Cultural Diversity and Suicide

Ethnic, Religious, Gender, and Sexual Orientation Perspectives

Mark M Leach

• Publisher: Routledge
• Year: 2014
• ISBN:
  9781317786580
• Edition: 1
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

This book adds a vital and overlooked dimension—diversity—to suicide assessments and interventions
The literature on the relationship between culture and suicide has historically been widely scattered and often difficult to find. Cultural Diversity and Suicide summarizes that widespread literature so that counselors can begin to include diversity issues as important variables that can help them become even more effective when conducting suicide assessments or interventions. For ease of reading, Cultural Diversity and Suicide is divided into chapters based on ethnicity. The book avoids broad generalizations whenever possible, thus each chapter specifically discusses critical within-group variables (issues relating to gender, age, religion, and sexuality) that should be considered when conducting suicide assessments and interventions. Each chapter includes at least one case study and incorporates clear headings that make it simple to find specific information. Cultural Diversity and Suicide is not a book of cookie-cutter approaches to suicide prevention, nor is it a primer for the novice. Rather, it has been carefully designed to help counselors and counselors-in-training gain a fuller understanding of the issues that may lead individuals from diverse backgrounds to consider suicide—and the cultural aspects of an individual's heritage that can influence that person's decision. Written for professionals who have a pre-existing understanding of how to work with suicidal clients, the book begins with a concise but essential overview of traditional suicide risk factors and a brief assessment model (an excellent "memory refresher"), and then moves quickly into specific diversity issues relevant to:

• European Americans
  
• African Americans
  
• Asian Americans
  
• Hispanic Americans
  
• Native Americans

Cultural Diversity and Suicide explores ethnicity and its relationship to suicide (for example, suicide rate and reason differences based on ethnic group or ethnic identity), plus meaningful within-group variables such as:

• lesbian/gay/bisexual issues and the increase in suicide rate based on sexual orientation and sexual identity
  
• religious differences—suicide rates among various religious groups, religious differences in views of suicide, views of the afterlife, burial practices, and views of lesbian/gay/bisexual people
  
• cultural buffers, such as extended family and religious practice
  
• suicide prevention interventions based on cultural differences (essentially, how traditional suicide prevention programs can be altered to include new variables)

This book is essential reading for everyone doing the vital work of conducting suicide assessments and interventions. Please consider making it part of your professional/teaching collection today.

Chapter 1

Introduction

Why not? I’m destined to go to Hell anyway.

Twenty-three-year-old European American Christian gay man when asked how suicide became an option for him

I remember most of my actively suicidal clients and I am sure that most counselors do. Working with suicidal clients is considered to be one of the most stressful components of the job of most counselors, given the emotional toll involved with the counselor, client, and family. Of the therapists involved in direct client care, 20 to 30 percent will experience a client’s suicide at some point during their career (Bongar, 2002; Greaney, 1995), whereas the number for psychiatrists increases to one-in-two (Chemtob, Hamada, Bauer, Kinney, & Torigoe, 1988). These clients are particularly taxing for most counselors-in-training, especially for early developmental level counselors and those who have not had significant experience with suicidal clients. In addition, graduate programs incorporating comprehensive and systematic suicide training are almost nonexistent (Westefeld et al., 2000). I teach graduate-level practical courses and conduct evaluations for a mental health center, and suicidal clients throw counselors-in-training into significant anxiety-filled emotional states. The level of responsibility for these clients and initial naïveté about what counseling entails often drives counselors to pursue other professional interests. The relationship between counselors-in-training and suicide becomes particularly difficult when considering that suicide, although rare nationally, is not rare for professional helpers (Bongar, 2002). In fact, approximately one in seven psychologists-in-training will experience a client who ultimately completes suicide (Brown, 1987).

Suicide is complex and multifaceted, with few answers as to how suicidal individuals become so, and why some people complete suicide whereas others with similar levels of depression, diagnostic “severity,” or alcohol intake do not. Suicide is a relatively rare event when considering actual numbers nationally, but when it does occur the impact can leave scars across family members and friends for years. For example, a few years ago an educated, forty-three-year-old European American male arrived at my office in a hospital, sat down, and immediately began to discuss how his brother-in-law drove to a lake a month prior and proceeded to use a gun to kill himself. My client felt responsible because “I should have seen it coming.” His relationship with his wife diminished due to his depression and consequent level of responsibility, and his work became no longer enjoyable. Through counseling we discussed choices and responsibility and his lingering dysphoria until he could begin to separate his brother-in-law from himself.

HOW DOES CULTURE AFFECT SUICIDE?

Predicting suicide has always been a bane to clinicians, as it is impossible to be completely accurate and prevent all clients from completing suicide. However, researchers and clinicians obtain a better understanding of the factors that contribute to a completed suicide by studying three approaches to the assessment of suicide. First, socio-demographic variables are assessed to determine risk factors, such as age and gender. Many of these are outlined in this chapter. Second, clinical signs are assessed; these include previous attempts, social support deficits, and recent negative events such as job loss or spousal death. Third, psychological tests have been widely used to predict suicide, but as yet the results have been insufficient (Firestone, 1997). Suicide, regardless of culture, is probably best predicted by a conglomeration of biological, psychological, cognitive, and sociocultural factors. We know a fair bit about the psychological and cognitive factors, have an increased understanding of biological factors, and have learned some information about sociocultural (often demographic) factors.

Unfortunately, what we know about culture as an important variable that influences suicide is modest. The empirical literature on cultural influences on suicide is sparse at best, but we can translate areas within the broad cultural diversity literature into the suicide assessment and treatment literature. Culture by itself does not cause suicide. Nothing by itself causes suicide. It is the influence of culture in addition to other psychological, social, and biological issues that helps clinicians gain a more robust understanding of suicide. Many present studies include ethnicity, gender, or religion as a cultural variable, but results gleaned from several of these studies present broad strokes at best. Knowing that African American men are more likely than African American women to use lethal methods to complete suicide is important cultural information, but it is general. What other African American cultural influences play a role in buffering or guiding the decision to kill oneself? What factors are embedded in African American culture, particularly for women, that contribute to making it unlikely they will complete suicide? Some studies have suggested no significant ethnic differences between, for example, African American suicide attempters and nonattempters and European American samples, but I am more interested in understanding and presenting the subjective and qualitative differences among the ethnic groups. The subjectivity of causes, buffers, and reasons for suicidal behavior are in need of further study and increased clinical judgment. Berman (1991) indicated that suicide risk is very subjective and we must understand the client’s experiences of stress, which stress factors are primarily overlooked by researchers and clinicians, and the personal meaning clients give to situations that may lead to suicide. Understanding individual and group meanings is difficult for both the clinician and the client. The clinician never fully understands what the client is thinking and feeling, and clients have different levels of what can be considered a “breaking point,” which, as Shneidman (1999) argues, is lethality.

It is through culture that we begin to understand personal meaning, because culture offers the lens through which suicide factors such as coping styles, buffers, emotional expression, family structures, and identity can be viewed. The majority of studies currently published and the majority of clinicians interviewed over the years have included culture superficially with phrases such as “I’ve had a number of Hispanic clients…” or “He’s a white male in his 20s…” Little is understood about the influence of within-group variables, such as acculturation, racial identity, extrinsic religiosity, gay identity development, and gender identity, on suicide. As the reader progresses through this book I am convinced that multiple research ideas will be conceived, and I have offered a few periodically in areas where virtually no research has been conducted. Clinicians will be able to see how the influence of culture may impact a present client, and direct sessions toward some of the culturally specific information found in this text. Researchers and clinicians who have examined some of these cultural factors in greater depth will be presented in this book.

Lester (1997a, 1997b) found that culture influences suicidal behavior and that we should focus on increasing our understanding of variables that are subject to change, such as social isolation, rather than those we cannot modify (e.g., age, sex). To extend his argument, we should focus on factors considered within the realm of cultural and social diversity, such as the status and respect associated with age within various cultural groups, the role of acculturative stress, racial identity instead of simply race, and gender roles instead of simply gender. Much of what we know about suicide is based on the dominant (European American) culture, which fails to highlight unique culture-specific experiences. What unique features of being European American add to the other typical risk factors that augment suicide in this country, especially since European Americans account for over 85 percent of completed suicides yearly? However, credit must also be given to the multitude of researchers and clinicians conducting studies on a variety of cultural variables. A growing number of cultural studies are being published, though the suicide and culture field is still in its infancy. The field appears to have matured sufficiently to the point of increasing its focus on examining a number of within-group variables, many of which will be presented in this book.

For example, what unique cultural factors contribute to Hispanic adolescent females engaging in nonfatal suicidal behaviors at a rate twice that of other ethnic adolescent groups? We know that many adolescents attempt suicide regardless of ethnicity and can easily say that failed interpersonal relationships, for example, contribute to these rates. However, we also know that, among other variables, the higher nonfatal rates among adolescent Latinas may be due to traditional gender role factors within Hispanic families (Kaplan, Turner, Romano, & Gonzalez-Ramos, 2000). Here, gender roles as a result of acculturation differences between parents and children become important within-group cultural variables in need of greater study. We also understand that middle-class adolescent Latinas are less likely to attempt suicide than those having backgrounds of lower socioeconomic status (SES), attesting indirectly to the role of economic viability as a cultural variable (often through parental education and subsequent child-rearing beliefs; Ng, 1996). Culture is a background variable that has the potential to influence and exacerbate suicide when conjoined with other well-established variables (e.g., depression, drug use, poor self-concept, mania, insufficient coping skills). For instance, what is the role of religion in the expression of depression and drug use among ethnic groups, and how do acculturation, generation in country, and language differences influence self-concept and coping, all of which impact suicide?

Clinicians generally accept the fact that religion, for example, may be an important variable to consider when assessing for suicide risk. The question is not whether religion is an influential variable, but of further refinement of our understanding of the segments of religion, its relationship to ethnic and cultural groups, and its relationship to suicide acceptability, which can help clinicians determine whether the person sitting in front of them is at significant suicide risk. As has been repeated many times, it is not whether someone is religious but how someone is religious (Spilka, Hood, Hunsberger, & Gorsuch, 2003). Similarly, knowing suicide rates among ethnic groups is important, but greater understanding of the role of acculturation within the Hispanic, Native American, and Asian communities and its relationship to suicide would be beneficial. Researchers have begun to examine the effects of acculturation on suicide ideation and nonfatal and fatal behaviors. It is hoped that they will continue to investigate the role of acculturation and identity on suicide so that clinicians can include acculturation into their decision-making assessment and treatment processes.

African Americans complete suicides at a rate lower than European Americans, but we know virtually nothing about the role of racial identity, or how people view themselves as racial beings, with regard to suicide risk. In fact, the only three studies assessing the influence of black racial identity on suicide found that increased black racial consciousness resulted in fewer completed suicides (Kaslow et al., 2004; Sanyika, 1995; Wells, 1995). Thus, the more developed the racial identity the less likely it is that one may complete suicide. We can only speculate on reasons why racial identity influences suicide because the research literature is very small. However, the consideration of racial identity during suicide risk evaluations leads to more robust assessments.

One of the earliest approaches to the study of suicide risk was to examine sociodemographic variables. Although clinicians should be considering these variables, many texts on suicide present only cursory glances at cultural issues embedded within them. For example, several texts have a section titled “Multicultural Issues in Suicide,” which includes suicide rates by ethnic group, perhaps broken down by gender and age. However, in order to determine cultural factors that contribute to the rates readers must undertake rather extensive literature searches. It is the within-group variability that is difficult to piece together. This within-group variability is the unique feature of this book. My intention in writing this book was to organize much of the dispersed literature into some categorical form so that the reader can easily access cultural information related to suicide. Hopefully, I have gathered much of the pertinent literature into one book that highlights the cultural factors embedded with the major ethnic groups in the United States. Clinicians can not only examine the suicide rates of each ethnic group, but can also begin to consider nuances embedded within each ethnic group that may assist in determining whether the client sitting in front of them is at high suicide risk.

A BRIEF HISTORY OF SUICIDE

Recorded history has documented a multitude of suicides, with some of the most famous examples stemming from the Bible, the arts, and other literature. Among the notable biblical references is Saul, who asked his swordbearer to kill him but then fell on his own sword to avert capture by the Philistines. Some scholars also argue that the story of Samson is a story of suicide, in that after years of torment by the Philistines he destroys the city and kills himself in the process. Later, Shakespeare writes that Lady Macbeth killed herself due to her insanity, and in Romeo and Juliet the main characters each take their own lives after believing the other has died.

Clemons (1990a, 1990b) wrote a wonderful synopsis of the history of suicide, which will be condensed here. In the fourth to fifth century, the Catholic Church deemed suicide to be sinful, because people who attempted or completed suicide were considered demon possessed. For the next few hundred years it was not unusual for people who had completed suicide to be buried in nonconsecrated ground. Today some religious groups still choose to bury such individuals in unsanctified ground or on the outer edges of the cemetery or outside the grounds completely. The suicide-as-sin idea still resonates among many religious faiths because of the belief that the suicidal person chooses death, a decision resting only with God. Therefore, the suicidal individual is blaspheming God, the greatest Old Testament sin, and will spend eternity in hell. The Catholic Church has historically believed that the sixth commandment of “Thou shall not kill” applies to killing oneself, and many other religious groups have maintained this belief.

In the sixth century, three Church councils devised distinctive punishments toward not only the suicidal individual but also toward the families of those who completed the act. Because suicide was considered sinful, suicides’ families were ostracized and persecuted for their family members’ sins. Family members could not inherit estates, often relegating the family to a low economic standing. Although some readers may think of this policy as antiquated, many of today’s insurance companies do not pay benefits to the family of a person who completes suicide—an idea inherited from deep historical cultural roots.

In the eighteenth century, Merian, a French physician, was the first to specifically adopt the notion that nonfatal and fatal suicides resulted from a mental disorder. By the late nineteenth century, through Durkheim’s famous works (1897/1951), suicide came to be known as a result of an individual not adapting well to his or her society. It is through these papers that we begin to see glimpses of the cultural aspects of suicide, as many people who have engaged in self-destructive behaviors felt marginalized from their family and the larger society. Given the diversity of ethnic groups in the United States, most culture researchers now deem the acculturation process to be a significant factor that impacts individual stress levels, with feelings of marginalization associated with higher stress and potentially higher suicide rates.

In the early twentieth century, Freud hypothesized that suicide was a result of unresolved intrapsychic struggles between the id, ego, and superego, and Leenaars (1999) argued that suicide has both intra-psychic (e.g., cognitive constriction, inability to adjust) and interpersonal dynamics (e.g., rejection–aggression, identification–egression). Recently, work in neuropsychology has suggested that there are biological reasons for suicide, with much of the research focusing on a deficiency in serotonin associated with depression. In addition, evidence from family studies suggests that suicide tends to be more prevalent in some families, though whether it is biologically based or viewed as more acceptable in some families than others has not been fully determined. As the reader can surmise from the information presented earlier, perspectives on suicide are varied and multiple. Many of the theories include cultural components and it is on the cultural influences on suicide that this book focuses.

DEFINITIONS OF SUICIDE

Suicide is defined as an intentional, self-inflicted act that results in death. Suicidal behaviors are actions by which an individual places himself or herself in harm’s way, and they may lead to self-destruction (Silverman & Maris, 1995). For example, driving too fast, drinking too much, and cutting one’s wrists depict self-destructive behaviors, the first two examples being more unconscious than the latter. It is extremely difficult to adequately define suicide because of the difficulty in defining intent. Clinicians are very aware of clients who self-mutilate or are sensation seeking (Peterson & Bongar, 1989), probably without fully intending to die, though one can never be certain. One of the major research areas within the field of suicidology is determining the internal factors that may lead to suicide. What do people believe about suicide? What are their feelings prior to attempting suicide? Is there a neurochemical component to suicide? I will emphasize questions such as the following: Is suicide culturally acceptable? What prevents people from attempting or completing suicide? How do suicidal behaviors change depending on particular cultural groups? How does culture influence suicide completions, attempts, and behaviors? In order to give the reader an introduction or a refresher to the study of suicide, it may help to define terms and discuss the major risk factors.

Fatal Suicide

In the United States suicide is the eleventh leading cause of death, but among ten- to twenty-four-year-olds it is the third (Krug, Dahlberg, Mercy, Zwi, & Lozano, 2002). Suicides among adolescents and young adults account for more deaths than from eight other leading causes of death combined, including heath disease, cancer, and pneumonia. Overall, there are approximately 30,000 completed suicides annually in the United States, a number greater than the number of homicides. In fact, there are about three suicides for every two homicides nationally. The number of fatal suicides has stayed fairly consistent for years. Completed suicide is actually a fairly rare event when considering the total number of people within the general population, occurring in about 11 per 100,000 people (retrieved January 6, 2004, from http://www.mentalhealth.samhsa.gov/suicideprevention/costtonation.asp). Fatal suicides are differentiated from nonfatal suicides in that the person “completes” suicide. The term “completed suicide” instead of “committed suicide” has been used among suicidologists for a number of years due to several philosophical reasons, including the belief that committing suicide implies a form of criminal behavior. For example, one commits a felony or adultery, and although suicide can still be considered a legal issue in many states and locales, suicidologists are attempting to decrease its legal focus and increase public awareness of suicide as a mental health issue.

The term completed suicide has also recently been questioned on a number of philosophical grounds. The main issue is that “suicide” implies intent, and it is very difficult to establish individual intent in many cases, especially since the person is dead (the interested reader should consult Alston & Anderson, 1995, and Simonds, McMahon, & Armstrong, 1991, for more detailed explanations). This book will use the terms “fatal” and “completed” with regard to a suicide resulting in death that is presumed to have been intentional and self-inflicted.

Nonfatal Suicide

The number of people who engage in nonfatal suicides (“attempts”) is much higher than people who complete suicide, with the former at approximately a 3 percent lifetime prevalence rate (Kral & Sakinofsky, 1994)...