Suicide Among Racial and Ethnic Minority Groups

Theory, Research, and Practice

Frederick T.L. Leong, Mark M. Leach, Frederick T.L. Leong, Mark M. Leach

• Publisher: Routledge
• Year: 2010
• eBook ISBN: 9781135916800
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Suicide is increasingly understood and predicted as an intersection of biological, psychological, cognitive, and sociocultural factors. We have some basic knowledge of these factors and how they interact, but presently we know very little about how culture can play a role as a variable that influences suicide. Suicide Among Racial and Ethnic Minority Groups will go a long way towards filling that gap by pulling together cutting edge empirical research from general cultural diversity literature and applying it to suicide assessment, treatment, and prevention theory and practice. By looking outside of the limited cross-cultural studies done within suicidal populations, the contributors – all established experts in both multicultural counseling and suicidology – expand the available empirical literature base in order to provide a deeper look into how culture can act as an important catalyst in suicidal intentions.

Following theoretical overviews, the text focuses on six broad ethic groups classified in the literature (African American, American Indian, Asian American, European American, Hawaiian & Pacific Islander, and Hispanic), with a main chapter devoted to each, relating each culture to suicide research, highlighting specific variables within the culture that can influence suicide, and presenting appropriate treatment considerations. A final section of the book consists of practical applications within specific settings (therapy, outreach, schools, psychiatric services) and prevention and training issues.

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CHAPTER

Suicide Among Racial and Ethnic Minority Groups

An Introduction

Frederick T. Leong and Mark M. Leach

Most of what is known about suicidal behaviors is derived from the dominant culture, for a number of reasons. First, the majority of persons attempting and completing suicide are European American if one were to assess sheer numbers. Approximately 30,000 people kill themselves each year in the United States, with almost 90% being White. Second, until less than 40 years ago, suicides were tabled as “White” or “Non-White.” Ethnic differences were nonexistent and there was little interest in determining culturally specific reasons for “Non-White” suicides. Third, the majority of suicidologists are European American and may consider groups of color but have not made them a focus of their research program. In essence, culture is considered a secondary factor instead of a primary factor. Fourth, although there is little literature assessing cultural issues relevant to ethnic suicide, there is an emerging amount. Finally, there has never been a call to the profession to begin to consider suicide from multiple worldviews. Leach (2006) was the first to compile much of the ethnic suicide literature, and this book is the second. The editors and authors of this text challenge researchers and clinicians to begin to consider suicide from a variety of cultural perspectives. Only through the addition of this knowledge will our understanding of suicide become more robust.

Because suicide is a major public health problem in the United States and much of our knowledge base of suicide is Eurocentric (i.e., based on the dominant European American culture), it is imperative that we begin to correct this oversight as another track within the scientific community’s attempt to address the problem ethnic disparities in health. Therefore, the primary purpose of this book is to address the question of how the complex nature and manifestation of culture, race, and ethnicity may influence suicide among the various cultural groups within the United States. We have sought to compile and integrate this limited knowledge base with the goal of providing some guidance to clinicians, educators, and researchers who are faced with the challenge of understanding, preventing, and intervening to reduce suicide among racial and ethnic minority groups in this country.

To achieve this purpose, the volume is divided into three sections, the first being Theoretical Inclusion of Multicultural Issues, the second Specific Racial and Ethnic Groups, and the third Prevention, Assessment, Treatment, Training, and Research Recommendations. In Chapters 2 and 3 of Section I, Leenaars and Lester introduce readers to the notion that suicide is multidimensional, and that the ecological model has recently gained attention as a framework from which to conceptualize ethnicity and suicide. This model states that different levels (e.g., individual, social, cultural) interact to contribute to suicidal behaviors. Drawing from their work examining suicide from a cross-cultural perspective, the authors attempt to translate current cultural manifestations of suicide into a U.S. ethnic perspective. Unfortunately, though accurately, they acknowledge the dearth of existing theories that take ethnicity into account, and also indicate that further theory development is needed. More questions are offered than answers, reinforcing the original intent of chapters’ inclusion: that suicide theoreticians should begin focusing their efforts on groups of color.

Leenaars mentions the need for an increased use of suicide-note investigations to further theory development. He then offers readers eight templates or patterns from which to understand suicide. Ethnicity and culture could seemingly be introduced into each one. Lester argues that we need to consider the linguistics of suicide, alluding to the fact that more research in the interpretation and expression of suicide with persons of color is needed. He also discusses the erroneous assumption that there is ethnic invariability in suicide, followed by international studies suggesting otherwise. Both Leenaars and Lester suggest that we begin to examine more closely our understanding of suicide internationally in order to glean ideas for theory development in the U.S. It is a place to begin discussions, although international research often comprises broad, almost categorical data. What is clear is that the authors are hopeful that theory development that includes more cultural data is possible, though fundamental questions surrounding suicide will have to be revisited or initially addressed.

In Section II, we invited leading scholars to critically review the literature with regards to suicide among racial and ethnic minority groups. In Chapter 4, which is concerned with African Americans, Utsey, Hook, and Stanard discuss the risk and protective factors related to African American suicide and highlight the pattern of males and adolescents as being the most likely to complete suicidal acts within that community. Although suicide rates have fluctuated in an unpredictable fashion over the past 40 years in comparison with other ethnic groups, surprisingly little is known about the reasons underlying these trends. These authors go on to propose and investigate cultural models that explain the lower rates of suicide in African Americans from various perspectives: sociological, psychological, and ecological. In addition, strength-based protective factors are examined that help buffer African Americans from high suicide rates. Examples of these factors include religious and spiritual strength, cohesive family relationships, close friendships, supportive social networks, lower rates of drug and alcohol consumption, and Black consciousness—better known as racial pride. At the same time, these authors identify certain sociocultural risk factors that do contribute to increased rates of suicide among African Americans. These include psychological distress, substance abuse and illicit drug use, the availability of lethal means, social isolation, family dysfunction, impaired interpersonal functioning, maladaptive coping skills, exposure to racial inequality, prior history of suicide attempts, or social stigma associated with mental distress. All of these factors are discussed within the cultural context of the African American community and with an eye to future research directions and implications for clinical practice and public policy.

Chapter 5 is concerned with Hispanics. In this chapter, Duarte-Velez and Bernal examine the conceptual methodological contextual and developmental issues related to suicide among Hispanic youth, as suicide is the third leading cause of death among this population. Youths are known to have the highest suicide rates within the Hispanic population and have the highest suicide risk behaviors in comparison with other ethnic groups. Due to both the large amount of diversity and the similarities found within the subgroups of this ethnic group, the authors suggest that considerations be given to conceptual factors such as ethnicity, ethnic identity, race, and context. Within-group diversity can be investigated using nation of origin, generational status in the U.S., and language use. These factors are also linked to methodological issues and will determine study design, sampling, recruitment, measurement, and sample retention. The bottom line is that careful, thoughtful, and culturally sensitive approaches need to be applied to these analytical issues when researching this topic within this ethnic group. The authors also discuss other sociocultural and environmental factors that are important to the development of identity and in turn affect suicidal behavior(s). Some examples include concepts such as familismo, machismo, and acculturation. The authors highlight studies where Latino youngsters who had attempted suicide were experiencing significantly more school, personality, behavioral, and family stressors than the matched-pair control groups. The main drawback discussed was how researchers use the term “Hispanic” for all subgroups without any further differentiation of these subgroups within the larger population.

In a review of existing studies related to suicide behavior among Hispanic youth, the authors first summarize comparative population-based studies of suicide behavior among adolescents, and concluded that the evidence is suggestive of differential rates by ethnicity for suicide ideation, attempts, lethal attempts, and suicide. The authors also note that the differences in the use of definitions and temporal frames have made it difficult to reach specific conclusions. Then, within-group studies focusing on Hispanics are reviewed that allow a more critical evaluation of research findings and the formulation of more specific conclusions. The authors underscore the significant relationship of social and psychological variables to suicide behavior in Hispanic groups, as well as the lack of a theory to inform the findings. Finally, the authors examined evidence-based treatment for suicidal Hispanic adolescents, and stressed the urgent need for well controlled trials and outcome studies, as well as the need to document results and findings.

In Chapter 6, Leong, Leach, and Gupta review the literature on suicide among Asian Americans and recommend directions for future research to fill in the current gaps. A case study is described and discussed with reference to the culture-specific factors associated with suicide among Asian Americans. Asian Americans are a heterogeneous group and at first glance it appears that there is not enough information regarding suicide among the various subgroups or among the Asian American ethnic group as a whole. Recently, there has been an increased interest and effort to fill in the gaps in the current research, most of which has been done among the university student population and has focused on completed suicides versus suicidal attempts or ideations.

The chapter introduces and highlights cultural factors characteristic of suicide among Asian Americans. Some of these factors have been investigated in depth and have undergone rigorous empirical testing, while some of these other factors have not yet been investigated. The five main areas discussed in this chapter are: Age and Gender; Religious and Spiritual Issues; Acculturation and Social Support; Familial and Social Integration; and Gay/Lesbian/Bisexual issues. Other contributing factors shared by other ethnic groups include depression and hopelessness, job loss, death in the family, relationship breakups, and perfectionism. All these factors are important for counselors and researchers to consider when determining suicide risk. These factors also have important policy implications. Future directions for research are discussed and provide a foundation for future efforts in areas of research, clinical practice, and public policy.

Studies on suicide and suicide behaviors or issues among Pacific Islanders are fairly rare. Else and Andrade present a comprehensive review of some of the pressing factors associated with suicide among this group in Chapter 7. Specifically, sociocultural information about suicide among Hawaiians, Samoans, and Micronesians is presented within a historical context. Pacific Islanders have traditionally been included in the more general category of “Asian Americans” or “Asian Americans and Pacific Islanders.” This grouping fails to take into account important differences in suicide rates, behaviors, and patterns among the various Asian subgroups. The important fact to highlight is that Pacific Islanders are not Asians and therefore factors associated with one group need to be delineated from the other. Contrary to popular belief, Pacific Islanders are not immigrants or descendants of American immigrants. Pacific Islanders are indigenous peoples and, similar to the suicide patterns displayed by Native Americans and Alaskan Natives, demonstrate the highest completed suicide rates in the world, especially for males between the ages of 15 and 25.

Pacific Islanders have been shown to display a preference for militaristic altruistic suicides, which, unlike terrorism suicide, are infused with a notion of nobility to carry out messages of resistance against enemies that cannot be defeated physically. Thus, the altruistic suicide offers an option to strive for metaphysical victory. Suicide in this framework gives it cultural meaning and relevance, especially with regard to group norms, conformity, and cohesion. Culture is extremely important in understanding, defining, investigating, and intervening with suicidality issues among Pacific Islanders. Chapter 7 also offers discussions of the influence of role norms and generational issues, traditions, and disparities between ideal, internalized ethnocultural identity and external persona in suicide among Pacific Islanders.

In Chapter 8, Alcantara and Gone discuss risk and protective factors for suicide within the Native American community using a transactional-ecological framework. They argue that it is important to realize that suicide is not only an individual and familial issue but a community and public concern, especially within smaller, tight-knit communities such as Native American communities. Suicide rates among Native Americans are proportionally almost twice as high as the national rate, with the majority being adolescent males, resulting in a great need to continue investigating causes and prevention efforts of suicide. The transactional-ecological framework is a developmental, preventive approach that focuses on the interactions between individuals and their environments, given that evidence indicates that local culture is influential with suicide ideation, attempts, and completions. The authors maintain that it is critically important to understand the trajectories that lead to intermediate negative outcomes that increase suicide risk but de-emphasize the individual and a particular disorder, and emphasize context. Restoring normative trajectories becomes the focus of intervention rather than an emphasis on an individual, disease model of treatment.

The third section of this volume is concerned with Prevention, Assessment, Treatment, Training, and Research aspects of suicide among racial and ethnic minority groups. This section begin with Chapter 9 by Walker, Townley, and Asiamah, who discuss the limited empirical information on suicide prevention efforts among ethnic minority groups. They initially make some interesting statements that raise even more interesting questions. For example, if suicide has different cultural meanings across ethnocultural groups, how can we adequately devise culturally inclusive prevention programs? Should we continue to use some existing prevention programs if they have not been adequately evaluated? The authors even report the question asked by Mishara (2006), president of the International Association for Suicide Prevention, when he asked how much of suicide is universal and how much of the etiology is culture-specific. It is good to know that prominent suicidologists are asking these questions, although due to the literature’s infancy, our current knowledge does not transfer easily into prevention efforts.

Walker et al. then summarize selected pieces of the ethnic suicide literature, though interested readers should be referred back to earlier chapters that expand on the summary. The authors highlight the few existing ethnic suicide prevention programs, focusing their efforts on American Indian suicide, because multiple, though largely unsystematic, programs have been developed and implemented. To increase research into prevention programs the authors propose three key domains for persons of color, including a “(1) accurate assessment and treatment of psychiatric symptoms, which include (2) the impact of race-related stressors and acculturative vulnerability, and (3) ethnocultural resilience.” They argue that ethnocultural perspectives may be most beneficial and systematic prevention models should be customized for specific ethnic groups. Walker et al. offer suggestions to begin to create these programs and cultural factors to consider. Multiple research questions follow to accelerate prevention research and program development.

In Chapter 10, Westefeld, Range, Greenfeld, and Kettman introduce readers to the paucity of literature and complexity involved with culturally sensitive suicide assessment. They indicate that inclusion of culture in risk assessment involves at least four facets: (1) ethnic minority inclusion in assessment instrument standardization, (2) awareness of disclosure differences, (3) knowledge of different ethnic groups, and (4) increased attention to cultural issues when assessing suicidal thoughts and actions. Currently, the few researchers who have considered ethnicity when developing risk assessment instruments do not use a multicultural framework as their theoretical foundation. Westefeld et al. summarize nicely the most widely used instruments, including their attention to ethnic issues. They argue for increased attention to broader segments of society when developing instruments to determine both reliability and validity with groups of color. Due to different definitions, perceptions, understanding, acceptability, and language associated with suicide, most current instruments have questionable utility. The authors’ views of language differences are consistent with views of other authors in this text. Suicide terminology differs among ethnic groups whether English is the first language or not, and it would benefit the field to continue to examine the role of language on suicide.

Assessment includes disclosure of potential lethality. The authors report literature indicating that ethnic minority individuals are reluctant to open up to European American counselors, although they may also be reluctant regardless of counselor ethnicity. Westefeld et al. mention that persons of color are less likely to disclose suicide ideation on intake forms, and highlight that racial identity and previous discrimination may be important suicide assessment factors to consider. Assessment of these and other cultural variables becomes especially important during less structured, face-to-face interviews, as it is unlikely that structured interviews and instruments can tap these cultural nuances. The authors then briefly summarize the literature on assessment with the four broad ethnic groups in the U.S., followed by the application of the Multicultural Assessment Procedure (MAP) (Ridley, Li, & Hill, 1998) to suicide assessment. The model is a generic, culturally sensitive approach to assessment and Westefeld et al. introduce the four-phase model and apply it to suicide assessment.

In Chapter 11, Rogers and Whitehead continue to delve into new territory along with the rest of the book’s authors by focusing on interventions and treat...

Table of contents

• Cover Page
• Half Title page
• Series page
• Title Page
• Copyright Page
• Contents
• Series Editor's Foreword
• About the Editors
• Contributors
• Chapter 1 Suicide Among Racial and Ethnic Minority Groups An Introduction
• Section Section1 Theories and Models
• Section 2 Research on Racial and Ethnic Cultures
• Section 3 Prevention, Assessment, Treatment, Training and Research
• Index