Acting On What We Know: Preventing Youth Suicide in First Nations

Current Prevention Practices: Primary, Secondary ("Intervention"), and Tertiary ("Postvention")

Prevention can be seen as circular, involving three interconnected stages. Primary prevention aims to reduce suicide risk by improving the physical, mental, emotional and spiritual health or well being of a population. [ Mental Health Branch, 1997; Lester, 1997. ] This has been called "before the fact" intervention. [ White, 1998. ] Secondary prevention (early intervention) aims to help with potentially suicidal individuals either before they injure themselves or during a suicidal crisis. Tertiary prevention (or postvention) focuses on people who have been affected by suicidal behaviour: suicide attempters, who are at high risk for a recurrence, and bereaved friends and family members, who are also at risk for increased distress, psychiatric morbidity and the development of suicidal thoughts and behaviours.
[ Kirmayer et al., 1993. ]

Primary prevention (risk reduction) can be done through programs such as public education, life skills, parenting programs, training of western and traditional/cultural health professionals in suicide assessment and prevention, providing support to families, crisis hot lines and reducing access to lethal means, in particular guns and drugs. Intervention programs include crisis counselling and close supervision and treatment of individuals who have expressed suicidal thoughts. Postvention efforts include counselling and other supports for individuals or groups close to a para-suicide or suicide victim, who might be at risk as a result of the trauma. [ O'Carroll, Mercy & Steward, 1988. ]

Suicide prevention methods can be targeted at different levels: social and cultural settings within the community, family interactions, processes involving vulnerable individuals, or crisis situations. There is general agreement that programs directed to several of these levels at the same time will get the best effects. There is controversy, though, on whether to attempt to influence a whole population or to screen for and target high-risk groups. [ Rose, 1995. ]

In the case of most First Nations communities, their small size and the high prevalence of attempted suicide makes a community-wide approach most appropriate. This has two added advantages: it avoids stigmatizing a specific group of individuals, and it fits with broader goals of community development, which will have a positive effect on the mental health of the whole population as well as vulnerable individuals. Community-wide approaches will be discussed further in Part 3 of this report.

Elements of Effective Suicide Prevention Programs

Suicide prevention generally involves finding ways to reduce risk factors and promote protective (preventive) factors. Risk and protective factors may be understood in terms of individual and collective "resilience", i.e. the ability to spring back from negative conditions. (Resilience is discussed in Part 4).

Research has clearly identified a wide range of suicide risk and protective factors in the general population, most of which apply to First Nations communities [ Barney, 2001; Borowsky et al., 1999; 2001; Cleary, 2000; Hawton et al., 2001; Houston et al., 2001; Kirmayer, 1994; Lester, 1997; Santa Mina & Gallup, 1998. ]. Identified risk factors include:

• Male
• Previous suicide attempt
• Violence victimization
• Violence perpetration
• Alcohol use
• Marijuana use
• School problems
• Mood disorder (i.e. major depression)
• Social isolation
• Poverty, unemployment

Protective factors are especially important in planning prevention that can be addressed to the broader community or cohort of youth. The following have been repeatedly identified as protective factors for youth [ American Academy of Child and Adolescent Psychiatry, 2001; Barney, 2001; ] :

• Perceived parent and family connectedness
• Emotional well-being (especially for females)
• Success at school

There may be some specific risk factors that affect First Nations communities due to their history, social circumstances and challenges [ Borowsky et al., 1999; Kirmayer, 1994; Kirmayer et al., 2000; Lester, 1997; Novins, et al., 1999.Borowsky et al., 2001; Malone et al., 2000. ] . For example:

• Economic marginalization, 'relative misery' [ Barber, 2001. ]
• Rapid culture change and cultural discontinuity [ Chandler & Lalonde, 1998 ]
• Forced assimilation
• Forced relocation
• Residential school experience (early separation and loss, forced assimilation, denigration of culture, exposure to violence and abuse), and
• Clustering effects due to the close ties and identification among youth in small communities. [ Wissow et al., 2001. ]

Each First Nations community has experienced its own mixture of these stressors and responded in terms of its own history and culture. Accordingly, interventions must reflect these specifics and be tailor-made for the community.

Ideally, a suicide prevention program for First Nations communities would meet the following criteria: have proven effectiveness, reach high-risk groups, be feasible given local resources, and address both immediate and basic, long-term causes.