National Youth Suicide Prevention Strategy Communications Project

This article provides a content analysis of treatment, support and postvention 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.

Treatment, support and postvention activities are aimed at individual young people with long-term or chronic problems which place them at sustained risk of suicide (CDHFS 1997). The nature of these problems is such that ongoing support is necessary. Postvention refers to support provided to family, friends and others affected by a completed suicide.

A total of 233 programs (25.4% of the 919 projects in the Stocktake) are identified as belonging to the category of treatment, support and postvention. Ten of these projects are funded under the National Strategy and 34 are funded by State/Territory strategies.

Table 1 shows the groups and populations targeted by treatment, support and postvention programs. Consistent with the definition of treatment, support and postvention, the vast majority of these programs target young people affected by individual (proximal) risk factors for suicide (n=206, 88.4%). Eleven different risk factors are identified as being targeted, with mental disorders emerging as the most frequently addressed. A substantial number of programs target young people with exposure to generalised disadvantage or multiple risk factors (n=30, 12.9%), homeless young people (n=27, 11.6%) and those who have self-harmed or made previous suicide attempts (n=24, 10.3%). Eighteen programs (7.7%) are identified as targeting people bereaved by suicide and 19 programs (8.2%) target subpopulations.

Table 3 shows the 20 interventions most frequently employed by projects where treatment, support and postvention is the main prevention approach.

The group most frequently targeted by treatment, support and postvention projects are young people affected by mental disorder. A total of 75 projects focus on this risk group. The main types of organisations involved in this work are mental health services, primarily Child and Adolescent Mental Health Services (n=24), Integrated Area/Regional Mental Health Services (n=18) and Community Mental Health Services (n=14). Community organisations are also involved in service provision to this group (n=10).

Almost all of the 24 programs based in Child and Adolescent or Child and Youth Mental Health Services are community-based services. Only one is an inpatient unit. Three of the programs based in CAMHS are NYSPS funded projects.

Descriptions of the programs suggest that most are providing a routine clinical service targeting a wide variety of mental disorders. Around half of the respondents provided detailed description of their target group beyond their having a mental disorder, or provided detail about the nature of interventions being used. Most of these services are providing standard assessment, clinical treatment and/or case management to young people with established ‘serious mental illness’ or ‘severe’ emotional and behavioural problems.

Only a small number of respondents described activities oriented specifically towards addressing suicidal behaviour. Interventions being used here include intensive case management for suicidal and self-harming young people, intensive home-based treatment, medium and longterm psychotherapy and group therapy. A NYSPS funded project based at the Centre for Young People’s Mental Health in Melbourne is developing mechanisms to improve early detection of suicidal young people and enhance their access to services. This project is also developing and trialing specific suicide prevention therapies. One of these is a group intervention based on Linchan’s Dialectical Behaviour Therapy.

It is also notable that only a small number of programs include a focus on particular mental disorders. The lack of focus on depression in particular is remarkable considering its strong association with suicide (Beautrais 1998). While several programs have a focus on early psychosis, only one respondent described a focus on depression, one a focus on anxiety disorders and one on dual diagnosis. These programs are developing specialist expertise in the early detection, treatment and management of these conditions in young people. This developmental process includes a strong focus on evaluation research. The program targeting depression entitled ‘Out of the Blues’ is funded under the NYSPS and is based at Southern CAMHS in Adelaide. Interventions being trialed here include: cognitive behaviour therapy; family therapy; one to one supportive counselling, and pharmacological treatment. The Young People and Psychiatric Illness (YPPI) program, also funded under the NYSPS, includes a focus on dual diagnosis and is developing and piloting a number of interventions. It is based at the Central Coast Youth Mental Health Service in NSW. The anxiety disorders program based at Royal North Shore Hospital in Sydney is trialing a brief and intensive intervention designed for rural outreach.

Two other types of activity are notable in their low level of prominence in this sample of activities. Only a very small number of respondents made special mention of interventions oriented towards rehabilitation, psychoeducation or living skills. Similarly, few programs appear to include collaboration with other agencies or provision of consultation and training to professionals in other services regarding service provision to young people living with mental health problems. One innovative program worthy of note in this regard is based at Yeronga Child and Youth Mental Health Service in South Brisbane. This service has developed an inter-clinic referral system for groups. The aim is to promote an interagency approach to provision of group therapy as well as to share expertise in the development of specialist group programs.

Area/Regional Mental Health Services are mental health services for specific catchment areas. Such services may include a number of units such as inpatient and community based services which may be integrated under a single budget holder. Projects included in this group are being administered at the Area/Regional level or the specific service could not be discerned.

A total of 18 projects in the stocktake that target people with mental disorders are based in such services. These services are generally targeting the adult population aged 18-65. The majority of the projects in this group involve routine treatment of mental disorders. Four respondents noted that their service includes a child/adolescent/youth team or service. The extent to which these teams function separately from the Area/Regional service appears to vary. Two of these projects are funded by state strategies.

Only one other respondent described activities that focus specifically on the needs of young people. This project provides intensive support to families with children with mental health problems.

Two projects reported activity focusing on suicide prevention specifically. Swan Adult Mental Health Service in WA has employed a Suicide Intervention Officer who provides urgent assessment and brief intensive followup to suicidal clients as well as consultation support to other relevant providers. The Suicide Intervention Officer is also developing best practice guidelines and protocols for management of suicidal and self-harming clients. A Suicide Prevention Worker employed by the Central Coast Area Mental Health Service in NSW is developing policies and guidelines to assist mental health workers and emergency department staff to enhance their skills in working with clients referred for issues around suicidality. This position also aims to improve identification, management and follow-up of such clients.

As with activities in Area/Regional Mental Health Services, activities in Community Mental Health Services generally target the adult populaton aged 18 to 65. Most provide routine treatment of mental disorders. Five of the 14 respondents described activities which include a special focus on young people, mostly recent onset psychosis. These programs tend to have a strong emphasis on rehabilitation, living skills and personal development.

Two respondents noted a concerted focus on suicide prevention however only one described their program in detail. This project based in the Rockdale Mental Health Team and funded under the NSW Strategy is entitled "Reducing Deliberate Self Harm Among Youth". The aims are to: enhance services in relation to deliberate self-harm; improve identification of young people at risk of suicide; improve the 'rate of return' from acute contact to outpatient contacts; establish reasons which promote or inhibit contacts after the initial crisis contact by interviewing young people and families; and improve the identification and referral process.

There are two main types of community organisations included in this sample: those providing supported accommodation, rehabilitation and other support services to people affected by mental illness such as the Richmond Fellowship, the Aftercare Association, the Mental Health Association and GROW; and disorder specific organisations which provide support groups, advocacy and community education.

Thirty projects were identified as targeting young people affected by generalised disadvantage or multiple risk factors. Three of these projects are funded under the NYSPS and two are funded under state/territory strategies. The organisations mainly involved with this target group are: religious organisations (n=9); mental health services (n=5); youth services (n=4) community organisations (n=3); and accommodation services (n=3).

These projects focus on providing intensive support of various forms to marginalised and alienated young people with multiple problems. Specific interventions include case management, counselling, advocacy, mentoring, practical support and wilderness camps. Within all these interventions there is a strong emphasis on fostering the development of personal skills and competencies that will assist young people build social support networks and establish a place and role for themselves in the community. Three of the 9 projects in religious organisations are National Strategy funded projects.

Five mental health services were identified as providing ongoing support services to marginalised young people exposed to general disadvantage. Two of these are providing counselling services to a wide variety of people at risk in the community as a component of a comprehensive specialist mental health service. Another service has a Community Support Team which provides intensive support to any person referred as a result of suicidal behaviour regardless of diagnostic status. A project based in the Inner City Mental Health Service in WA called YouthLink aims to enhance the health status and reduce levels of self harm among disadvantaged young people with a wide range of problems who are disconnected from existing mainstream services. A comprehensive service development strategy is being used to enhance service accessibility and appropriateness to this group. Specific activities include: identifying the factors constraining access to existing services by the target group and initiating action to improve access and utilisation; identifying the major gaps and deficiencies in the range of existing services for the target group and developing remedial strategies; providing clinical services under the auspices of primary agencies; and providing clinical consultancy and training to increase the confidence and competence of youth workers responding to members of this target group who may be affected by alcohol, drug or mental health problems.

Twenty-seven projects target young people who are homeless or at risk of homelessness. Three of these also target young people at generalised disadvantage and two of these three projects are NYSPS projects. The main types of organisations targeting homelessness are: religious organisations (n=10); accommodation services (n=6) and community organisations (n=5). Interventions targeting homeless young people mainly involve provision of medium to long term accommodation, as well as intensive support, frequently in the form of case management. Only a few programs provide family focused interventions such as mediation. Several of the more comprehensive programs included here are funded under the Supported Accommodation and Assistance Program (SAAP) by state governments.

Rather than providing accommodation directly, a number of programs aim to assist homeless young people gain access to and maintain accommodation along with other resources that will help stabilise their lives such as education, training, income support and employment. Several of these programs are funded by Job Placement Employment and Training (JPET) which is a program of the Department of Education, Employment, Training and Youth Affairs (DEETYA).

Several programs focus on homeless young peoples’ access to health care. Anglicare NT is implementing an innovative health program called ‘Health Connections for Youth’. The program focuses on mental health and drug and alcohol issues and aims to enhance homeless young peoples’ access to mainstream health services. Homeless young people are provided with support, individual and group-based health education, information, advocacy and referral. The program also resources mainstream services and community agencies and informs the broader community about the health needs of homeless young people and provides the opportunity to develop innovative services and resources to meet their needs. This program is funded under Innovative Health Services for Homeless Youth (IHSHY).

Twenty-four treatment and support programs are identified as targeting young people who are known to have self-harmed or made suicide attempts. This target group has been a major focus of strategic government activity. A large proportion of these 24 projects are funded by state and territory suicide prevention strategies (n=13). Two of the 24 projects are funded under the NYSPS. These programs are based mainly in: hospital inpatients/accident and emergency services (n=6); state government departments (n=5); inpatient mental health services (n=4) and community mental health services (n=4). The programs based in state government departments are funded under the WA Youth Suicide Prevention Strategy and include projects in hospital accident and emergency departments and community health services.

The programs in this group are similar to those targeting deliberate self harm that were identified as belonging to the Crisis intervention approach. There is considerable conceptual and practical overlap between these categories in regard to this risk group. Projects described here tended to place greater emphasis on the support and follow-up components of their intervention.

Programs in inpatients units and accident and emergency departments are providing a supportive service to young people presenting with self-harm or a suicide attempt. The comprehensiveness and intensity of the service provided ranges from very basic through to very comprehensive. The most basic service includes brief counselling on presentation or social work services available in business hours only. Services of medium comprehensiveness include elements such as assessment, counselling, referral and follow-up for up to 3 months from a hospital based Social Worker. The most comprehensive and intense services provide comprehensive assessment by a mental health professional, assertive follow-up for a minimum of six months, individual and family counselling, inpatient admission to a comprehensive clinical treatment program if required, development of protocols which aim to ensure seamless service provision, training and support for staff. Two hospital based programs indicated they are developing and maintaining information systems.

The programs based in general hospitals described above tend to be staffed by general hospital staff such as hospital based Social Workers. Sometimes mental health services are responsible for the provision of support and follow-up to people presenting with self harm or suicide attempt. A number of mental health services are also developing a more comprehensive service in this regard. The Mental Health Education Unit and Counselling Service at New England Area Health Service in NSW is piloting and evaluating a Green Card system. The Green Card is a low cost suicide intervention strategy developed in Bristol by Morgan et al (1993) to address low compliance, with treatment by deliberate self harm patients. Clients who are assessed as being at risk of suicide or who have made a previous attempt are offered a Green Card. The Green Card involves access to an on call Community Mental Health Team member 24 hours a day.

The South West Mental Health Service in WA is providing one of the few community oriented treatment, support and postvention services identified in the stocktake. A Suicide Intervention Counsellor works with a multidisciplinary mental health team of general practitioners, school staff, mental health workers, psychiatrists and community organisations. The service provides counselling for those who have attempted suicide or self harm and are considered at risk. This includes a comprehensive Mental State Evaluation Psychological assessment for individuals, couples, families and relevant groups within a 6 week follow up period. The service also provides referral to appropriate community agencies including those bereaved by completed suicide. Postvention for schools, and communities through community education, community development is also available.

Thirteen of the 24 treatment, support and postvention projects targeting young people who have self-harmed or made suicide attempts are funded under state government suicide prevention strategies. These projects have a focus on service development including activities such as development of protocols to guide assessment and followup, research into outcomes of followup and training for health service staff.

Twenty projects identified as belonging to the category of treatment, support and postvention target young people who are misusing substances. These 20 projects comprise 74% of all the projects targeting drug and alcohol use in the Stocktake.

In contrast to the risk factor of past attempt or self harm very few government strategy treatment and support projects have focused on this risk factor specifically. No National Strategy and only one state strategy project focus on this risk factor.

Thirteen of the 20 projects in this group are based in drug and alcohol services, five are based in religious organisations, one in a Community Health Centre and one in a youth health service.

The programs based in alcohol and drug services are remarkably diverse in their organisational structure and activities. These services include treatment units attached to hospitals as well as other community based services. Some services focus on clinical treatment including standard assessment, treatment and referral to other specialist services as required. Others offer more holistic support in addition to or instead of clinical treatment. The more holistic programs tend to include several of the following components: counselling; social work services such as legal advice; accommodation in a ‘therapeutic community’; health screening; support for families; support around mental health issues; programs for young people involved with the justice system; prevention and health promotion; case management.

Several respondents noted that their service operates according to the philosophy of harm minimisation.

In contrast to the drug and alcohol services provided by the health sector, programs in religious organisations tend to focus more on the provision of immediate care and sustenance for individuals in desperate circumstances such as a place to sleep and sober up as well as food to eat. Of the five programs implemented by religious organisations, three are part of the Salvation Army’s Bridge Program.

A total of 18 projects belonging to the treatment, support and postvention approach were identified as targeting people bereaved by suicide. This group contains two state strategy projects and no national strategy projects. Respondents from several other projects also mentioned some attention to bereavement from suicide in the context of more general grief and loss issues such as death from other causes or family breakdown.

Most of the projects in this group are based in community organisations (n=10). Several are based in religious organisations (n=2) and generalist health services (n=4).

The activities of community and religious organisations focus around provision of support for families and friends bereaved by suicide. The most common element of this is support groups. These are mostly based on the principle of self-help however some groups include equal participation or leadership by professionals. Some groups are ongoing and some are short term. Some target people advanced in the grieving process and some are for those recently bereaved.

A prominent organisation in the area of postvention is the Rose Foundation which provides one day retreats/workshops for people who are relatively advanced in their grieving process. The workshops focus on identifying issues and developing strategies for overcoming these issues. The Rose Foundation has also published a large amount of self help and educational material.

Programs in health services include support groups as well as more diverse activities. A program based in Noosa Community Health Centre in regional Queensland provides a community-wide postvention service which includes community debriefing, information dissemination via the media, individual counselling and active follow-up of relatives and friends considered to be at-risk. A program based at Cherberg Community Health Service in rural Queensland called the Suicide Intervention and Carer’s Group provides a support group plus community-based advocacy and support for suicide intervention and crisis care.

Several of the postvention programs have produced self-help and other educational literature for wide distribution. Considering the relatively small number of groups working in the postvention area, an impressive amount of printed material has been developed and published. Liliana Gibbs Productions has developed a video in which families bereaved by suicide tell their stories while carrying on with their lives.

Programs targeting young people involved in the justice system are based primarily in detention centres and prisons (n=6). The other programs are based in state government departments (n=2), a police service, a youth service, and a drug and alcohol service. This group of projects included one National Strategy project and one state strategy project. Queensland and Victoria were highly represented in this sample of projects.

A fairly wide range of activities were reported by detention centres and prisons. Not all programs include all of these elements. Activities reported, in order of frequency were: assessment of young people on entry to detention to identify those at risk; further assessment of those identified at risk to identify issues to be addressed; addressing problems through provision of therapeutic interventions such as counselling, therapy and treatment; case management and development of management and treatment plans; monitoring.

Interventions mentioned by only one or two respondents include: strategic accommodation such as placement in a buddy cell; referral to specialist service providers; structured work and study routine; prosocial program which aims to develop personal coping and problems solving skills as well as social skills; involvement of family and peers.

Queensland Corrections reported the use of Crisis Support Units which are purpose built safe facilities for acutely suicidal prisoners, staffed by senior psychologists and psychiatric nurses. In addition to provision of an extremely safe physical environment the Crisis Support Units address the issues that led to the prisoners’ suicidal crisis before releasing them back to the general prison setting.

Other organisations focus on the needs of young people currently not in detention. These programs aim to address the problems that often lead young people into repeated offending behaviour (recidivism). Interventions include: development of personal and social skills; treatment of drug and alcohol problems; programs for Aboriginal young people that develop cultural awareness and healing of grief and loss; vocational skills; family intervention and support.

An innovative program based at South Sydney Youth Service called the Koori Justice Project includes outreach to young people about to be released from detention in order to engage them in the ongoing support programs offered by the service. These programs are comprehensive and varied. Key principles and issues addressed include: cultural awareness and healing for Koori families; mental health issues; socioeconomic disadvantage; involving young people and community members in community and professional education programs that raise awareness of the issues affecting young people in South Sydney.

A total of 19 programs target subpopulations. These populations include young women (n=9); non-heterosexual young people (n=5); Aboriginal and Torres Strait Islander people (n=3) and young people from non-English speaking backgrounds (n=2). Most of these programs also include a focus on particular risk factors discussed above.

Most of the nine projects targeting young women also target specific risk factors discussed above. These include general disadvantage and marginalisation, drug and alcohol use, homelessness and mental disorder. These and the other projects targeting young women include a focus on issues and difficulties specific to women or which impact on young women differently than on young men. These issues include child abuse, rape, mothering young children without partners, eating disorders.

The five treatment and support programs targeting same-sex attracted and transgender young people provide intensive support to individuals from these groups who are experiencing major difficulties such as homelessness, prostitution, drug and alcohol use and are suffering acute and chronic distress and suicidality. Respondents note that same-sex attracted and transgender youth are often forced out of the family home at an early age and when this occurs may quickly become involved in prostitution, drug use and self-harm. Interventions include crisis and medium to long term accommodation, counselling and longterm therapy. These programs are being provided by gay and lesbian community organisations.

The three programs in this group include two programs targeting young people in the justice system described above and a program run by a Youth Involvement Council which provides a drop in centre and various other programs targeting a large Aboriginal community in the remote South Headland area of WA. A key element of these programs is the involvement of Aboriginal community members in the design and delivery of programs and close integration with wider community activities. In other words culturally sensitive programs tend to take place within a broader community development framework or approach that facilitates community engagement and ownership. (For further discussion of Stocktake projects belonging to the community development approach see Mitchell (1999) in Youth Suicide Prevention Bulletin No. 3).

One of the programs focusing on young people of NESB includes a counselling and support program for young refugees based at the Victorian Foundation for the Survivors of Torture. The second project is Club SPERANZA which provides support for people from diverse cultural and linguistic backgrounds bereaved by suicide. It is noted that SPERANZA is a universal multicultural sign post to hope, health, support and recovery.

The First Stocktake has identified support (or tertiary prevention) programs targeting most of the individual risk factors for suicide identified in Youth Suicide in Australia: a background monograph (CDHFS 1997) and other literature (Beautrais 1998). There do however appear to be some prominent gaps, particularly in relation to subpopulations which have been identified as being at higher than average risk of suicide. Most notably there is an absence of treatment and support programs tailored to the specific needs of young males. There also appears to be a very low level of activity targeting young Aboriginal and Torres Strait Islander young people. It is possible that the gap in relation to Aboriginal young people is due to sampling bias, specifically, a failure to adequately survey Aboriginal and Torres Strait Islander run organisations. The validity of the finding of a gap in programs targeting males is suggested by the relative frequency of programs targeting young women.

Responsibility for addressing the needs of subpopulations with special needs tends to fall on community organisations that have developed from social movements within those communities or populations. Male community organisations have historically been oriented towards activities such as sport, business and politics rather than social and emotional wellbeing.

Certain individual risk factors identified in the literature also appear to be underaddressed compared to others. These include unemployment, physical and intellectual disability, exposure to abuse, sexual assault and involvement in the justice system. It is likely that some of these risk factors are being addressed in programs targeting young people exposed to generalised disadvantage and multiple risk factors. However in the interests of accumulating a knowledge base that can inform development of better practice it will be important to identify and learn from programs that are attempting to address these risk factors in a specific way. It is hoped that the Second National Stocktake will better identify these programs if they are indeed occurring.

In relation to the risk factor of mental disorders it is notable that only a small number of programs include a focus on particular disorders. The lack of focus on depression in particular is remarkable considering its strong association with suicide. The failure to identify programs focusing on particular disorders could be due to a failure of the Stocktake to capture developmental activities taking place within academic clinical research programs. However it is notable in this regard that in their review of the international literature, Patton and Burns (1998) find relatively low levels of clinical effectiveness research that examines either psychological or pharmacological treatment of depression in young people.

Beautrais A (1998) Risk factors for suicide and attempted suicide amongst young people. In Commonwealth Department of Health and Aged Care.Youth Suicide Literature Review: Setting the Evidence-based Research Agenda for Australia. AGPS, Canberra.

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

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

Morgan HG, Jones EM, Owen JH (1993) Secondary prevention of non-fatal deliberate self harm: the Green Card study. British Journal of Psychiatry, 163, 111-112.

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. Contact: Webmaster.