National Youth Suicide Prevention Strategy Communications Project

This article provides a content analysis of crisis intervention and primary care activities identified in the first National Stocktake of Youth Suicide Prevention Activities which was conducted by the Australian Institute of Family Studies during 1997-1998. The methods used to conduct the stocktake and code the data are described elsewhere (Mitchell 1999) as are some important limitations of the data set which impact on reliability and validity and restrict the conclusions that can be drawn. This analysis focuses on three main fields from the stocktake database: populations and risk factors targeted; the types of organisations involved; and the main interventions used.

Crisis intervention and primary care were combined as descriptive concepts in Youth Suicide in Australia: the National Youth Suicide Prevention Strategy (CDHFS 1997). While they are clearly different activities, they are somewhat related in practice as a considerable number of programs providing primary care are also providing crisis intervention. Also if we try to place them within the public health model they would probably both belong to the same broad category of ‘secondary prevention’.

For the present purposes primary care has been defined according to WHO usage which describes primary care as the first level of the health care system (Barnes, Eribes et al 1995). Thus primary care includes care provided by primary care providers such as general practitioners, community health services and emergency departments and excludes activities by specialist services. Crisis intervention has been interpreted as any intervention which takes place in response to an acute crisis being experienced by a young person.

A total of 191 projects in the Stocktake (20.8% out of 919) are identified as belonging mainly to this category of Crisis intervention and primary care. Nine of these are NYSPS funded and 28 are state/territory strategy projects.

Table 1 below shows the types of populations targeted by Crisis intervention and primary care projects. The largest proportion of projects (n=81, 42.4%) are not targeted at any particular groups but are available to the general population of young people.

A large proportion of projects (n=71, 37.2%) are targeted at particular high risk groups. Four main high risk groups were identified. These are: generalised disadvantage (n=21, 11.0%), homelessness (n=19, 9.9%), past attempt or self harm (n=20, 10.5%) and individuals with mental illness (n=10, 5.2%). Only a small number of crisis intervention and primary care projects target particular subpopulations (n=17, 8.9%).

Table 2 shows the types of organisations administering projects where crisis intervention and primary care is the main prevention approach. Only organisational types represented at least twice are shown.

Six types of organisation dominate this area of activity: community organisations (n=30, 15.7%); community health services (n=25, 13.1%); youth services (n=23, 12.0%), schools (n=14, 7.3%); accident and emergency departments (n=13, 6.8%) and religious organisations (n=12, 6.3%).

Table 3 shows the 20 most frequent interventions being used by projects where crisis intervention and/or primary care is the main prevention approach.

A total of 76 projects in the category of Crisis intervention and primary care (39.8%) target the general population or do not involve any special targeting of subpopulations or high risk groups. Three main organisations are involved in administering these programs: community organisations (n=20, 24.7%), community health services (n=13, 16.0%) and youth services (n=11, 13.6%). There are also a number of programs based in state government departments (n=4), Area/Regional Health Services (n=4) and religious organisations (n=4).

The main interventions being provided by community organisations conducting Crisis intervention and primary care projects targeting the general population are: telephone counselling, face to face counselling, referral, family mediation, community education and inservice training.

Almost all the community organisations in this group are providing some form of counselling service, either by telephone or face to face. Included in this group are well known organisations such as Lifeline, Kids Helpline and Samaritan Befrienders that mainly provide a telephone counselling service. Lifeline is represented 7 times in this sample in the form of its various branches throughout Australia. Lifeline and Kids Helpline received substantial funding through the National Youth Suicide Prevention Strategy to enhance the accessibility and quality of the counselling service it provides to young people in crisis. This has included upgraded training of volunteer staff and extensive provision of community education to increase awareness of counselling services and encourage help seeking and help giving behaviour. There are also a number of small local community based counselling services in this group of projects. Services providing counselling also generally provide referral for young people identified as in need of further assistance.

A number of organisations such as Relationships Australia and some locally based counselling services are providing interventions to support young people and families in crisis and at risk of family breakdown. A small number of community organisations are also providing general support including practical assistance to young people and families in crisis. Another activity receiving attention by community organisations is community education and inservice training aimed at assisting community members or service providers identify young people in crisis, provide immediate care and direct them to appropriate help.

A substantial number of community organisations rely on the labour of volunteers but only a small proportion indicated that they are providing systematic training to these workers.

This group of 13 programs includes those being run from Community Health Centres or other community-based health services. A number involve Child, Adolescent and Family Teams or Youth Health Teams based in Community Health Services. These programs primarily involve the provision of the primary health care services routinely provided by these organisations. These primary health care services tend to include counselling and/or assessment services. Some of these agencies are also providing crisis intervention as part of their routine service. For example one Community Health Centre has a Child, Youth and Family Team with an urgent appointment system in place to ensure young people in crisis and with any degree of suicide risk have access to an assessment within 24 hours. A Royal Flying Doctor service based in the Kimberley area has staff trained in mental health and is involved in a local suicide prevention network.

This group of programs are being run by generalist youth services (ie non-health). These youth services are providing a range of supportive services to young people including counselling, cultural and recreational activities, drop-in centres, general support of a practical nature, dissemination of information about a range of issues, advocacy and referral. These services belong to the category of primary care in the sense that they are highly accessible, do not require referral and often act as a first port of call for young people requiring help for a range of issues. These youth services are also providing a crisis intervention service in that they are available to intervene immediately to assist young people in crisis and refer them to appropriate services as necessary. A number of these youth services include families within their client group and provide family counselling and mediation. Only a few respondents mention formal referral protocols with mental health services. One has an outreach mental health worker based at their centre for 2 days per week.

The programs in general practice settings include provision of primary health care with a focus on comprehensive assessment of mental health problems and risk for suicide as well as appropriate management, counselling and followup. A GP in a rural area noted that he saw significant numbers of youth at-risk and he was hoping to establish a larger program with the local Division. A Division of General Practice in Qld is providing a Youth Crisis Counselling service to young people who cannot access psychiatrists or psychologists for financial reasons as well as training GPs in identification of young people at risk. Another Division in rural NSW has established a fulltime Suicide Prevention Service which is providing crisis intervention, support and counselling to all clients referred by local GPs including young people. This service is also providing training to GPs and community education in suicide awareness.

The programs based in state/territory government departments, Area/Regional health services, religious organisations and family/parent services are similar to those in community organisations and community health services and youth services. They include elements of primary care, general support, youth outreach, counselling, family mediation and referral, with the capacity to provide intensive support to young people and families in times of crisis. The interventions provided by the mental health services included here focus on crisis intervention and counselling provided in a manner consistent with principles of primary care in terms of an emphasis on accessibility, rapid assessment and liaison with other services that might be required by clients.

The WA Youth Suicide Prevention in Schools Program located with the Education Department is part of the WA Government Youth Suicide Prevention Strategy. This project has developed and distributed two resource packages throughout WA. One of these entitled"Making a Difference - youth suicide prevention manual" is developed by YouthLink to support community based workers in identifying young people at risk of suicide, and to provide knowledge and skills in responding to suicidal behaviour. The other resource package targets schools (see below).

The crisis intervention and primary care projects targeting students are based mainly in schools (n=14). There are also activities in universities (n=4), community health services (n=3) and TAFE (n=2).

Projects based in schools, universities and TAFE largely comprise counselling and welfare services. These initiatives are characterised by a mainly reactive orientation of responding to students presenting with crises or other problems requiring support and counselling. Some of these educational settings also have proactive detection and prevention activities in place however these are not the main preoccupation of these programs. The largely reactive orientation distinguishes these programs from those categorised as belonging to an early intervention approach. A few settings are in the process of developing guidelines for suicide prevention at an organisational level.

Two of the projects based in community health services aim to raise awareness among students about the support options available to them at times of crisis and to encourage help seeking. One of these involves conducting a Life Crisis Discussion Group in schools which explores different ways that young people might deal with crises including negative options such as risk taking and positive options such as help seeking. Another project involves the provision of a community support service to rural schools by a community nurse.

The WA Youth Suicide Prevention in Schools Program located at the WA Education Department has developed and distributed a resource package entitled "Youth Suicide Prevention - a resource package for student services personnel" . This resource is specifically designed for student services personnel to assist them identify and respond to young people at risk of suicide. It specifically highlights the roles and responsibilities of school personnel in managing crises.

A total of 71 programs focus on young people identified as being at high risk due to exposure to particular risk factors.

Twenty-one programs target young people affected by general disadvantage and or a variety of risk factors. These programs are based mostly in youth services (n=5), community organisations (n=4), religious organisations (n=4), inpatient health services/general hospitals (n=3) and community health services (n=2). The main interventions being used are: counselling, general support, referral and family interventions.

Programs based in youth services and community organisations provide a range of supportive services to disdvantaged and marginalised young people. Services include counselling, referral, practical support, advocacy, provision of information, assistance accessing services, personal development programs, cultural and recreational activities. Services are provided according to a primary care model in that they are highly accessible, emphasise empowerment, and act as a first level of assistance and gateway to more specialist assistance if these are required. These programs are generally in a position to provide crisis intervention when necessary.

Programs based in religious organisations are slightly different to those provided by youth services and community organisations in that there is more of a focus on young people within the family and on providing relief and support to families through periods of crisis. The services provided are somewhat more reactive and tend to be more focused on provision of charitable practical support whereas programs based in youth services and other community organisations generally place greater emphasis on promoting independent living skills in addition to support through crises.

Three programs based in general hospitals aim to develop protocols for assessing young people presenting with crises and who may be at high risk of suicide. These programs did not appear to be focusing primarily on young people presenting with self-harm or attempts but had a wider or less precise definition of risk.

Two programs based in community health services provide mental health services within the context of a primary health care program. These include counselling, personal development programs and provision of information.

A particularly innovative primary care service is being developed by the Geelong Division of General Practice. The Clockwork Young Peoples Health Service provides a one stop ‘drop-in’ service focusing on broad physical and mental health issues. Staffed by GPs, a community health nurse and a psychologist, Clockwork is dedicated to providing a highly accessible and comprehensive health service culturally appropriate for marginalised young people who have difficulty accessing other services. An important element of accessibility and appropriateness is long appointment times and flexible hours. The service networks closely with other agencies to enhance smooth referral, avoid duplication and obtain input and feedback regarding service development. This service also provides a range of personal development and life skills groups for young people at risk as well as family therapy and mediation. Assistance is also provided to other GPs to develop their skills in working with young people at risk.

Finally, crisis intervention with a different emphasis to others in this group is provided by the Adolescent Protective Team in the Department of Human Services in Victoria. This team has a legal mandate to intervene when adolescents are identified as suffering from significant harm due to abuse or neglect. As part of this service they provide suicide risk assessment and have protocols in place for immediate preventive intervention.

Nineteen programs focus on young people who are homeless or at immediate risk of homelessness. The major organisations involved are refuges (n=5), youth services (n=4), community organisations (n=3), religious organisations (n=3) and community health services (n=2). The main interventions being used are: provision of accommodation, general support, family mediation and counselling.

Programs based in refuges provide short-term crisis accommodation as well as a range of supportive services such as counselling, casework, advocacy, information about services. There is considerable variation in the qualifications of staff of these refuges. Respondents from two refuges noted that the service is well staffed by qualified social workers and/or psychologists while one respondent from a refuge for young women noted that they had insufficient funding to employ a much needed mental health outreach worker.

Programs based in youth services are more variable. Three provide emergency accommodation as well as other support. An innovative program called the Rage Project based at Phoenix House Youth Services in NSW provides a brokerage and counselling service. The program aims to assist young homeless people access housing and services as needed. The Project pays for goods and services needed by the young person, which may include: accommodation; health needs; education expenses; legal expenses; employment related expenses; and recreation. The Rage Project also runs a study and support group with free tutoring for homeless students. Youth services appear to have a greater emphasis than refuges and other services on empowering young homeless people with independent living skills.

Most of the programs within religious organisations and community organisations focus on families. Here the aim is to prevent homelessness among children by working with families experiencing crises that place them at risk of breakdown. Strategies used include family mediation, family counselling and parenting education.

Two projects based in community health services are providing primary health care services to homeless young people using an outreach model. Both involve outreach via a mobile bus from which they provide information about health issues and services, referral and other health promoting initiatives such as needle exchange.

A total of 20 crisis intervention programs focus on young people who have self harmed or made suicide attempts. Seven of these are NYSPS funded projects. The main organisations involved are accident and emergency departments of general hospitals, Area/Regional health services and community health services. The main interventions being used are protocols, assessment, referral and follow-up. Some programs provide training to staff members and/or parents to assist them identify signs of risk for suicide. The National Strategy projects have a substantial research and service development component.

Programs based in accident and emergency departments of general hospitals are generally providing assessment and some form of intervention such as counselling or social work services to young people presenting with self-harm or suicide attempt. This group includes two NYSPS projects and a WA Strategy project which are developing protocols for assessment, intervention and follow-up. The NYSPS project based at Shoalhaven Hospital in NSW, which is now completed, involved research that documented changes in follow-up service provision following presentation and mapped these changes against any re-presentations for suicide attempt. The aim was to generate data that could be used to develop best practice guidelines for follow-up.

There are three NYSPS programs based in Area/Regional Health Services. These have taken a somewhat more comprehensive approach than those based in accident and emergency departments in that they have generally included research into suicide attempts and presentations across a range of settings within the Area/Region, research into staff attitudes, exploration of clinical pathways and current service responses. This research informed the development of best practice protocols and staff education.

Three projects are based in mental health services. Mental health services are often responsible for provision of clinical followup for people presenting to hospital following suicide attempt or self harm. Two of the projects represented here are providing this service routinely. A NYSPS project based at Blacktown Mental Health Service has involved rigorous evaluation of the followup service provided. This has included exploration of the followup provided to clients not diagnosed with mental disorder, who are often neglected when followup is provided exclusively by mental health services.

Programs in community health services are providing counselling to young people experiencing suicidal crisis or following an attempt. One of these involves close collaboration between a Child, Youth and Family Service, an Emergency Department and Acute Case Services to provide a 24 hour rapid response to young people and their families following a suicide attempt.

Another crisis intervention service represented in the database is that of the Poison Line telephone information service located at Canberra Hospital. The Poison Service attempts to: retrieve information about the caller and his/her location without alarming or alienating him/her; obtain information about the action taken or planned by the caller; encourage the caller to accept help, to get to a medical facility where follow-up can be initiated; reduce the incidence of repeat suicide/parasuicide attempts. By focusing on high risk groups this program aims to reduce the number of people who attempt suicide by drug overdose.

The National Youth Suicide Prevention Strategy has also funded a project by the Australian College for Emergency Medicine to develop guidelines for management of deliberate self-harm in young people.

Ten crisis intervention and primary care programs focus on young people affected by mental disorder. These are based mostly in mental health services including Child and Adolescent Mental Health Services, Area/Regional Mental Health Services and Community Mental Health Services.

Five of these programs involve specialist crisis services attached to the main service. Specialist crisis services generally provide a first contact service including rapid response assessment, emergency treatment followed by referral for ongoing management. These crisis services also tend to maintain close links with primary care providers such as GPs and youth and family services in order to enhance access to the crisis team.

Bundaberg Area Youth Service runs a small specialist mental health crisis service. This program operates on an outreach model and targets young people who are at risk of developing mental health problems as well as those with diagnosed mental disorders. The crisis service liaises closely with a mental health service. There would appear to be a need for further development of this type of program as lack of responsiveness by mental health services to young people in crisis but not currently diagnosed with mental disorder is a very common complaint by primary care providers, youth workers and other service providers who work regularly with young people.

The other programs targeting young people with mental health problems provide crisis intervention within the context of a generalist child and adolescent, community or inpatient mental health service.

Two programs focus on young people involved with the justice system. The New South Wales Police Service has a proactive and reactive role in preventing youth suicide, mostly using referral agencies. The police aim to get young people into professional care before drug/alcohol abuse or mental disorder reaches crisis point. The police also endeavor to take appropriate action with people in custody who may be suicidal.

A total of 17 projects target young people from particular subpopulations. Three programs targeting same sex attracted and transgender young people provide crisis telephone counselling and one provides accommodation. Four programs target the Aboriginal and Torres Strait Islander populations. Two of these provide primary health care, one provides case work and one provides community education focusing on suicidal young people. The programs targeting women include crisis accommodation and support, counselling, case work and welfare services. Three programs target young people from non-English speaking backgrounds. These include provision of primary welfare services by a Lebanese Women’s Association, streetwork targeting young people from non-English speaking backgrounds and a family mediation service that employs counsellors from numerous non-English speaking background communities. Males are a target population of three crisis intervention and primary care programs. These include: crisis accommodation and case management provided by a community organisation; a specialist suicide prevention project by a rural Division of General Practice which provides crisis support and counselling to men of all ages, and a Young Men’s Support Network which provides a counselling and group programs to support young men recover from traumatic experiences. This latter program also conducts workshops in schools.

Across all target groups there are two main types of program represented in this group of projects: (1) programs that provide crisis intervention only and (2) programs that provide crisis intervention as part of a comprehensive primary care service that is available before, during and after crisis. The first group of programs includes mainly telephone counselling and accident and emergency services. The National Youth Suicide Prevention Strategy has focused its support on this group of projects.

A recent review of the evaluation literature reveals no evidence that the widespread establishment of crisis focused programs in western countries has affected suicide rates in those countries (Patton & Burns 1998). However one study found evidence of an association between availability of crisis intervention services and a reduction in suicide rates for young white females, who were the commonest users of these services (Miller, Coombs, Leeper & Barton 1984). This suggests that efforts to increase utilisation of these services by young people at risk such as young males might be productive. This has been a major focus of the work funded by the NYSPS. Future research could also focus on identifying which, if any, aspects of the service provided by organisations such as Lifeline and Kids Helpline could be effective in reducing rates of suicidal behaviour among callers.

The NYSPS has also directed considerable resources to enhancing the capacity of health services to identify and appropriately respond to young people who present to hospital following self-harm and suicide attempt. At present there is little information available about interventions that are effective in enhancing engagement of young people who self harm or attempt suicide with services in the longer term (Patton & Burns 1998). Evaluation of the NYSPS projects in this area will hopefully provide some relevant data. There is also evidence that only 10% of adolescents who attempt suicide actually present to Accident and Emergency Departments (Patton, Harris, Carlin et al 1997 & Silburn, Zubrick & Acres, 1997 both cited in Patton & Burns 1998). There is a need for further research to investigate the effectiveness and cost effectiveness of interventions based in Accident and Emergency Departments. Considering the low proportion of attempters who present to hospital it may also be worthwhile to further explore community based methods of engaging with this risk group.

The NYSPS has given relatively less attention to the primary care component of crisis intervention and primary care programs. Primary care involves a wide variety of ‘first line’ services including traditional primary health care as well as community-based youth and welfare services. In responding to suicidal behaviour among young people these primary care services aim to be highly accessible and appropriate to the needs of young people, especially those affected by individual risk factors.

Certain types of organisations that we might expect to be highly involved in providing primary health care to young people at risk of suicide are not well represented in this sample of projects. The most notable of these is general practice. It is likely that general practitioners were not adequately included in the distribution of the stocktake questionnaire. The NYSPS is currently addressing the role of general practitioners through research into their roles and provision of education and training to enhance general practitioners’ skills in identifying, engaging and working with young people at risk of depression (see section on Education and Training projects). Collaboration between GPs and mental health services has received considerable attention through grants to Divisions of General Practice to develop models of Shared Care. Patton and Burns (1998) note that the availability and utilisation of treatments for depression in young people in primary care settings is unclear. It will be important for the Second National Stocktake to explore activity in this area more thoroughly.

The present analysis, though cursory, suggests a number of other issues affecting primary care services that may be worthy of attention in the future. Lack of backup services was identified as a major barrier to prevention of youth suicide by respondents describing crisis intervention and primary care projects. There is also evidence of considerable variability in the extent to which primary care programs are linked in with mental health services through formal and informal referral protocols or other forms of liaison. Primary care providers who work closely with young people at risk also commonly complain of a lack of responsiveness by mental health services to requests for crisis assessment and intervention prior to actual suicide attempt.

The lack of backup services has been addressed largely through enhancements to child and adolescent mental health services. Mental health policy also calls for greater collaboration between mental health and other primary care services (Australian Health Ministers 1998).

Exploration of successful models of collaboration between mental health services and other primary care providers, along with encouragement of initiatives modeled on demonstrably effective strategies could be an important area for future investment.

Returning to crisis intervention, police services might be expected to have more of a role to play in this area. It will be important to ensure police services are surveyed more thoroughly in the Second Stocktake.

The present analysis also reveals major gaps in the extent to which crisis intervention and primary care programs are addressing the needs of subpopulations with special needs. Only 8.9% of the programs in this group include special targeting of these populations. Greater attention needs to be given to high risk populations such as Aboriginal and Torres Strait Islander young people, same sex attracted youth, males and young people from non-English speaking backgrounds. It is notable that young people from several of these groups are underrepresented in the mental health system and overrepresented in the criminal justice system (Hearn 1993; Mitchell 1998).

Australian Health Ministers (1998) Second National Mental Health Plan. Mental Health Branch, Commonwealth Department of Health and Family Services.

Barnes D, Eribes C, Juarbe T, Nelson M, Proctor S, Sawyer L, Shaul M & Meleis A (1995) Primary Health Care and Primary Care: A Confusion of Philosophies. Nursing Outlook, 43 (1), 7-16.

CDHFS (1997) Youth Suicide in Australia: the national youth suicide prevention strategy. Australian Government Publishing Service, Canberra.

Hearn R (1993) Locked up, locked out: The denial and criminalisation of young people’s mental health crisis. Victorian Community Managed Mental Health Services Inc., Fitzroy.

Miller H, Coombs D, Leeper J & Barton S (1984) An analysis of the effects of suicide prevention facilities on suicide rates in the US. American Journal of Public Health, 74, 340.

Mitchell P (1998) Suicide and Young People in the Justice System. Youth Suicide Prevention Bulletin No.1., 13-19.

Mitchell P (1999) First national stocktake of youth suicide prevention activities: A content analysis. Youth Suicide Prevention Bulletin, No 2, 2-7.

NH&MRC (1997) Depression in young people: Clinical Practice Guidelines. Australian Government Publishing Service, Canberra.

Patton G & Burns J (1998) Preventive interventions for youth suicide: a risk factor based approach. In Commonwealth Department of Health and Aged Care.Youth Suicide Literature Review: Setting the Evidence-based Research Agenda for Australia. AGPS, Canberra.

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For further information about the Youth Suicide Prevention Communications Project, contact the Australian Institute of Family Studies, Level 20, 485 La Trobe Street, Melbourne, Victoria 3000, Australia. Telephone: (03) 9214 7888; International: 61 3 9214 7888. Facsimile: (03) 9214 7839; International: 61 3 9214 7839. Email: Webmaster.