In this article, we have discussed various facets of the cultural context that may influence adolescent suicidal behavior and help-seeking. There are several themes that cut across our discussion for different ethnic groups: acculturative stress and enculturation; the roles of collectivism, religion and spirituality, and the family in culturally sensitive interventions; different manifestations and interpretations of distress in different cultures; and the impact of stigma and cultural distrust on help-seeking and service utilization. We now discuss each of these cross-cutting themes before concluding with comments about the roles of psychologists in addressing the needs of these groups and about future research considerations and opportunities in this area.
Acculturation and Enculturation
Acculturation most obviously is a challenge for adolescents who are newly immigrant or whose parents immigrated to the United States from a different country. However, even for people indigenous to this country, or groups that have been in this country for centuries, there may be pressures and stresses associated with the balancing of assimilating to the majority culture while retaining one’s own cultural identity. Whereas not assimilating to a new culture can be stressful, holding on to some facets of one’s cultural heritage and, in turn, to the supports inherent in that culture may in some cases provide some protection against negative outcomes, including suicidality. In this regard, one explanation for the lower rates of suicide among African American females is that they have access to greater community supports, including extended family and the Black Church. Similarly, among American Indians, enculturation that includes links to traditional activities, Native spirituality, and extended family has been linked to positive outcomes. Particularly given the fact that less acculturated individuals may be less likely than others to use formal mental health services (Snowden & Yamada, 2005
), it is important to develop community-based services that are sensitive to, and build on the strengths inherent in, cultural heritage and supports.
The Role of the Family
Regardless of cultural heritage, the involvement and engagement of families are important facets of interventions for suicidal adolescents. In treatment, parents or caretakers help to ensure a safe environment in the home, monitor the suicidal adolescent, and are needed to help resolve family conflicts or stresses that may be related to suicidal behavior. Parents also play an important role in suicide prevention by recognizing the signs of mental health difficulties among youths and seeking help when appropriate. For both African Americans and American Indians, ties to the extended family often are considered sources of support that may be protective against suicidal behavior. In addition, in many Asian American and Latino families, there is a clear expectation of involvement in the therapeutic process because of views of interdependence with the family. Although research needs to elucidate the most effective ways of involving the family in interventions for reducing suicidality, to the extent that the family is involved, mental health professionals will have a better appreciation of the context in which an adolescent has engaged in or considered suicidal behavior.
Collectivism and Individualism
Collectivism is a central value of many cultures, although there are within-group differences in the degree to which groups evidence a collectivist versus an individualistic orientation. Collectivism or interdependence among peoples may offer support or provide a sense of belonging for at-risk individuals that may mitigate risk for suicidal behaviors. However, a collectivist orientation may also increase acculturative stress as well as the awareness of racial oppression and discrimination affecting the larger communities. Psychologists need to be aware of the degree to which the process of acculturation as well as a history of racism and societal pressures have served to erode a sense of community and interdependence among some people, and how a collectivist orientation may serve as both a protective factor and a risk factor for suicidal behaviors in different contexts.
Religion and Spirituality
One notable theme that was evident across cultures was the importance of religion and spirituality. For example, depending on the orientation of the church, involvement with the Black Church has been viewed as protective among some African Americans. In both Asian American and American Indian cultures, views regarding spirituality may shape the type of coping behaviors one engages in, and in American Indian cultures, views regarding traditional healers and healing rituals and ceremonies are inextricably linked with views of spirituality. People of different cultural backgrounds understandably may not seek help or respect intervention efforts if they do not perceive that their faith or beliefs will be honored or respected. Many individuals or families, even when seeking formal mental health services, are also seeking assistance from traditional healers or from their faith communities. For interventions to be effective within different cultural contexts, they must be flexible enough to be respectful of a culture’s faith traditions and belief systems. Partnerships with faith communities may provide many opportunities for suicide prevention activities within a culturally acceptable context.
Different Manifestations and Interpretations of Distress
Different cultural groups may manifest distress and interpret signs of distress differently. For example, both African American and Asian American youths may not verbalize suicide thoughts or intent as readily as other groups, and among Latinas, the series of behaviors that may lead up to suicidal behavior may be interpreted as part of the cultural syndrome nervios. Physicians, teachers, and other “gatekeepers” who are in a position to help identify adolescents at risk for suicidality, but who are not from the same culture as adolescents and their families, need to be especially alert to the fact that distress is not always expressed in the same ways among individuals from different backgrounds. In addition, clinicians need to be aware that even when suicidal thoughts are not readily volunteered, they often can be elicited with careful and sensitive assessment.
Cultural Mistrust, Stigma, and Help-Seeking
In each of the groups reviewed, there appeared to be stigma associated with mental health difficulties, including suicidality, and often with help-seeking. Stigma unfortunately is often accompanied by apprehensions and distrust about service use because of historical abuses, lack of familiarity with systems, and experiences with mental health professionals who are not culturally competent or sensitive. Education provided in faith communities, in the schools, or in the wider communities may be helpful in reducing stigma and raising awareness of potential mental health problems among youths and the availability of culturally sensitive resources for youths at risk for suicidal behavior. Culturally sensitive screening or routine assessment of suicide risk in settings not associated with mental health treatment (e.g., schools, primary care settings) may also be useful in identifying youths at risk.
Future Research Directions and Challenges
There are several different areas in which additional research is needed to help us better understand the context of suicidal behaviors among youths of different cultural backgrounds. Additional research examining culture-specific triggers or processes leading to suicidal behavior as well as culture-specific risk and protective factors is greatly needed. There are many hypotheses about factors potentially related to suicidal behavior and help-seeking (e.g., the ethic of John Henryism among African Americans) that warrant closer examination. In addition, one area in particular that has been under-researched is the reactions from family and community regarding suicidal behavior that may serve to increase or decrease risk for a recurrence of suicidal behavior.
The number of culturally sensitive prevention and treatment interventions for suicidal youths appears to be extremely limited. In this regard, an understudied area is the degree to which interventions focused on reducing risk factors (e.g., hopelessness in the community) and enhancing culturally relevant protective factors or supports (e.g., ties to elders or cultural traditions) can reduce suicidality. In addition, an important area of inquiry is the degree to which informal or traditional sources of help within the community are effective in addressing suicide risk among youths, particularly given the fact that suicidal adolescents may be more comfortable speaking with lay helpers or native healers than talking about difficulties with strangers in unfamiliar settings.
Multifaceted community-based efforts may be especially useful in culturally relevant suicide prevention. For example, the successful Western Athabaskan suicide prevention program had multiple components including a network of natural helpers, community education, suicide risk screening, postvention following suicidal behavior (e.g., support for individuals or families who have lost loved ones due to suicide), and adoption of guidelines for preventing suicide clusters. Nonetheless, for sustainability and increased effectiveness, such efforts at suicide prevention need to be developed in collaboration with the community, or to arise from the community itself, rather than be externally imposed. Efforts developed by and implemented by home communities have a greater likelihood of sustainability because of individual and community investment in the programs and because participants are able to experience first-hand the positive changes that occur as a result of interventions. Such community-based efforts have not often been the subject of research scrutiny and evaluation, but they have much promise in reducing adolescent suicidal behaviors and related problems. In this regard, it is of note that the Garrett Lee Smith Memorial Suicide Prevention Act recently provided funding for suicide prevention activities and their evaluation in 13 tribal communities.
One challenge in evaluating community-based efforts in suicide prevention is the fact that it is difficult to find appropriate comparisons against which to gauge the effects of the intervention. Without nontreated comparison sites or communities, it can be difficult to disentangle the effects of the intervention from changes occurring in the greater population over time. Selecting similar communities that are not initiating prevention efforts can also be problematic insofar as the different sets of communities may differ in their readiness to change. In this regard, innovative research approaches such as the dynamic wait list design may be useful and informative (Brown, Wyman, Guo, & Peña, 2006
). Practically, it often is impossible to introduce a new intervention simultaneously at different sites (e.g., different tribal communities). Building upon this, the timing or sequence of introduction of intervention to communities can be randomized, with the communities with the latest introductions of the intervention providing important comparison data against which the effects of the intervention introduced in earlier sites can be compared. To ensure that well-intended suicide prevention efforts actually have desired effects, additional innovative approaches to evaluation are needed.
Caveats and Closing Comments
Although we have focused on the broad differences between cultural groups in factors that may affect adolescent suicidal behavior, there also is a great deal of diversity within these groups. This diversity is apparent both in differing rates of suicidal behavior and cultural differences among individuals within racial and ethnic groups. Future research should focus much more on understanding (a) within-ethnic-group differences and how they are associated with different patterns of suicidal behaviors and (b) cultural differences that may increase or decrease the likelihood of thinking about or attempting suicide and seeking help or support.
In addition, when differences are observed among people of color or of different countries of origin, there is a tendency to attribute these differences to their ethnicity. However, newly immigrated individuals and individuals from ethnic groups who have been historically oppressed or disadvantaged may disproportionately have limited educational backgrounds or financial means. The socioeconomic status and educational background of clients and families often contribute to the cultural context or milieu but should not be confused with differences attributable to ethnicity (Hall, 2001
Many of the cultural groups described have been subject to trauma and political repression, either in their countries of origin, during the immigration process, or in this country. Interventions that reinforce the protective supports and the cultural strengths of these communities are needed to help address this trauma and its effect on mental health and to empower groups that have been the victims of oppression or that have been underserved (Comas-Díaz, 2000
The Ethical Principles and Code of Conduct and the Multicultural Guidelines of the APA (2002
underscore the importance of understanding cultural context. Particularly given the history of racism in psychology (e.g., the eugenics movement), psychologists need to be aware of the political climate and societal forces that may affect how ethnic minorities and underserved groups are viewed and treated and how this may affect their mental health needs and access to services. Psychologists have a special responsibility to combat racism and promote social equity (Comas-Díaz, 2000
). In this role, and through the development of new and effective culturally sensitive and appropriate interventions, they can hopefully affect those facets of cultural context that are associated with suicidal behaviors among young people.