Published on September 9th, 2016 | from CAMH

Suicide prevention in the north

By Dr. Allison Crawford, Medical Director, Northern Psychiatric Outreach Program and Telepsychiatry |

September 10 is World Suicide Prevention Day (WSPD), and this year’s theme is “connect, communicate, care.”  Each of these three words resonates for the work we do on a daily basis, both as healthcare professionals, and as members of a community.  Suicide Prevention can be a momentary act of listening; recognizing someone in need; a clinical intervention; putting research into practice; or working to effect change at a policy level.  To take action to prevent suicide requires us to act together at every level.

Although I am a psychiatrist, I reflect on how little suicide prevention was part of my medical and psychiatric training.  Even the training I did receive was focused on the narrow act of whether someone was “actively” contemplating suicide and would require hospitalization.  No one told me that many of many patients (and some of my colleagues in healthcare) would struggle with frequent thoughts about the meaning of life, hopelessness, death, and suicide on an ongoing basis.

Much less did anyone tell me about the larger social context of suicide, about the links to childhood abuse and adversity, and to social inequity such as poverty.  My own confrontation with the limits of my psychiatric, clinical approach during my work in Nunavut taught me this and catalyzed my own interest in suicide prevention.

I of course knew about high rates of suicide among Inuit and some other Indigenous communities in Canada.  But for the first years of my work in Nunavut, starting in 2005, I approached suicide prevention in much the same way as I had during my clinical training in downtown Toronto. I asked patients if they had thoughts of suicide, plans, had taken steps towards carrying them out.  I treated depression using psychotherapy and antidepressant medications. I commented on patients’ “high-risk” if they had made previous attempts.

All of these are important clinical manoeuvres, among others, that can identify and treat people who are at risk of suicide.  But all too often I would hear about youth who had ended their life by suicide having never come to the attention of mental health.
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A turning point in my understanding of suicide

In 2014 I returned to Cape Dorset, Nunavut, shortly after an 11 year-old boy ended his life by suicide.  He had been playing video games with friends.  While the others continued playing, he went into the bathroom unnoticed and ended his life by hanging.

I was asked to assess many other 10–15 year old youth in the aftermath, by understandably worried nurses, teachers, and parents.  At no other time have I felt my profession and skills so underequipped to manage the loss and worry I encountered in the community, or to predict who was most at risk.  I recognized that for suicide prevention to work in this community context it would have to extend far earlier than adolescence and far beyond the health centre walls.

At about the same time, and definitely influenced by these events, I responded to a call by Inuit Tapiriit Kanatami (ITK), the National Inuit organization, to help with the creation of their National Inuit Suicide Prevention Strategy (NISPS).  CAMH was successful in this bid, and over the two intervening years I have had the tremendous privilege of working for ITK and with their Board of Directors to create a suicide prevention strategy that draws on available international evidence and puts Inuit knowledge into action to meet the unique suicide prevention needs of Inuit in Canada.

Delving into the National Inuit Suicide Prevention Strategy

This work epitomized the “connect, communicate, and care” that are at the heart of WSPD 2016.

The first year of developing the strategy entailed connecting with each of the four Inuit Regions that make up Inuit Nunangat – Inuvialuit (in NWT); Nunatsiavut (in Labrador); Nunavik (in Northern Quebec); and Nunavut.

I had many humbling moments of being politely told that the language or terms were “too academic”, or failed to capture Inuit experience.  I had the amazing fortune of working with a talented team at ITK; in particular Tim Argetsinger who was able to communicate the most complex ideas into accessible, compelling language. Communication will be an ongoing imperative as the strategy is implemented, and to foster knowledge exchange between each region and unite Inuit in understanding why suicide is occurring and what can be done to address it, and will hopefully decrease stigma.

This understanding is also something that those working in healthcare could benefit from.  The NISPS understands risk and protective factors as encompassing both the community and the individual, and as accumulating throughout life.  Prevention is seen as stemming from a childhood where one is protected from adversity, where one is nurtured in a safe family environment.  Putting prevention within this context of childhood development will communicate the critical link between childhood adversity and later suicidal behaviour.  It is only by creating better childhoods that we can truly begin to reduce rates of suicide.

Many of the same risk factors for suicide globally also impact Inuit, including depression, substance use, impulsivity and aggression.  In keeping with this, the NISPS calls for a continuum of mental health services to be available for Inuit – but most importantly that these services be available in Inuktut and be culturally relevant for Inuit.

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The NISPS takes a multi-level approach and identifies six priority areas for suicide prevention:

  1. Create social equity, through addressing social determinants of health
  2. Create cultural continuity, through approaches that connect Inuit with their land, culture and language to foster healing
  3. Nurture healthy Inuit children
  4. Ensure access to a continuum of mental wellness services
  5. Heal unresolved trauma and grief
  6. Mobilize Inuit knowledge for resilience and suicide prevention.

Suicide and social equity

One of the advances that the NISPS makes in suicide prevention is placing it within the context of social equity: there can be no major gains in suicide prevention without advancing social equity and addressing the social determinants that underpin suicide. There is ample evidence from large studies such as the Adverse Childhood Experiences study in the US, and the Christchurch Child Development cohort in New Zealand, that amply demonstrate the impact of social disadvantage on later outcomes, including suicide. However, this is all too often left out of suicide prevention efforts.

Layout 1From local work to global impact

The work that ITK has done on the NISPS can have an impact globally.  Many countries other than Canada also show high rates of suicide among Indigenous communities.  Part of this dialogue has started with the RISING SUN (Reducing the Incidence of in Indigenous Communities – Strength United Through Networks) initiative of the Arctic Council.  Our work on the RISING SUN will contribute to and learn from suicide prevention efforts across circumpolar communities.

There are other countries that have created National suicide prevention strategies in collaboration with Indigenous communities, including New Zealand and Australia.  ITK’s strategy, however, extends this work in several ways: by focusing on early childhood; by including social determinants of health; by addressing historical trauma and the colonial context of increased suicide rates; and by emphasizing Indigenous knowledge and cultural continuity.  I discuss the global relevance of this work in The Lancet.

What it means to ‘care’

A final word goes to the notion of “care,” and while it is certainly true that we should care about what happens to our friends, our patients, and our communities, I think we are also called upon to question what kinds of care we provide and the limits of care.  The work on the NISPS has challenged me to think of collaboration instead of care.  Much historic harm, including through healthcare, has been done in the name of caring.  We need to work with Indigenous communities (and all communities) to be responsive to their needs, priorities, ways of knowing, and to what makes life meaningful to each community and to each individual.

I leave you with images from a mural by Elisapee Ishulutaq, a 91-year-old artist from Pangnirtung, Nunavut, who responded to the death by suicide of a youth in 1996 by painting.  She involved many youth from the community in creating this visual narrative.

 in-memory-muralFirst panel of the Elisapee Ishulutaq mural titled ‘In Memory.’

man-on-shoreThird panel from Elisapee Ishulutaq mural titled ‘Man on Shore.’

The community story that she creates is also about connecting, communicating and caring.  Through the process and the story she tells, she conveys the impact that suicide has had on every member of the community, and the way that its meaning cannot be separated from the environment, the land, and the living memory of the people who carry on.

My experience with working with ITK and with Inuit in Nunavut has similarly shown me that addressing suicide is also not possible without that grasp of its deep roots and cultural meaning, and without community engagement and collaboration.


allison-tim600Allison Crawford with Tim Argetsinger at the launch of the National Suicide Prevention Strategy in Kuujjuaq, July 27, 2016

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