focal point but if you read newspapers it is the focus. This bent for the past is damaging because it is a trapping. The discourse needs to be focused on the ways forward and in not holding oneself hostage to any past, or in holding any person or any set of events as responsible for any ongoing damage. Positive meanings and positive attitudes will lead to an understanding and forgiveness of the past and that the present and future can be shaped. Destructive and self-destructive behaviour should be understood as situational and that individual, familial and community attitudes determine the length of these behaviours. Governments investing their attention in helping resource communities and families for instance to support others is imperative.

Most suicidal behaviours are linked, and usually exclusively, to unhappiness. Therefore the majority of suicidal behaviour is preventable. I would argue that suicide and suicidal behaviour are the major health problems society face and of all our major health problems suicidal behaviour is the most preventable. Yet suicide prevention is not a governmental priority.

Where causality is limited to relationship and social factors and to vulnerable individuals’ sense or feelings of hopelessness, the descent into a sense of entrapment and the responsive trait of impulsivity, then this behaviour can be addressed by positive mentoring.

Unhappiness is a manifestation. The prevalence of suicide and suicidal behaviour is higher in high and middle income nations as opposed to low income nations. Similarly, rates of reported depressions and of hospitalisations from self-harm are higher in high and middle income nations. Life stresses that lead to suicidal behaviour in some cultures do not lead to suicidal behaviour in other cultures. Therefore the context of our meanings and our support groups are pivotal.

The outlier in the above are discriminated minorities and peoples. In nations, especially high and middle income nations, with relatively recent colonial oppressor histories, the descendants of First Peoples have been degenerated to discriminated minorities. Unless the descendants of First Peoples accept homogeneity and hard edged assimilation they consequently experience a deep sense of discrimination. This goes to the heart of identity, to self-worth and esteem and their historical and contemporary identities become a liability. These disaggregated groups report the world’s highest rates of depressions, unhappiness, self-harms, suicidal behaviour and suicides. When it’s about identity, whether for a vulnerable child, young adult, cultural group – the answers lay in respecting one another, being there for the other, empowering each other through meanings, relationships, freedoms and attitudinally.

Suicide prevention is about the positive self and any comprehensive response includes everyone. A comprehensive national response for suicide prevention requires understanding the above. Loose understandings will tighten if we begin to understand that the majority of suicidal behaviours are directly linked to trauma and unhappiness – to situational events. Contexts and understandings can be changed before dangerous reliefs from substance abusing are sought or before serious mental disorders set in.

The point is that suicides, our leading cause of violent deaths, which receive relative little mention in the news, are the most preventable violence. Self-destructive behaviours that can culminate in suicidal behaviours and distress families and communities are in fact a leading cause of familial breakdowns. Once again, the point is that this behaviour is the most preventable of the various destructive behaviours that impact families and communities. These need to be prioritised in national conversations, by the media, by our governments.

One in 9 Aboriginal and Torres Strait Islanders living have been to jail – with Western Australia and the Northern Territory the statistic rests at one in 6. Is it a surprise then that one in 19 Aboriginal and Torres Strait Islander deaths are registered as a suicide, a staggering and harrowing statistic? There is an under-reporting of suicide and my estimation is that one in 10 to one in 12 deaths are a suicide. The dramatic jailing rates and the abominable suicide rates appear intertwined.

Having visited prisons and long worked with ex-prisoners, most of them soon after release, in order to improve their lot, it is my view that in general people come out of prison worse than when they went in. Trauma – situational, multiple and composite – is the end result. The prisons I have visited are the sorriest tales worded up with punitive tribulations and obscene neglect, corrals of troubled souls. Prisons are not about restorative and rehabilitative practicalities but corrals where inmates who want to score wellbeing stand in queues so long that the majority will be denied support. They beg for healing, for forgiveness, for literacy, for voice, for education, for opportunity.

I am not going to argue the economic benefits to society; that it is cheaper to invest in people’s restorative wellbeing, education, and in alternatives to incarceration than it costs to incarcerate and deliriously punish. These arguments disgust me. These economic cost/benefit arguments indict us all as a society, damn our values and keep us hostage to vicious cycles. The economy should be geared to society and not that society should be hogtied to the economy. I insist on discussing moral imperatives instead of framing our values in economic assumptions.

We should be disgusted by a society that incarcerates the poorest of the poor, the sickest, the unwell, that discriminates against minorities who reject assimilation.

According to the Australian Bureau of Statistics (ABS), 86 per cent of prisoners did not complete Year 12, while more than 30 per cent did not get past Year 9. Former prisoners are an elevated risk group to suicide, which I estimate at least at 250 suicides per 100,000 people. Researchers Kate van Doreen, Stuart Kinner and Simon Forsyth, wrote “the risk of death is greatly elevated among ex-prisoners compared with the general population.” They stated, “Although many deaths are drug-related or the result of suicide, little is known about risk and protective factors for death in this population.”

Importantly, van Doreen, Kinner and Forsyth suggest “young people experience markedly increased risk of death in the year following release from adult prison.”

“This elevation in risk is greater than that experienced by older ex-prisoners. Among young ex-prisoners, the majority of deaths are due to preventable causes, particularly injury and poisoning, and suicide.”

According to the research, former inmates are ten times more likely to suicide or die an unnatural death in the first year post-release than at any time while in prison.

Youth in the juvenile justice system and child welfare systems are riddled with mental, emotional and behavioural risk factors that for many play out with suicidal ideation. But it’s after the childhood, a protective factor in itself despite that it maybe a train wreck childhood, in the twenties and thirties age groups that suicide ideation becomes more pronounced. Some overseas studies have found youth who have gone through juvenile detention are more than four times at greater risk to suicide. Children in foster care have been found three and four times more likely to suicide. LGBQTI are at least three and four times more likely to suicide. Other high risk groups include those with military service, those who have been sexually abused.

Disaggregation to elevated risk groups assists in understanding the act of self-harm in relation to the underlying intents. Tailor made responses will go to heart of the issues, to specific traumas and risk behaviours. Suicide risk factors are different for different groups and the lack of precise understandings makes it difficult to identify clearly the risk and protective factors.

Children who have been removed from their families have traumatising backgrounds compounded by the situational trauma of the removal and then there is the risk of a constancy of traumas and the elevated risk of degeneration into aggressive complex traumas. Despite the extensive data on self-harm and suicide very little data exists on identifying whether they had been children in care.

Suicide is the 3^rd most common cause of death globally of people aged 15 to 25 years. More than 150,000 adolescents take their lives every year. Studies are finding that a significant proportion had been removed from their families when children and/or had been to prison. Australia’s outrageously high rate of taking Aboriginal and Torres Islander children from their families and the just as outrageous jailing rates are culminating in the high self-harming and suicide tolls. Many children while in the care of the state and in foster care are known to self-harm. I argue that childhood is in general a protective factor and the unaddressed traumas of train wreck childhoods play out for many once they are outside of childhood, once on their own, and often are compounded by other pressures such as navigating adulthood and family building.

We all need connectedness, belonging and stability.

– Gerry Georgatos is a suicide prevention researcher, suicide prevention campaigner and prison reform advocate with the Institute of Social Justice and Human Rights.

Lifeline’s 24-hour hotline, 13 11 14

Crisis Support and Suicide Prevention Beyond Blue – 1300 22 4636

Listen to: ABC interview with journalist Nadine Maloney – spreading the love

Other articles and media on the extensiveness of suicides and on suicide prevention by Gerry Georgatos:

Migrant suicides – before it’s too late

Migrant suicide is lost in translation

Migrant suicides – more than 1 in 4 Australian suicides are of migrants but discussion is lost in translation

Suicides high among overseas born and second generation Australians

Oppression is the critical cognitive factor in the majority of the suicides

The generation of racists I grew up with are now in parliament

Attawapiskat suicides are the tip of the iceberg

Kunoth-Monks, Sansbury, Muir, Bonson, Waters