Centre for Rural Social Research

Suicide prevention: dilemmas and some solutions

Ray King

School of Education

Charles Sturt University, Wagga Wagga

This article was first published in Rural Society 4(3/4) December 1994. Rural Society is published by the Centre for Rural Social Research, Charles Sturt University, Wagga Wagga, Australia.

This article is © copyright, the author and the Centre for Rural Social Research. This text may be downloaded for personal use, or stored electronically, as long as no charge is made for access. The text may not be altered in any way and all hard copy or electronic versions MUST carry this header.

Why are we so concerned about suicide in Australia?

If you count the number of deaths by suicide over the last three years across Australia, you see a steady fall in numbers, from 1,847 in 1991 to 1,687 in 1993. According to the figures, there seems to be a declining problem. But if you take the rate of deaths by suicide as a proportion of deaths from all causes, you find the figures show an increase, from 1.5 to 1.9 %. You might say that it depends on what measure you take - there are indeed 'lies, damned lies and statistics'.

Before dismissing these statistics as some quirk in the process of counting, let us look a little closer at the trends. Over the last ten years Australia has lost the contribution of 22,372 people through suicide. This has been calculated to equal about 753,000 years of potential life. When we look a little closer at specific age groups the position becomes more serious. The suicide rate for 75 year olds and over has been consistently the highest over the years, followed by the rate for the age group 25-34. But there has been a substantial rise in suicides among younger males and females. The rate for males aged 15-24 increased from 19 deaths per 100,000 in 1982 to 27 in 1992. The female rate for the same age group doubled from 3 per 100,000 to 6 over the same ten year period. Similar trends exist in New Zealand; indeed Australasia leads the world in the rates of suicide for youth to age 24.

We should not ignore the incidence of attempted suicide. The rate of attempted suicide among 15 to 25 year old females has remained steady at about four to five times the rate for males. This is largely due to the methods used by females which tend to be more easily reversed. For example females are more likely to attempt suicide by ingesting substances whereas males are more likely to use guns or hanging. The availablility of firearms therefore becomes an important issue.

Suicide rates in rural areas

Although the number of suicides in Australia has fallen over the last two years, the number of male and female suicides in rural Australia has increased (males 382 to 414 and females 64 to 70). While rural males had a higher rate of suicide than urban males, the reverse was true for females. In rural areas and in small towns in some states, notably NSW, the increase in the suicide rate for younger males and females (15-24 years old) has been substantial.

It seems that our concern about the increasing suicide rates of young people is justified and that this is especially so for young males living in rural areas and in small towns. Furthermore, rural living is apparently a greater suicide risk factor for males than for females.

Preventing suicide in rural Australia

In 1991, for the first time, deaths from suicide were greater than deaths from motor vehicle accidents. In 1991, there were 2,360 suicides and 2,221 deaths from motor vehicle accidents. In 1993 the estimated figure for deaths from motor vehicle accidents, is 1,956 and from suicide, 2,081. Not surprisingly, given the Australia-wide campaign for safety on our roads and changing attitudes to drink driving, deaths due to motor vehicle accidents have dropped substantially, much more rapidly than deaths from suicide.

If the same resources were to be directed to suicide prevention in Australia as are directed to reducing motor vehicle accidents, would this have resulted in a substantial drop in the suicide rate, especially for younger people? The answer to this question depends on our capacity to identify the clear cut causes for suicide in the same way that we have for deaths from vehicle accidents (ie poor roads, high speeds driver fatigue and drink driving). There are no such clear cut causes for suicide but investment in suicide prevention appears none the less timely.

In relation to suicide prevention, there is no lack of willingness, just an absence of knowledge about best practice. This is not to say that there are no positive steps that we can take immediately to help suicidal people. There are ways in which we can help. These are to be discussed later in this article. A further dilemma in suicide prevention is that the causes of suicide in general, and specifically amonst young males in rural areas, are difficult to pin down.

Land degradation through drought carries with it the hidden costs of damage to the social structure of farming communities. Farmers become depressed, develop low self esteem and feelings of failure. They may feel that they have lost the family heritage in the land and may experience loss of social status and reduced income. This accumulation of loss and their part in it, in having to destroy their own livelihood through the slaughter of their animals, is devastating.

The economic plight of farmers and the drought have caused the shutting down of essential community services in smaller country towns, especially in finance, communications, health and welfare, and the loss of homes and employment for many families. At a time when rural communities are in most need of help, community-based resources have been cut back. These circumstances are likely to contribute to suicidal behaviour, but do not suggest specific actions that can be taken for its prevention.

Community provider services are at a loss to know where to target their efforts so as to have the greatest effect on suicide rates in the areas for which they are responsible. To some extent the relationships among differently funded providers can be competitive rather than enhancing. Problems of coordination of these compartmentalised services frustrate the attempts of any one group to mobilise community efforts, first to establish need, second to locate strategic points where treatment will have greatest effect and, third, to measure outcomes.

Another dilemma is that Australians are well behind some other countries, notably New Zealand, in their collection of information about the incidence of suicide and suicidal behaviour among gender and age populations and across different communities. Data on suicide attempts and completion are available from various sources such as the Australian Bureau of Statistics mainly based on information from death certificates. Casualty departments in hospitals, coroners' reports, death certificates, funeral directors' records and police records also contain information on suicide attempts and completions. Such information is difficult to obtain and to collate since there is no consistent format across agencies for recording this data.

Numerous programs across Australia are directed specifically at 'suicide prevention' but few have included evaluation strategies. Those that have lack valid criteria against which they can measure program outcomes. For example, the closeness of farming communities, long seen as a strength, may act as a deterrent when the demands of strict confidentiality prevent people from dealing with their own or a close family member's suicidal behaviour. While Lifeline is an invaluable confidential resource for isolated rural people, a valid and reliable evaluation of this service is made difficult for the same reason that the service seems, on the basis of its wide use, so successful: its commitment to confidentiality.

In the absence of base-line indicators of change in rates of suicidal behaviour in populations and by localities, it is impossible to determine best practice in suicide prevention.

We continue to be faced with the wide range of factors which might lead people to attempt and complete suicide (there is some evidence that attempters are in some ways different from those who complete). As a result calls for structural change are promoted, such as reducing unemployment, ameliorating poverty and improving what some see as the competitive, failure-producing, alienating, education system. Support for the family, improvement in family communication, education in parenting skills and providing a caring supportive and positive environment for children are also seen to address the major forces in suicide causation.

These are desirable goals, but they are longer term and not focused upon the 'here and now' of suicidal behaviour. Our immediate need is for strategies that intervene in existing processes of self- destructive or suicidal behaviour. Such strategies will focus on specific risk factors such as loss, change and abuse and on warning signs such as depression, poor self esteem and feelings of hopelessness. They do little however to lessen the underlying causes of suicide. Both long term and immediate approaches are needed.

There is ample evidence of the kinds of experiences that may place young people at risk. These may include:

loss of relationships (eg through death, geographical mobility, separation, divorce or incarceration)
change in significant areas of living which might affect feelings of self worth (eg through retirement, redundancy, demotion)
markedly changed school performance (eg due to relocation)
various types of abuse (eg psychological, physical, sexual).

Whether people respond to these risk factors by suicidal behaviour is dependent upon many other factors. These may include the history of coping with loss, change and abuse; the accumulation of losses; the clustering of factors; the existence of stable networks of caring people; access to people who are safe confidants; effective communication among family members; and the availability of various community providers of support, education and treatment.

Addressing the problem of suicide

Defining suicide as a problem is a necessary first step towards bringing together the various organisations and providers for suicide prevention. Defining it as a certain type of problem may limit the application of resources and thus their effectiveness. For example, defining suicide as mainly a mental health problem determines resources, influences means of access and affects community attitudes towards suicide.

Some believe that accepting the problem of suicide as a mental health issue may lead to an increase in the competence of mental health professionals in the community to identify and treat suicidal behaviour. This would be a desirable outcome. Generally mental health services acknowledge that suicidal behaviour is not purely a mental health issue (the majority of young people who suicide do not have a diagnosable mental disorder - World Health Organisation 1989). They agree that many approaches involving a range of people are required.

The NSW Parliament Standing Committee on Social Issues has a brief to investigate 'violence in society'. It decided to include the issue of rural suicide within its terms of reference: suicide was seen by the Committee as violence against the self. The view of the Committee is that personal and social factors play the major role in precipitating suicide attempts in the young. Thus techniques for reducing violence, stress management training and conflict resolution strategies are appropriate means of preventing suicide. However, to focus on suicide as a type of violence may not tap the central issues of rural youth suicide.

Central issues of suicide prevention

The central issues are to:

identify people currently at risk of adopting suicidal behaviour and to provide help for them
inform and educate as wide a spectrum of people as possible about means of suicide prevention
resource communities to initiate and to continue to maintain suicide prevention strategies.

Identifying youth at risk and providing help is likely to stop some suicides, but it is unlikely to stop people from becoming suicidal. The identification of people currently at risk of suicide seems to some providers to be an alternative to a general program of information sharing. It is often suggested that testing to locate high risk populations in schools would be more cost-effective than introducing a general program directed specifically at suicide prevention, should such a program be desirable. There is some doubt as to whether any existing test can effectively locate at-risk students. Such a test would need to be administered frequently because school populations change and because there is no telling at what point the impact of life events on some children would be such as to lead to suicidal behaviour. The identification of at-risk students is, however, an urgent problem for schools.

A pilot project in rural youth suicide prevention

A pilot project of youth suicide prevention was conducted in the Riverina, NSW, in 1993 and then extended to many other rural areas. It involved in-service training about suicide prevention for high school teachers of health, personal development and physical education. The program complemented current training programs in drugs, HIV/AIDS and other areas of health education.

As with in-servicing in other health areas, the objective of teaching about suicide was that teachers would introduce this component in their health, personal development and physical education classes. The teaching was done within the context of a new '25 hour program' which required an additional 25 hours per annum to be devoted to teaching about social issues in the curriculum for years 11 and 12.

An analogy with the process of remediation may help to emphasise the utility of adopting an educational rather than a treatment model for teaching about health and personal development in schools. Removing children for specialist remedial teaching from the classroom, although necessary in some cases, is not generally effective in the long run. It is far more cost efficient and educationally sound to give teachers the skills, knowledge, values and attitudes necessary to do the teaching.

The same argument applies to teaching about suicide prevention. Teachers gain confidence to act as first responders for suicide prevention (referring problems to school counsellors) and their heightened awareness transfers to other avenues of student care. What is perhaps most important, is that the program could go ahead in successive years at no further cost.

The Riverina pilot study was based on a population of 1100 secondary school students in years 11 and 12. The pilot project was extensively evaluated by means of a Solomon four group model. Evaluation established that:

the teaching was effective in changing students' knowledge of and attitudes to suicide
integration of suicide awareness and prevention teaching within health, personal development and physical education subjects was successful
the teaching was effective in changing erroneous beliefs about suicide
help seeking behaviour was enhanced for both self care and caring for others
school counsellors reported heightened awareness among students and teachers about the needs of suicidal persons
community adolescent care agencies reported increased concern shown by student clients about the suicidal behaviour of their friends
students were positive about the value of the teaching, especially about the need for such programs in schools.

Many schools have now adopted the program.

Schools are the major repositories of Australian youth and given the increasing rates of suicide among 15 to 24 year olds, are the most logical places to introduce programs of suicide prevention. Education programs for high school students established in the United States over the last decade are justified in part by the fact that young people contemplating suicide are more likely to confide with friends and peers than with adults. Overseas studies put the figure at about 90% of suicidal youth telling friends, but the Wagga Wagga pilot study set the figure at about 60% - girls being more likely than boys to share with peers.

Talking about suicide to young people as part of the instruction in health, physical education and personal development seems a logical step from the current focus on other social issues. It is a misconception that talking about these social problems will lead to an increased incidence. High school students encounter these issues in the media and talk to one another about them. The evaluation of the Riverina project showed that about half the girls could recall a friend expressing suicidal thoughts; 36% of the sample of girls (30% of boys) stated that they had experienced such feelings themselves.

Informing and educating the broader rural community about suicide

The author also participated in a community-based suicide awareness and prevention project on the NSW South Coast in 1994. This was a 'total community' project which targeted over 200 workers selected to reflect the wide spectrum of service providers in the area of suicide prevention, including Aboriginal people who constituted a significant proportion of the population.

Training in suicide awareness and prevention was given to teachers and other educators, police, ambulance workers, health workers, nurses, casualty staff in hospitals, funeral directors, clergy and general practitioners. Train the Trainer workshops were conducted to provide community members with skills to maintain the future direction and content of the teaching and a management committee was set up to further the aims of suicide awareness and prevention within the community.

The need for a community-wide program of suicide awareness and prevention was identified by the community. People were concerned about the increasing incidence of suicide. They were strongly supported by the local member of parliament who helped to obtain a government grant for a suicide awareness and prevention project. People asked that something positive be done along the lines of workshops and presentations that they had heard about in other regions. An influential member of the local community took up the challenge and spearheaded the project. Essentially this was a community initiated response to what was defined as a local community problem.

Workers in the private sector impact on a wider range of need. For example the trained operatives in the various telephone counselling services (Lifeline, Kidsline, Crisis Line) take calls from suicidal people from all walks of life. The people involved in the workshops and presentations believed that given the high rate of suicide in the locality, they would at some time encounter people showing suicidal behaviour. They wanted to be able to identify warning signs and risk factors, to be able to assess suicidality and to know where and how to seek help. Even those trained in the helping professions said their formal training did not include recognition of suicidal behaviour or how to assess lethality and perturbation, to judge suicidality or to effectively help suicidal people. Much of their expertise, they said, was gained on the job.

An educational program of day long workshops, presentations to professionals and focused workshops with particular categories of workers was provided. In addition the community was resourced to continue the prevention program and to fill gaps in service provision that came to light during the project. Selected members of the community were trained as trainers and the management committee identified services which needed to be established or extended and sought the means to do this.

The key feature of this pilot 'total community project' was that the community itself had taken responsibility for doing something about suicide in the locality. They had sought government funding to supplement their own contributions. They had created a coordinated network of cooperating services and people to promote the project and to continue the program after the initial stage had been completed. The community combined educational and resourcing components so that people would understand the problems and see that something could be done. At the same time there was evidence that something had been done.

This pilot project, based on a model of total community participation, was unique in Australia. It could well become the blueprint for rural communities which face problems of insufficient resources, difficulties in coordinating existing services and community concern but low participation due to lack of knowledge about what to do. State and Commonwealth Governments seeking ways to enhance services and emphasise community responsibility could well adopt this model as an exemplar of best practice of suicide awareness and prevention.

Further references

Australian Bureau of Statistics (1994) Suicides Australia, 1982-1992 Cat No. 3309.0

King, R. (1994) Teaching Aboriginal people about suicide awareness and prevention. Addendum to a prior submission to the Parliamentary Standing Committee on Social Issues, Wagga Wagga, August

King, R. & R. Kay (1994) How effective are school based suicide awareness and prevention programs? Paper presented at the National Conference of the Public Health Association of Australia, Canberra, February 28 - March 1

King, R. & R. Kay (1994) Suicide awareness education and prevention programs in schools. Submission to the Parliamentary Standing Committee on Social Issues, Sydney, March

King, R. & R. Kay (1994) To teach and how to teach. Suicide Prevention Australia Newsletter 2(2)

Mason, G. (1990) Youth suicide in Australia - prevention strategies Canberra: Department of Employment, Education and Training, Youth Bureau

Youth mental health and suicide prevention Wellington (New Zealand): Ministry of Health

World Health Organisation (1989) The health of youth Background document, technical discussions, Geneva

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