in Australia prevention ofsuicide A frameworkfor 1 Living Is For Everyone: A Framework for Prevention of in Australia livingisforeveryone.com.au Living Is For Everyone (LIFE) Framework (2007) ISBN: 1-74186-296-5 Online ISBN: 1-74186-297-3 Publications Number: P3 -2060 © Commonwealth of Australia 2008 This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no part may be reproduced by any process without prior written permission from the Commonwealth. Requests and inquiries concerning reproduction and rights should be addressed to the Commonwealth Copyright Administration, Attorney-General’s Department, Robert Garran Offices, National Circuit, Barton ACT 2600 or posted at http://www.ag.gov.au/cca The Australian Government Department of Health and Ageing has financially supported the production of this review/ publication. While every effort has been made to ensure that the information contained in the review/publication is accurate and up-to-date at the time of publication, the department does not accept responsibility for any errors, omissions or inaccuracies. Using the Living Is For Everyone (LIFE) resources

Which LIFE (2007) resource is most useful to you?

What do you want to know? Who are you? Which document matches your needs?

Living Is For Everyone: Research and You want to know about the latest Evidence in sets understanding of suicide and suicide the context for suicide prevention prevention. activity, summarising current theories, You may be an research, evidence and statistics

academic, researcher, relating to suicide and suicide livingisforeveryone.com.au prevention in Australia. You want to know that your suicide policy maker, member prevention activities are well founded of parliament, health and well informed. or community services Living Is For Everyone: A Framework professional, service for Prevention of Suicide in provider or community Australia provides a summary of organisation. current understandings of suicide You want to know about the overall and outlines the vision, purpose, purpose, structure, principles and principles, Action Areas, planned priorities for suicide prevention outcomes and strategies for in Australia. suicide prevention in Australia. Living Is For Everyone: A Framework for Prevention of

You may be a community member, professional carer, Living Is For Everyone: Practical You want something that explains service provider, Resources for Suicide Prevention more about suicide, why people employer, friend, family, is a set of plain language fact sheets suicide, and tells you what you can work colleague or arranged around topic areas that do or say to help prevent suicide, associate of someone summarise the key issues in suicide or to help people bereaved by you think is suicidal, or prevention and suggest further sources suicide. of people affected by a of information and help. suicide – or you yourself may be at risk of suicide.

The Living Is For Everyone website: livingisforeveryone.com.au has up-to-date information on suicide prevention activities in Australia and links to a wide range of resources, guidelines and fact sheets. Contents

Living Is For Everyone The Living Is For Everyone (LIFE)

(LIFE) materials...... 06 Action Areas...... 26

Audience for the LIFE (2007) materials...... 07 Action Area 1...... 26 How the LIFE (2007) materials Improving the evidence base and understanding were developed...... 07 of suicide prevention

Outcome 1.1...... 27 Understanding of imminent risk Suicide Prevention in Australia...... 08 and how best to intervene

Background...... 08 Outcome 1.2...... 27 The Council of Australian Governments (COAG) Understanding of whole of community risk

Agreement July 2006...... 08 and protective factors, and how best to build Government and non-government resilience of communities and individuals suicide prevention and related activities...... 08 Outcome 1.3...... 27 Application and continued development What is known about suicide of the evidence base for suicide prevention among high risk populations and suicide prevention?...... 10 Outcome 1.4...... 27 Improved access to suicide prevention Risk and protective factors for suicide...... 10 resources and information Influencing risk and protective factors...... 11 Applying our knowledge of risk and Action Area 2...... 28 protective factors in suicide prevention...... 12 Building individual resilience and the capacity What assists in protecting people for self-help against suicide?...... 12 Outcome 2.1...... 28 What is resilience?...... 13 Improved individual resilience Vulnerability and suicide risk...... 14 and wellbeing Tipping points...... 14 Outcome 2.2...... 28 Warning signs...... 16 An environment that encourages and supports help-seeking The Living Is For Everyone Action Area 3...... 30 (LIFE) Framework for Suicide Improving community strength, resilience

Prevention...... 18 and capacity in suicide prevention Outcome 3.1...... 30 Context...... 18 Improved community strength and resilience The LIFE (2007) model...... 18 Outcome 3.2...... 30 LIFE Framework continuum Increased community awareness of what of suicide prevention activities...... 19 is needed to prevent suicide

Outcome 3.3...... 30

The LIFE Framework for Action...... 22 Improved capability to respond at potential tipping points and points of imminent risk Strategic directions...... 22

Principles underpinning the LIFE Framework Action Area 4...... 31 for Action...... 22 Taking a coordinated approach Considerations in implementing the to suicide prevention

LIFE Framework for Action...... 23 Outcome 4.1...... 31 Summary of Action Areas...... 24 Local services linking effectively so that people The importance of evaluating suicide experience a seamless service prevention activities...... 24 Outcome 4.2...... 31 Program and policy coordination and cooperation, through partnerships between governments, peak and professional bodies and non-government organisations

Outcome 4.3...... 31 Regionally integrated approaches

Action Area 5...... 32 Providing targeted suicide prevention activities

Outcome 5.1...... 32 Improved access to a range of support and care for people feeling suicidal

Outcome 5.2...... 32 Systemic, long-term, structural interventions in areas of greatest need

Outcome 5.3...... 32 Reduced incidence of suicide and suicidal behaviour in the groups at highest risk

Outcome 5.4...... 32 Improved understanding, skills and capacity of front-line workers, families and carers

Action Area 6...... 33 Implementing standards and quality in suicide prevention

Outcome 6.1...... 33 Improved practice, national standards and shared learning

Outcome 6.2...... 33 Improved capabilities and promotion of sound practice in evaluation

Outcome 6.3...... 33 Systemic improvements in the quality, quantity, access and response to information about suicide prevention programs and services

Appendix A...... 34 Relevant government and non-government policies, programs and activities

Glossary of terms...... 36

References...... 40

Acknowledgements...... 42

suicide prevention activities will do no harm suicide prevention activities will do no harm there will be community ownership and responsibility for action to prevent suicide; and service delivery will be client-centred. Living Is For Is Living Everyone materials (LIFE) Living Is For Everyone (LIFE) Framework (2007) is the initiatives latest in a series of national suicide prevention in Australia that began in the early 1990s. It provides national policy for action based on the best available evidence to guide activities aimed at reducing the rate at which people take their own lives. The materials aim to support population health approaches and prevention activities that will assist in reducing the loss of life through suicide in Australia. The LIFE (2007) package of materials includes: This document, Living Is For Everyone: A Framework outlines the for Prevention of Suicide in Australia (2007), proposed vision, purpose, principles, action areas, and It replaces outcomes for suicide prevention in Australia. the Living Is For Everyone (LIFE) Framework (2000). that: The LIFE Framework is based on the understanding •  •  •  Living Is For Everyone: Research and Evidence in Suicide Prevention sets the context for suicide prevention activity, summarising current theories, research, evidence and statistics relating to suicide and suicide prevention in Australia. Suicide for Resources Practical Everyone: For Is Living areas, topic by arranged sheets, fact of set a is Prevention providing practical information about suicide prevention. The LIFE (2007) package of materials is located at livingisforeveryone.com.au

Living Is For Everyone: A Framework for Prevention of Suicide in Australia 06 livingisforeveryone.com.au be suicidal,orwhohasbeenaffectedbyasuicide. work colleaguesorassociatesofsomeonewhomay providers,employers,friends,family,carers, service Prevention isprimarilyaimedatcommunitymembers, PracticalResourcesforSuicide Living IsForEveryone: community organisations. providersand professionals,service services researchers, policymakers,healthorcommunity in Australiaareparticularlyaimedatacademics, AFrameworkforPreventionofSuicide Everyone: and EvidenceinSuicidePreventionLivingIsFor Research The twodocuments,LivingIsForEveryone: the tragiclossoflifetosuicideinAustralia. suicide, andoftherolethatpeoplecanplayinreducing taking theirownlifeorwhohavebeenaffectedby appropriate waysofrespondingtopeopleconsidering aim toimproveunderstandingaboutsuicide,of involved insuicidepreventionactivities.Thematerials by peopleacrosstheAustraliancommunitywhoare The LIFE(2007)materialshavebeenproducedforuse materials Audience fortheLIFE(2007) revision andreplacementoftheearlierLIFEFramework. developed in2007fromtheseconsultationsandisa The newLIFEFrameworksuiteofresourceswas national research. canvassing ofthemostrecentinternationaland The consultationsweresupplementedbyawider bereaved bysuicide;andfamilies,friendsindividuals. and recreationclubs;specialinterestgroups;people non governmentsectors;localcommunities,services providersinthepublicand peak bodiesandservice professionals; researchers; healthandcommunityservice and stategovernmentdepartments,academics community andincludedrepresentativesfromnational These consultationsinvolvedthewiderAustralian consultations fromNovember2006toJune2007. The newframeworkwasdevelopedafterextensive commissioned in2007. that reviewaredevelopmentoftheLIFEFrameworkwas the widercommunityinsuicideprevention.Asaresultof practical documentsandresourceswasneededtoassist commissioned. Itbecameapparentthatasetofmore with keystakeholdersontheLIFEFrameworkwas In early2006,anindependentreviewandconsultation and itremainsanimportantsourcedocument. suicide preventioninternationallyandwithinAustralia, research, evidenceandinformationaboutsuicide population. Ithasplayedanimportantroleinproviding mental healthandresilienceacrosstheAustralian the tragedyofsuicide,topreventandpromote provided astrategicplanfornationalactiontoaddress (the LIFEFramework)wasreleased.Thatframework for PreventionofSuicideandSelf-harminAustralia AFramework In 2000,theLivingIsForEveryone: were developed How theLIFE(2007)materials 07 Living Is For Everyone: A Framework for Prevention of Suicide in Australia livingisforeveryone.com.au

Contact details for further information on these initiatives can be found at Appendix A. Government and non-government and related suicide prevention activities The National Action Plan on 2006-2011 Health Mental on Plan Action National The intervention; early and prevention promotion, on focuses improving mental health services; providing opportunities for increased recovery and participation in the community through employment and stable accommodation; such as Queensland, it includes community sector and other non-government representatives. agreed nationally against monitored be also will Plan The progress measures over a five-year period and will be subject to an independent review at the end of this period. better-coordinated care; and building workforce capacity. care; and building workforce better-coordinated This National Action Plan sets out agreed funding commitments, outcomes, and most importantly, emphasise that action for directions policy specific coordination and collaboration between government, COAG The providers. non-government and private seamless statement emphasised the need for a more system. care connected and commitment the is Plan Action National the of element key A for thefrom the Australian Government to double funding to million $61 (from Strategy Prevention Suicide National prevention suicide of expansion the enable to million) $123 in risk high at groups targeting those particularly programs, the community. and State each in Group Health Mental COAG A has been established. These groups involve the Territory working Territories and States the and Commonwealth together to coordinate implementation. In some cases,

i COAG is the peak intergovernmental forum in Australia, comprising the Chief Ministers and the President Territory State Premiers, Prime Minister, of the Australian Local Government Association (ALGA). Agreement July 2006 Agreement i  In July 2006, COAG agreed to a National Action Plan on Mental Health 2006-2011 involving a joint package of measures and significant new investment by all governments over five years to promote better mental health and provide additional support to people with mental illness, their families and their carers. The Council of Australian Governments (COAG) Background Prevention Suicide in Australia was commissioned, and these resources are designed to replace the original LIFE Framework. Australian governments, communities and organisations organisations and communities governments, Australian ten than more for efforts prevention suicide supported have a decrease inyears, and these efforts have contributed to of 14.7the age standardised rate of suicide from a peak 100,000 per 10.3 to 1997 in people 100,000 per is the latest in people in 2005. The LIFE Framework (2007) in Australiaa series of national suicide prevention initiatives that began in the mid 1990s. national a develop to countries first the of one was Australia focus initial The prevention. suicide to approach strategic was primarily on . In the 1995-1996 Federal years to developBudget, $13 million was allocated over four the In distress. in youth for plan national a implement and expand to allocated was million $18 further a year, following with a total Strategy, Suicide Prevention the National Youth 1999. of $31 million allocated between 1995 and Prevention for Framework A Everyone: For Is In 2000, Living strategic a provided of Suicide and Self-harm in Australia framework for national action to prevent suicide and promote mental health and resilience across the Australian population. In 2006-07, a redevelopment of the LIFE Framework

Living Is For Everyone: A Framework for Prevention of Suicide in Australia 08 livingisforeveryone.com.au

non-modifiable - things we cannot change. modifiable - things we can change; and the contextual level or the broader life environment which includes the social, political, environmental, cultural and economic factors that contribute to available options and quality of life. the social level, which includes relationships and friends, involvement with others such as family, workmates, the wider community and the person’s sense of belonging; and and physical health, self-esteem, and ability to deal and physical health, self-esteem, and ability with difficult circumstances, manage emotions, or cope with stress; the individual or personal level which includes mental protective factors, which reduce the likelihood of person’s suicidal behaviour and work to improve a ability to cope with difficult circumstances. risk factors, sometimes called vulnerability factors because they increase the likelihood of suicidal behaviour; and For example, in some areas of Australia isolated older according to statistics, to take men may be more likely, their own life. Nothing can be done about their age or gender (non-modifiable factors that increase risk), but it is possible to change their social isolation (modifiable factors). • Risk and protective factors may be: • •  • 

Risk and protective factors are often at opposite ends Risk and protective factors are often at opposite isolation of the same continuum. For example, social factor) () and social connectedness (protective are both extremes of . levels: Risk and protective factors can exist at three • •  Risk and protective factors factors Risk and protective for suicide someone is The many factors that influence whether likely to be suicidal are known as: • . This rate has been dropping steadily since ii a peak of 14.7 suicides per 100,000 people in 1997. a peak of 14.7 suicides per 100,000 people deaths. Males accounted for nearly 80% of these This compares with 1,638 deaths by motor vehicle accidents in the same period. amongst young men aged 20 to 34. Suicide rates are fairly similar for females of all ages with the highest age-specific rate in the 35-39 years age group (6.9 per 100,000) and the lowest in the 15-19 years age group (3.6 per 100,000). The age-specific suicide death rates for males shows significant variations between age groups, with the highest being in the 30-34 years age group (27.5 per 100,000) and the lowest in the 15-19 years age group (9.5 per 100,000), and in men aged over 75 the rate was 21.6 per 100,000. This is an age-standardised rate of 10.3 per 100,000 This is an age-standardised rate of 10.3 per people of the Australian population over time. The age-standardised rate accounts for the changing age structure The age-standardised  • •  • Suicide accounted for almost a quarter of all deaths • •  Reducing the rate at which people take their own lives is the responsibility of all Australians and this is best achieved by a coordinated response across the community. ii What is known about suicide suicide about known is What prevention? and suicide Around two thousand Australians take their own lives Around two thousand Australians take their every year with impacts on families, friends, workplaces and communities. in Australia People of all ages and from all walks of life to take their own life and the causes often appear and be a complex mix of adverse life events, social geographical isolation, cultural and family background, socio-economic disadvantage, genetic makeup, of mental and physical health, the extent of support to family and friends, and the ability of a person adversity. manage life events and bounce back from in In 2005, 2,101 deaths by suicide were registered Australia (Australian Bureau of Statistics, 2007): • 

Living Is For Everyone: A Framework for Prevention of Suicide in Australia 10 livingisforeveryone.com.au risk factors. several with person another in suicide than likely less is factor risk one with person a in suicide that assume to no risk.Riskfactorsareindicatorsonlyanditisincorrect Equally, itcannotbeassumedthatlowriskmeans 2008). suicide (DeLeo&Krysinska, about myths common the of one is This ill. mentally is behaviour suicidal in engages who everyone that - wrongly again, - assumed be may it linked, are illness increased risk.Similarly, becausesuicideandmental at automatically is person elderly every or male every that - incorrectly - assumed be might it research, on based example, For 2000). Hawton, & (Platt characteristics andrisksofthatgrouporpopulation particular grouporpopulationnecessarilysharesthe it isimportantnottoassumethatanindividualina life, own their taking someone of risk the assessing In factors togetherthatmightresultinsuicidalbehaviours. risk proximal and distal of action the is it person, each In • • two broadgroups(Moscicki,1999).Theseare: that apersonwillbecomesuicidalcanbedividedinto that is,thecharacteristicsincreaselikelihood span. Riskfactorsforpeopletakingtheirownlife– interactions betweenriskfactorsacrossaperson’s life Suicidal behaviours,bothfatalandnon-fatal,resultfrom include negativerecentlifeevents,oracrisis. a persontotaketheirownlife.Proximalriskfactors precursorfor themselves, noraretheyanecessary take theirownlife.However, theyarenotsufficientin suicidal) canbeviewedastriggersforapersonto proximal riskfactors(closertothetimeofbecoming and psychopathology; vulnerability. Theyinclude,forexample,geneticfactors taking theirownlifeorarelikelytoincreasetheperson’s suicidal) arethosethatexposeapersontotheriskof distal riskfactors(furtherawayintimefrombecoming

•  • factors, whichmaybeforanumberofreasons: reduced riskandthepresenceofprotectiveand/or There isnotastraightone-to-onerelationshipbetween • whichoftheriskfactorscanbechanged(modifiable) •  •  identifying: understanding ofriskfactorstopreventsuicideinvolves that increasetheriskforaretired,olderman.Applyingan young manatriskaregenerallyquitedifferenttothose than others.Forexample,thefactorsthatmayputa Particular riskfactorsaremoreimportantforsomegroups few riskfactorsandmanyprotectivefactors. take theirownlife,andsomewhodoliveshave Most peoplewithmultipleriskfactorsdonotattemptto aboutsuicide. protective factorsdon’texplaineverything many riskfactorsandfewprotectivefactors.But People whoattempttotaketheirownlifeusuallyhave factors Influencing riskandprotective differences occur. have notyetbeenabletoexplainhowandwhythese time. Despitemanyyearsofresearch,researchers life worthliving,andtheseviewsmayalsochangeover widelyintheirbeliefsabout whatmakes People vary resilient; and these riskfactors,andthosewhoaremostlikelytobe individuals whoaremostlikelytobebadlyaffectedby present foraparticularpersonorgroupofpeople; the riskfactors(individual,social,contextual)thatare competence. sense ofself,theirabilitytocopeandpersonal who isfeelingsuicidalitcriticaltounderstandtheir and learnfromlife’s challenges.To assistsomeone in aperson’s lifeatthetime,andtheirabilitytogrow on individuals,dependingwhatelseishappening differentimpacts The samelifeeventcanhavevery to reducethelevelofrisk. 11 Living Is For Everyone: A Framework for Prevention of Suicide in Australia livingisforeveryone.com.au What assists in protecting people people in protecting What assists suicide? against Everyone stress and difficult circumstances experiences people can handle these tough during their life. Most be able to make something good times and may even There are others however from a difficult situation. when faced with difficult who may respond negatively may become discouraged or or traumatic events and more vulnerable. One of the main defeated and become activities is to build resilience aims of suicide prevention and in whole communities, in individuals, their families events, to respond to life’s to increase their capacity whatever they may be. self- Many factors shape how each person develops and surviveimage, life skills and the ability to manage events. under pressure or when faced with life changing are linked to Some of these factors are genetic, some some are current and past physical or mental health, some the result of previous life or family experiences, the and some relate to are cultural or gender-related, social support systems. person’s reducing exposure to social and contextual risk through reducing exposure to social and contextual groups structural changes that target specific at risk socially or such as remote Indigenous communities, geographically isolated older men or people with a mental illness. For example, developing social support networks, improved employment prospects or access to affordable housing. increasing individual protective factors through activities that help to build self-esteem, psychological strength and personal competence. For example, teaching young people social and emotional skills, fostering positive peer relationships and relationships with teachers and other adults, and encouraging help-seeking behaviours. providing easier access to appropriate care and support that is in the right place, at the right time, using the right approach. For example, non- judgemental assistance for people bereaved by suicide, provided by their peers, in the places they frequent and where they feel most comfortable. reducing risk and increasing protection for people who are in current crisis. Such groups might include those who have attempted to take their own life, or who have been recently discharged from mental health care. The most recent research suggests that an understanding understanding an that suggests research recent most The populations identify to used best is suicide in factors risk of risk, at be might that groups socio-economic specific or risk. The mainrather than attempting to identify individuals at categorisedbe can who people of majority the that is reason life. It isas at risk do not and will not ever take their own which alone factors risk from determine to difficult extremely less likely toindividuals within an at risk group are more or become suicidal. prevention suicide that recommend researchers Most andinitiatives should focus on constellations of risk protective factors. Activities may include: •  •  •  • Applying our knowledge of risk Applying our knowledge factors in suicide and protective prevention A further challenge lies in the strong relationship between between relationship strong the in lies challenge further  A Australia, in present At health. and factors socio-economic location geographic between link strong a is there socio-economic disadvantage(regional, rural and remote), status) and ill health. This relationship(low socio-economic much be to tend rates suicide - suicide for exists also areas in and locations remote and rural regional, in higher disadvantage. of higher socio-economic

Living Is For Everyone: A Framework for Prevention of Suicide in Australia 12 livingisforeveryone.com.au potentially traumaticincidents. vulnerable andlessabletocopeinthefuturewith abuse ortraumainafamilymaymakepersonmore resilience, whilelackoffamilysupportorexposureto environment thatissupportiveandcaringwillenhance vulnerability ortoresilience.Forinstanceafamily The samecircumstancemaycontributeeitherto effectively toworkthroughdifficulties. and usingcopingstrategiesproblem-solvingskills involves engagingwithfriendsandfamilyforsupport, experiences intoconstructiveones.Beingresilient negative experiencesoflife,turningpotentiallytraumatic ability tolearnandgrowthroughthepositive and respondpositivelytodifficultsituations.Itisthe trauma orstress,toadaptchangingcircumstances Resilience istheabilitytobouncebackafterexperiencing and wellbeing. Figure 1:Factorsthatcontributetoindividualhealth What isresilience? Rudd, 2000) (Adapted fromBeautrais,1998;Kumpfer, 1999;Maslow, 1943; image Self- Body Mind Heart Spirit Behaviour physical capacity. Health; physicalenergy;and Physical healthincludes: critical andcreativethinking. Planning; problemsolving;help-seeking;and Problem solvingskillsincludes: Emotional skills;humour;andempathy. Emotional stabilityincludes: and meaning. Motivation; purposeinlife;spirituality;beliefs; Sense ofpurposeincludes: and caring. Life skills;communication;flexibility; Social skillsinclude: and mentalhealthwellbeing. Self-esteem; secureidentity;abilitytocope; Sense ofselfincludes: Individual healthandwellbeing (Commonwealth ofAustralia,2007). work toinfluenceaperson’s reactiontolifeevents Figure 2summarisesthesefactorsthattogether future (expectations,hopes,dreamsandfears). the past(cultural,social,family),andanticipationof social interactionsandaccumulatedexperiencesfrom that canoccurthroughouttheirlifeincludefamilylife, on theindividual’s abilitytomanagetherangeofevents provoking situations.Otherexternalfactorsthatimpact capacity tomanagewhenplacedindifficultoranxiety- together tobuildindividualresilienceandincreasethe Figure 1isjustoneofthefourmainfactorsthatwork However, individualhealthandwellbeingdescribedin those experiences. life’s eventsandstresses,supportthemthrough strengths andcapacitiestoprepareindividualsfortheir are regardedascontributingtoresilienceandbuilding building blocksofindividualhealthandwellbeingthat and attitudetolife.Figure 1summarisesthemaininternal develop andhowtheybuildtheirresilience,wellbeing There havebeenmanytheoriesabouthowindividuals to adverselifeevents. influence aperson’s abilitytorespondpositively Figure 2:Thefourmaingroupsoffactorsthat support community Social and experience and Life history factors or individual Predisposing wellbeing health and Individual experiences; and history ofcoping. experiences; andhistory to trauma;pastsocialandcultural physical andmentalhealth;exposure andcontext;previous Family history geographic inclusionorisolation. economic background;andsocial/ personality; ethnicity/culture;socio- Genes; genderandidentity; solving skills;andphysicalhealth. purpose; emotionalstability;problem Sense ofself;socialskills;sense carers andmentalhealthpractitioners. availability ofsensitiveprofessionals/ and securesupportenvironments; school; levelofconnectedness;safe friends, localdoctor, localcommunity, Support andunderstandingfromfamily, 13 Living Is For Everyone: A Framework for Prevention of Suicide in Australia livingisforeveryone.com.au Tipping points Tipping thinking of taking their own life Many people who are can’t see any other way out of do not want to die, but likely to be deeply ambivalent their situation. They are suicidal thoughts or intentions. or confused about their change rapidly in a short period Their state of mind may own life usually as the result of of time. People take their but it is often just one or two a complex range of factors, actions such as making a plan or things that can trigger their own life. finding a means to take risk of taking their own life person’s The point at which a precipitating increases due to the occurrence of some points varyevent may be called a tipping point. Tipping for every individual, but there are some indicators of stress. times at which people may be under particular be likened The warning signs and tipping points can potential for to signposts that give early warning of the referred to someone to take their own life. Sometimes mental as triggers or precipitating events, they include other disorders or physical illnesses, alcohol and/or loss or , feelings of interpersonal life rejection, or the experience of potentially traumatic events (unexpected changes in life circumstances). an outcome of reckless behaviour. Suicide is, for Suicide an outcome of reckless behaviour. other drugs, example, often associated with alcohol or or it may result from dangerous or life threatening to activities. Such behaviour is sometimes referred as a death wish. may an attempt to end unmanageable pain. This from stemming be psychological pain and despair, be chronic humiliation, guilt, shame, or loss; or it may physical pain or debilitating illness. a direct result of a mental illness, such as clinical a direct result of a mental illness, such as many people depression or schizophrenia. However, with a mental illness are not affected by suicidal and not everyone who takes thoughts or behaviour, ill. their own life is mentally disturbed or mentally an attempt to send a message or gain a particular defiance, vengeance, outcome such as notoriety, or to leave a particular legacy or impact. an altruistic or heroic act, relieving others of a burden, or dying for a cause; or dying to save another, right to choose the an expression of the person’s manner of their death. In some circumstances, the specific means or place of taking their own life has particular symbolic significance to the person. Vulnerability and suicide risk and suicide Vulnerability Despite many years of research into suicide and suicide Despite many years of and overseas, it is still not possible prevention in Australia a person is likely to take their to predict reliably whether which interventionsown life; or to be sure are the most from taking their own life. effective to prevent people be an impulsive and irrational For some, suicide may be a carefully considered choice act. For others it may person believes that his or her - particularly where the Some people take their own death will benefit others. apparently without warning. life or harm themselves of suicidal intent, especially to Some give an indication The most friends and loved ones and to professionals. for people recent theories about the different motivations any one or to take their own life suggest that it may be combination of: •  •  •  •  •  • 

Living Is For Everyone: A Framework for Prevention of Suicide in Australia 14 livingisforeveryone.com.au 15 Living Is For Everyone: A Framework for Prevention of Suicide in Australia livingisforeveryone.com.au • intent to die expressed • has plan in mind • has access to lethal means • impulsive, aggressive or anti-social behaviour Imminent risk Imminent saying they have no reason for living or no sense of purpose in life. and/or friends; and/or giving away possessions or saying goodbye to family dramatic changes in mood, such as sudden feelings of happiness after a long period of sadness or depression; abnormal sleep patterns - not sleeping or sleeping abnormal sleep patterns - not sleeping or all the time; anxiety or agitation; withdrawing from friends, family or the community; increased use of alcohol or other drugs; there’s expressing feelings of being trapped, like no way out; seemingly without thinking; engaging in reckless or risky behaviours, using expressions of rage, anger or seeking revenge; using expressions of rage, anger or seeking expressing feelings of hopelessness; Tipping point • ending relationship • respect loss of status or • debilitating physical illness or accident • of death or suicide relative or friend • suicide of someone of famous or member peer group • argument at home • bullied being abused or • suicide media report on or • 

• • •  • • • • 

• • • Warning signs Warning • hopelessness • – like feeling trapped way out no there’s • or increasing alcohol drug use • withdrawing from society friends, family or • no no reason for living, in life sense of purpose • or uncharacteristic or impaired judgement behaviour looking for ways to take their own life, or talking about their plan to do so; talking or writing about death, dying or taking their life (especially when this is out of character or unusual for the person); Risk factors • health problems mental • gender – male • family discord, violence or abuse • family • alcohol or other substance abuse • social or geographical isolation • financial stress • bereavement • prior Warning signs Warning Examples of typical triggers and precipitating events to suicide. precipitating events of typical triggers and Examples FIgure 3: For families, friends and work colleagues, knowing the For families, friends and work colleagues, quickly main warning signs and responding to them main life. This is the and effectively may save a person’s component of indicated interventions that are outlined be noted it should in the following section. However, own life, that in many cases of someone taking their are obvious there appear to be no warning signals that miss them. and even the most skilled professionals may be at a A warning sign indicates that a person might about heightened risk, is having serious thoughts or taking taking their own life, and may be planning signs may be a cry for actions towards this. Warning friends, help, and they can provide a chance for family, associates and professionals to intervene and potentially prevent the person from dying or injuring themself. The following behaviours are more common among people who are feeling like taking their own life, although many people show some of these signs at some point in their lives, especially when they are tired, stressed or upset: • threatening to hurt themselves or take their own life; • •

Living Is For Everyone: A Framework for Prevention of Suicide in Australia 16 livingisforeveryone.com.au

 The model recognises that individuals respond differently when faced with adverse events. They do not always follow a logical or linear decline in health – from risk, to warning sign, to tipping points, to the need for specialised care. A person may move, with no apparent warning, from apparent good health directly into distress and despair and a need for immediate specialised care. Community-based safety nets to support people as Community-based safety nets to support or are they move from one treatment setting to another, There is strong discharged back into the community. and in evidence - both from health systems generally, are most relation to suicide in particular - that people between exposed to risk at these handover points interventions. This is when things are most likely to go  wrong and when support is most critical; and The new model uses more everyday language, to make it accessible to a wider audience; The individual’s health, wellbeing and responses to life health, wellbeing and responses The individual’s that events are at the centre of the model, recognising and vary in their people respond and cope differently, vulnerability and resilience; •  •  •  The LIFE (2007) model The LIFE (2007) the Mrazek In light of recent research and consultations, further in 2007 and Haggerty (1994) model was adapted for the LIFE Framework to focus on the following key features: • 

iii Intervention - To take action or provide a service so as to produce an a service so as to produce take action or provide Intervention - To health or outcome or modify a situation. Any action taken to improve a disease or dysfunctional behaviour. change the course of, or treat  iii (prevention, treatment, maintenance, recovery). This model has been widely used, and has been adapted for use in the Australian National Mental Health Strategy (Raphael, 2000) and the 2000 version of the Australian National Suicide Prevention Strategy (Commonwealth of Australia, 2005). Context Living Is For Everyone Is Living The for Suicide Framework (LIFE) Prevention Traditionally, approaches to care in the health sector were Traditionally, secondary and tertiary based on the concepts of primary, prevention. Primary prevention aims to prevent the onset Secondary prevention aims to of a particular disorder. identify and treat persons who have no symptoms, disease. but have developed risk factors or preclinical effects of prevention aims to minimise the Tertiary complications and prevent an established disorder, 1996). Force, (U.S. Preventative Services Task the In the 1980s, with increasing awareness of contextual, complexity of the factors (risk, protective, model personal) that influence any illness, the traditional indicated was replaced by the universal, selective and prevention model, introduced by Gordon (1983). clients rather This model focussed on different groups of measures than on the treatment mechanisms. Universal a whole population or a can be applied to everybody, can whole community; selective preventative measures be applied to a sub-group at known increased risk; and indicated measures target individuals who are at high risk. This approach is now the basis of suicide prevention in the United States. model Mrazek and Haggerty (1994) adapted Gordon’s to include the whole spectrum of interventions

Living Is For Everyone: A Framework for Prevention of Suicide in Australia 18 livingisforeveryone.com.au 2.  populationorpopulationstoreduceaccessmeans aimtoengagethewholeofa 1. Universalinterventions The eightdomainsare:

• safetynetsshouldbeprovidedtosupportpeople • •  The LIFE(2007)modelisbasedonthepremisethat: of suicideprevention activities LIFE Frameworkcontinuum families,schoolsandcommunities. suicide,andtocreatestrongermoresupportive ofsuicide,reduceinappropriatemediacoverage –  –  –  the communitythrough: moving betweentreatmentoptions,andbackinto of careandsupport(seeFigure4); activities willoccuracrosseightoverlappingdomains in ordertoreducethelossoflifethroughsuicide, needs oftheindividualandcommunity; in a coordinated and integrated way according to the the community and that interventions should be provided across individuals, professionalgroupsandservices the responsibility for suicide prevention rests with strength andresilience. ofchild abusetobuild with childrenwhoaresurvivors and losstheirelevatedriskofsuicide;orworking who havetakentheirownlifetorespondgrief include, forinstance,workingwithfamiliesofthose that promotesself-helpandsupport.Thismight resilience, strengthandcapacityanenvironment and communitieswhoareidentifiedasatrisktobuild entailworkingwithgroups Selective interventions workplaces, andcommunitygroups. families, professionals, communitysupportservices, cooperation andcommunicationbetweenhealth and backintothecommunity; effective clienthand-overpracticesbetweenservices recovery afterdischargefromclinicalcare; recovery tosupportandfoster community-based services

7.  6.  5.  4.  3.  people at-risk. warning signsandtakeappropriateactiontosupport community members can be educated to recognise be given to doctors or psychologists, or family and that have caused the illness. Alternatively, referral can their current situation by solving some of the problems depression). Thesepeoplecanbehelpedtomanage known to heighten the risk of suicide (eg severe signs of suicide risk or present symptoms of an illness Indicated interventions target people who are showing immediate familyandtheirlocalcommunity. to improveprotectivefactorsfortheindividual,their in thefuture.Alongsidethis,effortscanbemade for suicidetoremovethemorreducetheirimpact a timetodirectlyfocusondistalorbackgroundrisks risk ofadversehealtheffects.Inparticular, thismay be andreducethe integrated caretoconsolidaterecovery preparing forapositivefuture.Thisentailscontinuing Longer-term treatmentandsupporttoassistin assist recovery. any underlyingconditions,improvewellbeingand behaviours andcomprehensivelytreatmanage Integrated, professionalcaretomanagesuicidal Standard treatmentwhenspecialisedcareisneeded. information andcareasneeded. toensureclient’sinterventions accesstofurther and integratedsupportcare,monitors first pointofprofessionalcontactthatprovidestargeted treatment andspecialisedcareisneeded.Thisthe Finding andaccessingearlycaresupportwhen care whenvulnerabilityandexposuretoriskarehigh. and potentialtippingpointsbyprovidingsupport signs ofhighorimminentrisk,adversecircumstances Symptom identification-knowingandbeingalertto 19 Living Is For Everyone: A Framework for Prevention of Suicide in Australia livingisforeveryone.com.au maintaining an environment where individuals, families maintaining an environment build resilience and improve and communities can wellbeing during times of their general health and growth adversity (individual, family and community and development). providing access to specialist care and integrated local support for those who are feeling chronically suicidal or are exposed to greater risk of suicide (specialised care); and of individuals who might be feeling suicidal of individuals who might care); (targeted support and building the capacity for meeting the needs building the capacity Figure 4 provides a summaryFigure of the range of types of suicide prevention activities and interventions that are to reducing essential for a whole of community response of suicide, of the rate of suicide in Australia, and the risk suicide attempts and of suicidal behaviours in individuals. For each activity/intervention the following outcomes; is defined: the target group; the proposed and who might be involved in the activity/intervention. • • 

•

involving professionals, involving professionals, Ongoing care and support organisations, friends and workplaces, community to adapt, cope, and build family to support people within an environment of strength and resilience the opportunity to increase self-help. This may be about the issues broader community education of the strategies that may be and build awareness needed to prevent recurrences. assisting people to help themselves and creating an assisting people to help themselves and creating self- environment that supports self-help (promoting help); early recognising early warning signs and providing intervention to assist people to resolve issues and/or access appropriate help (responding to help-seeking behaviours); increasing understanding of suicide and suicide and local prevention and the capacity for individuals communities to recognise and respond to early warning people signs and to take appropriate steps to make safe (promoting local understanding and support); 8.  Suicide prevention interventions that are represented include: across these domains •  •  •

Living Is For Everyone: A Framework for Prevention of Suicide in Australia 20 livingisforeveryone.com.au Figure 4: LIFE Framework continuum of suicide prevention activities.

Target Outcomes Who is involved? groups

Universal Activities Reducing access to means of suicide, altering Involving: individuals, families, consumer and intervention that apply to media coverage of suicide, providing community carer organisations, multicultural organisations, everyone (whole education about suicide prevention and creating local councils, sporting and recreational clubs, populations) stronger and more supportive families, schools workplaces, media, educational organisations, and communities. providers of education and information on mental health and suicide prevention, service clubs and pubs.

Selective For communities Building resilience, strength and capacity and an Involving: individuals, families, consumer and intervention and groups environment that promotes self-help and help- carer organisations, multicultural organisations, potentially seeking and provides support. local councils, sporting and recreational clubs, at risk workplaces, media, educational organisations, Divisions of GP, service clubs and pubs. 21

Indicated For individuals at Building strength, resilience, local understanding, Involving: individuals, families, consumer and carer intervention high risk capacity and support; being alert to early signs of organisations, multicultural organisations, GPs, risk; and taking action to reduce problems police, gerontologists, rehabilitation providers, and symptoms. emergency workers, specialist physicians, sporting and recreational clubs, workplaces, educational organisations, service clubs and pubs. livingisforeveryone.com.au

Symptom When Being alert to signs of high risk, adverse health Involving: GPs, help lines, police, gerontologists, identification vulnerability and effects and potential tipping points; and providing rehabilitation providers, emergency workers, exposure to risk support and care. specialist physicians, teachers, pharmacists, are high workplaces family and friends and other gatekeepers.

Early Finding and Providing first point of professional contact; Involving: GPs, psychologists, allied mental treatment accessing targeted and integrated support and care; health professionals, Aboriginal Health Workers, Living Is For Everyone: A Framework for Prevention of Suicide in Australia early care and and monitoring and ensuring access to further emergency departments, police, gerontologists, support information and care. emergency workers, specialist physicians, community health services, help lines, crisis teams, school counsellors.

Standard When Providing integrated professional care to manage Involving: psychiatrists, psychologists, GPs, treatment specialised care suicidal behaviours and improve wellbeing as a allied mental health professionals, Aboriginal is needed step in recovery. Health Workers.

Longer-term Preparing for a Providing ongoing integrated care to consolidate Involving: psychiatrists, psychologists, GPs, allied treatment positive future recovery and reduce the risk of adverse health mental health professionals, families, workplaces, and support effects. local community organisations and clubs, rehabilitation services, Aboriginal Health Workers, help lines.

Ongoing Getting back Building strength, resilience, and adaptation and Involving: GPs, allied mental health professionals, care and into life skills, and an environment that supports Aboriginal Health Workers, community support self-help and help-seeking. service providers, families, local community organisations, workplaces and clubs.

Safety Nets for people moving between treatment options, and back into the community. These include: • community-based services to support and foster recovery after discharge from clinical care • effective client hand-over practices between services and back into the community; and • effective cooperation and communication between health professionals, community support services, schools, families, workplaces and community groups. The LIFE Framework for Action

Principles underpinning the LIFE Strategic directions Framework for Action

22 The LIFE Framework reflects a vision that suicide There are a set of binding principles underpinning the livingisforeveryone.com.au A Framework for Prevention of Suicide in Australia Living Is For Everyone: prevention activities will reduce suicide attempts and LIFE Framework. They are: the loss of life through suicide by providing individuals, 1. Suicide prevention activities should first do no harm. families and communities with access to support so Some activities that aim to protect against suicide that no-one in crisis or experiencing personal adversity have the potential to increase suicide risk amongst sees suicide as their only option. vulnerable groups. Activities need to respect the The purpose of the LIFE (2007) materials is to provide context, health, receptivity and needs of the person information, resource materials and strategies that who is feeling suicidal. will support population health approaches and suicide 2. Suicide prevention is a shared responsibility across prevention activities undertaken across the Australian the community, families and friends, professional community and thereby contribute to a reduction in groups, and non-government and government suicide and suicide attempts. agencies. The central goal of the LIFE Framework is to reduce 3. Activities should be designed and implemented suicide attempts, the loss of life through suicide and to target and involve: the impact of suicidal behaviour in Australia. This requires – the whole population a number of interlinked and coordinated strategies that – specific communities and groups who are known reflect universal, selective and indicated approaches. to be at risk of suicide; and Suicide prevention activities, programs and interventions  – individuals at risk. will aim to build: 4.  Activities need to include access to clinical or • stronger individuals, families and communities professional treatment for those in crisis and support for people who are recovering and getting back • individual and group resilience to traumatic events into life. • community capacity to identify need and respond 5. Activities must be appropriate to the social and • the capability for communities and individuals to cultural needs of the groups or populations being respond quickly and appropriately; and served. • a coordinated response, and provide smooth 6. Information, service and support need to be provided transitions to and between care. at the right time, when it can best be received, understood and applied. 7. Activities need to be located at places and in environments where the target groups are comfortable, and where the activities will reach and be accessible to those who most need them. 8. Local suicide prevention activities must be sustainable to ensure continuity and consistency of service. 9. Suicide prevention activities should either be, or aim to become, evidence-based, outcome focused and independently evaluated. • •  the followingmustbetakenintoaccount: In designingactivities,actionsandprograms, the LIFE Framework for Action Considerations in implementing 11.  10. – – – – – improvingprotectivefactors; – reducingaccesstothemeansofsuicide; – reducingexposuretoriskofsuicide; There shouldbeafocuson: rapidly availablewhenitisneeded. of distress,specialisedcareneedstobereadilyand is gradualandvisible,orrapidwithnooutwardsign needs. Inparticular, whetherthepathtowardssuicide Care andsupportmustmatchpeople’s different   people atrisk. networks, thelocaldoctorandwork colleaguesof education fortheimmediatefamily, friends,social or traumatised;and those who are mentally ill, grieving, profoundly distressed improving community understanding of the needs of the rightsupport,inplace,attime; identifying theindividual’s particularneedsandproviding carers andhealthservices; community, intheworkplace,fromprofessional access to a range of support - from the family and providing individuals who are feeling suicidal with to provideasafe,secureandcaringenvironment. approachandaim should reflectamulti-disciplinary forpeoplewhoarerecognisedassuicidal Services interest groups,individuals,familiesandcommunities. acrossdifferentcultures, offers –andhowthesevary contribute toqualityoflifeandtheopportunities environmental, culturalandeconomicfactorsthat that mayinfluencesuiciderisk–themanysocial, Activities needtobesensitivethebroaderfactors

23 23 Living Is For Everyone: A Framework for Prevention of Suicide in Australia livingisforeveryone.com.au

improvements in individual protective or resiliency factors (eg improved coping skills, more help-seeking behaviours, better social connectedness, better understanding of mental illness); and ensuring access to the range of required support and ensuring access to the range of required support care for people feeling suicidal. changes in behaviours and response to suicide prevention strategies; creating environments where it is acceptable to express creating environments where it is acceptable fear of emotions and suicidal thoughts without a and personal weakness or stigmatisation; acrimony, increase in individual and/or community awareness of appropriate suicide prevention; creating environments that encourage and creating environments support help-seeking; vulnerabilities and factors risk in reductions feelings illness, mental (eg behaviours suicidal to of hopelessness); building individual resilience and the capacity building individual resilience for self-help; reductions in suicide attempts and/or suicidal thinking; early identification and intervention;early identification and Action Area 6 Action Area prevention. Implementing standards and quality in suicide evidence Suicide prevention programs need to reflect communicate of what works and does not work, and to it effectively to the point of need. •  •  •  •  • •  •  •  The importance of evaluating activities suicide prevention projects, Systematic evaluation of all suicide prevention continued activities and programs is essential for the that development of best practice. It will ensure evidence, of foundation solid a interventionson based are that resources and effort are allocated appropriately and that the required outcomes and impacts can be achieved. For an evaluation to be effective it must be planned, built into all activities and measure the significant outputs and outcomes that will show how well a program is working. Measures relevant to suicide prevention may include: • Action Area 5 Action Area prevention activities. Providing targeted suicide individuals and prevent suicide, address the needs of To key elements: there are a number of • improving understanding about the prevalence and improving understanding causes of suicide; increasing understanding about interventions that are likely to be the most effective; determining what services and interventions are needed, for which specific groups; evaluating interventions and services provided; and providing reliable information to the community about suicide and suicide prevention. Action Area 1 Action Area base and understanding of Improving the evidence suicide prevention. of the evidence for suicide and Improving the quality fundamental to the development, suicide prevention is of effective suicide prevention implementation and review A sound evidence base will policies and practices. assist in: •  •  •  • •  2 Action Area self-help. for capacity the and resilience individual Building Protecting against suicidal behaviour includes as providing implementing preventative measures such accessible environments where appropriate support is and as well as implementing programs that promote support wellbeing, and social connectedness. 3 Action Area capacity Improving community strength, resilience and in suicide prevention. Improving individual, family and community awareness and understanding of suicide and suicide prevention will increase the capacity of communities to prevent and respond to suicide. 4 Action Area a coordinated approach to suicide prevention. Taking Effective suicide prevention relies on communities, organisations and all levels of government working together using sound evidence, with a careful assessment of outcomes. Summary of Action Areas of Action Summary

Living Is For Everyone: A Framework for Prevention of Suicide in Australia 24 livingisforeveryone.com.au Figure 5:Indicatorsforevaluationofsuicidepreventionactivities. (accountability). (impact) ordeliveredonitscontractualobligations has madeadifferenceorachieveditsstatedobjectives the evaluationwillusuallyfocusonwhetherproject has beenfundedorsponsoredbyanoutsideagency, On the other hand, where a project that is known to work, project (practiceorprocessimprovement). unfolds, toimproveandrefinethedevelopmentof type, evaluationisoftenfedbackintotheprojectasit implementation (processevaluation).Inprojectsofthis largely onwhatcanbelearntfromitsdevelopmentand evaluation ofaprototypeoraninnovativeideawillfocus size, scopeandintentofeachproject.Forinstance, The type(s)ofevaluationusedwilldependonthe •  3. 2.

1.  indicators Effectiveness the adverseimpactofsystemonindividuals. modelsorpracticestoreduce improvements inservice Sustainability Stakeholder satisfaction objectives outcomesmet Policy and program • • • • • • • • • •     outcome issustainable understood and adopted outcome iseasily applicable outcome isrelevantand customers/consumers project partners key stakeholders sponsoring agency objectives project/service program objectives policy objectives indicators Program quality 6. 5. 4.

Quality ofservice Quality ofproducts Quality ofprocess • • • • • • • • • • •     understanding knowledge and competence/ professional equitable accessible target marketcovered appropriate toneed right type,mix,range adequacy stakeholders engagement ofkey methodologies quality ofactivitiesand requirements conforms to Efficiency indicators 9. 8. 7. 10. Time efficiency prevention activitiesagainsttheseindicators. that maybeusefulinevaluatingandreportingsuicide Figure 5setsoutelevencategoriesofmeasures • • • • indicators of: Evaluations ofsuicidepreventionactivitiesmayfocuson be systematicallyevaluated. from theactionareasdefinedonfollowingpageswill It isassumedthatallsuicidepreventionactivitiesarising Cost efficiency Resource efficiency Allocative efficiency • • • • • • • • • • quantity. efficiency; and program quality effectiveness    meets agreedtimelines responsiveness value formoney recurrent cost absolute cost consumables infrastructure staffing this outcome investment for best returnon prevention the issueofsuicide resources inaddressing best useofavailable Quantity indicators 11. 

• • • • intermsof: Quantity delivered

inputs toproject agreed targets need policy 25 Living Is For Everyone: A Framework for Prevention of Suicide in Australia livingisforeveryone.com.au The Living Is For Everyone (LIFE) Action Areas

Action Area 1

26 Improving the evidence base and livingisforeveryone.com.au A Framework for Prevention of Suicide in Australia Living Is For Everyone: understanding of suicide prevention

Improving the quality of the evidence for suicide and suicide prevention is fundamental to the development, implementation and review of effective suicide prevention policies and practices. A sound evidence base will assist in: • improving understanding about the prevalence and causes of suicide; • increasing understanding about interventions that are likely to be the most effective; • determining what services and interventions are needed, for which specific groups; • evaluating interventions and services provided; and • providing reliable information to the community about suicide and suicide prevention. Action Area1 how besttointervene Understanding ofimminentriskand Outcome 1.1. Outcomes and individuals resilience ofcommunities factors, andhowbesttobuild community riskandprotective Understanding ofwhole Outcome 1.2. risk populations for suicidepreventionamonghigh development oftheevidencebase Application andcontinued Outcome 1.3. and information prevention resources Improved accesstosuicide Outcome 1.4. ii. i. Strategies v. iv.  iii.  ii. i. iv.  iii.  ii. i. ii. i. tipping pointsandimminentriskfactors. Improve theevidencebaseforidentificationanddifferentiationofwarningsigns, impact on,andrelevanceto,theincidenceofsuicidalbehaviours. andtheir Identify andclarifythelinkbetweensuicidepreventionactivitiesinterventions in relevantsystematic,longitudinal,multi-disciplinary, multi-sitestudies. Synthesise andstrengthenunderstandingofsuicidethroughincorporation prevented acrossdifferentculturalandat-riskgroups Improve understandingoftheculturalsignificancesuicideandhowcanbe communication (egmedia,internet,MySpace,YouTube, chatrooms,instantmessaging). Research the influence and impact on suicidal behaviours of new technologies/multi-media communities and/orthoseadverselyaffectedbyclimatechangeornaturaldisasters. building inthelong-termpreventionofsuicide,includingruralandremote Improve theevidencebaseforimpactofcommunitycapacityandresilience social andenvironmentalinfluencesonsuicidesuicidalbehaviours. Develop abetterunderstandingofthepositiveandnegativeimpactseconomic, previously attemptedsuicideorengageinself-harmingbehaviours. Measure theeffectivenessofmanagementandcareoptionsforpeople whohave behaviour andemotionalopenness. toencouragemen’sApply anddeveloptheevidencebaseofinterventions help-seeking bereaved bysuicide. Apply anddeveloptheevidencebasetoidentifyaddressneedsofpeople for AboriginalandTorres StraitIslandercommunities. thatwork Apply anddeveloptheresearchevidenceofinterventions through suicide. Progress anationalstandardisedrecordingsystemrelatingtodeaths resources insuicideprevention. Contribute toacentreforthecollectionanddisseminationofqualityinformation and 27 Living Is For Everyone: A Framework for Prevention of Suicide in Australia livingisforeveryone.com.au Develop and promote programs that raise awareness of the importance of social Develop and promote programs that raise awareness suicide prevention (eg via the media, and emotional wellbeing, mental disorders and schools and workplaces). Develop and promote programs to enhance help-seeking behaviour among high-risk groups and in people that are known to be least likely to seek help including young some Strait Islander communities and people from people, men, Aboriginal and Torres culturally and linguistically diverse communities. to destigmatise conditions that contribute to suicide risk (eg mental illness, Work homelessness, financial hardship) with a view to encouraging help-seeking behaviour. Develop and promote universal programs to support the acquisition of life skills that Develop and promote universal programs to support social competence, communication, enhance individual and community resilience (eg problem-solving, community development skills). programs for the whole community, Develop and promote mental health and wellbeing risk groups or populations including those designed to support particular high initiatives for children (eg culturally appropriate programs for diverse communities, whose parents have a mental illness, etc). trauma or prevention suicide in role key a have that professions to support Provide staff improve delivery, service enhance wellbeing, and health mental safeguard to response, health professionals, law enforcementretention and minimise the likelihood of suicide (eg officers, emergency services education and social service personnel, professionals). where it is acceptable Foster environments (eg families, schools, workplaces) stress, sadness, ) without a fear of stigmatisation. to express emotions (anxiety, i. ii. iii.  Strategies i. ii. iii.   iv. Outcome 2.2. An environment that encourages and supports help-seeking Outcomes Outcome 2.1. Improved individual resilience and wellbeing Action Area 2 Building individual resilience and the capacity Building individual for self-help behaviour includes Protecting against suicidal measures such as providing implementing preventative appropriate support is accessible environments where programs that promote and as well as implementing and social connectedness. support wellbeing, optimism Action Area 2 Area Action

Living Is For Everyone: A Framework for Prevention of Suicide in Australia 28 livingisforeveryone.com.au

Enable locally based networks and cooperative partnerships to respond effectively to traumatic traumatic to effectively respond to partnerships cooperative and networks based locally Enable incidents or significant changes in local circumstances (eg drought, industry closures). Develop materials and provide locally based support to assist staff and volunteers in organisations such as pubs, clubs, cultural and religious centres and recreational and sporting groups, to identify potential suicidal behaviour and to respond effectively. Expand and resource the capacity of schools, workplaces and other relevant settings, to identify and provide support to those at risk. Use the media and other strategies to raise awareness of the risk factors, warning signs and tipping points for suicide. Develop and disseminate resources that recognise and support the important role of and friends, colleagues and peers in suicide prevention. impact on family, Educate communities to identify and respond to warning signs, tipping points and Educate communities to identify and respond to imminent risk factors associated with suicide. community knowledge and with the mainstream and multilingual media to improve Work and encourage responsible coverage of understanding of suicide and suicide prevention these issues. by actively communicating the range Reduce the stigma and myths surrounding suicide behaviours. and complexity of factors that contribute to suicidal to work together to reduce risk Develop and promote strategies that enable organisations and communities. factors and strengthen protective factors in individuals Raise awareness of the characteristics of healthy and resilient communities, Raise awareness of the characteristics of healthy and support their development. to promote the development and Use mentoring and leadership development programs sharing of good practice in local communities. support groups within local communities Develop and promote strategies that enable and to work together on suicide prevention.

i. ii. iii.   iv. v. i. ii. iii.   iv. Strategies i. ii. iii.  Outcome 3.3. Improved capability to respond at potential tipping points and points of imminent risk Outcome 3.2. Increased community awareness of what is needed to prevent suicide Outcomes Outcome 3.1. Improved community strength and resilience Action Area 3 Improving community strength, resilience and Improving community prevention capacity in suicide family and community awareness Improving individual, suicide and suicide prevention and understanding of of communities to prevent will increase the capacity and respond to suicide. Action Area 3 Area Action

Living Is For Everyone: A Framework for Prevention of Suicide in Australia 30 livingisforeveryone.com.au Action Area4 assessment ofoutcomes. together usingsoundevidence,withacareful organisations andalllevelsofgovernmentworking Effective suicidepreventionreliesoncommunities, suicide prevention Taking acoordinatedapproachto Action Area 4 service that peopleexperienceaseamless linkingeffectivelyso Local services Outcome 4.1. Outcomes government organisations professional bodiesandnon- between governments,peakand cooperation, throughpartnerships Program andpolicycoordination Outcome 4.2. Regionally integratedapproaches Outcome 4.3. vi.  v. iv.  iii.  ii. i. Strategies iv.  iii.  ii. i. v. iv.  iii. ii. i. suicide prevention. Promote andsupportlinkagesbetweencommunitybasedclinicalinitiativesin protocols. and outcomemeasures,jointservice/client dealing withprivacyandconfidentialityrequirementsbarriers,developinglocaldata agreements, Develop practicaltoolsforinformationsharing,includingsharedservice of potentialsuicidalbehaviour. recreational andsocialgroupstoidentifyquicklyrespondeffectivelyindicators Strengthen thecapacityforfamilies,schools,workplaces,pubs,clubsandsports, to suicidepreventioninlocalcommunities. Develop andpromoteclient-centred,sharedcase-managementapproaches responses. improve service Develop anunderstandingofpeople’s inordertoinformand journeystofindservices to locallybasedsuicidepreventionactivities. Encourage andresourceintegrated,cross-functional,cross-agencysolutions with suicideprevention. Address theinformationneedsofdifferentprofessionalandcommunity groupsconcerned provision. coordinated communityservice providers)tosupport teamsandservice evaluation toolsforprofessionals,multidisciplinary Design andimplementresourcestools(egsharedcareguidelines, protocolsand to supportinformationsharingandreduceduplicationofeffort. institutions, non-governmentorganisations(NGOs),peakandprofessionalbodies, Support and improve linkages and cooperation between governments, academic prevention. community, justice,employmentandotherpolicyprograms, forbettersuicide Develop cross-governmentmechanismstoimprovetheintegrationofhealth,housing, protocols andjointclientassessments. metrics,jointservice agreements,localdataandservice Develop sharedservice agencies involvedincommunityand emergencyservices. Strengthen localcapacitybysupporting sharingofpracticeandexperienceacross Actively engagelocalgovernmentinsuicideprevention. Increase cooperationwithinregionstoimprovesuicidepreventionactivities. to supportbetterregionalcooperationinsuicidepreventionactivities. Promote naturalcatchmentapproaches,includingreducingjurisdictional barriers,

31 Living Is For Everyone: A Framework for Prevention of Suicide in Australia livingisforeveryone.com.au

ensuring access to the range of required support and ensuring access to the suicidal. care for people feeling creating environments where it is acceptable to express creating environments thoughts without a fear of emotions and suicidal weakness or stigmatisation; and personal acrimony, •  •  Develop and promote innovative programs to reach those in high-risk populations who traditionally do not Develop and promote innovative programs to reach access health services. Make services highly visible and approachable. attempted suicide and their families. Develop support systems for individuals who have problems who are at risk of suicide. Support people with mental illness and related Identify communities in which suicide and suicidal behaviour is prevalent, and proactively develop Identify communities in which suicide and suicidal strategies and services underlying causes and contributing factors. that address the high risk groups and communities, to enable them Provide and resource mentoring and support for to undertake effective suicide prevention activities. Support interventions as high risk. This includes men aged 20-54 and over 75, men for groups identified communities, people with a mental illness, people with substance Strait Islander in Aboriginal and Torres in rural and use problems, people in contact with the justice system, people who attempt suicide, people remote communities, gay and lesbian communities, and people bereaved by suicide. Develop effective and sustainable interventions behaviours are for groups and communities where suicidal prevalent, by encouraging ownership and active involvement. are Develop and promote mental health and wellbeing programs in occupational groups whose members subject to frequent traumatic events (eg Police, Emergency Services). and Provide support to the caring professions to minimise the likelihood of suicide amongst carers clinical professionals. Implement guidelines and support tools to improve the understanding and skills of front-line workers who Implement guidelines and support tools to improve the understanding and skills of front-line workers tipping routinely interact with high risk groups, to identify and respond rapidly to suicide warning signs, points and imminent risk factors. groups Provide education and information for consumers and carers involved with at-risk individuals and to enable them to identify and respond rapidly to suicidal behaviour. Develop and resource discharge planning, clinical handover and transition to community care and support that recognises the increased risk to individuals at and after discharge. Educate and inform professionals, service providers, families and community organisations in the provision of safe and secure care environments for people at risk. Provide access to training programs at undergraduate, post-graduate and vocational levels. Wherever possible, these should be multidisciplinary and cross-agency. Strategies i. ii. iii. iv. i. ii. i. ii. iii.   iv. i. ii. iii.   iv. v. early identification and intervention;early identification and capacity for the and resilience individual building self-help; that encourage and creating environments support help-seeking; Outcomes Outcome 5.1. Improved access to a range of support and care for people feeling suicidal Outcome 5.2. Systemic, long- term, structural interventions in areas of greatest need Outcome 5.3. Reduced incidence of suicide and suicidal behaviour in the groups at highest risk Outcome 5.4. Improved understanding, skills and capacity of front-line workers, families and carers Action Area 5 Providing targeted suicide prevention activities Providing targeted individuals and prevent suicide, address the needs of To key elements: there are a number of • •  •  Action Area 5 Area Action

Living Is For Everyone: A Framework for Prevention of Suicide in Australia 32 livingisforeveryone.com.au Action Area6 it effectivelytothepointofneed. of whatworksanddoesnotwork,tocommunicate Suicide preventionprogramsneedtoreflectevidence suicide prevention Implementing standardsandqualityin Action Area 6 Outcomes standards andsharedlearning Improved practice,national Outcome 6.1. of soundpracticeinevaluation Improved capabilitiesandpromotion Outcome 6.2. and services suicide preventionprograms response toinformationabout quality, quantity, accessand Systemic improvementsinthe Outcome 6.3. Strategies iii. ii. i. iv. iii.  ii. i. iv.  iii.  ii. i. Identify theskillsandtrainingrequiredtoworkeffectivelyinsuicideprevention. Disseminate evidencetounderpinpractice. Develop andpromotenationalstandardsspecifictosuicideprevention. Improve thecapacitytoundertakesoundevaluations. Develop andpromoterobustaccountableevaluationmodelsprocesses. of suicidepreventionandassistincontinuouslyimprovingpractices. Promote theroleofevaluationandresearchinexpandingevidencebase Promote systematicevaluationofsuicidepreventioninitiatives. community responsestoemergingpracticeandidentifieddemonstrableneeds. Promote andprovidefundingarrangementstoenablefacilitateflexible good practice. Encourage andsupportsharedlearningstoreduceduplicationpromote programs canbuildonpastexperience. Enable accesstoinformationaboutsuicidepreventionprograms,sothatnew to ensurethatinformationonsuicideprogramsisavailable. Develop andmaintaintimely, robustandtransparentreportingsystems 33 Living Is For Everyone: A Framework for Prevention of Suicide in Australia livingisforeveryone.com.au New South Wales NSW Health www.health.nsw.gov.au Centre for Mental Health www.health.nsw.gov.au/policy/cmh Victoria Victoria Health www.health.vic.gov.au Mental Health www.health.vic.gov.au/mentalhealth Tasmania Department of Health and Human Services Suicide Prevention Steering Tasmanian Committee (TSPSC) www.dhhs.tas.gov.au Mental Health www.dhhs.tas.gov.au/health__and__wellbeing/ mental_health Queensland Department of Communities www.communities.qld.gov.au Suicide Prevention www.communities.qld.gov.au/community/ suicide_prevention

State and Territory Government State and Territory Australia Western Ministerial Council on Suicide Prevention WA www.mcsp.org.au Suicide Prevention Plan WA www.mcsp.org.au/prevention/prevention_plan South Australia Government of South Australia Department of Health www.health.sa.gov.au Mental Health www.health.sa.gov.au/mentalhealth National Suicide Prevention Strategy livingisforeveryone.com.au Department of Health and Ageing and www.mentalhealth.gov.au www.health.gov.au National Drug Strategy 2004-2009 www.nationaldrugstrategy.gov.au National Alcohol Strategy 2006-2009 www.alcohol.gov.au people National Policy Framework for Indigenous www.indigenous.gov.au Department of Families, Housing, Community Australian Government Services and Indigenous Affairs’ Community Mental Health Programs www.facsia.gov.au Program Family Court of Australia Mental Health Support www.familycourt.gov.au Affairs Department of Veterans’ www.dva.gov.au Appendix A: Appendix and government Relevant policies, non-government and activities programs

Living Is For Everyone: A Framework for Prevention of Suicide in Australia 34 livingisforeveryone.com.au www.health.act.gov.au/mentalhealth Mental Health www.health.act.gov.au ACT Health Australian CapitalTerritory www.health.nt.gov.au/Mental_Health Mental Health www.health.nt.gov.au Department ofHealthandFamilies TerritoryNorthern 35 Living Is For Everyone: A Framework for Prevention of Suicide in Australia livingisforeveryone.com.au Clinical paradigm: This paradigm focuses on repairing of human damage within a disease or medical model functioning. Cognitive: Mental processes and conscious intellectual solving, activities such as planning, reasoning, problem new words thinking, remembering, reasoning, learning or imagining. Common factors (therapy): Features of therapy differing that are common to success, despite the specific theoretical position of each therapist and the techniques used. Community ownership: A community takes and agrees responsibility for an issue, such as suicide, sustainable to work together to develop effective and solutions. Connectedness: Enquiry into protective factors for people suicide has focused on the capacities within (resilience factors) and on external protective factors sense of (Seifer et al. 1992), including a person’s belonging and connectedness with others. There is school or a evidence that connections with family, significant adult can reduce risk of suicide for young people. Feelings of connectedness to a partner or parent or responsibility for care of children appear to be protective factors, and connectedness within a community has been linked to health and wellbeing. Content: The quality and the proportion or quantity of information adequately matched to the need. Engagement with longer-term Continuing care: treatment, support and care where needed. Data: Statistics that inform on specific aspects of suicide, such as rates and trends of suicide and suicide attempts. Data collection can also be a means of monitoring service follow-up arrangements, such as post-discharge or outcomes. Individual - Enhancing and/or developing personal  Individual - Enhancing and/or developing personal aptitude, strength, coping and/or independence. organisations, Community - The ability of a community’s groups and individuals (collectively) to build their structures, systems, people and skills, so they are better able to define, implement, manage and achieve their shared objectives. Glossary terms of Strait Islander: A person Aboriginal and/or Torres Strait Islander descent; who is of Aboriginal or Torres Torres or and identifies as an Australian Aboriginal such by Strait Islander person; and is accepted as the community in which s/he lives or has lived. life that Adverse life event: An incident within one’s disruption, has the potential to cause emotional upset, or negative health outcomes. The period after a loss (usually through Bereavement: mourning death) during which grief is experienced and occurs (Raphael, 1984). Best practice: The use of methods (often evidence- optimal based) that achieve improvements and/or outcomes. Capacity building: Client-centred therapy or the person- Client-centred: centred approach is a movement associated with humanistic that emphasises ‘the capacity of each individual to arrive at a personal understanding using feelings and intuition rather of his or her destiny, than being guided by doctrine and reason. Rather than focusing on the origins of client problems in childhood events (psychodynamic) or the achievement of new patterns of behaviour in the future (behavioural)… concentrate on the here and now experiencing of the client’ (McLeod, 2003, p. 157).

Living Is For Everyone: A Framework for Prevention of Suicide in Australia 36 livingisforeveryone.com.au enhances therapeuticwork. that permitstheclienttoexperiencesafety, andthus Holding environment: Referstoatherapeuticsetting or otherdifficultcircumstances. help orsupportinordertocopewithadverselifeevents Help-seeking: Theprocessofanindividualaskingfor laboratories, andothermedicalservices. care andprovidesreferralstospecialists,hospitals, provider,such asaprimary-care whocoordinatespatient local opinionleaderoraspecificallydesignatedperson, oversees theactionsofothers.Thiscouldbeaninformal either anorganisationoracommunitywhocoordinates Gatekeeper: Apersonwhoholdsaninfluentialpositionin on clearevidencefromexistingliterature. Evidence-based: Approachesthatuseandarebased (Commonwealth ofAustralia,2001,p.4). questions andreviewingongoingstrategyaction’ questions, reflectingontheanswerstothese Evaluation: ‘Thecontinuousprocessofasking of resources(time,cost,labour). a minimumofwasteandtheconsumption Efficiency: Theproductionofanagreedoutputwith result oroutcome. todeliveradesired Efficacy: Thecapacityofaservice about aneffectoroutcome. Effectiveness: Whetherthereisthecapacitytobring Distal factors:seeriskfactors. without theintenttodie,includingself-injury. destruction oralterationofbodytissues,with Deliberate self-harm:Anybehaviourscausing Glossary ofterms(continued) Glossary emotions and/orthinking. experiences somedisturbance or impairmentofnormal Mental healthproblem: Asituationinwhichaperson disorders. Therearemany differentmental require intervention. an individual’s thinkingandemotionalabilitiesmay illness ordisorderthatresultsinsignificantimpairmentof : Arecognised,medicallydiagnosable provided. resource) throughwhichinformationorsupportis Medium: Themode,meansorcarrier(person in long-termchange. perceived tobenegativebythoseinvolvedandresults Loss: Lossisproducedbyanincidentwhich (Commonwealth, StateorTerritory) isresponsible. Jurisdiction: Theareaforwhichaparticulargovernment a diseaseordysfunctionalbehaviour(Moore,2004). taken toimprovehealthorchangethecourseoftreat to produceanoutcomeormodifyasituation.Anyaction Intervention: To soas takeaction orprovideaservice a rangeofissuesusingmulti-facetedapproach. Integrated response:thatrespondto Interventions lives orhaslived. is acceptedassuchbythecommunityinwhichs/he Australian AboriginalorTorres StraitIslanderperson;and or Torres Strait Islanderdescent;andidentifiesasan Indigenous Australians:ApersonwhoisofAboriginal aim ofpreventingaconditionfromarising. showing earlysignsofriskforhealthproblems,withthe Indicated Intervention:Work withindividualswhoare maybenecessary.likely inthenearfuture;intervention Imminent risk:Thepointatwhichsuicideisextremely 37 Living Is For Everyone: A Framework for Prevention of Suicide in Australia livingisforeveryone.com.au Recovery: Recovery the process of a gradual is hopeful and meaningful restoration of a satisfying, way of life. that promote Resilience: Capacities within a person as mental health and wellbeing, positive outcomes, such from factors that might otherwise and provide protection of suicide. Resilience is often place that person at risk to bounce back from adversity. described as the ability to resilience include personal Factors that contribute for dealing with adversity, coping skills and strategies skills, such as problem-solving, cognitive and emotional communication skills and help-seeking behaviours. Risk factors: Factors such as biological, psychological, with social and cultural agents that are associated probability. suicide/suicide ideation and increase their factors, such Risk factors can be defined as either distal factors, as genetic or neurochemical factors, or proximal means - such as life events or the availability of lethal factors which can ‘trigger’ a suicide or suicidal behaviour. Selective intervention: Activities that target population or community groups at higher risk for a particular or particular problem, rather than the whole population the families individuals. This might include working with for instance of those bereaved through suicide or, over time. children who have been traumatised or abused Self-injury: Deliberate damage of body tissue, often in the intent to response to psychosocial distress, without die. Sometimes called non-suicidal self-injury, self-inflicted injuries or self-harm. life. Suicide: The act of purposely ending one’s Suicidal behaviour: Includes the spectrum of activities related to suicide and self-harm including suicidal thinking, self-harming behaviours not aimed at causing death and suicide attempts. Some writers also include deliberate recklessness and risk-taking behaviours as suicidal behaviours. : Thoughts about attempting or completing suicide. Actions or initiatives to reduce Suicide prevention: the risk of suicide among populations or specific target groups. assist with the burden or the weight of an Support: To Support can take many issue, problem or adversity. forms, including information provision, services and face-to-face counselling. Action to maximise mental Action to maximise mental Mental health promotion: among populations and individuals. health and wellbeing or facets. Multi-faceted: Having many aspects Approaches approach: multi-disciplinary Multi-sector, of expertise from a range that involve a combination involving agencies, of disciplines and professions, from a range of distinct organisations, and persons enterprise and/or society. parts or branches of and trained peers Peer education: The use of identified awareness or to provide information aimed at increasing influencing behaviour change. Population-based interventions: Interventions targeting activities populations rather than individuals. They include targeting the whole population as well as activities or targeting population subgroups such as rural Strait Islander peoples. Aboriginal and Torres (PTSD): Disorder Stress Post Traumatic who A psychological disorder affecting individuals traumatic have experienced or witnessed profoundly or wartime rape, events, such as torture, murder, of the combat, characterised by recurrent flashbacks fatigue, anxiety, traumatic event, nightmares, irritability, 1994). forgetfulness, and social withdrawal (Edgerton, Postvention: Interventions to support and assist the bereaved after a suicide has occurred. factors: Non-modifiable factors that may Predisposing susceptibility to suicidal behaviours, increase a person’s gender, such as genetic and neurobiological factors, culture, socio-economic background and personality, level of isolation. Preventing conditions of ill health from Prevention: arising. The care system that forms the first point Primary care: of contact for those in the community seeking assistance. It includes community-based care from generalist services Aboriginal medical such as general practitioners, services, community-based school counsellors and health and welfare services. factors: Capacities, qualities, environmental Protective and personal resources that drive individuals towards and health. growth, stability, factors: see risk factors. Proximal Receptivity of client: The capacity and willingness of the person to receive and absorb information and support. Glossary terms (continued) of

Living Is For Everyone: A Framework for Prevention of Suicide in Australia 38 livingisforeveryone.com.au from family, friendsandnormalactivities. possessions, talkingaboutsuicideorthewithdrawal increased riskofsuicide,suchasgivingaway Warning signs:Behavioursthatindicateapossible supportive families,schoolsandcommunities. to meansofsuicide,orcreatestrongerandmore prevention, theseincludeactivitiestoreduceaccess the wholeofapopulationorpopulations.Insuicide thattarget Universal intervention:Interventions an increaseinsymptomsofamentaldisorder. precipitating event,suchasanegativelifeeventor suicide increasesduetotheoccurrenceofsome Tipping point:Thepointatwhichaperson’s riskof and meaningfullyapplied. opportune momentforittobereceived,understood orsupportatthemostappropriate service Timeliness ofservice:Provisioninformation, over thelong-term. Sustainability: Theabilityofaprogramtofunction ofterms(continued) Glossary 39 Living Is For Everyone: A Framework for Prevention of Suicide in Australia livingisforeveryone.com.au Kumpfer KL (1999). Factors and processes contributing Kumpfer KL (1999). Factors and processes Resilience and to resilience: The resilience framework. In development: Positive life adaptations (eds. MD Glantz and JL Johnson), pp. 179-224. Kluwer Academic/ Plenum Publishers: New York. Maslow AH (1943). A theory of human motivation. Psychological Review 50, 370-396. , McLeod J (2003). An introduction to counselling 3rd edn. Open University Press: Maidenhead. Moore B (ed.) (2004). The Australian Oxford Dictionary. Oxford University Press: Melbourne. In HarvardMoscicki E (1999). of suicide. and Medical School guide to suicide assessment intervention (ed. DJ Jacobs), pp. 40-51. Jossey-Bass Publishers: San Francisco. Mrazek PJ, Haggerty RJ (1994). Reducing the risks for mental health disorders: Frontiers for preventive intervention research. National Academy Press Institute of : Washington. Platt S, Hawton K (2000). Suicidal behaviour and the labour market. In The international handbook of suicide and attempted suicide (eds. K Hawton and K van Heeringen), pp. 309-384. John Wiley & Sons: Chichester. Raphael B (1984). The Anatomy of Bereavement: A handbook for the Caring Professions. Hutchinson: London. , Australian Bureau of Statistics (2007). Suicides 2005 Cat. No. 3309.0. ABS: Canberra. Beautrais AL (1998). Risk factors for suicide and . National attempted suicide amongst young people Health and Medical Research Council: Canberra. Commonwealth of Australia (2000). Living is for everyone suicide and LIFE (2000): A framework for prevention of self-harm in Australia. Department of Health and Aged Care: Canberra. Commonwealth of Australia (2001). Evaluation: A Guide to Good Practice. Promotion and Prevention Section, Mental Health and Special Programs Branch, Department of Health and Aged Care: Canberra. Commonwealth of Australia (2005). A Framework for Effective Community-Based Suicide Prevention (Draft for Consultation). Australian Government’s Community Life Project: Adelaide. Commonwealth of Australia (2007). Living Is For Everyone: In Suicide Prevention. Research and Evidence Department of Health and Ageing: Canberra. De Leo D, Krysinska and self-directed K (2008). Suicide violence. In International Encyclopaedia of (ed. K. Heggenhougen), pp. 267-275. Academic Press: San Diego. Edgerton JE (1994). American Psychiatric Glossary, DC. 7th edn. American Psychiatric Press: Washington Gordon RS Jr (1983). An operational classification of disease prevention. Public Health Reports 98, 107-109. References

Living Is For Everyone: A Framework for Prevention of Suicide in Australia 40 livingisforeveryone.com.au Baltimore. &Wilkins: , 2ndedn.Williams clinical preventativeservices TaskU.S. PreventativeServices Force(1996).Guideto 31,893-903. of ChildandAdolescentPsychiatry oftheAmericanAcademy 4 and13yearsofage.Journal Child andfamilyfactorsthatameliorateriskbetween Seifer R,SameroffAJ,BaldwinCP, BaldwinA(1992). Life-Threatening Behaviour31,18-33. behavioural modelofsuicidality. Suicideand Rudd MD(2000).Thesuicidalmode:Acognitive- Strategy, CommonwealthofAustralia,Canberra. provision ofmentalhealthcare,NationalMentalHealth Raphael B(2000).Apopulationhealthmodelforthe References (continued) 41 Living Is For Everyone: A Framework for Prevention of Suicide in Australia livingisforeveryone.com.au The diversity reference group to the project were The diversity reference group to the project Jill Fisher (Chair), Mick Adams, Melba Townsend, Julian Krieg, Nooria Mehraby, Shorey, Travis Gerald Wyatt, Hilary Knack and Samantha Harrison. advisoryThe following three Australian Government of the committees contributed to the development LIFE (2007) resources: The National Advisory Council on Suicide Prevention; The Community and Expert Advisory Forum; and Group. The Indigenous Strategies Working attended There were many hundreds of people who the community consultations. Acknowledgements The LIFE (2007) suite of documents have been prepared The LIFE (2007) suite of documents have of Health and for the Australian Government Department by Ageing by a consortium of organisations supported and a wide network of specialist consultants, advisers community consultations. Pty Ltd, The lead consultants were Corporate Diagnostics and United Synergies Ltd, Professor Graham Martin and Judith Murray (University of Queensland) Dr. Greengage Research and Communications. by NOVA Additional editing and review was provided Public Policy Pty Ltd. John The main sub-consultants were Professor Sunrise Mendoza, Associate Professor Nicholas Procter, Institute Solutions, GKY Internet, Auseinet, the Australian Griffith for Suicide Research and Prevention (AISRAP, and the University), Oxygen Kiosk, DDSN Interactive Four Design Group. Specialist advisers who commented on and assisted with various drafts during the project included Professor Beverley Raphael, Professor Diego De Leo, Professor Hazell, Professor Don Zoellner, Trevor Ian Webster, Professor Edward White, Professor Ernest Hunter, Angela Dr. Karolina Krysinska, Lorraine Wheeler, Dr. Don Dr. Michael Dudley, Susan Beaton, Dr. Kirsner, Spencer and John Arms (NSW Central Coast Coroner).

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