DISCUSSION PAPER
What makes a suicide prevention
strategy work?
April 2013
Table of Contents
1.
Introduction ....................................................................................................... 3
2.
Roundtable Format............................................................................................ 4
3.
Key Themes ....................................................................................................... 5
3.1
3.2
3.3
3.4
3.5
4.
Leadership .................................................................................................. 5
A Model of Suicide to Underpin Policy ........................................................ 5
Evidence of What Works in Suicide Prevention........................................... 7
Integrating Suicide Prevention Across Policy Domains. .............................. 7
The Role of Communities and Community Organisations ........................... 8
Key Points for Discussion ................................................................................ 9
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shall be treated as confidential and that it may not be copied, used or disclosed to others for any purpose except as
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© Lifeline Foundation – Discussion Paper on Suicide Prevention Strategies
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1.
Introduction
This Discussion Paper reflects the issues and questions raised in a Roundtable hosted
by the Lifeline Foundation in June 2012 on the general topic of What Makes a Suicide
Prevention Strategy Work?
Preparation of the Discussion Paper was undertaken by Sara Maxwell, a consultant
with considerable experience in suicide prevention policy analysis.
The Lifeline Foundation for Suicide Prevention operates to harness knowledge about
crisis intervention and community based suicide prevention responses, drawing on an
emerging evidence base that Lifeline itself contributes to through its service operations.
The Lifeline Foundation draws on Australian and international expertise and is
supported by an Expert Advisory Group made up of notable academics and
professional practitioners.
Lifeline is an interested stakeholder in the development of strategic suicide prevention,
and in the generation of evidence based programs that are effective in achieving
reductions in suicide deaths. Lifeline has contributed to suicide prevention in Australia
for 50 years since its inception as a direct response to the need for crisis intervention in
suicide prevention. Lifeline operates a multitude of community based suicide
prevention programs, addressing risk and protective factors in people’s lives.
This Roundtable brought together many participants in suicide prevention, for
discussion and exchange of views about the issues facing the development and
evaluation of suicide prevention strategies and related policy and program settings.
A list of the participants in the Roundtable is at Attachment A.
Questions posed from the Roundtable have been framed in this Discussion Paper to
foster further consideration of the opportunities and challenges facing suicide
prevention.
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2.
Roundtable Format
Visiting speaker Professor Rory O’Connor, of Stirling University, UK, presented on his
experience and insights in the following topics:
•
Scotland’s Suicide Prevention Strategy, Choose Life, its successes, challenges
and key learnings for Australia.
•
The key challenges for suicide prevention identified by contributors to the latest
edition of The International Handbook of Suicide Prevention (2011) edited by
O’Connor, R., Platt, S and Gordon, J.
•
Introduction to the Integrated Motivational – Volitional Model of Suicidal
Behaviour.
Roundtable participants shared comments and questions on Rory O’Connor’s
presentation and the applicability of the issues to the Australian context.
Small groups further explored particular themes that emerged during the discussion,
specifically around the following questions:
•
What makes a sound suicide prevention strategy?
•
How should evaluation of a suicide prevention strategy be framed?
•
How does suicide prevention relate to mental health and other policy domains
including substance misuse, unemployment? What are the key linkages to
monitor for effectiveness?
The Roundtable concluded with a summation of the issues and themes.
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3.
Key Themes
Using the Scottish Suicide Prevention Strategy, Choose Life, and the United Nations
Prevention of Suicide: Guidelines for the Formulation and Implementation of National
Strategies as the background for discussions, the Roundtable participants identified
some of the challenges and possible solutions for an effective national approach to
suicide prevention.
The key themes that emerged from the Roundtable discussion on making sure suicide
prevention strategies work fell within the related areas of ‘what it takes’ and ‘what to
look for’.
Themes included:
•
Leadership
•
A model of suicide to underpin policy
•
Evidence of what works in suicide prevention
•
Integrating suicide prevention across other policy domains
•
The role of communities and community organisations in suicide prevention
3.1
Leadership
An overarching theme which emerged was that of leadership.
Identified as being essential to building and implementing a sound suicide prevention
strategy, leadership in Australia faces the challenges of Commonwealth and
State/Territory Government structures and the need to integrate suicide prevention
across several policy domains.
Political mobilisation and greater demonstrations of prevention effectiveness were
some suggested solutions. Effective leadership was discussed in conjunction with other
themes of the Roundtable, considered to be both complementary to, and aided by,
greater evidence for suicide prevention, a clearly articulated model of suicide, and the
integration of suicide prevention across other policy domains and communities.
3.2
A Model of Suicide to Underpin Policy
Professor O’Connor’s presentation of the Integrated Motivational-Volitional (IMV) Model
of suicidal behaviour was met with interest and discussion from Roundtable
participants.
The IMV model incorporates and is complementary to other models and theories of
suicide but attempts to add further understanding to the factors which influence the
development of suicidal ideation and behaviour. It is a three stage model which links
background risk factors and events with the development of psychosocial factors which
increase the likelihood that suicide ideation emerges through to those factors which are
associated with suicidal thoughts being acted upon (i.e.: suicidal behaviour).
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The above model is in R O’Connor, S Platt, J Gordon (Eds.) International Handbook of
Suicide Prevention: Research, Policy and Practice. Chichester: Wiley Blackwell
Participant discussion of the applicability of the IMV model to the Australian national
strategy context and national prevention strategies and activities, highlighted a
disconnect between current policy and the complexities of individual suicidal processes
(and a clear understanding of needs). Consensus emerged that there may be potential
to demonstrate more effective preventative strategies in Australia if policy and activities
were structured around a clearly articulated understanding of the development of
suicidal behaviour in individuals and across populations.
The benefits of having a model of suicidal behaviour such as the IMV model included:
•
Building policy from a strong evidence base
•
Ability to test a model across demographic groups
•
Ability to link preventative activities to a clear understanding of need
•
Ability to target interventions to appropriate phases of risk
•
Clarity of direction and rationale for those in leadership positions
•
Aiding the articulation of strategy and activities
•
Aiding the identification of knowledge gaps
•
Evaluation and monitoring
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3.3
Evidence of What Works in Suicide Prevention.
The most recent edition of the International Handbook on Suicide Prevention includes
contributors’ perspectives of the greatest challenges to preventing suicide in the
coming decades. A strong theme to emerge from these perspectives is the lack of
knowledge and understanding of what works to prevent suicide and the recognition that
there is no ‘one size fits all’ solution to suicide prevention.
Roundtable participants concurred with this theme, balancing it with acknowledgement
of the quality of many current activities.
A finding presented to the Senate Inquiry into Suicide in Australia in 2009 found that
few funded suicide prevention activities in Australia were clearly evidence based or
subjected to rigorous evaluations (this is not a problem particular to Australia but a
worldwide issue).
Suicide prevention research remains under-prioritised in national funding streams, and
often focuses on risk assessment rather than on the development of interventions and
a more in-depth understanding of the suicide protective factors. To assist the
development of effective programs it was agreed that research on suicide risk must be
matched by best practice trials of clinical and social interventions and evaluations.
Further discussion of how to frame research and evaluation into suicide prevention
centred on the use of models of suicidal behaviour.
Often not conducive to traditional rational evaluation models, suicide prevention
evaluations have traditionally lacked innovation. One alternative evaluation model
discussed by Round Table participants is that of realist evaluations, which consider the
context of an intervention and the mechanism through which it is enacted when
measuring its effectiveness. This allows for a closer understanding of the causes of
and barriers to change. To ensure this is a robust process, the evaluation framework
must be built into program design from the beginning and activities planned according
to evidence based principles.
3.4
Integrating Suicide Prevention Across Policy Domains.
In Scotland, the origins of Choose Life were focused on a public health approach to
suicide prevention, with some partners perceiving that the traditional medical models of
care did not receive sufficient consideration initially. Identifying and addressing this,
and assertively positioning suicide prevention across other policy domains achieved a
more holistic and effective national approach. Suicide prevention in Scotland has
achieved a 17% reduction in deaths since Choose Life was implemented, although the
full attribution of this fall to the strategy is not possible.
Roundtable participants shared perceptions of the Australian policy context, agreeing
that there is potential for greater integration of suicide prevention activities across other
social policy domains. The link between social deprivation/ social exclusion and suicide
risk is not adequately prioritised in Australian preventative policy, possibly because of
the lack of disaggregated and accurate data on the impact of suicide across
communities. An example put forward by participants to improve integration across
policy domains was the potential role of social welfare agency Centerlink in suicide
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prevention, as a frontline point of contact with many at-risk groups, and with
accessibility to large proportions of the population. Similar proposals for points of risk
identification and intervention included the justice and education systems and
substance abuse and mental health care.
According to Roundtable participants the challenges of integrating suicide prevention
into other policy domains fall within the following areas:
•
Lack of leadership
•
Fear of the unknown and the lack of understanding of the issue of suicide
•
Fear of taking on extra responsibilities
•
Unwillingness to bear the cost of an underfunded mental health system
Potential ways to address these could include:
•
Setting achievable targets and providing resourcing
•
Increasing awareness and training
•
Target those most in need of training
•
Explain the value added and need for integration
•
Improve data collection to justify suicide prevention to other policy domains
•
Track the effectiveness of existing and newly integrated policy
•
Ensure the responsibility of the business community is met
•
Measure and publicise the financial and social costs of suicide and the savings
made by improved policy and practice.
Assertive leadership at a national level and across domains, with consultative
mechanisms embedded into policy formulation and implementation was suggested as
a strategic way to achieve sustainable integration.
The potential of the newly established National Mental Health Commission and the
National Report Card on Mental Health and Suicide Prevention in promoting integration
was cautiously welcomed by participants.
3.5
The Role of Communities and Community Organisations
The integration of suicide prevention across other policy domains was linked with a
discussion of the role of communities and community organisations in suicide
prevention.
Seen to be central to the national approach to the problem of suicide and as
recognised key players in service provision, community organisations and nongovernment agencies may be neglected by national strategic improvements if not
assertively targeted. Examples included training and capacity building, especially when
linking service delivery to an evidence base and best practice evaluations.
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The need to increase buy-in for national approaches was suggested to be enhanced by
greater engagement by the mechanisms of the National Suicide Prevention Strategy
with communities and community organisations. Again the articulation of policy and
direction, as assisted by an evidence based model of suicide and clear demonstrations
of effectiveness, were considered to aid the integration of suicide prevention across
communities and community organisations.
Greater community awareness and understanding of suicide was furthermore identified
as encouraging political mobilisation and leadership.
4.
Key Points for Discussion
From the issues raised above, the Roundtable generated several important discussion
points and these are posed below.
1. How can the community support and harness leadership for suicide
prevention?
2. Can a model of suicide behaviour such as the IMV model be used to
underpin policy with evidence based principles and a greater
understanding of the complexities of individual need? How would such
a model fit with traditional public health approaches to suicide
prevention?
3. How are communities and community organisations currently positioned
within the Australian approach to suicide prevention? What
improvements are needed and how can they be achieved?
Your Chance to Comment
Comments in response to the discussion points may be made by email:
•
send your comment to [email protected]
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Attachment A – Participant Organisations in Roundtable
Australian Institute for Suicide Research and Prevention, Griffith University
Centre for Suicide Prevention Studies in Young People University of Queensland
Crisis Support Services (now On The Line)
Kids Helpline
Lifeline
OzHelp
Queensland Alcohol and Drug Association
ReachOut
Suicide Prevention Australia
United Synergies (StandBy)
UnitingCare Community
Western Health and Social Care Trust Northern Ireland (Visiting Scholarship)
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