Expert Reviewers
Connor Lafortune, MIR in progress, Enaadmaget wiibimadziiyins (Life Promotion)
Suzanne McLeod, PhD, Assistant Professor, University of Manitoba
Introduction
Many Indigenous communities in Canada have high rates of suicide. Within these communities, Indigenous young people in particular are affected. The purpose of this toolkit is to guide people working with Indigenous youth to co-create a safety plan with an Indigenous young person who is thinking about suicide.
Thoughts of suicide can burden people and hold them hostage. Experiencing these thoughts is to experience “absolute darkness, hopelessness, pain,” and nothing matters but stopping that pain. As friends and caregivers, we may feel at a loss to support people with these thoughts; we may feel that taking someone to the emergency room is our only option; that crisis medical support is necessary.
If the person thinking about suicide is in immediate crisis, the emergency room is an appropriate level of care. Otherwise, co-developing a safety plan is the best way forward (Petit et al., 2018).
If you or someone you know is actively thinking about suicide, call or text 988. Suicide Crisis Helpline, the national crisis line, will respond to your call. 988 also connects to the Hope for Wellness Helpline, which is for Indigenous people in Canada. Hope for Wellness can also be reached at 1-855-242-3310, or online via chat at www.hopeforwellness.ca.
Both crisis lines are toll-free and available 24/7. In an emergency, call 911.
What to expect
This toolkit will provide a brief introduction to people in the general population about trauma and suicide in Indigenous people. It will also describe what a safety plan is and how to create one together with an Indigenous young person who may be considering suicide. It will illustrate how safety plans work and why they are one of the best tools to help mitigate future suicidal behaviours.
We also recommend reading the following resources, created by Indigenous organizations:
- Life Promotion toolkit by Indigenous youth
- First Nations Mental Wellness Continuum Framework Summary Report
- Métis Nation of Alberta Life Promotion Guide: Weaving Together Métis Knowledge and Practice
- National Inuit Suicide Prevention Strategy
Suicide and colonialism
Historically, suicide was a rare occurrence among First Nations people and Inuit (Kirmayer, 2007). It was only after contact with Europeans and the subsequent effects of colonialism, including intergenerational trauma, that suicide became prevalent.
Acts of violent oppression and discrimination by governments and other colonial institutions towards Indigenous people are both historical and ongoing. These acts continue to affect Indigenous communities, Nations, and individuals. Practices such as the forced settlement of entire peoples, relocation from traditional territories, removal of children from their homes into residential schools, and removal of children from their homes into non-Indigenous homes or institutions are continuing to affect people today (Linklater, 2014; Haskell & Randall, 2009).
These colonial practices led to the suppression of culture, traditional values, and family stability. Despite resistance and efforts to maintain cultural integrity, in many cases, traditional knowledge of parents, Elders, and Knowledge Keepers were disrupted, the foundations of resiliency unable to be passed along to children who were taken away. In addition, forced relocation and the reserve system severed traditional ties to the land and systems that had enabled Indigenous people to thrive for generations (Elias, 2012).
This has left generations of young people seeking to reconnect to their cultural roots, roots which create a strong connection to life. Within the broader Canadian society, young Indigenous people face ongoing racism, intolerance, and ignorance, all factors that contribute to a decreased sense of belonging, identity, and hope.
This has led some youth to consider suicide. A smaller number of these youth act on their suicidal thoughts despite efforts to save their lives and find alternatives to despair.
Learn more in our toolkit, Indigenous people, trauma, and suicide prevention.
Healing through cultural practices
(An excerpt from Wise Practices)
Wise Practices are what people are doing to promote life and reduce suicide among young people based on what is already working and/or showing promise in Indigenous communities across the country. Learn more: Wise Practices for Youth.
“‘Culture as healing’ is an Indigenous approach to life promotion that addresses the whole unique person, in the context of (their) family, community, land, history, and worldview.
Culture as healing aims to deepen connections with self, others, and land as a path towards wholeness and wellbeing; these are in keeping with Indigenous values of holism and interdependency. It recognizes healing as simultaneously a deeply intimate and personal experience, and a relational and collective process. When we support the healing of others, we are also doing the work of healing the community now and into the future.”
According to Wise Practices, healing through culture includes:
- Building and nurturing relationships with family, community, and land
- Revitalizing language and teachings
- Avoiding one-size-fits-all approaches, which would look different depending on who you are, where you are, and with whom you’re working
(Wise Practices, 2021)
Providing culturally appropriate services
Cultural safety and competence are key components in providing services to Indigenous people. Without them, there are greater chances of inaccurate or inappropriate assessments, inadequate treatment, and risk of re-traumatization (Twigg & Hengen, 2009). Therefore, there are some important requirements for those who work with Indigenous people.
- They need to be trained to deliver a trauma-informed, culturally competent, and strengths-based approach in an Indigenous context.
- They must be aware of the interplay of historical events and social conditions that impact both the community and the individual.
(Haskell & Randell, 2009; Linklater, 2014)
Moving from crisis to wellness
In many Indigenous cultures, Life Promotion consists of four key elements that are integral to mental wellness: hope, belonging, meaning, and purpose. These four aspects work together and, when aligned, contribute to the mental wellness of individuals and communities (Thunderbird Partnership Foundation & Health Canada, 2015).
- Hope drives optimism about tomorrow; of the future of individuals and of families inseparably
- Belonging is connectedness – relationships with family, community, land, and self
- Meaning is the understanding of how our lives and those of our families and communities are a part of the history of who were are as a people, the recognition of our gifts and dreams, and what it means to be alive
- Purpose creates an understanding that every person is sacred, that the physical body is “home” for the spirit, heart, and mind, all of which are interconnected
(Adapted from “First Nations Mental Wellness Continuum,” Thunderbird Partnership Foundation and Health Canada, 2015)
These same elements can function at the level of individual wellness. This toolkit uses hope, belonging, meaning, and purpose as the basis of a safety plan for Indigenous youth.
Ground your safety planning conversation in the building of relationship between yourself and the young person, and their relationship with hope, belonging, meaning and purpose.
What is a safety plan?
A safety plan is a document that supports and guides someone when they are experiencing thoughts of suicide, to help them avoid a state of intense suicidal crisis. Anyone in a trusting relationship with the person considering suicide can help draft the plan; they do not need to be a professional.
When developing the plan, the person experiencing thoughts of suicide identifies:
- their personal warning signs
- coping strategies that have worked for them in the past, and/or strategies they think may work in the future
- people who are sources of support in their lives (friends, family, Elders, Knowledge Keepers, professionals, crisis supports, community (including Nation and Clan families))
- how means of suicide can be removed from their environment (method used to die by suicide)
- their personal reasons for living, or what has helped them stay alive
A suicidal crisis refers to “a suicide attempt or an incident in which an emotionally distraught person seriously considers or plans to imminently attempt to take (their) own life” (Suicide Prevention Resource Center, n.d.).
When is a safety plan written?
A safety plan is written when a person is not experiencing intense suicidal thoughts. It may be written after a suicidal crisis, but not during, as an individual can become overwhelmed with suicidal thoughts and confusion and may not be able to think clearly at this time. A safety plan is written when a person has hope for life, or even can consider the possibility of life. They need to be able to identify their reasons for living, and positive actions they can take to prevent their thoughts from becoming intense and overwhelming.
A safety plan can be developed over time or in one sitting by the person with thoughts of suicide together with you, their caregiver, or friend. The plan can change as the circumstances for the individual change and be revised accordingly.
Why does it work?
A safety plan is a strengths-based approach: a person’s unique gifts are identified and emphasized so they can draw on them when their suicidal thoughts become intense. The goal is to draw upon their strengths during subsequent recovery and healing processes (Xie, 2013). External personal supports are another integral safety plan component, such as a person’s family, friends, community, and culture. Drawing on strengths is the entry-level activity; reaching out for help may also become necessary (Xie, 2013; Bergmans, personal communication, 2019).
The safety plan is organized in stages. It starts with strategies the individual can implement by themselves at home and ends with 24/7 emergency contact numbers that can be used when there is imminent danger or crisis.
The person with thoughts of suicide can verify, along with their caregiver or friend, whether coping skills are feasible, as well as whether the chosen contact people are appropriate (Bergmans, personal communication, 2019).
When implemented, safety plans become self-strengthening. For people who experience recurring suicidal thoughts or crises, one strength becomes knowing they have weathered the storm before and have navigated their way out.
What is going on for the young person?
Before speaking with the young person you’re worried about, reflect on what you already know about them. Be aware of what is bringing the young person closer to life (their protective factors) and what is contributing to their thoughts of suicide (risk factors). Knowing this will inform your own understanding of the young person’s risk of suicide and what level of support they will need. You can also use this information to inform the young person’s safety plan. For example, if you know that the young person is part of a drumming circle, you may gently ask if they might want to add that activity as a coping strategy.
Mental – Meaning
These questions relate to the young person’s sense of self.
- What are their beliefs about themselves and the world?
- What is their understanding of death and suicide?
- Do they exhibit any signs of depression, mental unwellness, or substance misuse issues?
- Do they have any cultural understandings that inform their views on life and death?
Risk-factor examples: Low self-esteem, being exposed to racism and/or discrimination, disconnection with culture as identity, lack of traditional naming, (for children) lacking full comprehension of the concept of death, risk-taking behaviours, and mental health issues.
Protective factor examples: Positive self-worth, trust, traditional naming, involvement in cultural and other positive activities, connection with land, and relationship with an Elder.
Emotional – Belonging
These questions relate to the young person’s relationships and attachments.
- Do they have close relationships with adults or peers? Friends?
- Have they been bullied?
- Do they have a sense of community? (culture, clan, nationhood, kinship)
- What opportunities do they have to be creative or play?
Risk factor examples: Disrupted or unstable relationships, bullying, intergenerational trauma, physical or sexual abuse, change of caregivers.
Protective factor examples: Feeling nurtured, family balance, family connection, positive school experiences, supportive relationship with at least one adult, opportunities to play, create, explore, and learn.
Spiritual – Hope
These questions relate to the young person’s gifts and supports.
- Are they connected to community, culture, and traditions?
- What are their gifts?
- What are their experiences of and thoughts about school?
- Do they have plans or goals for the future?
Risk factor examples: Difficulty communicating feelings, lack problem-solving skills, hopelessness, learning challenges, access to preferred means of suicide, absence of community, clan, cultural or spiritual supports.
Protective factor examples: Ability to share feelings, problem-solving skills, hopefulness, plans for the future, community, clan, kinship, cultural, and spiritual supports.
Physical – Purpose
These questions relate to the young person’s environment.
- What is their home environment like? Who do they live with?
- Are they currently living with their family? Are they currently living in-care (if so, how long)?
- Where do they live (on/off reserve, urban/rural/remote)? Are they connected to their ancestral home, land, reserve?
- Have they been exposed to violence, abuse, or the suicide of a family member or friend? What are their reasons for living? What do they love to do? Who do they love?
Risk factor examples: Exposure to violence, unstable home, no identified reasons for living, isolation, limited access to resources.
Protective factor examples: Feeling safe (having a safe, stable home), basic health needs being met (e.g. warmth, having enough food and water, caring for one’s health and body), access to land, access to ceremony, access to resources for mental health care, reasons for living.
Building the safety plan
Once you’ve reflected on what you know about the young person, have a conversation with them. The above guiding questions ‘What’s going on for this young person?’ are not intended to be asked interview-style – rather, allow them to fuel the conversation. Together, complete the asset map diagram, to illustrate to the young person all the strengths (protective factors) they have in their life. Gently, discuss the risk factors, too. Having a supportive conversation about what has happened to the young person (as opposed to ‘what’s wrong with the young person’) is an opportunity for them to expand their knowledge of how the greater context of their world is affecting them now.
Developing trust
When developing a safety plan with a young Indigenous person it is crucial that a relationship of trust and respect is established. Be aware that due to past and ongoing discrimination and racism against Indigenous people, the young person may be reluctant to speak with or trust non-Indigenous people. This conversation needs to be culturally appropriate for the young person. You must be willing to learn about the young person’s culture (or lack of connection thereof) and keep in mind a holistic, whole-person framework, considering the physical, mental, emotional, and spiritual.
Suicide safety plan
Once the asset map is complete, together with the young person, begin building the safety plan itself. The following is an adaptation of Stanley and Brown’s Safety Plan Intervention (2012). As you discuss each section, capture the young person’s responses on the safety plan template in this toolkit.
Step 1: List important reasons to live, or how and why that person is still alive.
Guiding questions for the young person thinking about suicide
When do you feel most at ease during the day? Who do you love? What do you enjoy doing? What did you used to enjoy doing? What is important to you, or used to be important to you? What has kept you alive up until now?
What gives you hope? Where do you find a sense of belonging? What brings you meaning? What drives your purpose in life?
Note: These reasons can become apparent through conversation and through the process of a suicide intervention. You may need to identify these for the young person based on what they’ve told you or what you already know.
Examples
My dog is important enough to me that I want to stay alive to take care of him.
My little brother will be lost if I’m not around. I have to stay alive for him.
My grandfather is important to me. His stories fill me with hope and pride.
When to implement?
At any time before or during a suicidal crisis.
How to implement?
The young person can refer to these reasons for living at any time, as often as they want, to remind them of the positive aspects of their lives.
Friends and caregivers can use these reasons in organic conversation, to help gently remind that young person of their reasons for living (Stanley & Brown, 2012).
Step 2: List warning signs that indicate a suicidal crisis may be developing
Guiding questions for the young person thinking about suicide
What (situations, thoughts, feelings, body sensations, or behaviours) do you experience that lead you to feeling numb or hopeless? Think about some of the more subtle cues.
Examples
Situation: Parents are fighting again
Thoughts: “I am so fed up with this and I can’t handle it anymore”
Body sensations: Increased heart rate, trembling, sense of impending danger, feeling tense/nervous/restless, trouble sleeping
Behaviours: Watch violent movies, irregular eating schedule
When to implement?
At any time before a suicidal crisis.
How to implement?
Being aware of one’s own warning signs can alert the young person to the fact that they may be at high risk of thinking about suicide when these situations/thoughts/body sensations arise. They can put the plan in action and move onto the next step: coping strategies.
Being aware of personal warning signs can help friends and caregivers identify when that young person may need more support even before they’ve asked for it.
Step 3: List coping strategies, people, and places that can be used to divert thoughts from suicide.
Guiding questions for the young person thinking about suicide
Hope – Spiritual
What do you do to connect to spirit or culture?
What activities give you hope?
Where can you go to feel grounded, where your mind can be led away from thoughts of suicide?
What are you good at?
Belonging – Emotional
Who can you talk to or where can you go to feel a sense of belonging or community?
Who helps take your mind away from thoughts of suicide?
What do you enjoy doing?
Meaning – Mental
What activities give you a sense of meaning?
What activities make you feel connected to your community, culture, and traditions?
Purpose – Physical
What physical activities can you do to help cope with thoughts of suicide?
What activities give you a sense of purpose?
Examples
Hope – Spiritual: Walking in nature, listening to music
Belonging – Emotional: Participating in ceremony, hanging out with friends
Meaning – Mental: Talking to an Elder, drawing
Purpose – Physical: Taking care of my dog, hanging out with family or friends
When to implement?
At any time before a suicidal crisis, or when suicidal thoughts emerge but are not intense.
How to implement?
The young person can go to these places or contact these people to help distance themselves from their thoughts of suicide, encouraging them to feel better. These skills can be used throughout their lives, not just in moments of crisis, to promote life.
Ask them if they have a way (transportation) to get to places that could help them.
Step 4: List the steps to be taken to reduce access to means of suicide from the environment.
Guiding questions for the young person thinking about suicide
How have you thought about dying by suicide before, and how can you make that method more difficult to access?
Examples
Pills: Give to pharmacist or parent for disposal
Guns (or rope): Remove from home (e.g., give to a family member)
Step 5: List all the people, community, mental health providers, and crisis lines that can be contacted in a crisis and their contact information
Guiding question for the young person thinking about suicide
Who among your friends, family, community, service providers, Elders, or Knowledge Keepers can you can talk to when you need help (when your thoughts become overwhelming or you’re thinking about suicide)?
Young Indigenous people may have faced racism and discrimination when accessing mainstream supports. Ensure the resources listed here are safe spaces for them that offer culturally-competent care.
Examples
Mom/aunties/friends: work phone, cell phone
Engage Elders and/or Knowledge Keepers or others from the community
Counsellor: work phone, cell phone, hours available
Closest health centre or hospital: Regions Hospital, 640 Jackson Street
Closest community centre or recreation centre
Crisis Line: 988 (call or text), Suicide Crisis Helpline
1-855-242-3310, Hope for Wellness or chat at hopeforwellness.ca
When to implement?
At any time before a suicidal crisis, or when suicidal thoughts emerge and are becoming more intense.
How to implement?
The young person can reach out and talk to these people at any time to guide their current thoughts or thinking away from suicide, or to let them know when their thoughts are becoming intense, signaling that they need support.
Friends and caregivers can respond to the person by supporting them through this difficult time: listening to them, going to visit them, making sure to check in often, asking what specifically they can do to help.
How to co-develop a safety plan
Do not tell the young person what to do or talk down to them – it is crucial that they are involved in the process and participate as much as possible. The co-development of a safety plan involves a collaborative, in-depth conversation. Try and find that balance with the young person where they can feel ownership and investment in their situation, but not feel overly burdened. Go over each step together, thoroughly and thoughtfully (Berk & Clarke, 2019). There may be times where, through organic or structured conversation, you will identify potential safety plan items for the young person– bring these into the plan! For example, if they mention that they need to get home to spend time with their dog, that is a potential reason to live. You can suggest adding the positive things you hear coming from them at any point.
“You talked about how excited your dog is to see you when you get home earlier. Can you tell me a bit more about him?” Then, “It sounds like he’s really important to you. Do you think we could add him onto your safety plan as a reason for living?”
How to implement a safety plan
- Discuss with the young person how the plan will be used
- What is the young person’s role? What is your role as the helper?
- Who else is involved? How will you communicate with them?
- How do they see the safety plan affecting their lives/do they believe in the safety plan’s effectiveness?
This implementation cannot rest completely on the young person – they will need continued support from you or another trusted adult in their life.
Once complete, you and the young person should keep copies of the safety plan in an accessible place. The safety plan needs to be handy so that they can always find it when they are experiencing intense thoughts of suicide. Some people choose to always keep their plan with them, e.g., on their phone or in their wallet.
Each step in the safety plan plays a role in supporting the person with thoughts of suicide, as well as yourself, and other friends and caregivers. Refer to the “Suicide safety plan” for how and when to implement each step.
Keep in mind that the safety plan is not written in stone: it can be revised as often as is needed. The plan can be reviewed at any time, especially if the person experiencing thoughts of suicide has found any portion of it ineffective in helping them cope with their thoughts. For example, if one contact person was found to be difficult to get in touch with on several occasions, or if a coping strategy is no longer effective or accessible.
Is a safety plan the same as a no-suicide contract?
A no-suicide contract is different from a safety plan in that it is “an agreement, usually written, between a mental health service user (in this case, a young person) and clinician, whereby the service user pledges not to harm (themselves)” (McMyler & Prymachuk, 2008, p.512). It was introduced in 1973 by Robert Drye, Robert Goulding, and Mary Goulding. Mental health service users are expected to seek help when they feel they can no longer honour their commitment to the contract (Rudd, Mandrusiak & Joiner, 2006).
The no-suicide contract has been widely used by clinicians working with patients considering suicide (Rudd, Mandrusiak & Joiner, 2006). However, there is a lack of evidence to support contracts as clinically effective tools. Both service users and clinicians have voiced strong opposition to their use. Moreover, important ethical and conceptual issues in the use of such contracts have been identified, including the potential for coercion from the clinician for their own protection, and the ethical implications of restricting a service user’s choices when they may be already struggling for control. A strength-based approach like a safety plan, on the contrary, not only encourages the service user’s input and agency, it is a true partnership with the physician or caregiver, bound by hope (McMyler & Prymachuk, 2008; Rudd, Mandrusiak & Joiner, 2006).
References
Berk, M. & Clarke, S. (2019).Safety planning and risk management. In M. Berk (Ed.), Evidence-based treatment approaches for suicidal adolescents: Translating science into practice (63-84).Washington, D.C.: American Psychiatric Association Publishing.
Drye, R., Gouling, R. & Goulding, M. (1973). No-suicide decisions: Patient monitoring of suicidal risk.American Journal of Psychiatry, 130(2), 171-174. https://doi.org/10.1176/ajp.130.2.171
Elias, B., et al. (2012). Trauma and suicide behaviour histories among a Canadian indigenous population: An empirical exploration of the potential role of Canada’s residential school system. Social Science & Medicine, 74(10), 1560-1569. https://doi.org/10.1016/j.socscimed.2012.01.026
Haskell, L. & Randall, M. (2009). Disrupted attachments: A social context complex trauma framework and the lives of Aboriginal peoples in Canada.Journal of Aboriginal Health,5(3), 48-99. https://ssrn.com/abstract=1569034
Kirmayer, L., et al. (2007). Suicide among Aboriginal people in Canada. Ottawa, ON.: Aboriginal Healing Foundation.
Linklater, R. (2014).Decolonising trauma work: Indigenous practitioners share stories and strategies. Toronto, ON.: Fernwood Books Ltd.
McMyler, C. & Prymachuk, S. (2008). Do “no-suicide’ contacts work?Journal of Psychiatric and Mental Health Nursing, 15(6),512-522. https://doi.org/10.1111/j.1365-2850.2008.01286.x
Petit, J., Buitron, V. & Green, K. (2018). Assessment and management of suicide risk in children and adolescents. Cognitive Behavioral Practice, 25(4),460-472. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6884133/
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Stanley, B. & Brown, G. (2011).Safety plan. http://suicidesafetyplan.com/uploads/SAFETY_PLAN_form_8.21.12.pdf
Stanley, B. & Brown, G. (2012). Safety planning intervention: A brief intervention to mitigate suicide risk.Cognitive and Behavioral Practice, 19(2), 256-264. https://psycnet.apa.org/doi/10.1016/j.cbpra.2011.01.001
Suicide Prevention Resource Center. (n.d.)Topics and terms. https://www.sprc.org/about-suicide/topics-terms
Thunderbird Partnership Foundation & Health Canada. (2015). First Nations Mental Wellness Continuum Framework. https://thunderbirdpf.org/first-nations-mental-wellness-continuum-framework/
Twigg, R. & Hengen, T. (2009). Going back to the roots: Using the medicine wheel in the healing process.First Peoples Child & Family Review,4(1), 10-19. https://doi.org/10.7202/1069345ar
Xie, H. (2013). Strengths-based approach for mental health recovery.Iranian Journal of Psychiatry and Behavioral Science, 7(2), 5-10. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3939995
Wise Practices. (2021). Action guide for communities: Bringing Wise Practices to life. https://wisepractices.ca/action-guide-for-communities
