Outline

1. GoingUpstreamMental health promotionas suicide prevention? Building a framework for LGBTI PopulationsAtari Metcalf, Evaluation Manager, Inspire Foundation & Board Director, Suicide Prevention AustraliaMindOUT Symposium | October 2012 MindOUT Symposium October 2012

2. Outline • What do we mean by ‘mental health promotion’ exactly? • What is the role of MHP in the prevention of suicide? • Why do we need a MHP Framework for LGBTI populations? • What would a MHP Framework for LGBTI populations encompass? • Discussion

3. What do we mean by mental health promotion…

4. Taking a walk upstream… Upstream – determinants (macro, environmental level – gov’t policy & legislation, social and economic resources) Midstream – risk & protective factors (behavioural & individual prevention programs) Downstream – treatment, crisis intervention (clinical research and practice)

5. …working across the spectrum (Mrazek & Haggerty)

6. ‘Mental Health’ – more than the absence of illness The World Health Organisation describes ‘mental health’ as a state of complete mental, spiritual and social wellbeing where: “every individual realizes [their] own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to [their] community”. Similarly, VicHealth define ‘mental health’ as: “…the embodiment of social, emotional and spiritual wellbeing. Mental health provides individuals with thevitality necessary for active living, to achieve goals and to interact with one another in ways that are respectful and just. (VicHealth 1999).

7. ‘Mental Health Promotion’ The Melbourne Charter for Mental Health Promotion: “Mental health promotion is a strategic and sustainable approach to eliminating or minimising those factors which give rise to distress and loss of wellbeing and introducing and maximisingthose which create thecircumstances in which all can flourish. It is also important in the process of recovery from illness or episodes of illness.”

8. The Melbourne Charter for Promoting Mental Health The Melbourne Charter asserts that mental health and wellbeing are: • an indivisible part of general health; • essential for the wellbeing and optimal functioning of individuals, families, communities and societies; and • a fundamental right of every human being, without discrimination. The Melbourne Charter affirms that mental health and wellbeing are: • of universal relevance; • most threatened by poor and unequal living conditions, conflict and violence; and • a key indicator of a nation’s social and economic development. The Melbourne Charter believes that mental health and wellbeing are: • everybody’s concern and responsibility; • best achieved in equitable, just and non-violent societies; and • advanced through respectful, participatory means where culture and cultural heritage and diversity is acknowledged and valued.

9. Mental health promotion interventions continuum

10. The role of Mental Health Promotion in Suicide Prevention

11. The premise… • “Mentally healthy, happy and resilient people, with good social supports do not suicide” The role of Mental Health Promotion is twofold, working to prevent suicide in both direct and indirect ways: • Prevention of mental illness • Improving quality of life and building resiliency

12. Determinants …factors that typically operate at the environmental (system, social or community) level and affect the likelihood that people will be exposed to a disease or condition or, when exposed, the likelihood of their developing the condition. Examples: poverty, access to healthcare, employment opportunities, education and housing; socially inclusive societies that value diversity Actions: reducing exposure to social and contextual risk through structural changes such as improved access to economic resources, housing, and legislative reforms to protect human rights; improved visibility and recognition of LGBTI people

13. Risk factors …increase the likelihood that a mental health problem will develop and/or increase susceptibility to suicide Single risk factors often have only a minimal effect on their own but may combine to have a strong interactive effect, and exposure to multiple risk factors over time has a cumulative effect (Kazdin & Kagan 1994). Examples: AOD use, mental illness, bereavement/exposure to suicide, experiences of trauma violence, discrimination, abuse, exclusion and family conflict, access to means, ‘hopelessness’ Actions: reducing exposure to, or mitigating risk, by building protective factors. Addressing homophobia, transphobia and continued stigma surrounding intersex is critical. Stop. Think. Respect. Campaign and Proud Schools are recent examples.

14. Homophobic & transphobic abuse is associated with suicide and poorer mental health Figure 14. Relationships between homophobic abuse, self-harm and suicide (Hillier et al. 2011)

15. Protective factors Protective factors build resilience in the face of adversity and moderate the impact of stress and transient symptoms/events on wellbeing. They can be truly protective, reducing the exposure to risk, or they may be compensatory, reducing the effect of risk factors (Rutter 1985). Examples: social connection, supportive family & peer relationships, adaptive coping skills, self-determination, efficacy and resiliency, sense of belonging and self-esteem, optimism and hopefulness Actions: supporting parents and families; peer education and support programs (particularly around ‘coming out’), opportunities to engage and participate in the community

16. Supportive families responses to disclosure buffer impact of homophobia on suicide risk Figure 21. Rates of attempted suicide in young people when supported or rejected by family (Hillier et al. 2011)

17. Supportive policies and peers also buffer impact of homophobia on suicide risk Writing Themselves in Again 3 also found: • Knowledge that their school had policies that protected them from homophobia, meant that young people who suffered no abuse, were less likely to self harm and attempt suicide. • Young people who attended a school that was supportive, rather than homophobic, were less likely to self harm and attempt suicide

18. Mix of ‘universal’ and ‘targeted’ strategies are needed Some groups are considered more ‘at risk’ than others: • Young people • Older people • Trans* people • Intersex people • CaLD, refugee and Aboriginal and Torres Strait Islander LGBTI people • Rural, regional and remote LGBTI people

19. Challenges • Limited evidence, particularly in relation to groups ‘most at risk’ to guide action • Distal (upstream) interventions are difficult to evaluate • Absence of quality data on LGBTI suicide makes it difficult to plan initiatives and monitor if are efforts are working

20. Why a MHP framework for LGBTI populations and what might it encompass?

21. Why? • Existing frameworks do not specifically or comprehensively address LGBTI populations, who have unique needs • Suicide prevention, and especially LGBTI targeted suicide prevention, is undertaken by a disparate sector, lacking coordination • Many of the determinants of suicide and mental health lie outside of the health sector • There are limited resources - risk of duplicating efforts

22. What might it seek to achieve? • Build a shared vision to work towards • Define outcomes • Set priorities for action • Ensure best available evidence is used to guide action • Strategically target key sub-populations • Identify domains and settings for action • Foster collaboration and strengthen partnerships • Improve monitoring and evaluation • Improve coordination Ultimately: contribute to improved mental health and wellbeing and the prevention of suicide via a sustainable and comprehensive approach

23. How might it build on existing frameworks The Melbourne Charter states that population-based approaches for promoting mental health and wellbeing and preventing mental illness work by: • utilisingprinciples of public participation, engagement and empowerment • redressing inequities and discriminatory practices that exclude the most socially disadvantaged or people at risk • action in everyday contexts such as in schools, workplaces, sports clubs, community-based activities, government services and the natural environment • providing access to quality care and recovery-focused services for those who are experiencing poor mental health or mental illness • combining advocacy, communication, policy and legislation, together with community participation and evidence-building strategies

24. How might it build on existing frameworks • joining up policies and practices across sectors including education, housing, mental health services, employment and industry, transport, arts, sports, urban planning and justice; and are • accompanied by person-centered responses to mental distress and loss of wellbeing which foster hope, offer choices, support people to lead their own recoveries

25. What might it look like? Key social determinants of MH & Themes for Action Population Groups & Health Promotion Action Areas \ Methods Settings for Action Intermediate Outcomes Long-term Benefits

26. Discussion