Crisis services respond with appropriate interventions for people who have survived as well as those affected by suicide attempts. Crisis services can reduce suicides when coupled with mental health follow-up care, and can be an effective alternative to emergency department care and hospitalisation. They include:
- Helplines for callers in suicidal crisis
- Mobile crisis teams (eg National Indigenous Critical Response Service)
- Walk-in crisis clinics
- Hospital-based psychiatric emergency services
- Outreach clinics
- Peer-based crisis services
Peer-based crisis services are located in a house or community setting with the aim of diverting people from hospital. Operated by peers with professional training in crisis support, they build mutual, trusting relationships within a safe environment.
Crisis responses to suicide or trauma are an important part of a systems approach to suicide prevention in Indigenous communities, including reducing the risk of suicide clusters.
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Aboriginal Aftercare Service
The Pika Wiya Health Service Aboriginal Corporations’ Aboriginal Aftercare program was commissioned by Country SA PHN in Port Augusta, South Australia due to its relatively high Indigenous suicide rate.
The program development was guided by the findings from the Aboriginal and Torres Strait Islander Suicide Prevention Evaluation Project (ATSISPEP). Community consultation was carried out by the Country SA PHN and the Black Dog Institute.
Contact: Chez Curnow
Manager Mental Health & AOD
Phone: 08 8565 8900
This project was initiated by the Country SA PHN (CSA PHN) under the National Suicide Prevention Trial.
The CSA PHN worked with the Black Dog Institute on a series of community forums in the Port Augusta area as it had a relatively high Indigenous suicide rate and its population – 14,000 people from 27 language groups – meant there was ‘critical mass’ to evaluate a new approach.
Community consultations in 2017 indicated people were keen for follow-up services for people leaving hospital after a suicide crisis, identifying this as a gap in local services.1
An Aboriginal working group was established in collaboration with the local community, including people with lived experience and representatives from the local health network and Aboriginal Community Controlled Health Organisation (ACCHO). The group spent eight months documenting the co-design process and developing a model, followed by four months of stakeholder consultation.
CSA PHN commissioned the Pika Wiya Health Service Aboriginal Corporation to deliver the Aboriginal Aftercare Service in Port Augusta. Pika Wiya Health Service Corporation recruited an aftercare team comprising the clinical team leader, who is a social worker, and two Aboriginal health workers. The aftercare team sits within the social and emotional wellbeing team (SEWB) and has internal supports from a psychologist and visiting psychiatrist.
Research shows that a previous suicide attempt is one of the strongest predictors of a further attempt. In order to reduce the likelihood of a further attempt, a coordinated plan is required for those survivors of that initial attempt. This requires immediate intervention and individualised care and referral after discharge and throughout the next 3 months.
The consultation process2 revealed that the aftercare service needs to include:
- a recognition of the importance of community
- appropriate service funding, delivery availability and resourcing
- implementation in a culturally safe manner including an evaluation of the design
- recruitment of support staff who have trauma experience and lived experience
- Ability to extend client care past 3 months to 6 months, to provide a culturally safe service where there is increased complexity in presentation.
- traditional healers, social and emotional wellbeing support and Aboriginal leadership
- recognition by Western medical practitioners and providers of the existing cultural expertise, mentoring and leadership within the Aboriginal community and,
- the integration of medical, mental health and other services.
Additionally, the Aboriginal working group recommended2 that the design should include:
- face to face contact while in the hospital emergency department
- culturally respectful communication
- the importance of cultural and spiritual factors when considering treatment options
- involving family for background information and assistance in the assessment, care planning and treatment processes and,
- providing social and emotional well-being support to family and community, inclusive of children.
The program has drawn upon the Black Dog Institute’s Guidelines for Integrated suicide-related crisis and follow-up care in Emergency Departments and other acute settings as a guide for developing the Aboriginal Aftercare Service Design.2 The working group recommend that these guidelines be reviewed after 12 months of service delivery, and adapted or changed to reflect new learnings. The Aftercare Service comprises seven non-hierarchical interventions. These are:
1. Brief contact interventions
This is a non-clinical intervention which uses minimal intrusion activities such as telephone calls, text messages to encourage help-seeking behaviours which are helpful in reducing the frequency of suicide attempts.
2. Coordinated assertive aftercare:
This intervention contains five distinct processes. These are:
- face to face contact – during the stay in the emergency department, the person is met by the service provider
- assertive follow-up – the person is met again by a service provider within 24 hours of discharge
- ongoing risk assessment and planning – a safety plan is developed with the individual’s goals and encourages safety in daily life
- encouragement and motivation to adhere to treatment – this is to reduce the barriers to further care where follow-up appointments are managed to ensure that the person connects with appropriate health and other social support services and,
- problem solving and solution focussed counselling – this includes intensive contacts through face-to-face or electronic communications
3. Brief therapy combined with brief contact interventions
A more structured intervention consisting of narrative therapies to help the individual better understand the factors that have led to the attempt. This may be one to ten brief contacts with an appropriate person such as a counsellor or psychologist using a person-centred narrative therapy.
4. Combined clinical and non-clinical models of care
Using the individual’s family or other care givers, including friends, the brief contacts are to help the individual gain a sense of belonging in the community and with his or her family. This would include appropriate activities to help the person connect to culture, community and country.
5. Post-discharge plans and primary health care
Intensive follow-up plans are established along with a safety plan for the individual in conjunction with the person’s family and care givers. Established medical practitioners are also included in this intervention.
6. Coordinated support to utilise available services
A case manager ensures that the individual is able to access and attend culturally appropriate post-care services for health management as well as reconnect with friends, family and the community.
7. Providing support for caregivers and recognising their role
Friends and family of the individual benefit from ongoing support for chronic mental health issues. These people who are supporting the person receive culturally appropriate education, upskilling and capacity building.
Guidelines for Integrated Suicide-Related Crisis and Follow-Up Care.
A complementary document for the admitting hospital’s emergency department are the Guidelines for Integrated Suicide-Related Crisis and Follow-Up Care.4 These guidelines consist of six steps for urgent care, clinical assessment and discharge. Briefly, these are:
1. Triage and notification to the Suicide Response Team or Mental Health Team
This involves stabilising the patient and offering to notifying friends, family or carer.
2. Comprehensive Psychosocial Assessment
The Comprehensive Psychosocial Assessment (CPA) is a broad assessment of a person’s mental, physical and emotional health, as well as their ability to function in the community. It covers assessment of suicidality, medical/ mental health assessment and history, coping resources and support and the ability to recover in the community. Importantly, the CPA is an opportunity to build rapport and show compassion and understanding.
3. Treatment care plan – inpatient and/or outpatient
Draft of treatment plan prepared and the individual is informed of various options for care.
4. Arrange referral and follow-up services
Aftercare providers finalise the plan and gain consent from the individual for personal information to be shared with service providers. Referrals and appointments are then arranged for 24 to 72 hours after discharge.
5. Discharge Care Plan
This plan includes an explanation of the plan as well as recommendations for treatment and support, relapse prevention and emergency contact details. The patient is discharged with medications and service provider contacts. Aftercare staff arrange for client transport a referral to supporting services by telephone.
6. Follow-up care and case management
This step is described in the Aboriginal Aftercare Service Design which is briefly described above.
The project has produced two sets of guidelines – for use in the emergency department at Port Augusta Hospital and for the community mental health team. These are the Aboriginal Aftercare Service Design2 and the Guidelines for Integrated Suicide-Related Crisis and Follow-Up Care.4 Each offers a comprehensive staged approach to maintaining contact through admission and after discharge with a mix of psychosocial, clinical and healing approaches with a strong focus on family and community.
An unanticipated positive outcome has been greater collaboration between clinical and cultural workers across the spectrum of mental health services. Mental health plans and referrals overseen by the visiting psychiatrist now frequently include a recommendation for healing alongside other supports. Aftercare workers have been invited to participate in traditional healing on country with ngangkari. The Pitjantjatjara word ngangkari is defined as an Indigenous practitioner of bush medicine (see Further Reading). Hospital mental health staff similarly are reported to be more comfortable referring people post-discharge to social and emotional wellbeing services and GP services knowing that these services can draw on the expertise of the aftercare team. Ongoing clinical management including medication support now sits with the Pika Wiya Health Service and not the hospital which continues to build the capacity within the health service.
From December 2018 to June 2019, around 120 people have been supported with 13 to 20 referrals a month to the end of 2019. Three-quarters of referrals are from the emergency department while the remainder come directly from the ACCHO which demonstrates that the Aftercare Service is appropriately supporting the most acute needs. The Aftercare Service is also working with established postvention services that includes the National Indigenous Critical Response Service and Beyond Blue’s service, The Way Back.
We could not find any evidence that this program has been evaluated.
The Aboriginal Aftercare Service is consciously based on ATSISPEP’s three levels of intervention5 that are:
- Universal Interventions which attend to those factors that create dysfunction as well as creating an environment in which individuals and the community are able to seek help before suicide attempts.
- Selective Interventions which focus on youth who are at higher risk of suicide.
- Indicated Interventions which ensure that those who are a risk to themselves or have attempted suicide are assisted in their recovery.
The program has been managed by the Pika Wiya Health Service Aboriginal Corporation and the ACCHO which meets the recognised need for strengthening Indigenous governance. The use of the lived experience of Aboriginal and Torres Strait Islander people in Port Augusta through the workshops during the development of the design has established a community and cultural focus in the design. The design includes a broad, closely-integrated use of public health services and other services such as culturally-safe healing and reconnection to culture and country.
While the program managers are collecting data which will be used to improve services, no formal evaluation of the program has taken place. CBPATSISP recognises that this program is still developing however this program is demonstrating a commitment to recognised principles and therefore is recognised as a promising program.
- National Suicide Prevention Trial: Survey Data Report April 2018. Not available online. Country SA PHN, Nuriootpa South Australia.
- Aboriginal Aftercare Service Design November 2019. Country SA PHN, Nuriootpa South Australia.
- LifeSpan strategies and components. Black Dog Institute.
- Guidelines for integrated suicide-related crisis and follow-up care for Aboriginal and Torres Strait Islander people in the Emergency Department in Port Augusta, South Australia November 2019. Country SA PHN, Nuriootpa South Australia. N/A
- Dudgeon, P., Milroy, J., Calma, T., Luxford, Y., Ring, I., Walker, R., Cox, A., Georgatos, G., & Holland, C. (2016). Solutions That Work: What the Evidence and Our People Tell Us. Aboriginal and Torres Strait Islander Suicide Prevention Evaluation Project Report. Perth, WA: University of Western Australia.
Ngangkari – Traditional Healers. Ngaanyatjarra Pitjantatjara Yankunytjatjara Women’s Council
HOPE – Hospital Outreach Post-suicidal Engagement
The HOPE Initiative will provide tailored, holistic support to people post a suicide attempt with the aim of supporting the person and their carers and families to identify and build the protective factors that reduce the risk of suicide attempt/completed suicide.
Contact: Program Coordinator for HOPE is Eileesh Diviney (DHHS), Senior Policy Officer Dept. of Health and Human Services
HOPE – Hospital Outreach Post-suicidal Engagement – initiative provides practical support for people across Victoria who have thought about suicide or made an attempt on their life, and need an intensive response in the months following. HOPE is part of the state government’s Victorian Suicide Prevention Framework 2016-25, a co-ordinated strategy to halve the state’s suicide rate by 2025.
HOPE was trialed at hospitals including Peninsula Health (Frankston Hospital), Alfred Health (The Alfred), St Vincent’s Health (St Vincent’s Hospital), Barwon Health (Geelong Hospital), Eastern Health (Maroondah Hospital) and Albury Wodonga Health (Wangaratta Hospital). The program has assessed and supported more than 500 people since 2018. The government funding will enable the program to be rolled out in an additional six hospitals and health services including Ballarat Health Services.
New sites were selected based on suicide and intentional self-injury data analysis; population demographics; and community profiles so that rural communities are able to have the same level of access and quality treatment and positive outcomes as the larger communities. HOPE is auspiced with PHNS to provide advise on where to best target the funding and resources to meet the different needs of different communities. Funding has been provided to appoint an Aboriginal Suicide Prevention Coordinator in Albury-Wandonga.
The initiative which links with local communities aims to:
- Help people for up to three months after they leave hospital following a suicide attempt.
- Support carers and families to identify factors and build strategies to reduce the risk of suicide.
- Establish really good partnerships with all our services including Aboriginal Community Controlled Health Services.
- Leverage off earlier service pathways and assertive outreach work undertaken as a part of the HOPE project in Benalla.
- Build capacity within the community to contribute to suicide prevention planning and to achieve better coordination of support services. ·
- Enhance greater understanding and respect of Aboriginal culture and the holistic view of health and wellbeing, while harnessing the skills and strengths of local Aboriginal people and community.
The success of HOPE in the communities requires building the capacity of local Aboriginal and Torres Strait Islander people to contribute to the HOPE project and suicide prevention planning through:
- Building safety in the community through suicide prevention education
- Building confidence in the mental health service pathway through identifying current barriers to service.
- Working with service providers to address identified barriers to accessing services and work towards developing cultural competency
Thirrili National Indigenous Critical Response Service
Thirrili Ltd is a not for profit organisation which aims to contribute to the broader social wellbeing of Aboriginal and Torres Strait Islander people. Thirrili offers a range of programs which are designed to address fully the systemic and long standing causal issues for which solutions have eluded us for too long. We stand ready to partner with governments, academia and the broader service system to tackle these issues.
Contact: Jacqueline McGowan-Jones Chief Executive Officer
Executive Manager, Corporate Services: Catherine Elvins
Phone: (03) 8578 1410
Thirrili was established in 2017 and is a Bunuba word meaning power and strength. It provides postvention assistance and support after suicide for Aboriginal and Torres Strait Islander people. Using a strength-based approach, Thirrili provides telephone and face-to-face assistance. The organisation uses a decentralised staffing model as well as using other postvention support networks to provide support in all Australian states and territories.
Thirrili works with communities that have experienced suicide or are currently experiencing trauma as well as communities who have recognised that increased governance and community capacity building are important to strengthen postvention.
Using a four-step Response Assessment Process2, Thirrili ensures that it uses local resources where appropriate. The four steps are:
- Receipt of a notification of an incident
- Verification of the person who has died or has been injured
- Seeking client or family consent to obtain personal details and a description of the incident and to assess the most appropriate response, and
- To work with local service providers and explore their ability to respond to family members and help structure a response.
Critical Response Support Advocates consider the throughcare plan and how this plan will assist the individuals’ physical and mental health, social and emotional wellbeing and the benefits to cultural, spiritual and community health. A key part of the plan is to help develop capacity and governance within the community. Follow-up contacts are made to ensure that the community and families are building resilience and are continuing to heal.
This may involve an advocate attending the location (or using a local service provider) to assist with the grieving process, liaising with the family to arrange a funeral or other culturally-appropriate interactions. The advocate would also assist the family in dealing with perhaps physically-distant government agencies or financial institutions that are involved after a suicide.
Using an evidenced-based model, Thirrili recognises that Aboriginal and Torres Strait Islander people grieve differently to non-Indigenous people in a number of significant ways (that is, sometimes greater time is required for recovery and the need to observe cultural obligations) as a result of strong, closely-linked family circles and community bonds. Additionally, Aboriginal and Torres Strait Islander people have experienced trauma from historical cultural dislocation, family separation and disruption to community values.1
Thirrili aims to assist communities across Australia to:
- build local community capacity and resilience through active involvement during the period immediately after an event
- coordinating and responding to the needs of communities, families and individuals, after a suicide or other traumatic incident(s)
- providing through-care bereavement support to individuals and families and strengthening their access to coordinated care, and
- identification and implementation of local suicide prevention and postvention activities in order to prevent and better respond to traumatic incidents.
Thirrili seeks to:
- assist communities to be able to develop greater capacity
- to be able to attend to the family and community’s needs with greater sense of support, and
- to be able to commence their healing process.
Thirrili is also involved in systems change at all levels from a national perspective to regional and remote areas. This is accomplished by:
- sharing knowledge of good practices
- participating with similar organisations and other networks involved supporting postvention responses
- providing training and links to training providers to deliver postvention support
- influencing service system development through networking and partnerships
- maintaining currency with policy development with government and awareness of political developments affecting program implementation
- providing advice to opinion leaders and policy makers, and
- advocating changes to better address emerging issues.
The NICRS programs are currently being evaluated.
Thirrili demonstrates best practice in providing services to the Aboriginal and Torres Strait Islander community. The Model of Care ensures that the community and the family are cared for after a suicide in a way that is culturally safe and respectful. This Model of Care allows for the community and the family to determine who delivers the care and the time of the care which includes advocates who are often familiar with the community. The program allows for the development of capacity of the community in dealing with the trauma associated with the recent loss as well as to begin to address the wider grief and loss and transgenerational trauma that is experienced. The Thirrili program includes follow-up on a three-monthly basis.
- Defining and addressing Aboriginal and Torres Strait Islander trauma, grief and postvention. A Literature Review 2018. Thirrili. Richmond Victoria.
- National Indigenous Critical Response Service Model of Care. Thirrili. Richmond Victoria.
The National Indigenous Critical Response Service supports individuals, families, and communities affected by suicide or other significant trauma.
A Critical Response Support Advocate can be contacted 24/7 by calling 1800 805 801
The telephone service is usually answered by one of our Critical Response Support Advocates. If for some reason the call is diverted to message bank, callers are asked to leave a message with their best contact number and the Support Advocate will call them back as soon as possible.
If you or someone you know is suicidal
If you are looking for help, please call one of the following national helplines:
- Lifeline Counselling Service: 13 11 14
- Suicide Call Back Service: 1300 659 467 (cost of a local call)