A total of 23 participants participated in three focus groups conducted at three locations in the NSW. Participant numbers were comparable across the groups (Awabakal n=8, Biripi n=7, Kamilaroi n=8).
As shown in Figure 1, four broad themes were identified as underpinning the responses to the focus group questions. These included:
- Suicide is a whole community issue;
- The ripple effect of suicide;
- Silence and its impact; and
- Being powerless to act.
Whilst there were discrete differences in focus group responses across geographical regions, age and gender, these core themes were apparent in every focus group. The key features of each of the themes are discussed below.
Suicide is a whole community issue
All participants spoke about how important it was to discuss suicide in Aboriginal communities. Participants stated it was important to ‘get out there and not be ashamed to talk about suicide’ (FGg, Speaker 21), particularly because of the perceived increase in and personal impact of suicide in Aboriginal communities. Despite identifying it as being important, the overwhelming majority of participants stated discussions about suicide are not ‘really [occurring] in Aboriginal communities’ (FGb, Speaker14). In the small number of cases where such discussions were occurring, they were described as being led by community members with experience in Aboriginal SEWB -type positions.
‘I mean I talk about suicide at work, that’s the only time.’ (FGg, Speaker 55)
‘It’s not about what’s hard, it’s not discussed in our communities.’ (FGb, Speaker 20)
‘I think it is the elephant in the room, no one wants to talk, acknowledge the fact that suicide exists, but it’s such a horrible thing to think about, that you’d rather not think about it.’ (FGg, Speaker 10)
A small number of participants reported that discussing suicide was not always helpful. Some viewed suicide as an individual decision, believing that ‘no matter what you say or do it’s not going to prevent them from committing suicide’ (FGa, Speaker 47). One respondent who shared their lived experience of a suicide attempt spoke about their anger towards the person who got them to the hospital thinking ‘how dare you think you can tell me what I can do with my life’ (FGg, Speaker 15). These comments highlighted the sensitivity needed to navigate discussions about and responses to suicide crises.
In each focus group, participants shared personal stories of the perceived community consequences of not discussing suicide, particularly the potential of amplifying the ‘ripple effect’ of trauma experienced in Aboriginal communities following a death by suicide. Peoples’ own lived experiences appeared to motivate many participants to advocate for why communities needed to discuss suicide, as it was seen as being a way to prevent further deaths and to ensure that other families and communities do not have to experience the ‘long-lasting’ (FGg, Speaker 55), cross-generational effects of losing a loved one to suicide.
‘Suicide has a ripple effect. There needs to be discussions and education about how long the ripple effect continues for.’ (FGg, Speaker 55)
‘People are left behind. They’re also saying “I should have gone there that day. I should have done, why didn’t I do?” I think that is the hardest thing the community left behind are left to clean that and the guilt is huge, [a] mammoth amount of guilt.’ (FGa, 27:20)
‘I've been aware of instances where siblings have [ended their life by suicide] 12 months later because it solved their sibling’s problem - so that’s what I will do too. So then the family loses two.’ (FGa, Speaker 20)
‘The grieving process actually still continues and then they still self-medicate and then other problems arise and then that family member ends up in Mental Health, so it's just an ongoing process where they're just following each other.’(FGb, 44:43)
The ripple effect of trauma following a suicide death was described by participants as including initial grief at the time of the loved one’s death that was felt by the whole community; a sense of strong support and connection at the funeral and for a period following; a sense of isolation and ‘silence’ following the funeral when people returned to their own lives; and in some cases an experience of a cascade of negative events in the family that were managed in ‘silence’. One participant stated that:
Families are forgotten after a month, and in honest truth, it’s just like a burial. Someone dies in the community, everybody comes to your house for a whole month and all of a sudden they go away and they think and they say. “It’s part of life, get on with life”. (FGb, Speaker 66).
The negative events experienced by bereaved families included family units breaking down; disruptions in education, employment and community participation; and in some cases the onset of substance use or mental health issues. The impact of these negative events was also felt by the community at large, with subsequent negative events experienced as additional trauma for the broader family and community.
‘When you lose kids, it’s very, very damaging to your own self. Let alone what happens to the community and how many people come up behind you.’ (FGb, Speaker 38)
‘Because you want to die and be with them. It doesn’t matter how you die you just want to be with them.’ (FGg, Speaker 26)
‘All the left-over hurt and grief and misplaced anger, where is it gonna go, and the people who were left behind, everyone is hurting.’ (FGg, Speaker 55).
‘Silence’ and its impact
Participants frequently spoke of a ‘silence’ around suicide in their communities, including for community members who had been bereaved by suicide. Participants described how ‘silence’ resulted in family and community members feeling unable to share their experience of losing a loved one to suicide. This resulted in people bereaved feeling isolated from their informal systems of support, feeling stuck and unsupported in their experience of grief and loss and feeling unable to break the ‘silence’ within the family given that in the past it had resulted in family turmoil. One participant reported that their family and community had not talked about a loved one who had died by suicide for ‘16 years, 17 years’ (FGg, Speaker 55). This silence had caused the participant a great deal of sadness; they felt that the memory of their loved one had been lost and that any attempt to discuss this resulted in a breakdown in family relationships and the onset of or relapse into substance use for some family members. The ‘cost’ of silence was described by many participants. One participant stated:
No one in my family wants to talk about it, that’s the first conversation I think that we have had about my brother in 16 years, 17 years, and my father’s response was ‘oh it’s something that you gotta get over’, my mother’s response- wasn’t even a response. Sixteen years and haven’t talked about it, haven’t talked about my cousin, my brother, we don’t talk about it, we don’t talk about anyone. (FGg, Speaker 55)
The shame felt by participants and people in the community when discussing suicide and poor mental health was reported by participants as being a factor that prevented discussions about suicide and mental health in their community. The feeling of shame experienced by participants was largely described as being associated with having witnessed the poor treatment of people living with mental health issues in their community. Participants reflected on their own experiences and reported that people living with mental health issues were often isolated in their community; were not provided with the support they needed from community members; were often labelled as ‘womba or whatever you want to call it’ (FGb, 10:25) (meaning crazy) by other community members; and that the police would often be called to take a person to hospital. One participant acknowledged that ‘there’s no getting away [from the shame], it doesn’t matter how far outside of the country you go, you still have contact with those people, there’s that shame factor’ (FGa, Speaker 43). Participants felt that if people were to discuss suicide in their community they too would be treated poorly, and this would bring shame to them and their family. ‘Community members that suffer mental health issues, when they go off, people close their doors, they just ring the police’ (FGg, Speaker 15).
Participants reported being ‘really scared to have [mental health and suicide] discussions with people’ (FGa, Speaker23) because they feared the conversation could cause harm to the individual or the community, or that they would not be able to provide appropriate support to a community member if they had the conversation. In their responses, participants described being fearful that the conversation would put ‘the idea in the person’s head’ (FGa, Speaker 37), would in some way ‘glorify’ (FGa, Speaker 31) or ‘normalise’ (FGa, Speaker 31) the idea of suicide, that it would in some way be ‘overstepping the boundaries’ (FGa, Speaker 12) of what was right and wrong to say, that it could potentially trigger ‘unresolved grief and loss issues’ (FGa, Speaker 34) by bringing up ‘stuff that they are not ready for’ (FGa, Speaker 34) that might ‘push them over the edge’(FGb, Speaker 22). Participants reported that these fears often resulted in them not talking about suicide even when it may have been needed.
Furthermore, many participants described being afraid to discuss suicide given that people who had spoken of having mental health issues or of suicide in the past had been forcibly removed from their community. They described personally witnessing community members ‘that suffered [from a mental health issue] being placed away, out of sight, out of mind’ (FGb, Speaker 20) in mental health facilities far away from the community and reported being afraid of this occurring to other community members. Participants reported that once placed in these institutions, the community member/s would ‘never come back to the community’ (FGb, 11:02). The fear of being removed from the community was identified as a potent factor in preventing people from having discussions about suicide in their communities.
Despite being fearful, the participants reported a strong desire to face the fear and to have more open discussions about suicide and mental health in their community. They spoke of wanting access to information and training and resources to build their skills and confidence to safely have these discussions. This included recognising ‘the signs and symptoms of suicide’ (FGb, 43:39) and ‘general knowledge of mental health’ (FGb, Speaker 64); support to understand ‘what they can say, because it’s hard to know what to say to somebody’ (FGg, Speaker 5) if they recognise any signs and symptoms in a community member; and guidance about how to specifically support a person who is thinking of suicide, information about support services and what to say following a death by suicide in the community.
I think sometimes too many people feel that they might be putting the ideas in [someone’s] head by talking about it. ‘I shouldn’t say this because what if I start thinking along that line and that’s what they do’. That’s where the discomfort comes from. (FGa, Speaker 37)
‘Some family members won’t even talk to the family and they’re frightened to talk to them because they don’t want to push them over the edge.’ (FGb, Speaker 22)
Negative experiences when accessing mental health services
Negative experiences when accessing mental health services were reported by most participants as another factor that prevented discussions about suicide. Negative experiences were grouped into the following sub-themes: generally feeling not supported by mainstream services; personal experiences of poor follow-up and engagement in support; having experienced no involvement in the mental health treatment and discharge decisions that affected their family and community; having received culturally inappropriate care; and having experienced or witnessed racism when interacting with health services.
As summarised in Figure 6, these factors contributed to the development of ‘mistrust’ between the Aboriginal communities and mental health services and a general reluctance to discuss suicide, given that community members did not feel they could turn to mental health services for reliable or helpful support when a person was suicidal.
‘You’ve got to build up trust up in the hospital.’ (FGb, 24:03)
‘You’re not educating the family on what they’re medicating with. You’re not educating us. You know, what are the symptoms? What are the signs? You know, and things like that.’ (FGb, Speaker 49)
‘So a lot of people get ridiculed if you show too much attention on, you know, getting Aboriginal people where they need to be within their health.’ (FGb, 27:37)
‘It’s that our people for too long have been stigmatised and discriminated against.’ (FGb, Speaker 62)
Consistent with participants’ experiences of ‘silence’ around discussing suicide in families and communities, they also described experiencing another type of silence when attempting to access mental health services. These services were described as frequently having failed to connect with those bereaved by suicide, those in a suicide crisis or those with mental health issues in a timely way, if at all, with the impact being that community members were turned away by mental health services with no follow-up support. This left already vulnerable Aboriginal community members feeling lonely and not able to reach out for support from either their informal support (family and community) or formal support (mental health services) systems.
‘It could be families out there that aren’t getting support [that’s what we are talking about]. There needs to be some sort of discussion and education around what happens to the family unit when someone does decide to leave and the ripple effect and how long that ripple effect continues on for, just makes the rift wider and wider.’ (FGg, Speaker 55)
‘But our biggest problem there with mental health is there’s no support up there, there is no support at the hospital.’ (FGb, Speaker 28)
‘To contact the helpline and then you don’t get help, you go back to ED and you don’t get help, and then you go to mental health and you don’t get help.’ (FGb, Speaker 55)
‘My baby brother died at least 15 years ago, I’m still waiting to get into community health ... I mean how long does it take to get me in when someone has died?’ (FGb, Speaker 26)
Powerless to act
The combined impact of the ripple effect, silence around suicide and people’s poor experiences when accessing mental health services manifested in participants reporting a sense of being ‘powerless to act’ when worried about someone and unable to call on meaningful support from others (in the community or mental health services). Other specific factors reported by community members that contributed to the theme of being ‘powerless to act’ are summarised in Figure 7.
Feeling ill-treated when supporting a community member to access mental health care
In the face of the barriers to accessing mainstream mental health services, participants described how they and others in the community had at times no choice but to engage with a mainstream mental health service when trying to support an Aboriginal community member who was actively suicidal or acutely unwell. When forced to access existing services, participants reported feeling like the system would often treat them like a ‘troublemaker’ (FGb, Speaker 55) or would at times call the ‘police on them’ (FGb, Speaker 55) when all they were trying to do was support a friend or family member. The persistent negative experiences reported by participants when attempting to access support left some participants feeling powerless and like ‘they didn’t even have the right to good respectful health care’ (FGg, Speaker 62) and that ‘you get knocked down and you just can’t possibly get back up again’ (FGg, Speaker 62). The powerlessness described by participants extended to having no confidence that if they chose to make a complaint about their treatment that it would be treated seriously and recognising that if they did make a complaint about the service ‘Where [were they] going to go? There isn’t another service for over one hundred kilometres.’ (FGg, Speaker 76).
No Aboriginal-specific mental health/suicide service
The sense of powerlessness in discussing suicide and being able to support people during a suicide crisis appeared to be amplified by the absence of a ‘trusting’ relationship with mental health services and the absence of Aboriginal-specific mental health services. The majority of participants reported feeling that there was no Aboriginal-specific service or no one in their community that Aboriginal people could sit down and have a ‘talk with to steer them in the right direction’ (FGg, Speaker 16) or someone that ‘they can identify with and they can feel safe with and they will open up to’ (FGg, Speaker 16). Participants reported that having access to Aboriginal-specific supports in their community was important because community members ‘especially young ones, they won’t open up to [just] anyone, they won’t [just] go to anyone’ (FGg, Speaker 26) and the community had felt in the past that they were not understood by counsellors who lacked an ‘understanding [of] where I am coming from, my way of thinking and their training is totally wrong with working with Aboriginal people’ (FGb, Speaker 22). Participants reported that improving their access to an Aboriginal-specific mental health service and addressing the limited existing capacity of mental health services to provide culturally appropriate care and incorporating more Aboriginal workers or Aboriginal mental health clinicians would be appropriate ways to address the issues.