CE Corner

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"CE Corner" is a continuing education article offered by the APA Office of CE in Psychology.

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CE credits: 1

Learning objectives: After reading this article, CE candidates will be able to assess:

  1. Consider the different motivations for suicide among people of different cultures, races and ethnicities.
  2. Describe the cultural factors that may increase—or decrease—racial and ethnic minorities’ vulnerability to suicide.
  3. Discuss culturally relevant research-based directions and strategies for suicide prevention.

A Korean-American man dies by suicide. Was it because he lost his job and felt intense shame over the loss of his breadwinner role in a patriarchal culture?

A Latina teenager attempts suicide. Was she upset because her immigrant parents restricted her movements and intruded on her decisions and relationships?

American Indians have the country’s highest rate of suicide. Is it related to generations of human rights abuses and trauma?

Suicide Rates by Race and EthnicityIn the United States, the most common explanation offered for suicide is depression. But that isn’t necessarily the case for these individuals and others among the nation’s ever-growing numbers of ethnic minorities, says suicide researcher Joyce P. Chu, PhD, an associate professor at Palo Alto University in California. “It is often a completely different, culturally informed experience,” says Chu. “Understanding the cultural meaning behind things and other cultural factors is so important, but we’re not often trained to do that.”

Research by Chu and colleagues has shown that while licensed psychologists acknowledge the importance of addressing clients’ cultural backgrounds when assessing their risk of suicide, most have had a bare minimum of training in how to do so (Training and Education in Professional Psychology, Vol. 11, No. 2, 2017). As a result, they feel uncomfortable putting culturally competent suicide-risk assessment into practice.

Now that’s starting to change. Chu and Palo Alto colleagues Bruce Bongar, PhD, and Peter Goldblum, PhD, are developing new risk-assessment tools that take into account variations in how members of ethnic-minority groups view suicide. They are exploring unique risk and protective factors, knowledge of which can form the basis of new, more culturally attuned prevention and treatment efforts. And they are already starting to put such tools into practice, with promising results.

Differing motives

Overall, suicide rates in the United States are lower among ethnic-minority populations than among white European-Americans, says Mary O. Odafe, a clinical psychology graduate student at the University of Houston who has reviewed the past decade’s worth of research on suicide in adults along with associate professor Rheeda Walker, PhD, and several other colleagues (Current Psychiatry Reviews, Vol. 12, No. 2, 2016). But a closer look at the data reveals important variations by group, Odafe says (see “Unique Cultural Factors”).

While Asian- and Pacific Islander-Americans are only about half as likely to die by suicide as the national average, for example, American Indians and Alaska Natives have the highest rate among any ethnic group in the country.

Importantly, there are variations within ethnic groups as well, Odafe adds. “The experience of a black immigrant is different from the experience of African-Americans without immediate ancestry in Africa or black Caribbean nations,” she points out. “Recent immigrants across ethnic groups report lower prevalence of suicide ideation and attempts than their U.S.-born counterparts, but the risk for suicide gradually increases with longer duration spent in the U.S.” Plus, says Odafe, the terms “Asian-American” and “Latino” encompass a wide variety of subcultures.

Suicidal behavior varies not just within and between cultures, but by sex and age, too, says Silvia Sara Canetto, PhD, a psychology professor at Colorado State University in Fort Collins. “Attention to intersectionalities of culture, sex and age is crucial in suicidality research and prevention,” says Canetto.

Such cultural distinctions reflect differences in what motivates people to choose—or to reject—suicide, says Chu. In an analysis of qualitative data on 232 white, Asian- and Latino-Americans, Chu and colleagues found that members of ethnic minorities often die by suicide for different reasons than their white counterparts (Journal of Clinical Psychology, Vol. 73, No. 10, 2017). Latinos, for example, were more likely than whites to be motivated by external circumstances, such as job loss, abuse or discrimination, and less likely to be motivated by internal feelings of hopelessness or worthlessness.

All communities have cultural “scripts” for suicide, says Canetto. These scripts are implicit blueprints for when, where and how to engage in suicidal behavior and how to respond to such behavior, she says.

“It is often easier to see how suicide is scripted in cultures other than one’s own,” says Canetto, who reviewed the literature on women’s suicidality in Muslim-majority communities (Crisis: The Journal of Crisis Intervention and Suicide Prevention, Vol. 36, No. 6, 2015). For those in the United States, for instance, it’s easy to see as culturally scripted the method (such as burning) and narrative (protest against and escape from society’s oppression of women) associated with the suicides of Muslim women in Iraqi Kurdistan, she says.

It’s not so easy to see the scripts in your own culture, however. U.S. psychologists often assume that culture is something others—those outside the United States, for example—have, says Canetto. “The experience of European-descent populations is assumed to be culture-free,” says Canetto, who has challenged this assumption via several studies of the suicide scripts of majority-­European-descent communities.

Prompted by the fact that U.S. suicide rates are highest among older men of European descent, Canetto, with colleagues Erin Winterrowd, PhD, and Katrin Benoit, examined suicide-related beliefs and attitudes in a predominantly European-descent community. They asked participants what they thought were the most likely reasons for older adult suicide, what factors might protect older adults from suicide and how they evaluated older adult suicide depending on what they thought precipitated it. Respondents believed that illness and disability are the most important precipitants of older adult suicide (Aging & Mental Health, Vol. 21, No. 2, 2017). They also viewed suicide prompted by health and disability problems as more acceptable and rational than suicide prompted by other presumed precipitants.

Such attitudes may enable suicide among European-descent older adults, says Canetto. “­European-American older adults with health and disability problems may see themselves—or may be seen by others—as experiencing a situation for which suicide is a reasonable, and perhaps even a moral, response,” she says.

Older European-American men are especially vulnerable to this script, adds Canetto. In a qualitative study, she reports evidence of dominant narratives of suicide as masculine behavior (Men and Masculinities, Vol. 20, No. 1, 2017). Suicide is seen “as a way for powerful, older white men to escape the so-called indignities of aging and be in control of their deaths as they had been in control of their lives,” says Canetto.

Internal and external pressures

Other cultural factors may also increase—or decrease—ethnic minorities’ vulnerability to suicide (see “Unique Cultural Factors”).

Some risk factors come from within the cultures themselves. For Asian-Americans, the loss of “face”—one’s prestige and position in society—can prompt suicidal thoughts, says Frederick T.L. Leong, PhD, a psychology professor at Michigan State University. “It’s related to shame that one has brought on one’s family name,” explains Leong, who has examined this phenomenon in Chinese-, Japanese- and other East Asian-Americans (Psychological Assessment, online first publication, 2017).

That sense of shame can also keep Asian-Americans from seeking help when they are in distress, adds Leong. In a review of the literature on suicide among Asian-Americans, Leong and colleagues found that more than one-third of this population rejects the idea of professional help even when they are having suicidal thoughts (“Advancing the Science of Suicidal Behavior: Understanding and Intervention,” 2014).

Such findings highlight the importance of nonprofessional “gatekeepers,” such as school personnel, co-workers and family members, who can identify individuals at risk of suicide and direct them to the help they need, says Y. Joel Wong, PhD, an associate professor of counseling psychology at Indiana University.

Wong’s own research underscores the role school pressures can play in suicide risk for Asian-Americans. He and his colleagues analyzed data from more than 100,000 individuals in the Centers for Disease Control and Prevention’s National Violent Death Reporting System, which includes information on suicide-precipitating factors drawn from police investigations and medical examiner reports. They found that school problems are more than twice as likely to be a contributing factor to suicide for Asian- and Pacific Islander- Americans than for their white counterparts (Death Studies, Vol. 41, No. 5, 2017). “There’s a lot of discussion in the literature about Asian-Americans—and their parents—putting a lot of pressure on students to do well in school,” says Wong. “Teachers and administrators should conduct suicide assessments more regularly and not be blinded by the model-minority stereotype of Asian-Americans.”

In addition, the study found that financial problems were more likely to contribute to suicide in older Asian-­Americans than in their white peers. That finding suggests that co-workers and relatives could help identify and intervene with people having trouble providing for their families.

However, a desire not to let loved ones down could serve as a protective factor for some Asian-Americans, adds Wong. In a small study of Asian-­American college students who had considered suicide within the past year, Kimberly K. Tran, PhD, an associate professor of psychology at Fayetteville State University in North Carolina, Wong and colleagues asked students to respond to open-ended questions about what helped them through their crises. One common theme was a desire not to hurt or burden others, the researchers found (Death Studies, Vol. 39, No. 8, 2015).

“That sense of knowing you may be letting your family down by killing yourself may be protective,” says Wong.

For families that have recently immigrated to the United States, the clash between old and new values can prompt thoughts of suicide in those caught between two cultures.

Latina adolescents are especially at risk, says psychologist Luis H. Zayas, PhD, a professor of psychiatry at the Dell Medical School and dean of the Steve Hicks School of Social Work at the University of Texas at Austin. While young Latina women rarely die from suicide, he points out, they are nearly twice as likely to attempt it as their white counterparts (“Advancing the Science of Suicidal Behavior: Understanding and Intervention,” 2014).

In a small qualitative study based on interviews with Latina teens who had attempted suicide and their parents, Zayas and University of Texas anthropologist Lauren E. Gulbas, PhD, found that these girls feel stuck between two cultures (Qualitative Health Research, Vol. 25, No. 5, 2015). As a result, the authors suggest, the teens can feel distressingly isolated and may turn to self-destruction.

There often seemed to be a similar pattern of family conflict, says Zayas. Girls would be moving toward more autonomy, wanting a boyfriend or wanting to wear different clothes, while their parents were clinging to older traditions, he says.

In a study based on interviews with Latina teens who had undergone treatment after attempting suicide, Zayas and co-authors emphasize the importance of engaging parents in their daughters’ therapy (Archives of Suicide Research, Vol. 22, No. 1, 2018). Acting as an advocate, the therapist can explain the girls’ needs to their parents, Zayas explains. Doing so helps parents understand how different their daughter’s adolescence is from their own, which typically happened in another country.

Larger societal factors like discrimination can also prompt thoughts of suicide, according to research by Walker of the University of Houston. In a longitudinal study of 722 African-American young people, for example, Walker and colleagues found that those who experienced racial discrimination thought more about death than those who did not experience discrimination (Suicide and Life-Threatening Behavior, Vol. 47. No. 1, 2017).

“We have to expand our traditional models of suicide-risk assessment to include experiences of discrimination,” says Walker. It’s also important to assess an individual’s attachment to their cultural group of origin. “Given the importance of feeling connected to others, if a­ vulnerable person who identifies as a racial or ethnic minority also feels disconnected or detached, that could be an added risk factor that would need to be explored,” she says.

Even discrimination against one’s forebears can have an impact, according to research on historical trauma. In a study of First Nations adults living on reservations in Canada, for example, neuroscientist Robyn Jane McQuaid, PhD, of the University of Ottawa and colleagues examined the impact of a government policy in which indigenous children were removed from their homes and forced to attend boarding schools where they were punished for speaking their own languages or maintaining their cultural traditions.

McQuaid and her colleagues found that the risks of suicidal ideation and attempts were higher for those in families in which the previous generation had experienced the Indian Residential School system than for individuals without such familial history (The Canadian Journal of Psychiatry, Vol. 62, No. 6, 2017). They also found that having two generations with such experience was associated with even higher odds of reporting suicide attempts.

Culturally responsive, intersectional prevention

Now, psychologists are putting such research into action by incorporating culture into their prevention efforts and developing recommendations and tools for other clinicians. While the field is still emerging, they suggest the following directions and strategies:

Broaden the range of risk­assessment questions. “If you look at the way we do safety planning and management of suicide risk, it has been very ‘one note,’” says Chu. In typical assessments, psychologists may simply ask clients if they’re depressed, if they’re suicidal and if they have access to firearms.

Those questions alone may not be enough to assess risk among ethnic minorities. Ethnic minorities might be more likely to express suicidal ideation in terms of fatigue, reckless behavior or anger rather than depression, says Chu. And while white men tend to use guns for suicide, older Asian-American women typically hang themselves, for example.

Ethnic-minority clients may skip suicide-related assessment questions altogether, adds Laura M. Anderson, PhD, a licensed psychologist and assistant professor at the University of Buffalo School of Nursing. In a study drawing on National Youth Risk Behavior Survey data from more than 15,000 adolescents, Anderson and colleagues found that ethnic-minority (www.cdc.gov/features/yrbs/index.html) young people were simultaneously at higher risk for serious suicidal behavior and more likely to skip questions related to actual suicide attempts (Death Studies, Vol. 39, No. 10, 2015).

“When you read about African-Americans being at lower risk of suicide, this may not be valid when 20 percent aren’t answering a key question about the behavior,” says Anderson. “And it’s difficult to formulate interventions and make judgments about suicidality among a particular group when a fifth of them aren’t responding about the most lethal behavioral risk—­previous attempts.”

Use the latest instruments. Along with her Palo Alto colleagues Bongar and Goldblum, Chu has developed a new 14-item version of their Cultural Assessment of Risk for Suicide (Archives of Suicide Research, online first publication, 2017). The screening tool draws on two decades of empirical research to identify four broad suicide risk categories: the culture’s language of distress, the stress of being a minority, family conflict and cultural beliefs that make suicide stressors and suicide acceptable or not. (For a copy of the manual, email Chu at jchu@paloaltou.edu.)

Chu and her co-authors demonstrated how this more culturally attuned approach works in a case study of a Japanese-American transgender veteran (Practice Innovations, Vol. 2, No. 2, 2017). By looking beyond the traditional risk factor of depression, the culturally oriented screening tool revealed the woman’s hidden suicidal ideation and the manifestation of suicidal thoughts as anger, resulting in her therapist developing a new safety plan emphasizing anger-management strategies.

Seek out culturally attuned, intersectionally focused intervention programs. More psychologists are developing prevention and treatment programs with diverse populations in mind. W. LaVome Robinson, PhD, a clinical psychology professor at DePaul University in Chicago, for example, has culturally adapted a stress-reduction program that has demonstrated promise for reducing suicide among African-American youth (Practice Innovations, Vol. 1, No. 2, 2016). The adapted program replaces European-American names and language with those familiar to African-American young people, emphasizes the African-American value of collaboration in building stress-reduction strategies and focuses on racism, community violence, poverty and other issues characteristic of participants’ experiences.

A unique aspect of the intervention is the contribution of the youth themselves in the adaptation process, says Robinson. “We believe this process of participatory research explains, at least in part, the acceptance and very positive ratings of the intervention by the youth participants in addition to the promising findings regarding the reduction of suicide risk at post-test for youth showing high-risk status at pre-test,” she says.

Another study by Robinson and colleagues found that African-American girls are almost twice as likely to report frequent thoughts of death or suicide and also consider suicide at lower levels of depression than European-American peers (Journal of Adolescence, Vol. 53, 2016).

Suicidal behavior among African-American youth is growing at an alarming rate, adds Robinson, pointing to research that shows a near doubling of the suicide rate among African-American children ages 5 to 11 between 1993 and 2012 (JAMA Pediatrics, Vol. 169, No. 7, 2015). “Without effective prevention strategies, that trend could continue and even worsen,” she says.

Another successful program is the American Indian Life Skills Development Curriculum developed by Teresa LaFromboise, PhD, chair of Native American studies and a professor of developmental and psychological sciences at Stanford University’s Graduate School of Education. Created in collaboration with members of the Zuni Pueblo and Cherokee Nation of Oklahoma, the program teaches middle and high school students problem-solving, depression- and anger-management techniques, goal-setting and other skills. In addition to addressing risk factors such as historical trauma, acculturation stress, community violence and substance abuse, the program incorporates protective factors such as traditional values and spiritual practices. Several evaluations have found that the program reduces hopelessness, suicidal ideation, suicide attempts and completed suicides (“Evidence-Based Psychological Practice With Ethnic Minorities,” 2016).

Get training on intersectional dimensions of suicide, including culture, age and gender. Graduate education in psychology may include training in suicide-risk assessment and in cultural competence, but few programs combine the two topics, says Chu. Now, a “seedling of a movement” to do so is starting to emerge, she says.

Chu, along with Palo Alto colleagues Bongar, Goldblum and Christopher M. Weaver, PhD, for example, are developing a continuing-education program on suicide that incorporates cultural factors. The move is in response to a new California law that requires six hours of training in suicide prevention and intervention for psychologists who are seeking or renewing their licenses in 2020 and beyond.

“We want to provide Suicide 101 training but infuse it with material on cultural competence,” says Chu. “We’re trying to make that a reality.”