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Gillard highlights structural, social determinants as key to Indigenous suicide gap

Introduction by Croakey: Recognising and addressing the post-colonial, intergenerational determinants of Aboriginal and Torres Strait Islander mental health and supporting community-led solutions will be key to tackling “alarming” Indigenous suicide rates, former Australian prime minister Julia Gillard said in an impassioned public address this week.

Gillard, who is now chair of Beyond Blue, said it was hard to believe that, with Indigenous Australians now twice as likely to die from suicide as their counterparts, there were no mental health or suicide prevention targets in Australia’s Closing the Gap Strategy.

Highlighting the protective role of culture, the former PM said solutions to the “alarming” rates of suicide among Aboriginal and Torres Strait Islander peoples — the leading cause of death for 15-34-year-olds in this group — would not be found in paternalistic approaches but devised and led by Indigenous communities.

Addressing the social determinants, many of which are a legacy of past and ongoing government policies, had to be the key starting point, Gillard said:

The significance of culture has never been as apparent to me as when I visited Aboriginal and Torres Strait Islander communities.

Culture is a word that is often tangled up with nationality, but it entails much more.

Our culture determines so much of our identity; our values, the way we view the world, the way we interact with others, our sense of belonging.

Our culture protects us. And if a single piece of our culture is taken away, erased or replaced, it leaves us feeling uncertain, disconnected.

Today, First Nations people are twice as likely to die by suicide than non-Indigenous people. Since 2012, suicide has been the leading cause of death among young Aboriginal and Torres Strait Islander people aged 15 to 34 years of age.

Improving social and emotional wellbeing in Aboriginal and Torres Strait Islander communities and reversing the suicide toll are inextricably linked to issues of post-colonial, intergenerational trauma, the need for secure housing, a fair go inside and outside the justice system, access to education and employment opportunities, and tackling racism.

And as many Aboriginal and Torres Strait Islander people continue to remind us, Indigenous policies must be led by Indigenous people whose solutions look different to ours.

I am heartened that we have, for the first time, Aboriginal people from both sides of politics leading Indigenous policy.

It is hard to believe that, despite the alarming statistics on Indigenous suicide and psychological distress, there are no mental health or suicide prevention targets in Australia’s Closing the Gap strategy. Rectifying this is something Beyond Blue has been calling for.

You can read Gillard’s entire 2019 Diego De Leo Oration below.

Our archive of stories on suicide, including coverage of last year’s Aboriginal and Torres Strait Islander Suicide Prevention and World Indigenous Suicide Prevention conferences can be found here.


Julia Gillard delivers the 2019 Beyond Blue Diego de Leo Address

I acknowledge the Traditional Owners of the land on which we meet, the Boon Wurrung people of the Kulin Nation, and, in a spirit of reconciliation, pay my respect to their Elders – past and present.

I would like also to acknowledge and thank the Chair of Suicide Prevention Australia, Angela Emslie, and CEO, Nieves Murray, for their leadership and the invitation to deliver the 2019 Diego De Leo Address.

It is always a privilege to give an oration in honour of an individual who has been a major contributor to the lives of others, and this is certainly true of Professor Diego De Leo.

We are all beneficiaries of his work, his humanity and, particularly, his decision to make Australia his home for many years.

As many in this room will know, Diego now lives in Italy having returned to his birth country in 2016 after retiring as Director of the Australian Institute for Suicide Research and Prevention.

He remains an Emeritus Professor at the Institute and continues to review research and contribute to its activities.

Diego’s roles in establishing Australia’s first suicide register in Queensland and in initiating World Suicide Prevention Day continue to impel and persuade us to pursue excellence and innovation.

I am sure he will recognise last week’s release by the Australian Bureau of Statistics of its pilot study into psychosocial risk factors for suicide as breaking new ground.

This is the first time the ABS has connected coronial, police and toxicology data to its national data on suicide deaths.

Unsurprisingly it confirms that the circumstances behind each suicide are complex and multi-factorial.

They include family cohesion, relationship factors, use of drugs and alcohol and financial stress. There is no single reason why a person attempts or dies by suicide.

The pilot study found that approximately 63 per cent of all suicide deaths in 2017 had one or more associated psychosocial risk factors, and this proportion was similar across gender and age groups.

It is important verification, exactly the more granular information we need routinely and long-term.

As Diego has always said, suicide is a very complex phenomenon and to be properly addressed it requires multiple remedies inside but, importantly, outside of the health and mental health spheres.

We need people to feel connected and we need more research.

So, in preparing for this speech, I tried to get a sense of the person and what drove him to dedicate his career to improving our knowledge of suicide and suicidal behaviours.

Once, when asked why he chose to make suicide prevention his vocation, Diego replied that he had always been attracted to difficult things.

It was certainly a difficult, tragic and life-changing event that drove the then 29-year-old towards what would become his life’s work.

In his last year as a registrar in psychiatry at the University of Padua in northern Italy, Diego was mentoring a newly appointed registrar.

As Diego has described it, the Department of Psychiatry at Padua was, in those days, characterised by the psychoanalytical approach.

Young registrars were ‘encouraged’ to become fully immersed in the theories of Freud and his followers.

However, Diego’s interest lay in other theories.

The possibility that negative emotions and psychological distress may provoke changes and even diseases in the body fascinated him.

That a physical illness may be the result, at least in part, of constant worry and stress.

He hoped his choice of psychiatry would help clarify these issues.

His cheerful young registrar shared his passion for that mind-body interface and they began a clandestine study of psychosomatics.

Inevitably, their heresy was uncovered. The pair found themselves isolated from mainstream initiatives within the department and able to obtain only limited access to funding opportunities.

But these experiences cemented their friendship.

I would like to share with you Diego’s own words about what happened next:

“About three years after the beginning of our research …, the first paper appeared in a reputable medical journal.

“As soon as I received a copy of the publication, I called my friend to invite him for a toast in celebration of our small achievement.

“On the phone he said that he was very busy, but he would try to make time for a meeting over the weekend.

“I didn’t hear from him but paid no particular attention to that: he often disappeared for days with his girlfriend of the moment.

“But two weeks without communication had never occurred before.

“One morning, a colleague asked me: ‘Have you heard what your young friend has done? He has killed himself. Didn’t you realise how much that guy was suffering?’

“I could not believe it… I did not see him suffering at all.

“[My colleague then followed up with:] ‘What sort of psychiatrist are you going to be if you are not even able to understand the people around you?’

“Years later, I still distinctly remember the words. Indeed, I remember everything of that moment.”

Following his friend’s suicide, Diego dedicated himself to research into suicidal behaviours and prevention.

Today he is a world leader in his field, with a passionate commitment to excellence in scientific research, but even more importantly, for people, families and communities, the practical application of that research in the world.

Diego has played – and continues to play – an immeasurable role in helping us all better understand this uniquely human tragedy…

…in changing our thinking and practice

…and in bringing us together today.

With his emphasis on the practical application of research and his life experience of loss to suicide, Diego is exactly the kind of mental health leader who deeply understands the need to truly hear our fellow human beings.

To listen to, capture and amplify people’s voices and experiences so we better understand what is needed and how to respond as policymakers, professionals, practitioners.

But more importantly, as people.

Talking about suicide – openly, publicly, even privately – is relatively new for most of us.
When I was growing up in Adelaide in the 1960s and ‘70s, people didn’t talk about such things.

If they did it was in whispers. It was something we didn’t have the words for.  We kept it hidden, covered up.

Yet the World Health Organization estimates that each year one million people die by suicide around the world, and 4.5 million people have their lives deeply affected by suicide.

As we all know, here in Australia, we lost 3127 sons, daughters, dads, mums, brothers, sisters, friends and colleagues in 2017.

Each of those deaths represents immense suffering, not just for the individuals who took their own lives, but for all who live on with that loss.

In 2009, understanding the value of listening – really listening – Diego invited people who had previously attempted suicide to contribute a personal chapter to his new book, Turning Points.

One of those chapters was by Trevor who wrote:

“I regret not talking about my problems to those I knew would have listened… Had I done that, maybe the trauma I put myself and everyone I love through may have been avoided. I was afraid of being labelled a ‘looney’. I know now that I was not. I wish I had talked…”

In publishing these stories, Diego was challenging us to not be arrogant enough to think that only people like us have the solutions and skills to prevent suicide.

Rather, he was urging that we must constantly listen to and learn from those people who would much rather not have expertise in this field: those who live with suicidal thoughts, and those bereaved by suicide.

And because the factors that contribute to suicidal thoughts and behaviour start in our homes, schools, workplaces and communities – and start long before someone enters a service.

We must continually remind ourselves that the relationship between mental ill health and suicide is not always linear and it will never have a linear solution.

We have a responsibility to keep dragging suicide out of the shadows and equipping everyone, if we truly believe in the mantra that “suicide prevention is everyone’s business.”

Getting people to talk about suicide is now central to Beyond Blue’s work.

We believe in translating excellent research to inform practice.

But also taking and applying research evidence – both qualitative and quantitative – outside of clinical settings to empower people and communities in ways that are useful to them.

Using technology and the channels on our smartphones that we use more and more to consume information, educate ourselves, connect with one another.

We strongly push the message that you can talk, because for many Australians, the idea we can safely discuss suicide and ask questions of those we are worried about, is still new and confronting.

Of course, it’s natural for people to worry about saying or doing the right thing – or the wrong thing. But we have the research to show caring conversations matter.

In February 2018, Beyond Blue released research by the University of Melbourne and Whereto Research Based Consulting, which detailed what advice can be given to the public to increase the likelihood that they will ask about and support someone who may be at risk of suicide.

This was rigorous, scientific but also humanistic research that I hope Diego would approve of.

The research team spoke to experts, studied existing literature and surveyed over 3,000 Australians from all walks of life.

People who said they had not been affected in any way by suicide.

People who had been touched directly by suicide.

And people who had attempted suicide in the previous 12 months.

Those who had thought about or attempted suicide confirmed that having someone listen to them with empathy and show care and support was the most important and helpful thing to them.

The research confirmed a deep community concern about suicide, and that most people want to do more to prevent suicide in their communities, but don’t know how.

They were unsure where to start, how to identify the often very subtle verbal and non-verbal warning signs.

The words to use, or even whether they should say anything at all.

Because:

• 50 per cent of research participants believed only a professional can help prevent suicide;

• 40 per cent worried that talking about suicide made things worse;

• And 30 per cent believed discussing suicide would make it happen.

That research underpinned a collaborative response by the Black Dog Institute, Everymind, headspace, Lifeline, ReachOut, RU OK? and Beyond Blue.

The result was the #YouCanTalk campaign.

#YouCanTalk aims to debunk the myths, build up the confidence of the community, and equip individuals to have safe and helpful conversations about suicide and provide empathetic and practical support to people thinking about suicide.

It is about mobilising the community and empowering family and friends to act as ‘eyes and ears’, hopefully before their loved ones reach crisis point.

The first phase of the social media campaign went live in July last year.

Using the combined power and reach of the social networks and online communities of all seven organisations, the message reached an audience of over 18 million and was the top trending Twitter topic on launch day.

A second phase is in development with an expanded group that now includes SANE Australia, the Centre of Best Practice in Aboriginal and Torres Strait Islander Suicide Prevention and Roses in the Ocean.

#YouCanTalk is owned, and can be used, by everyone.

And it’s already having positive ripple effects.

In March, giant steel letters spelling out #YouCanTalk appeared on a hilltop along the Geelong Ring Road.

The letters were erected by property developers Villawood following the suicide of their CEO that past Christmas.

The Geelong Cats got behind it too.

Last month, Triple M were inspired to stop talking for a day to encourage their listeners – 80 per cent of whom are male – to talk about suicide.

No shows, no ads, no news or traffic reports.

Just music, interspersed with encouraging messages from their presenters, celebrities and people with lived experience encouraging listeners to talk, and reminding them that Lifeline and Beyond Blue are just a phone call away.

Democratisation of excellent research knowledge. Translation of data to action. This is what Diego De Leo has championed all his working life.

For me, though, the most powerful memento from #YouCanTalk is the power of collaboration.

This is not something we have always been good at.

I know from my own time in politics that decision-makers get let off the hook if advocates compete and criticise, rather than cohere.

But this is our moment.

Too many lives are being lost. Too many others’ lives are being shattered.  There is too much heartache.

We cannot keep doing the same things, as they have always been done.

Never before has public sentiment, political will, and the mental health and suicide prevention sectors been so aligned.

I have not met one federal, state or territory Premier, Minister or backbencher who is not deeply concerned by our suicide rate.

Here in Victoria, Premier Daniel Andrews has said he will accept all findings of the Royal Commission into the Victorian Mental Health System which is due to file an interim report by November.

We have heard powerful testimony from people, family members, first responders and service providers about their experiences and what needs to change.

Nationally, the Productivity Commission’s sweeping inquiry is underway.

It has a mandate to look into every corner, at every level of government, and across all of the places and factors that support our mental health, resilience, connectedness and opportunities that allow us to live contributing lives.

Because, as the ABS pilot study confirms, we all know the solutions lie beyond just health. They lie in tackling:

• poverty and financial stress;

• family breakdown;

• violence and trauma such as sexual assault and emotional neglect – especially in childhood;

• education and employment;

• social supports and connection;

• housing and justice;

• And gender and culture.

It is nearly ten years since the Marmot Review into health inequity was released in the UK, but its observations remain true to this day.

It found: “This link between social conditions and health is not a footnote to the ‘real’ concerns with health – health care and unhealthy behaviours – it should become the main focus.”

These social determinants are particularly relevant in the early years.

We know that childhood experiences shape the adults we become.

I witnessed this first-hand as an MP, and later as Prime Minister.

By chance I was in Newcastle on August 8, 2012, when a funeral was held for John Pirona, a local man who had taken his own life.

John had been sexually abused at school.

John came to symbolise the pain of so many in Newcastle and around the country.

The Royal Commission into Institutional Responses to Child Sexual Abuse I established came too late for too many, who as small children were abused and traumatised and whose capacity to cope had been overwhelmed by their pain.

But it was not too late for justice and it was not too late to provide a voice and remedy for survivors, and to double-down on efforts to safeguard today’s children.

Bringing these experiences with me to my role at Beyond Blue, I am convinced we need to face complex challenges head on, including focusing our efforts much earlier in life, before the consequences of adversity really take hold.

Whole-of-government, whole-of-sector, whole-of-community, every-one of us has a role to play.

And we must continue to lead with determination and hope, now more than ever.

There is considerable hope and expectation that the contemporaneous Productivity Commission Inquiry and Victorian Royal Commission will work together and reach integrated complementary recommendations that lay the foundations for the system and supports that people need.

It will then be up to us all to be united in calling for a plan for the long term; funded for the long term; that takes a social determinants, person-centred approach that spans prevention to crisis support.

As our peak body, SPA has been calling for a whole-of-government focus on suicide prevention.

At the Federal level, Christine Morgan has recently been appointed as Australia’s first National Suicide Prevention Adviser, with a remit to work across government and report to the PM.

This was my reasoning too when, as PM, I set up the National Mental Health Commission to advise me directly.

It is incumbent on us all to support Christine in her task.

To be clear on our expectations and clear in our advice on solutions to our political leaders, who have committed to work with us for change.

I know from my former life that this window of opportunity has been opened by years of hard yakka by dedicated people like Diego De Leo; of bi-partisanship in Canberra and across all the states and territories; of indefatigable advocacy by individuals and loved ones impacted by suicide.

It is a moment not to be squandered by territorialism, squabbling over funding allocations, or short-term thinking.

In every part of our country, and for the sake of our society and economy, we need to continue to stress that maintaining good mental health and preventing suicide is a social, economic and political imperative.

As we all know, this imperative is especially vital for some groups who face significantly higher risk of suicide.

People of culturally and linguistically diverse backgrounds, LGBTI communities, rural and regional Australians, and our young people and the most elderly.

Once again, I am drawn to the leadership of Professor De Leo who observed that great cultural sensitivity should be applied when designing effective suicide-prevention strategies to tackle social issues of such importance and magnitude.

That they must reflect the unique needs and experiences of communities and that the communities themselves must show us the way.

He points out that many risk factors for suicide are the same for both Indigenous and non-Indigenous people: trauma, housing stress, substance abuse and unemployment among them.

But there are also personal issues that show more frequently in Indigenous suicide such as relationship breakdown and recent bereavement.

The significance of culture has never been as apparent to me as when I visited Aboriginal and Torres Strait Islander communities.

Culture is a word that is often tangled up with nationality, but it entails much more.

Our culture determines so much of our identity; our values, the way we view the world, the way we interact with others, our sense of belonging.

Our culture protects us.

And if a single piece of our culture is taken away, erased or replaced, it leaves us feeling uncertain, disconnected.

Today, First Nations people are twice as likely to die by suicide than non-Indigenous people.

Since 2012, suicide has been the leading cause of death among young Aboriginal and Torres Strait Islander people aged 15 to 34 years of age.

Improving social and emotional wellbeing in Aboriginal and Torres Strait Islander communities and reversing the suicide toll are inextricably linked to issues of post-colonial, intergenerational trauma, the need for secure housing, a fair go inside and outside the justice system, access to education and employment opportunities, and tackling racism.

And as many Aboriginal and Torres Strait Islander people continue to remind us, Indigenous policies must be led by Indigenous people whose solutions look different to ours.

I am heartened that we have, for the first time, Aboriginal people from both sides of politics leading Indigenous policy.

It is hard to believe that, despite the alarming statistics on Indigenous suicide and psychological distress, there are no mental health or suicide prevention targets in Australia’s Closing the Gap strategy.

Rectifying this is something Beyond Blue has been calling for.

Working together we can achieve great things as we saw recently with the release of Beyond The Emergency, a three-year collaboration that investigated ambulance call-outs to men in acute psychological distress or suicidal crisis.

Beyond The Emergency is a world-first study by Turning Point and Monash University in partnership with ambulance services nationally who provided access to their data, backed by The Movember Foundation and Beyond Blue.

Among its aims was to better understand the scale and nature of male mental health presentations to ambulance services around Australia.

It revealed that ambulances around the country make on average 82 attendances a day to men in a suicidal crisis.

That is 30,000 men having suicidal thoughts or attempting suicide over the course of one year.

However, 42 per cent of those men had more than one ambulance attendance; and over seven per cent had called an ambulance ten times or more.

Prior to this, our best understanding of the scale of the problem came from hospital data on presentations to emergency departments, which report around 10,000 cases annually.

This is because hospital ED data is typically only able to record one reason for presentation.

The medical emergency may require treatment for lacerations or broken bones, but not record related issues such as deliberate self-harm.

Turning Point’s research is continuing and will now include ambulance data for all people.

This is important because gender plays a significant role in suicidal behaviour and suicide prevention.

In the nine years from 2008 the rate of female suicides increased steadily, reaching a 10-year high in 2017.

Rates for females hospitalised from intentional self-harm were at least 40 per cent higher than male rates between the period 2000 to 2012.

Our knowledge of the causes of these differences remains incomplete, particularly for those who attempt suicide.

Understanding more will help us better understand the gender specific risk factors so we can improve how we tailor and target suicide prevention measures.

In addition, we will learn more about the challenges faced by ambulance officers, paramedics and hospital staff when dealing with anyone in a suicidal crisis.

Whether they are transported by ambulance, accompanied by friends or family, or make their own way to emergency departments, people are turning up there because they have nowhere else to go.

We must stop this revolving door of acute mental health and suicide presentations at hospital emergency departments by valuing and investing more in community-based supports and alternative pathways and workforces.

If people do not have life-threatening injuries, they are often better served in alternative ‘safe spaces’ in the community, such as The Haven Café here in Melbourne.

These safe spaces provide an alternative, calm environment, in the community or sometimes onsite with hospitals and other health services, staffed with people – often peers – trained to deal with these issues and who have the time it takes to support people in crisis.

Suicide is one of the greatest public health challenges of our time, but that does not mean we cannot achieve change.

When we work together Australians can make the seemingly impossible possible.

We have done it before.  We can do it again.

The seatbelt campaign in the 1970s saw Victoria become the first jurisdiction in the world to make seatbelts mandatory and prove that lives could be saved when legislators, law enforcement, community campaigners and the public agree on a common cause.

We built on that success with decades of anti-drink-driving campaigns and improved road safety.

Then, of course, Australia has led the world in reducing smoking rates through sustained anti-smoking campaigns, quit lines and programs, by taxation and pricing, advertising restrictions and plain packaging of tobacco products.

So, it must be with suicide prevention.

Beyond Blue is advocating with many others for a universal system for suicide prevention so all people, at any time or in any place, can get the support they need when they are feeling suicidal.

Such a system should take a social determinants approach, recognising that suicidality is influenced by communities, relationships and a range of socio-economic factors.

The system should target a variety of positions on the continuum of suicidality.

People in pre-suicidal distress should have access to brief, low intensity interventions to address early signs of distress.

These can be through self-referral, such as helplines, online peer forums, online therapies or referral by community gatekeepers – GPs, nurses, community workers and first responders.

People experiencing suicidal ideation should have appropriate options to stay safe in the community.

They should have easy to access, personalised safety plans, such as the BeyondNow smartphone app, to help them get through the times when they are feeling unsafe or suicidal.

Again, we also need to scale up alternatives to clinical and emergency department settings, which often escalate and intensify suicidal feelings.

We need ‘safe spaces’ in local communities with support from family, friends, peer workers and others.

And we need good aftercare following a suicidal crisis or attempt so that people can return to life, to hope and to the future.

This means we need to involve our communities, schools, workplaces as well as health services.

And we need to listen and let people know that they have been heard.

Because just one conversation could be life-changing.

I think that is one of my greatest revelations since joining Beyond Blue.

Diego De Leo showed that we should not be afraid of or resistant to new information or knowledge or the proposition that we could do better.

Share the knowledge, translate the evidence into action, never underestimate the power of human warmth and empathy… this is the ethos of Diego De Leo.

We should follow his lead.

Thank you.


If you or someone you know needs help or support, call Lifeline on 13 11 14 (24 hours-a-day), contact your local Aboriginal Community-Controlled Organisation, call Beyondblue on 1300 22 4636 or call Q Life: 1800 184 527.

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