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Addressing indigenous suicide: a special case? A response to Colin Tatz.

Abstract: Colin Tatz's article on Aboriginal suicide prevention seeks to extricate indigenous psychiatry and suicide prevention from what he regards as domination by Western medical/mental health approaches. Although Tatz fails to do justice to such approaches, because he empties them of sociocultural, historical and political content relevant to mental health, some extreme forms of psychiatry (e.g. the problematic drift of Western psychiatry towards biological reductionism) may confirm his concerns. The article lacks supporting evidence for its assertions that indigenous peoples do not experience depression, that suicide prevention approaches generally have failed and that their endpoint ('prevention' rather than 'alleviation') is flawed, and that Western medical approaches to mental illness are essentially urban, white, middle-class and hedonistic in intent. Nevertheless, Tatz raises perennially important issues to do with the realities of history and power that profoundly affect the health and wellbeing of Aborigines. These include avoiding the temptation to objectify and minimise the lived experience of members of oppressed groups, restoring the debate about existential and 'purpose of life' issues, and a timely protest against 'mainstreaming'. The latter criticism is applicable in the academy, the political arena, multicultural mental health and (indigenous) suicide prevention. Tatz also offers valuable though not easily comparable data based on fieldwork experience, alludes to the difficulties of research with indigenous peoples, and suggests some compelling directions for further enquiry.

It is argued that there is a need for a forum for experienced researchers and authorities such as Colin Tatz to meet with indigenous community leaders, other stakeholders, and health planners to advance the indigenous component of the national suicide prevention strategy.

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Colin Tatz's valuable, troubling article is more a free-ranging, impatient polemic or an admonition than a systematic work of scholarship. Its chief aim appears to be to question the value of medical and psychiatric models of understanding and addressing suicide, especially indigenous suicide. Its scope, tone and often unqualified and unargued assertions create a problem for the respondent. A full response to all of Tatz's points would include reference to a suite of papers in the various areas germane to his article. This feat is not attempted here. Tatz's manner and method also create a problem for Tatz himself. When, for example, he inveighs against 'explanations and solutions' (statistics, research methods, theories, catalogues of risk factors, and therapies) (p. 1), one response is that he can hardly be serious: these are mainstays of modern scientific discussion and even much non-scientific scholarship. An alternative possibility, however, is to discern the positive, provocative intent and warning that Tatz offers.

Colin Tatz is a colleague and a personal friend. His piece, despite some flaws and deficiencies of argument, makes a worthy contribution to Australian and indigenous suicidology. A number of his assertions invite rebuttal, while others bear the weight of independent observation and analysis, raising the need for further investigation.

Difficulties

The central problems with Tatz's position can be summarised as follows. Perhaps mirroring the assumption in some medical circles that biomedical/ natural science approaches are the only valid ones, Tatz assumes a monolithic, either/or, sociocultural versus biomedical, model of suicide and its prevention, and makes a strong case for the former while relegating the latter to insignificance. Though he commends 'radicals' within psychiatry (e.g. the Australian psychiatrists D'Sousa and Halasz, who are concerned with spirituality), he also treats psychiatry as unitary, and seems unaware of the discipline's internal debates, particularly recently as it drifts towards biology (see further below). Specifically, Tatz claims that Western approaches to suicide prevention primarily focus on medical/mental illness, that mental illness is a 'myth', and that the medicalised, mental illness approach is essentially urban, white, middle-class and hedonistic in intent. He also argues that indigenous persons do not experience depression, that suicide prevention approaches generally have failed, and their endpoint ('prevention' rather than 'alleviation') is flawed. Although he controversially argues that Aboriginal suicide is different, he does not offer a coherent alternative strategy. Each of these will be briefly mentioned in turn.

To assert that Western suicide prevention strategies primarily focus on mental illness and are mostly blind to cultural, social and political factors is to ignore longstanding approaches within psychiatry that acknowledge the latter. It is true that, although much psychiatric literature indicates that mental illnesses are associated with suicide and attempted suicide (Beautrais 2000; Hawton & van Heeringen 2000, passim), sociocultural and political factors noted by Tatz are often not discussed in depth. Doctors, psychiatrists and psychologists are generally untrained in the social sciences. Despite this, however, the 'external' as well as the 'internal' risk factors for suicide that Tatz cites in the Abstract figure in many psychiatric studies of suicide, both indigenous and non-indigenous. They are also frequently regarded as risk factors for mental illness (e.g. Bille-Brahe 2000; Eckersley & Dear 2002; Hunter 1988; Parker & Ben-Tovim 2002).

Suicide research and prevention in particular has never been the sole preserve of psychiatry or mental health, and the social determinants, correlates and consequences of suicide and suicidal behaviour have been the subject of study for over a century (Durkheim 1951). International conferences, for example of the International Association of Suicide Prevention (IASP), continue to exemplify this breadth among the presenters and attendees. Current evidence about suicide and suicide prevention from a wide range of academic, clinical and public sources also suggests that sociocultural and biomedical approaches are both important. The social factors for suicide operate through final common pathways in the lives of individuals. Mental disorders and depression in particular may be the means by which the malaise of indigenous persons and communities is expressed. So-called 'psychological autopsy' studies regularly find that the vast majority of suicides (approximately 80-90%) are associated with 'mental illness' (i.e. cases meet criteria for mental disorders appearing in psychiatric diagnostic systems and elicited using standardised diagnostic interviews with relatives, friends, GPs, workmates, and so on) (Hawton & van Heeringen 2000). However, they do not explain the sociocultural or spiritual matrix in which such disorders occur. The medical/psychiatric approach to suicide, rather than seeing suicide as a disease or mental disorder (as Tatz asserts), regards it as a behaviour that has to be interpreted by and within the societies in which it occurs (Hassan 1995). It frequently but not necessarily signifies the presence of mental illness.

More broadly speaking, the general health and mental health of individuals have long been causally linked to social and cultural factors. Examples of this abound. The modern science of epidemiology, the study of illness in populations, assumes that social factors are important in mental health and in suicide prevention (Henderson 1988). A crucial premise of modern psychiatric studies of stigma is that mental illness, disability and related personal suffering are inseparable from social context, the way such illnesses are socially constructed, and the way in which persons with such illnesses are treated (Sane Australia n.d.). The discipline of trans-cultural psychiatry has long addressed the importance of cross-cultural readings of symptoms and illnesses such as anxiety, depression and post-traumatic stress disorder. In Australia today, such psychiatry is often carried on through those who work with and speak/write about refugee, migrant and indigenous mental health. State-based torture and trauma rehabilitation centres, and networks such as NACCHO (National Aboriginal Community-Controlled Health Organisation) and Multicultural Mental Health Australia, testify to the importance of culture in understanding social and emotional wellbeing.

Tatz asserts that the medicalised, mental illness approach is essentially urban, white, middle-class and hedonistic in intent. Although some schools of psychotherapy and psychoanalysis are stereotypically like this (the 'Woody Allen phenomenon'), Tatz needs to provide evidence. Medicine and psychiatry owe much to natural science origins, may sometimes arguably pursue the mirage of objectivity and 'value-neutrality', and may be coopted by broader social agendas, such as those of the drug companies, which indeed are cosmopolitan and promote the pleasure principle. But many of medicine's and psychiatry's origins and traditions remain humanistic. Recent ethical debates within medicine (e.g. in relation to disadvantaged populations and asylum-seekers) concern the provision of mental health care for all persons, whether they are citizens or not (Silove 2O00).

In relation to psychiatric diagnosis, Tatz adopts an 'anti-psychiatric' point of view, explicitly following Thomas Szasz in regarding mental illness as a myth, and cites some controversial categories in DSM-IV to make his point. Justifying this approach and sweeping assertion requires an examination of the science and politics of psychiatric diagnosis, classification, treatments, practice settings and research. Unfortunately this task is beyond the scope of an article, and probably requires a book (Bloch et al. 2001 have made a start on it in their classic Psychiatric ethics). In relation to classification of individual disorders, the authors of DSM-IV sought to capture the importance of culture and spirituality through an appendix and V codes. These enable more accurate diagnosis, and potentially broaden psychiatrists' openness to cultural, religious and spiritual issues in their patients' material (Andary et al. 2003; Lukoff et al. 1992; Turner et al. 1995). Tatz is particularly sceptical about depression, and in so doing taps into long-running debates. Is depression a symptom or a disorder? Is it a unitary medical illness for which counselling, therapy and medication are the most appropriate interventions, or heterogeneous, as various as the cultures and spiritualities that give rise to it (Marsella 2003; Parker 2004)?

Tatz's mentor Szasz, in suggesting that illnesses are primarily created and perpetuated by doctors, arguably trivialises the experiences of patients and fails the tests of common sense and compassion. Debates regarding the niceties of DSM-IV diagnostic categories do not substantially alter the agonising, disabling realities of, say, melancholic depression or schizophrenia, or the experience of generations of patients with these clinical conditions. Yet Tatz also clearly believes that schizophrenia and bipolar disorder are the result of the interaction of a number of genes with an unknown number of environmental, cultural and social factors. So Tatz's position here is unclear. Is Tatz a Szaszian? Does he see a role for the biomedical, biochemical and genetic approach, or not?

In relation to indigenous suicide specifically, it seems unusual for Tatz to compare indigenous suicide in New South Wales (a state), with New Zealand (a country), with Nunavut (a territory). For example, he does not mention indigenous suicide elsewhere in Australia, or overseas. In relation to causation, he claims an absence of depression and other psychiatric disorders among indigenous suicides in New South Wales (his own) and Nunavut studies, and also notes the importance of under-14 suicide in Aboriginal communities, thus arguably providing convergent evidence for his contention that Aboriginal suicide is different. However, this does not accord with depression noted in studies of other cultures, including indigenous ones. The World Health Organization's report (WHO 1993) noted the predicted increasing importance of depression internationally to the year 2020. There is an extensive literature related to the cross-cultural aspects of depression (e.g. Kleinman 2004), which can only be alluded to here. Parker and Ben-Tovim (2002), both psychiatrists, have provided evidence for depression and other psychiatric disorders among Northern Territory Indigenous suicides that may contradict Tatz's contention. To the best of this respondent's knowledge there has not been a published study of indigenous suicides that has specifically considered the incidence of depression and other illnesses, using standardised psychiatric diagnostic interviews with relatives and friends, workmates and medical attendants. (This is the 'gold standard' methodology in this area; such interviews have been translated and used in different cultural settings). Isaacs' and Neily's studies, cited by Tatz, are apparently not available for a general readership. The question of rates of depression and other psychiatric disorders in indigenous suicides still remains to be resolved. Tatz also asks which of those who are depressed go on to commit suicide. Although this is impossible to predict, various studies have investigated those with depression who go on to commit suicide, versus those who don't (Lonnquist 2000). Hopelessness may be an important part of the answer.

Tatz regards the primary aim of the social response to suicide being that of 'alleviation', rather than 'the less grandiose aim' of prevention, by which he seems to mean reduction rather than cessation, though nowhere is this defined. Rhetoric from politicians and others sometimes claims that 'even one life lost is one too many'. Western, medically oriented suicide prevention generally does not aim for the cessation of suicide, but for more attainable targets of reducing suicide rates by a certain percentage within a certain time (e.g. UK DH 2003). In this respect, public health strategies aim, strictly speaking, at alleviation rather than prevention, and thus align with Tatz's own prescription.

Tatz prematurely concludes that the National Youth Suicide Prevention Strategy (NYSPS) (1995-1999, $31 million), its successor, the Living is for Everyone (LIFE) program (all ages, 2000-, $66 million) (CDHSH 1995a,b; CDHAC 2000), and more specifically, the indigenous component of the latter (unreviewed by him), have failed. Although there was been a dearth of postvention programs and significant issues with Aboriginal access and engagement in NYSPS (Mitchell 2000), these suicide prevention programs are among the most innovative, progressive and comprehensive in the world. Significant gains were made by NYSPS: a substantial minority of projects demonstrated positive impacts on individual and environmental risk and protective factors, and significant reductions in disability occurred for youth attending mental health services (Mitchell 2000). Also, from 1997 to 2001, suicide rates among males aged 15-24 fell from 31 to 20 per 100 000, and among males aged 25-34 from 41 to 33 per 100 000, though the latter retain the highest age and sex rates (ABS 2001). One cannot demonstrate that this was due to the NYSPS/LIFE strategies alone, but such trends may signify that these initiatives have been effective.

Strengths

However, it would be a mistake to use the loopholes in Tatz's piece to dismiss it. It makes a significant contribution, and it is critical to discern the positive, provocative intent behind the polemic.

1. The statistics about indigenous suicide are of grave concern. Tatz sought to overcome the difficulty in ascertaining Indigenous status in relation to Aboriginal deaths in New South Wales by making inquiries from Aboriginal communities involved, rather than solely relying on statistics from coronial or Australian Bureau of Statistics sources, with the significant difficulties involved (Tatz 1999). His study procedure therefore adopted a higher standard for enumeration than those conventionally used.

2. Tatz expresses frustration with Western approaches to suicide prevention when they objectify and minimise the subjective lived experience of being a member of an oppressed group. He considers the stigma incurred by those indigenous persons who suicide: being indigenous increases suicide risk, not because the group is intrinsically flawed or sick, but because of the oppressions that it suffers. Tatz also highlights a major cultural loss in our current 'evidence-based' climate: in the quest for 'evidence' (and the dominance of natural science varieties of it), something intrinsic to human experience has been lost. The point is fairly made. At Suicide Prevention Australia's recent conference, held on 30-31 October 2004 at the University of New South Wales, Indigenous persons were represented. Nevertheless, mental health consumers argued that the voice of the suicide survivor has been lost in the medical and mental health discourse about suicide prevention. This criticism had substance, since the organising committee, of which I was the chair, had initially omitted to include them. In the refrain 'Nothing about us without us', mental health consumers make clear that the experience of suicidal persons cannot be objectivised. This lesson has to be repeatedly relearnt.

3. Tatz's characterisation and critique of the 'medical/mental health model' is very relevant if we consider the drift of Western mental health towards biological psychiatry. Political policies (e.g. George Bush's 1990 announcement of the 'Decade of the Brain'), biological research funding and increasing influence of biological psychiatry journals, all underwrite this trend (Jones & Mendell 1999). Psychiatric illnesses such as major depressive disorder, bipolar disorder and schizophrenia are regularly described as primarily brain diseases, like Parkinson's disease and multiple sclerosis (e.g. Torrey 2003). Neurobiology, diagnostic instruments, psychopharmacology and packaged forms of psychological treatment dominate the landscape. Tatz himself in the present article has commented on misleading language within biological psychiatry (e.g. the fuzzy concept of 'chemical imbalance'). Whatever the possible reasons for this shift (including drug company promotion, professional boundary definition, and so on (Dudley & Andrews, forthcoming; Moncrieff 2003), this medicalisation of psychiatry undermines its broad intellectual foundations. Positivism and natural science assumptions deny or diminish sociocultural readings of psychiatry, for example arguing that they may be important in treatment but not in causation (e.g. Torrey 2003). The notion that 'biology is destiny' negates human choice and values. Biological reductionism defines disease and treatment narrowly. The assumption of scientific objectivity means that social values and interests vested within research go unexamined (Ross & Pam 1995:8, 211-41). Arguably, cultural and spiritual concerns, although basic to formulations of personhood and social reality to persons across the globe, have traditionally fallen outside the strict confines of European psychiatry (Fabrega 2000). International Western psychiatry tends to bracket 'spiritual' matters with (trans-) cultural psychiatry, usually seen as pertaining to peoples or cultures that are non-secular and Western; it is therefore possible that Western psychiatrists and patients may experience blind spots when examining their own culture, its soul-searching and malaises.

4. Tatz's approach should also be seen as a timely protest against 'mainstreaming'. The academy fosters a plurality of interpretive frameworks, including medical and cross-cultural ones, but pluralism may potentially minimise the realities of power that profoundly affect the wellbeing of Aborigines. In the political arena, mainstreaming of Indigenous concerns under the present federal government may deny Indigenous difference within Australian culture. This effectively revises frontier history, including the impact of the so-called 'stolen generations', extinguishes native title, denies the need for an apology and thwarts reconciliation, and subverts Indigenous control of institutions (e.g. ATSIC), re-asserting white control (Dodson 2003). In this respect, the present government has arguably revived older assimilative approaches to Aboriginal health and welfare. This is notwithstanding the recent announcement of a ground-breaking rapprochement between it and key Aboriginal leaders (Australian, 4 December 2004), and the acceptance of 'mutual obligation' for the problems facing Aboriginal communities. 'Mainstreaming' also potentially neglects unique aspects of Aboriginal suicidal behaviour that need to be addressed, including the lower age of Indigenous suicides, the frequency of suicide clusters, the association with complex patterns of community grief, the overwhelming predominance of alcohol, and the use of hanging (Tatz 1999). Although Tatz's alternatives to mainstreaming are never spelt out, his objection places at the centre of debate the concerns of Aboriginal people themselves, including the so-called 'symbolic' issues. Redressing these will be crucial to addressing longstanding concerns about Aboriginal social and emotional wellbeing, and suicide rates.

It should also be noted that similar concerns about 'mainstreaming' also attach to multicultural mental health and suicide prevention in general. The Australian government's 'trailblazing' suicide prevention programs, its commitments to migrant and refugee mental health, and the welcome emergence of the network Multicultural Mental Health Australia, stand in contrast to its policy regarding indefinite mandatory detention of on-shore asylum-seekers (Dudley 2003; HREOC 2004). Like past and many present government policies on Indigenous people, policies on asylum-seekers represent a convergence of health and human rights concerns. Basic human rights apparently only apply to those with Australian citizenship, while 'others' (currently identified under Immigration law as 'illegal non-citizens') have fewer rights and are therefore less worthy of concern and professional services.

5. Tatz has raised the question of purpose in life and spirituality in suicide prevention. Perhaps because of restricted definitions of science and suspicions of religion, religion and spirituality have been historically neglected in Australian mental health discourse in general and psychiatry in particular (though this recently has been changing). However, the rise of individualism and consumerism, the decline of organised religion and the erosion of social bonds have all been implicated in the rise of youth suicide in Western industrialised societies (Eckersley & Dear 2002). For those working in communities, spirituality can provide a framework for ethics and justice, liberate the imagination, and can potentially be the fount of resistance to individualism, consumerism and the social forces that marginalise. Moreover, a growing body of high-quality research indicates that what we tell ourselves about our lives and their ultimate significance is central to our health and wellbeing, and to the prevention and management of both physical and psychological disorders (Koenig et al. 2001). Spirituality, culture, the sciences and medicine share much common ground. This is relevant to all social groups, but for none more so than for indigenous peoples, for whom, despite the tragic impact of white culture, spirituality has always been centre stage. Indeed, new generations of non-Indigenous Australians, without engaging in wholesale rejection or (mis-)appropriation of Aboriginal cultures, may benefit from exposure to and dialogue concerning Australian Indigenous spiritualities. In the light of continuing high suicide rates, especially among young adult males, and especially in Indigenous communities, the need for cross-cultural dialogue and for further exploration of the spiritual dimension in Australian mental health promotion, service delivery and research, is pressing.

6. Tatz in this article and elsewhere has alluded to traditional problems attaching to medical and natural science research approaches to indigenous communities. The National Health and Medical Research Council, in its Values and ethics: guidelines for ethical conduct in Aboriginal and Torres Strait Islander research (NHMRC 2003), has sought to minimise some of the traditional problems attaching to Indigenous research. It has affirmed the values of reciprocity, respect, equality, responsibility, survival and protection, and spirituality in this area. However, despite the existence of these guidelines, the difficulties were exemplified when approximately five years ago Tatz and I applied with co-authors for government funds that had been earmarked to research risk for suicide and suicide attempts in young persons (including Indigenous youth). The chair of the reviewing committee forwarded responses to our proposal from one reviewer, who asked why we had not considered doing genetic testing as part of our study, including for Indigenous peoples. The cultural sensitivities surrounding research and genetic testing for Indigenous peoples were not 'on the radar'.

7. So is Aboriginal suicide different, as Tatz has contended? A yes/no response is not possible. Tatz elsewhere cautions against attempting to match the experience of Aboriginal with non-Aboriginal persons, arguing that there are no other groups whose backgrounds and circumstances so match the Aboriginal experience that the effects of any causative factor can be studied (Tatz 1999). That is, in terms of the realities of power, Aboriginal suicide is vastly different from white, and if Aboriginal suicide is different, it is for such reasons of history and power. He also comments on the unique aspects of Aboriginal suicidal behaviour, noted above. Such trends are noted in other indigenous cultures, and as noted, depression may be a feature in such settings. Indigenous male suicide rates have started much lower than non-indigenous rates, and are now much higher than non-indigenous. However, the general direction of both is sharply upwards. This also suggests the possibility that some features may be shared by indigenous and non-indigenous suicide, and by indigenous and non-indigenous peoples in relation to mental health, as well as these being markedly different in some ways.

Conclusion and future directions

The figures that Tatz provides make clear the urgent priority of addressing the issue of indigenous suicide. Multiple sources of knowledge and wisdom are required to further the extraordinarily complex task of suicide prevention, and additional layers of complexity must be added for Indigenous suicide prevention. The indigenous component of a national suicide prevention strategy cannot stand alone. This would run the risk of resurrecting failed segregationist policies, would arguably weaken the ability of mainstream services to respond in culturally sensitive ways, and would potentially deny to Aborigines mainstream approaches that may be of value. But it must incorporate Aboriginal trader-standings of and responses to suicidal behaviour (Elliott-Farrelly 2004).

Tatz's contributions to indigenous suicide prevention are therefore important. On the one hand, he casts doubt over the value of suicide prevention programs from the viewpoint of a political scientist, without providing an explicit 'evidence base'. On the other, in reminding us of the cultural and historical dimension in understanding suicide, and the political dimension in its alleviation, he does a service to suicide prevention in general, and Indigenous suicide prevention. Tatz's work also suggests some compelling directions for further enquiry, which have only been partly addressed in existing studies. For example, how often is Australian Indigenous suicide associated with clinical depression or a mental disorder, and in what ways are its patterns different to non-Indigenous? Is there a difference for example in the factors affecting Indigenous youth who engage and do not engage in self-harm?

It would be helpful if Tatz, from his long history of work in the field, outlined how he would want the national suicide prevention strategy to advance in the Indigenous area, and if this were part of a continuing exchange with Indigenous community leaders, other stakeholders, health planners and academics to advance the Indigenous component of the national suicide prevention strategy.

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Michael Dudley

Sydney Children's and Prince of Wales Hospitals University of New South Wales

Dr Michael Dudley is a psychiatrist at Sydney Children's and Prince of Wales Hospitals, and senior lecturer at the University of New South Wales. He researches suicide, works with self-harming young people, and chairs Suicide Prevention Australia (SPA), a non-government organisation which provides leadership, education and advocacy for suicide prevention. He also works with young refugees and researches adolescent resilience. He has interests in psychiatry, culture and human rights, and has written about: the Nazi psychiatrists; contradictory Australian national policies on suicide prevention, especially regarding asylum-seekers; the image of psychiatry in contemporary Australian literature; and the relationship of religion, spirituality and psychiatry.

Sydney Children's and Prince of Wales Hospitals University of New South Wales <m.dudley@unsw.edu.au>
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Author:Dudley, Michael
Publication:Australian Aboriginal Studies
Geographic Code:8AUST
Date:Sep 22, 2004
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