National Youth Suicide Prevention Strategy Communications Project

As part of the Communications Project of the National Youth Suicide Prevention Strategy, the Australian Institute of Family Studies has recently completed a national stocktake of youth suicide prevention activities. Information on over 900 projects throughout Australia has been collected and entered into a database. This article provides a content analysis of information from the Stocktake database about projects that adopt an ‘early intervention’ approach to suicide prevention.

Identifying and describing the range of ‘early intervention’ activities in the Stocktake database is largely an exercise of exploration and discovery. However as in explorations and investigations of any kind, what we are able to ‘discover’ will always be constrained by the preconceptions we have about what we are looking for. In overcoming or seeing past these constraints it helps to try and be clear about what our preconceptions are.

The National Youth Suicide Prevention Strategy (NYSPS) has involved a comprehensive variety of approaches to the persisting high rate of suicide among young people in Australia. Ways of thinking about these various approaches are evolving as the current Strategy enters its later stages and as information becomes available about the process of project implementation.

When the NYSPS was initiated the following direct approaches to prevention were identified in the major policy document (CDHFS 1997):

• Injury prevention;

• Primary prevention and cultural change;

• Crisis intervention and primary care;

• Support and postvention;

• Community development and support;

• Indigenous, specialised and culturally diverse.

One of the steps I took in analysing the data from the National Stocktake of activities was to categorise each of the direct prevention projects (as opposed to projects that operate at a broad system level) into one (and only one) of these main prevention approaches (except ‘Indigenous, specialised and culturally diverse’ which was incorporated into a separate field for target population). This was not always an easy task and there was one important area of particular difficulty. I kept finding projects that were clearly oriented towards intervening as early as possible in emerging problems that could place young people at risk of suicide in the future. These projects did not fit into any of the five categories identified in the policy document so I created a new category of early intervention.

But what do I mean by early intervention? The categorisation system above (even an extended one) is problematic in attempting to answer this question. We might be able to clearly distinguish early intervention from primary prevention but there is quite a lot of overlap between early intervention and concepts such as ‘primary care’ and ‘community development’. Primary health care services are (or should be) a key setting for effective early intervention and community development is a key strategy for expanding the network of people who can play a role in identifying young people at risk and facilitating their early access to appropriate help. Concepts such as early intervention, primary care and community development do not actually belong in the same conceptual system. Early intervention is an approach to suicide prevention while primary care is a setting and community development, a specific activity or intervention.

At a recent meeting of the expert panel which is providing advice to the Australian Institute of Family Studies in the conduct of the National Communications Project of the NYSPS there was general agreement that the most useful and up-to-date concepts for describing approaches to suicide prevention are: (1) the public health concepts of primary; secondary and tertiary prevention (Commission on Chronic Illness 1957 cited in Mrazek & Haggerty 1994) which refer to the stage of development of disorder in affected populations; and (2) the concepts of universal; selective and indicated prevention (Mrazek & Haggerty 1994), more familiar in mental health circles, which refer to the population groups targeted.

For the sake of simplicity I have chosen to use the public health framework of primary, secondary and tertiary prevention in the present exploration of early intervention projects. Further, for the sake of clarity I have placed early intervention firmly within the realm of secondary prevention.

Secondary prevention is concerned with lowering the prevalence of problems or disorders in the population (Mrazek & Haggerty 1994). Secondary prevention includes intervening when risk factors are detected to prevent or delay the onset of disorder (or the outcome being prevented) and intervention in the course of an emerging problem/disorder with the aim of shortening its course or preventing its reoccurrence. In the context of suicide prevention, secondary sprevention involves intervening early when risk factors for suicide have emerged or are emerging to prevent the onset of suicide related behaviour. Secondary prevention occurs before suicide related behaviours emerge. Once suicide related behaviours have emerged, intervention is by definition, within the public health framework, tertiary prevention. Primary prevention of suicide involves preventing the development of proximal (also referred to as second-order or person-level by Silverman & Felner 1995) risk factors for suicide.

The term ‘early intervention’ also clearly implies an element of selectivity, and perhaps, specificity, in terms of who interventions should be directed towards. Thus the concepts of selective and indicated prevention as defined by Mrazek & Haggerty (1994) are clearly very useful here. This suggests that a precise definition and understanding of the place of early intervention in the spectrum of interventions may require a framework that utilises the insights of both the established frameworks, in relationship with each other.

Mrazek and Haggerty (1994) have rejected a framework that blends or integrates these contrasting conceptual systems and here is not the proper place to attempt full explication of an integrated framework that might be appropriate. Suffice it to say that Mrazek and Haggerty reject this integration in the context of presenting a framework for understanding prevention of mental disorders and we are talking here about prevention of suicide related behaviours, for which mental disorders are but one risk factor, albeit a most important one. It is mainly for this reason that I prefer not to use the intervention framework provided by Mrazek & Haggerty (1994). I do however occasionally borrow the terms selective and indicated because I find them useful words although there is a risk of using them in ways and places that Mrazek and Haggerty might disapprove of.

The first National Stocktake collected data on over 900 projects. This includes 65 projects funded under the National Youth Suicide Prevention Strategy (NYSPS).

A total of 85 projects are included in this analysis of early intervention projects. These include 59 projects where early intervention is identified as the main prevention approach and a further 26 that were categorised as belonging to other prevention approaches but included a strong focus on early intervention strategies. Only 5 of the 85 projects are NYSPS funded projects.

Projects are included in the category of early intervention if they belong to the domain of secondary prevention and included an element of proactive case finding or other mechanisms for enhancing early identification of candidates for intervention.

Projects that involve treatment or intervention with clearly established disorders or problems that did not also include evidence of an element of proactive case finding or other mechanisms for enhancing early identification were not included in the category of early intervention. This is a conservative application of the definition of early intervention as secondary prevention. From the information provided in the Stocktake it is often very difficult to discern whether projects are intervening only before the onset of suicide related behaviour (‘indicated prevention’ at the risk of misusing Mrazek and Haggerty’s term) or whether they were also including individuals who had developed these behaviours (tertiary prevention). In reality the populations targeted by many services are very mixed and include young people who have and have not developed self-harm and suicide related behaviour without making clear distinctions between them. A conservative approach was adopted in the present analysis in an attempt to minimise inclusion of projects that were primarily tertiary prevention.

In the present analysis it is also important to distinguish early intervention from primary prevention. Thus selectively targeted primary prevention has not been included as early intervention.

Data from the 85 early intervention projects were organised according to two further fields: target group and organisational setting.

Early intervention projects were focused on five major target groups: (1) the general population (n=9); (2) students (n=26); (3) young people exposed to a wide range of general risk factors (n=14); (4) young people with emerging or early stage mental health problems (n=21); and (5) young people belonging to other particular high risk groups (n=15) eg homeless, Aboriginal and Torres Strait Islander, involved in the justice system, males, victims of sexual assault, bereaved by suicide.

These projects were being conducted by four types of organisations: community organisations (n=5); Divisions of General Practice (n=2); a Public Health Unit (n=1); and a Family/Parent/Child Service (n=1).

The main strategy employed by early intervention projects targeting the general population was community education aimed at enhancing community awareness of mental health and youth suicide issues. Community education was explicitly aimed at enhancing community members’ ability to identify young people at risk and assist them to access appropriate help for any problems they may be having. In other words the aim was to enhance early intervention.

In addition to community education, Divisions of General Practice were promoting the development of networks between general practitioners and other service providers and providing training to their members in the identification, referral and management of young people at risk.

A wide range of organisations were involved in projects targeting students. The main types of organisation were: schools (n=13); community organisations (n=2); youth services (n=2), a Child and Adolescent Mental Health Service, a Community Mental Health Service, a Police Service, a University, a Community Health Service, a Family/Parent/Child Service and a Professional Association.

Activity in schools was focused on establishing systems for identifying students experiencing problems that could place them at risk of suicide and ensuring that they are provided with appropriate support such as counselling or referral to other services. These systems tended to involve policies and procedures as well as definition of clear roles for staff. Some systems included all staff while some included only certain designated staff.

The other major area of activity in schools is provision of education to students (and to a lesser extent, teachers) about mental health, mental illness, suicide and helping strategies. As with education provided to the general population the aim is to enhance the capacity of young people to identify problems in themselves and their peers in order to facilitate access to appropriate help.

A smaller number of schools were implementing secondary prevention programs selectively targeted at young people identified as being at risk. These included personal/life skills groups and coping with depression groups.

Projects conducted by other organisations targeting students were similar to those based in schools. Provision of education about mental illness, suicide, how to seek help as well as identification of individuals at risk were major activities. There were also two projects targeting students at risk of school drop out.

These projects were based in a very wide variety of organisational settings. These included: youth services (n=3); Child and Adolescent Mental Health Services (n=2); Police Services (n=2); Community Health Services (n=2); universities (n=2); a community organisation (n=1); a religious organisation (n=1); a government department (n=1); a Community Mental Health Service (n=1); and a Division of General Practice (n=1).

As with projects targeting the general population and students there was a strong focus on activities which aimed to identify or facilitate identification of young people at risk. The main strategies in this regard were community development and community education aimed at enhancing the capacity of community members to identify and assist young people at risk. Another important strategy was development of interagency networks to enhance referral processes and collaboration. A few services were also providing training to providers in other services aimed at assisting them identify young people at risk.

On the intervention side, several services were providing counselling and general support to marginalised young people. One youth service was also providing group based programs in schools and a Child and Adolescent Mental Health Service was providing a life problem solving skills group targeting young people who were presenting with a wide range of behaviour and social problems. A program based in a university focused on developing resilience and other skills for coping with depression and anxiety. A Police Service was conducting five day camps with young people identified as at high risk of becoming involved with the justice system. The aim was to build self esteem, self discipline and responsibility through character building and challenging activities.

A particularly innovative project was reported by a Division of General Practice which involved developing a one stop ‘drop-in’ primary health service dedicated to providing a highly accessible and comprehensive health service culturally appropriate for marginalised young people who have difficulty accessing other services. This service also provided a range of personal development and life skills groups for young people at risk.

Interventions with this target group had a tendency to take the form of outreach. Outreach bridges both active case finding and intervention in that it brings services out to marginalised young people in the places they inhabit rather than waiting for them to seek help from traditional centre-based service. Outreach was explicitly mentioned as being practiced by a youth service and one Child and Adolescent Mental Health Service. Activities by several community organisations such as youth clubs and can also be considered a form of outreach, especially when linked to appropriate specialist services, because they provide critical ongoing support to many marginalised young people who lack access or may be reluctant to approach other services on their own.

A number of project descriptions mentioned the importance of a multisystemic approach to intervening with young people exposed to multiple risk factors. These projects were intervening in a number of systems such as family, school, health, welfare and the justice system in order to provide a holistic approach to the complex problems affecting highly marginalised young people.

Activities in this category were being conducted entirely by mental health services, primarily Child and Adolescent Mental Health Services (n=10); Community Mental Health Services (n=6); and integrated Area/Regional Mental Health Services (n=4). Very similar activities were being conducted in these different types of mental health service. They will therefore be discussed together.

Twelve of the 21 projects in mental health services were early psychosis programs. Only four of the 21 targeted other specific mental disorders. For other projects no particular diagnostic group was mentioned as being targeted. Six projects, including some of those that targeted particular mental disorders, had a special focus on identifying and responding to young people with mental disorder who are at particularly high risk of suicide or self-harm.

By definition all these programs were proactively seeking to identify cases and enhance access to services. A popular strategy for case finding was networking with other services to facilitate referral by those services. One project was providing training to primary health care professionals in the identification of emerging mental disorder and appropriate responses.

A much smaller number of mental health services indicated that they were using strategies such as community outreach and community education to promote broad awareness of their service among young people and families.

Projects in this category included those targeting young people who are: homeless or at risk of homelessness (n=6), of Aboriginal and Torres Strait Islander background and/or culturally diverse (n=4), involved in the justice system (n=2), males (n=2); victims of sexual assault (n=1), bereaved by suicide (n=1).

The types of organisations and the broad types of interventions being directed to young people in these specific high risk groups were largely similar to those described in the section on Projects targeting young people exposed to a wide range of general risk factors. Indeed many of the young people targeted by projects in this category have exposure to a range of risk factors. Projects targeting specific risk factors are described separately here because they offer an opportunity to learn more about ways of tailoring interventions to specific needs. Reporting will focus on these specific differences.

Homelessness The projects targeting young people at risk of homelessness included interventions to help them reconcile with families and help families gain access to other services that can support them through the difficulties that threaten to break the family. Interventions with homeless youth included provision of accommodation, counselling and general support, assistance with family reconciliation and advocacy to assist access to schools, health services and income support. One of the projects targeting homeless youth had a special focus on identifying warning signs for self-harm and suicide related behaviour and putting in place strategies to prevent suicide.

Aboriginal and Torres Strait Islanders One of these projects focused on providing training to a variety of professionals to develop their skills in working with Aboriginal and Torres Strait Islander youth at risk of suicide. Another project involved a systemic approach to identifying ATSI youth with early warning signs and developing interventions. A third project included the ATSI community as one of several groups in a comprehensive multicultural community and professional education program regarding youth suicide issues.

Justice system Early intervention projects targeting young people in the justice system included a diversionary program and a program that teaches cultural awareness to Aboriginal young people.

Males Projects targeting males included an 8 week aggression management program for young men who are beginning to act out with violent behaviours and a community education seminar on men’s health that included a focus on how to help other men seek help if suicide arises as an issue.

Other A project in a sexual assault service provided community and professional education about sexual assault issues including the suicide risk associated with being a victim of sexual assault. The aim was to enhance service responses to young people affected by this risk factor for suicide. A Child and Adolescent Mental Health Service was running a support group for young people who had experienced a suicide in their family and who were judged to be at risk themselves.

In this analysis, early intervention is defined as belonging to the category of secondary prevention, which is concerned with intervening when risk factors or early signs of disorder have emerged in order to prevent or delay the emergence of the outcome being prevented (ie suicide related behaviour).

Early intervention in youth suicide prevention involves two essential types of activity: (1) identification of young people with elevated risk for suicide related behaviour (early identification) and (2) intervention to interrupt the process (trajectory) whereby risk factors or early signs may lead to the development of the outcome being prevented.

The analysis revealed four main types of activities belonging to the category of early identification. These were:

• Education of community members in mental health, mental illness and suicide issues to enhance their capacity to identify signs of risk and direct young people at risk to appropriate help. This type of intervention has been labelled as "Gatekeeper Training" (Potter, Powell & Kachur 1995). This type of community education was also being conducted in schools, targeting students and teachers.

• Networking among a diverse variety of service providers to facilitate the referral, or smooth the pathway, of young people to appropriate services and seal gaps in the system.

• Establishment of other formal systems (eg in schools) for identifying and referring young people identified as being at risk.

• Education of primary health care professionals in the identification of young people at risk.

The data reported here suggest that early intervention in suicide prevention is different from other types of intervention (eg traditional treatment of mental health problems) in several key respects:

• Target groups are highly diverse and individual members of target groups are often exposed to multiple risk factors for suicide. This indicates the value of multisystemic interventions that are appropriate to the complex problems of the target groups. The diversity of problems affecting the target group underlines the importance of supporting the involvement of a diverse variety of services and other organisations in comprehensive and coordinated approaches to early intervention. In other words, enhancing interagency collaboration would appear to be critical.

• An emphasis on intervening as early as possible, combined with the marginalised existence of many of these young people indicates the need for interventions that are oriented towards outreach, that is, interventions that are conducted in the places where young people at risk are going about their lives. The importance of outreach in effective early intervention is underlined by the potential to combine identification and intervention activities to enhance cost-effectiveness. Outreach is probably a relatively underdeveloped aspect of early intervention in youth suicide prevention compared to other types of centre-based intervention. Venues where such outreach is currently occurring include schools, youth services and a range of community organisations. There appears to be a relatively low level of outreach activity by mental health services.

It might be argued that direct outreach by mental health services (especially that aimed primarily at early identification) could be a prohibitively expensive strategy for services that are currently struggling to address current levels of demand for centre-based services. However issues of equity in access to services for disadvantaged and marginalised young people arise here. Highly cost-effective outreach might be achieved in a de-facto manner by enhancing collaboration between mental health services and other organisations involved in direct outreach to young people. Early interventions directed to selected groups of young people in their usual work and recreational environments (eg schools and youth clubs) could also prove more cost effective than centre-based individually focused interventions in the long term.

The major limitations concern: (1) the representativeness of the Stocktake database with regard to the actual range of youth suicide prevention activities taking place nationally; and (2) the representativeness of the 85 projects selected for this analysis of early intervention projects in comparison with the range of projects in the database that could have been included.

The projects in the Stocktake database constitute a sample of current activity and it is unclear to what extent this sample is representative of the full diversity of activities. For example, information from the database suggests that there is a very low level of focused youth suicide prevention activity in key areas for early intervention such as the juvenile justice system and drug and alcohol services. It is difficult to determine whether this is an accurate reflection of reality or whether these areas were poorly sampled in the data collection process.

The present analysis is probably underinclusive with regard to the number of projects in the Stocktake database that could be considered to involve early intervention. For instance projects that were categorised as ‘Crisis intervention and primary care’ and ‘Community development and support’ under the field of ‘Main prevention approach’ were excluded from the present analysis unless they were also categorised as including ‘early intervention’ as one of the three ‘Main interventions/activities’ that they were implementing. It is possible that a substantial number of these projects involved early intervention as one of their main interventions but that this emphasis was more subtle and thus obscured by the more explicit prominence of other types of interventions.

The second National Stocktake will seek to overcome some of these post-hoc coding problems by asking respondents to clearly identify three key interventions/activities and a main prevention approach that they believe best describe their program.

These coding problems also reflect one of the problems with the original conceptual framework used to categorise projects funded under the National Youth Suicide Prevention Strategy and suggest the need for further work aimed at reaching broad agreement about an appropriate conceptual system for approaches to suicide prevention. Such a system will need to have conceptual integrity with regard to the dimensions used to characterise or define approaches to suicide prevention. For instance I would argue that it is inappropriate to include multiple dimensions such as settings (eg primary care), target groups (eg indigenous), and specific interventions (eg crisis intervention and community development) within a single conceptual framework for defining approaches to suicide prevention. A framework with conceptual integrity must employ one or perhaps two concepts only, which in combination define each and every category within it.

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

Mrazek PJ & Haggerty RJ (eds) (1994) Reducing risks for mental disorders: Frontiers for preventive intervention research. Institute of Medicine. National Academy Press, Washington DC.

Potter LB, Powell KE & Kachur SP (1995) Suicide prevention from a public health perspective. In MM Silverman and RW Maris (Eds) Suicide Prevention: Toward the Year 2000. Guilford Press, New York.

Silverman MM & Felner RD (1995) The place of suicide prevention in the spectrum of intervention: Definitions of critical terms and constructs. In MM Silverman and RW Maris (Eds) Suicide Prevention: Toward the Year 2000. Guilford Press, New York.

Definitions (World Health Organisation)

Suicide: Death from injury, poisoning or suffocation where there is evidence, either explicit or implicit, that the injury was self-inflicted and that the dissident intended to kill himself or herself. (The term completed suicide or death by suicide can be used interchangeably with the term suicide).

Suicide attempt: A potentially self injurious behaviour with a non-fatal outcome for which there is evidence, either explicit or implicit, that the person intended at some level to kill himself or herself. A suicide attempt may or may not result in injuries.

Suicide related behaviour: Potentially self injurious behaviour for which there is explicit or implicit evidence either that a person intended, at some level, to kill himself or herself, or, that a person wished to use the appearance of intending to kill himself or herself in order to attend some other end. Suicide related behaviour comprises suicidal acts and instrumental suicide related behaviour.

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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. Contact: Webmaster.