Project: Discussion Question Assignment

Suggested Further Reading for SOCW 6090 (PDF) for a list of resources to review.

 

Week 3

• American Association of Suicidology. (2018). Retrieved from http://www.suicidology.org

• American Foundation for Suicide Prevention. (2016). Meet the researchers: An introduction to the latest in suicide research. Retrieved from https://afsp.org/ourwork/research/meet-the-researchers-an-introduction-to-the-latest-in-suicideresearch/

• American Foundation for Suicide Prevention. (2018). Retrieved from https://afsp.org

• The Columbia Lighthouse Project. (2016). Retrieved from http://cssrs.columbia.edu/

• National Institute of Mental Health. (2017). Suicide prevention. Retrieved from https://www.nimh.nih.gov/health/topics/suicide-prevention/index.shtml

• Substance Abuse and Mental Health Services Administration. (2017). Suicide prevention. Retrieved from https://www.samhsa.gov/suicide-prevention

• Suicide Prevention Resource Center. (2018). Retrieved from https://www.sprc.org

• U.S. Department of Veterans Affairs. (2013). Assessment and management for patients at risk for suicide. Retrieved from https://www.healthquality.va.gov/guidelines/MH/srb/

• Zero Suicide in Health and Behavioral Health Care. (2018). Retrieved from https://zerosuicide.sprc.org

Psychological Assessment © 2013 American Psychological Association

2013, Vol. 25, No. 2, 424–434 1040-3590/13/$12.00 DOI: 10.1037/a0031264

A Tool for the Culturally Competent Assessment of Suicide: The Cultural Assessment of Risk for Suicide (CARS) Measure

Joyce Chu, Rebecca Floyd, and Hy Diep Palo Alto University

Seth Pardo Alliant International University

Peter Goldblum Palo Alto University

Bruce Bongar Palo Alto University and Stanford University School of Medicine

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Despite important differences in suicide presentation and risk among ethnic and sexual minority groups, cultural variations have typically been left out of systematic risk assessment paradigms. A new self-report instrument for the culturally competent assessment of suicide, the Cultural Assessment of Risk for Suicide (CARS) measure, was administered to a diverse sample of 950 adults from the general population. Exploratory factor analysis yielded a 39-item, 8-factor structure subsumed under and consistent with the Cultural Theory and Model of Suicide (Chu, Goldblum, Floyd, & Bongar, 2010), which characterizes the vast majority of cultural variation in suicide risk among ethnic and sexual minority groups. Psychometric properties showed that the CARS total and subscale scores demonstrated good internal consistency, convergent validity with scores on other suicide-related measures (the Suicide Ideation Scale, the Beck Depression Inventory suicide item, and the Beck Hopelessness Scale), and an ability to discriminate between participants with versus without history of suicide attempts. Regression analyses indicated that the CARS measure can be used with a general population, providing information predictive of suicidal behavior beyond that of minority status alone. Minorities, however, reported experiencing the CARS cultural risk factors to a greater extent than nonminorities, though effect sizes were small. Overall, results show that the CARS items are reliable, and the instrument identifies cultural suicide risk factors not previously attended to in suicide assessment. The CARS is the first to operationalize a systematic model that accounts for cultural competency across multiple cultural identities in suicide risk assessment efforts. Project: Discussion Question Assignment

Keywords: culture, diversity, suicide, assessment, measurement

Recently, investigators have illuminated a lack of systematic incorporation of cultural variation into standard suicide risk assessment practice (Chu, Goldblum, Floyd, & Bongar, 2010; Leach, 2006; Leong & Leach, 2008). Even though cultural literature has shown that suicide rates, expression, experience, risk factors, and protective factors vary across gender, ethnic, age, sexual orientation, and other cultural groups (see Chu et al., 2010, for a review), standard risk assessment protocol does not systematically account for these differences. Without particular attention to cultural variation in suicide risk expression, suicide risk may be underdetected and managed improperly (e.g., Joe & Kaplan, 2001;

Langhinrichsen-Rohling, Friend, & Powell, 2009; Morrison & Downey, 2000; Rockett, Samora, & Coben, 2006; Wendler & Matthews, 2006; Willis, Coombs, Drentea, & Cockerham, 2003). Burr (2002), for example, interviewed mental health care professionals and argued that stereotypes and knowledge based on Western culture may result in misdirected assessment and treatment of suicide and depression for South Asian communities. Other research has shown greater misclassification of suicides in African Americans and Latinos compared with European Americans (Phillips & Ruth, 1993; Rockett et al., 2010; Violanti, 2010). The current study provides a critique of existing approaches to culturally competent suicide risk assessment and presents a measure (CARS; the Cultural Assessment of Risk for Suicide measure) designed to facilitate systematic integration of cultural competency into suicide risk assessment.

How Culture Affects Suicide Risk

Cultural literature has shown that suicide rates vary across gender, ethnic, age, sexual orientation, and other cultural groups. When aggregated across age, U.S. suicide rates have been historically highest in White males and lowest in African American women (Centers for Disease Control and Prevention, 2009). A more detailed examination, however, shows that suicide rates are

This article was published Online First January 28, 2013. Joyce Chu, Rebecca Floyd, and Hy Diep, Department of Psychology, Palo Alto University; Seth Pardo, Rockway Institute, Alliant International University; Peter Goldblum, Department of Psychology, Palo Alto University; Bruce Bongar, Department of Psychology, Palo Alto University, and Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine. Correspondence concerning this article should be

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growing quickly among African American adolescent boys (Heron, 2007; Joe & Kaplan, 2001) and among older adults are highest in Asian Americans (Bartels et al., 2002; Centers for Disease Control and Prevention, 2009; Shiang et al., 1997). Additionally, research shows that suicidal behavior is elevated among Latino adolescents (Centers for Disease Control and Prevention, 2004; Choi, Meininger, & Roberts, 2006) and LGBTQ1 adolescents (young gay men in particular; King et al., 2008; McDaniel, Purcell, & D’Augelli, 2001; Meyer, 2003). Minority group variations in suicide rates may reflect underlying differences in other important aspects of suicide: expression, experience, risk factors, or protective factors (see Chu et al., 2010, for a detailed review). These cultural differences in suicide among ethnic and sexual orientation minorities affect the types of questions one must ask to accurately capture and predict self-harm risk. For example, within a clinical setting, ethnic minorities are referred to as hidden ideators—clients who are less likely than Whites to self-disclose feelings of suicide unless directly assessed by clinicians (Morrison & Downey, 2000). Methods of query that decrease the potential of stigma or embarrassment may elicit a more accurate picture of risk for someone prone to hidden suicidal ideation. Assessing for family conflict may be a particularly important indicator of suicide risk for individuals from interdependent cultures such as Asian Americans or Latinos (Cheng et al., 2010; Fortuna, Perez, Canino, Sribney, & Alegria, 2007; Garcia, Skay, Sieving, Naughton, & Bearinger, 2008; Lau, Jernewall, Zane, & Myers, 2002). Additionally, research shows that LGBTQ individuals often turn to community supports in the face of rejection from family members, making high levels of family rejection and alienation from one’s social community particularly important suicide risk factors (D’Augelli, 2002; McBee-Strayer & Rogers, 2002; Ryan, Huebner, Diaz, & Sanchez, 2009; Van Heeringen & Vincke, 2000). Assessing social isolation from a supportive LGBTQ community may be a better indicator of suicide risk than social isolation from friends for an LGBTQ client struggling with the coming-out process. To understand how clinicians typically account for such cultural variations in their risk assessment efforts, we turn to an examination of current suicide risk assessment tools and procedures.

How Is Cultural Variation Currently Incorporated Into Suicide Risk Assessment?

Several researchers have provided guidelines for the incorporation of cultural influence into current suicide risk assessment practices. Westefeld, Range, Greenfeld, and Kettmann (2008), for example, recommended that four aspects of cultural sensitivity be included in the science and process of risk assessment: (a) inclusion of ethnic minorities in the standardization of suicide instruments, (b) awareness of differences in likelihood to disclose suicide information, (c) recognition and acknowledgment of various minority groups, and (d) careful attention to cultural issues when assessing for suicidal thoughts and behaviors. Worchel and Gearing (2010) advised that culturally competent suicide assessment should include careful and active consideration of culture-specific risk and protective factors and attitudes regarding suicide acceptability. In its seminal document providing practice guidelines on the assessment of suicidal behaviors, the American Psychiatric

Association Work Group on Suicidal Behaviors (2003) provided general recommendations to explore common contributors to suicide in different cultural groups and cultural differences in beliefs about death and view of suicide as part of the suicide assessment process. These assessment guidelines also advised remembering that cultural beliefs influence one’s willingness to talk about suicide. Other researchers have recommended the inclusion of specific cultural factors into risk assessment for certain minority groups. Kaslow et al. (2004), for example, recommended assessing for aggression in flagging suicide risk for African Americans, whereas Cheng et al. (2010) advised that family conflict and perceived discrimination are instrumental in identifying Asian Americans at risk for suicide. An abundance of individual empirical studies delineate a multitude of cultural risk and protective factors that should be integrated into the risk assessment practices for specific cultural groups. Project: Discussion Question Assignment

Weaknesses of Existing Cultural Risk Assessment

Taken together, existing efforts to integrate cultural factors into risk assessment practices have been sparse and unsystematic and carry several weaknesses. First, most recommendations are general without specific or concrete guidelines to direct the incorporation of cultural factors into suicide assessment, leaving clinicians and researchers without a course of action for an arguably complex task. Second, individual recommendations to include specific cultural factors into assessment efforts do not aid clinicians in synthesizing the volume of findings identifying differences in suicide-related factors for multiple ethnic and sexual minority groups. The range of research on cultural suicide risk factors is difficult for any one clinician or researcher to comprehensively grasp or access quickly within the limited time often allowed in crisis situations. Additionally, people typically identify not with one cultural group but instead with multiple identities (e.g., an African American woman who is bisexual carries multiple identity categories), making prioritization or synthesis of research findings for suicide in these multiple cultural groups an involved effort. Third, specific to existing suicide assessment tools, most suicide questionnaires are presumed to have reliable and valid interpretations of suicide risk for cultural minorities without empirical research to support such assumptions (Molock & Douglas, 1999; Molock, Matlin, & Prempeh, 2008). Furthering the problem, few suicide questionnaires were specifically developed with minority populations in mind (e.g., Brown, 2002; Dana, 2000; Wendler & Matthews, 2006; Westefeld et al., 2008). Although some validation samples may have included (usually limited numbers of) minority group members, measure items do not assess for the range of risk factors unique to cultural minority groups and do not incorporate the variation in language or content of query needed to account for important cultural minority differences in how suicide develops, is expressed, or is experienced (Brown, 2002; Colucci, 2006; Leach & Leong, 2008; Westefeld et al., 2008). Project: Discussion Question Assignment

1 “LGBTQ” populations are also referred to as sexual minorities. LGBTQ is an abbreviation for lesbian, gay, bisexual, and transgender or transsexual individuals, and people questioning their sexual orientation.

ThisdocumentiscopyrightedbytheAmericanPsychologicalAssociationoroneofitsalliedpublishers. Thisarticleisintendedsolelyforthepersonaluseoftheindividualuserandisnottobedisseminatedbroadly.

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CULTURAL ASSESSMENT OF RISK FOR SUICIDE (CARS)

A New Approach for Culturally Competent Risk Assessment: The Cultural Assessment of Risk for Suicide (CARS) Measure

The numerous challenges of recommendations that are too general, limited measures validated on diverse samples, a complex range of research findings, and multiple cultural identities have presented barriers to the systematic incorporation of cultural variations into risk assessment practices. To address the need for parsimony in culturally competent risk assessment, Chu et al. (2010) developed the Cultural Theory and Model of Suicide that inductively categorized cultural differences in suicide into major risk or protective factors common across four major ethnic and sexual minority groups (African American, Asian American, Latino/a American, and LGBTQ). Chu et al. (2010) performed a comprehensive literature review of studies in North America from 1991 to 2011 that examined cultural factors related to beliefs, norms, practices, or customs that have been shown to influence suicidal behaviors. As such, findings on the effects of simple minority status or on prevalence rates were excluded. Results found that over 95% of empirical data showing unique cultural factors in suicide risk for the four referenced ethnic and sexual minority groups were encompassed within four major categories: Cultural Sanctions, Idioms of Distress, Minority Stress, and Social Discord. The first factor, Cultural Sanctions, is defined by Chu et al. (2010) as cultural values or practices conveying messages about the acceptability of suicide as an option or the acceptability or shame associated with certain life events that may precipitate suicide risk. The association of moral objections and lower acceptance of suicide to decreased suicidal behavior in African American communities is an example of a Cultural Sanction risk factor (Neeleman, Wessley, & Lewis, 1998). Idioms of Distress are defined as cultural variations in one’s likelihood to express suicidality, the way suicide symptoms are expressed, and chosen methods or means of attempting suicide. The tendency to express suicidality as risky behavior among Latinos exemplifies the Idioms of Distress factor (Olshen, 2007). The third cultural factor, Minority Stress, includes stresses cultural minorities experience because of social identity or position (e.g., acculturation, discrimination related strain, or social disadvantages). Mistreatment, harassment, and discrimination as strong suicide risk factors for sexual minority groups illustrates the Minority Stress factor (Clements-Nolle, Marx, & Katz, 2006; Huebner, Rebchook, & Kegeles, 2004). The final factor of Social Discord includes the suicide risk factors of alienation, conflict, or lack of integration with one’s family, community, or friends. The association of family conflict with increased suicide risk among Asian Americans is an example of Social Discord as a cultural risk factor (Cheng et al., 2010; Lau et al., 2002). The categories of the Cultural Model of Suicide integrate and streamline the body of knowledge regarding cultural suicide factors and identify a set of risk factors that have not been incorporated into existing suicide assessment tools. Chu et al. (2010) highlighted the need for development of an assessment tool based on the Cultural Model of Suicide to operationalize its framework in clinical, screening, and research application. Project: Discussion Question Assignment

The Present Study

The purpose of the present study was to develop and examine psychometric properties of scores on a measure of cultural suicide risk based on the Cultural Model of Suicide (Chu et al., 2010). The Cultural Assessment of Risk for Suicide (CARS) measure assesses cultural factors not typically examined in general suicide assessment research. We sought to administer the CARS with a diverse community sample overly inclusive of the racial/ethnic and sexual minority individuals often overlooked in previous suicide assessment study samples. An exploratory factor analysis (EFA) followed by internal consistency calculation was performed to examine the consistency of scores on the CARS with the major cultural categories of risk from the Cultural Model of Suicide: Cultural Sanctions, Idioms of Distress, Minority Stress, and Social Discord. We expected the CARS to demonstrate good convergent validity with other established measures of suicidal ideation and risk and to show further evidence of construct validity in terms of its ability to discriminate between participants with high versus low suicide attempt history. Wealso tested the CARS measure’s application in assessing risk for cultural minority versus nonminority groups. Because the cultural factors of the CARS encompass cultural context, beliefs, values, norms, and practices separate from differences in suicide risk due to simple minority status alone (Chu et al., 2010), we hypothesized that the CARS would apply to a general population, providing information predictive of suicidal behavior beyond that of cultural minority versus nonminority status. Yet, we expected that cultural minorities would report experiencing the cultural constructs assessed by the CARS to a greater extent than nonminorities. Project: Discussion Question Assignment

Method

Participants The total sample included 950 participants who were 18 years and older (M 25.26 years, SD 10.39) and diverse in ethnicity and sexual orientation. The sample was composed of mostly women (63.8%) but also included 31.1% men, 1.3% transgender (four male-to-female and eight female-to-male), and 3.9% unspecified. The sample was diverse and overly inclusive of ethnic and sexual minorities typically underrepresented in suicide assessment study samples. For example, 22.4% of participants identified as having a nonheterosexual orientation (10.5% homosexual, 8.2% bisexual, 3.5% questioning, and 1% unlabeled). More than half of the respondents identified as ethnic minorities, including 34.1% Asian Americans, 19.1% Latino/a American, and 5.8% African Americans. Suicide risk was also adequately represented, with roughly16.4%oftherespondentsreportedahistoryofoneormore suicide attempts. Project: Discussion Question Assignment

Procedures Participants were recruited from universities, colleges, community fliers, social networking sites, and online advertisements targeted at recruiting a sample diverse in ethnicity and sexual orientation. Participants completed a set of questionnaires either online via Survey Monkey (75.3%) or via paper form completed in

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CHU, FLOYD, DIEP, PARDO, GOLDBLUM, AND BONGAR

person (24.7%). The study was advertised to potential participants as a study of culture and self-harm risk assessment. Recruitment from colleges and universities was accomplished through announcements made during class with the permission of the instructor or through listings on university human subject pools. Student respondents were offered extra credit or course credit in exchange for their participation. University and college recruitment involved both paper and online administration, depending on the preference of the course instructor or subject pool administrator. Recruitment through social networking sites and online advertisements was accomplished via postings on www .craigslist.org. In addition, investigators shared Survey Monkey links accompanied by a brief description of the study as a study of culture and self-harm risk assessment to their network of online contacts. Snowball sampling continued as contacts were free to forward the link to their own contacts. Finally, fliers with the Survey Monkey link were posted in coffee shops and grocery stores. After providing informed consent, participants were prompted to fill out a demographic questionnaire, the Cultural Assessment of Risk for Suicide (CARS), one item assessing suicidal behaviors from the Beck Depression Inventory (BDI; Beck & Steer, 1987), a question about past suicide attempts, the Suicide Ideation Scale (SIS; Rudd, 1989), and the Beck Hopelessness Scale (BHS; Beck & Steer, 1988). The BDI suicide item, SIS, and BHS were used to assess the convergent validity of the CARS. Participants were provided debriefing information that included suicide crisis telephone numbers and Web resources. Contact information for the principle investigator (a licensed psychologist), and the institutional review board chair were also provided to allow participants opportunities to ask further questions or express concerns. This study was approved by and operated in accordance with a human subject’s review committee.

Measures

Demographic questionnaire. Participants were asked to complete demographic questions regarding age, gender, race or ethnicity, and sexual orientation identity.

The Cultural Assessment of Risk for Suicide (CARS).

The CARS included an initial set of 52 items developed to assess for the four cultural risk categories of the Cultural Model of Suicide (Cultural Sanctions, Idioms of Distress, Minority Stress, and Social Discord) with the purpose of guiding the researcher or clinician in incorporating cultural factors into risk assessment efforts. The CARS was designed to be used in adjunct to usual suicide assessment procedures. All initial CARS items were based on the psychological literature on cultural variations in suicidal behaviors and refined by a research team of three licensed clinical psychologists and 11 clinical psychology doctoral students. Items are rated on a 6-point Likert scale (1 =strongly disagree,2 = moderately disagree,3= slightly disagree,4= slightly agree,5= moderately agree, and 6 = strongly agree), and participants are instructed to “Choose the response that best applies to you.” Higher scores on the CARS indicate greater suicide risk.

Suicide item from the Beck Depression Inventory (BDI; Beck & Steer, 1987). The BDI is a 21-item self-report questionnaire assessing depression symptoms. Item 9 was administered to participants to assess suicidal ideation on a 4-point scale (from 0 =

I don’t have any thoughts of harming myself and 1 = I have thoughts of harming myself, but I would not carry them out to 3 = I would kill myself if I could). This BDI suicide item demonstrates good stand-alone convergent validity with the Beck Scale for Suicide Ideation in inpatient and outpatient samples in terms of desire to attempt suicide (r = .56–.58; Beck & Steer, 1991).

Past suicide attempts. Respondents reported lifetime history of suicide attempts using Item 20 from the Beck Scale for Suicide Ideation (BSI; Beck & Steer, 1991): 0 = I have never attempted suicide;1= I have attempted suicide once; or 2= I have attempted suicide two or more times. The latter two response options were combined to create two participant groups: those who never attempted suicide versus those who have attempted suicide one or more times.

Suicide Ideation Scale (SIS; Rudd, 1989). The SIS is a 10-item self-report measure of a continuum of suicidal thoughts from covert ideation to overt ideation and attempts among nonclinical and clinical samples. Items are scored on a 5-point Likert scale (from 1 = never to 5 = always). The SIS items have shown high internal consistency (coefficient a=.86). The measure’s ability to determine suicide risk has moderate convergent validity via correlations with the Beck Hopelessness Scale (r = .49) and the Center for Epidemiologic Studies–Depression Scale (r = .55; Rudd, 1989). The SIS also discriminates between individuals who have attempted versus those who have not attempted suicide (Rudd, 1989). In the present study, items of the SIS had a Cronbach’s alpha value of .94. Project: Discussion Question Assignment

Beck Hopelessness Scale (BHS; Beck & Steer, 1988). The BHSisa20-itemtrue–false self-report measure of hopelessness, or positive and negative beliefs about the future. The BHS has shown highly consistent scores among clinical and nonclinical populations with Kuder–Richardson reliabilities from .87 to .93 (Beck & Steer, 1988) and scores that correlate moderately well with scores on the Suicide Intent Scale (e.g., Beck, Steer, & McElroy, 1982; Dyer & Kreitman, 1984) and suicide ideation items on the Scale for Suicidal Ideation (r = .46; Beck, Steer, Beck, & Newman, 1993). The BHS has also shown excellent predictive validity as a risk factor for suicide attempts and completed suicide in numerous studies(e.g.,Beck,Brown,Berchick,Stewart,&Steer,1990;Beck & Steer, 1989; Brown, Beck, Steer, & Grisham, 2000). In the present study, items of the BHS had a Cronbach’s alpha value of .90.

Results

Factor Analysis

We conducted an EFA on the data to discern the underlying factor structure of the CARS scale. The solution was produced using an oblique rotation because some correlations between factors were expected. Three criteria guided the exploratory factor analysis to ensure a coherent solution: (a) a minimum of three variables per factor, (b) factor loading size greater than .40, and (c) inclusion of items in factors with the strongest factor cross-loading (Costello & Osbourne, 2005; Guadagnoli & Velicer, 1988; Kahn, 2006; Velicer & Fava, 1998). We combined several approaches to determine the number of factors to retain in the final solution, including parallel analysis (Hayton, Allen, & Scarpello, 2004), examination of the scree plot

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Advancing Suicide Prevention Research With Rural American Indian and Alaska Native Populations

| Lisa Wexler, PhD, Michael Chandler, PhD, Joseph P. Gone, PhD, Mary Cwik, PhD, Laurence J. Kirmayer, MD, Teresa LaFromboise, PhD, Teresa Brockie, PhD, Victoria O’Keefe, MA, John Walkup, MD, and James Allen, PhD

 

As part of the National Action Alliance for Suicide Prevention’s American Indian and Alaska Native (AI/AN) Task Force, a multidisciplinary group of AI/AN suicide research experts convened to outline pressing issues related to this subfield of suicidology. Suicide disproportionately affects Indigenous peoples, and remote Indigenous communities can offer vital and unique insights with relevance to other rural and marginalized groups. Outcomes from this meeting include identifying the central challenges impeding progress in this subfield and a description of promising research directions to yield practical results. These proposed directions expand the alliance’s prioritized research agenda and offer pathways to advance the field of suicide research in Indigenous communities and beyond. (Am J Public Health. 2015;105:891-899. doi:10.2105/AJPH.2014. 302517). Project: Discussion Question Assignment

Although the Surgeon General published a call to action to prevent suicide in 1999,1 national rates of suicide have shown little improvement, and from 2002 to 2010 suicide moved from the 11th to the 10th leading cause of death in the United States2,3 National suicide rates are consistently higher among White men aged 65 years and older than in younger age groups.3 However, suicide remains one of the top 5 causes of death for American adults younger than 45 years and one of the top 3 for adolescents and young adults.2 Although suicide is clearly an important public health priority for all Americans, it is an especially critical issue for American Indians and Alaska Natives (AI/ANs). North America’s Indigenous peoples have disproportionately high rates of suicide deaths, attempts, and ideation, and suicide deaths are approximately 50% higher for AI/AN people than for White people.1,3 However, AI/AN elder suicides are quite rare. Suicide is the second leading cause of death among AI/AN adolescents and young adults, and their rate of suicide is 2.5 times as high as the national average across all ethnocultural groups.2 AI/AN young men are particularly vulnerable4; the Centers for Disease Control and Prevention has reported that AI/AN youths aged 10 to 24 years have the highest suicide rates of all ethnocultural groups

in the United States, at 31.27 per 100 000 among male youths and 10.16 per 100 000 among female youths. To eliminate this health disparity, research identifying the unique factors contributing to AI/AN suicide is essential to tailor interventions to fit the particular cultural and situational contexts in which they occur.1 Driven by the pressing need to better understand and reduce AI/AN suicide, the AI/AN Task Force of the National Action Alliance for Suicide Prevention (NAASP) created a working group to identify research priority areas that have the most potential to reduce suicide and suicidal behavior in AI/AN communities. For this purpose, we (L. W., T. L., and ]. P. G.) worked with Jeff Schulden from the National Institute on Drug Abuse and LaShawndra Price from the National Institute of Mental Health to convene a 2-day, multidisciplinary meeting of suicide researchers in August 2013. The working group identified 3 undertakings as crucial for advancing research in this area: the need to (1) summarize current knowledge about the problem of Indigenous1 suicide, (2) designate key challenges in Indigenous suicide research, and (3) propose future directions that might spur innovation in suicide research among Indigenous people.

Several innovative and promising approaches are currently unaddressed in the NAASP research agenda.5 We, as Indigenous suicide research experts, believe that 3 core issues in research and clinical care are vital for suicide prevention in AI/AN and other communities. Our suggestions are not meant to be prescriptive but rather to highlight the ways in which some dominant approaches can constrain AI/AN suicide research. The proposed areas of study offer some promising new directions for AI/AN research and for suicide research more generally. Project: Discussion Question Assignment

EXPERT MEETING

We were involved in a 3-stage process of consensus building about current challenges and future directions for Indigenous suicide prevention research, and this article is a product of those efforts. We participated in premeeting reflections and presented and discussed our perspectives in a 2-day meeting at the Aspen Institute in Washington, DC, August 19-20, 2013. After the meeting, authors gave feedback on this article through 5 rounds of editing. We describe the procedures involved in developing the agenda of the meeting so that readers will be better able to analyze and make use of the results. To begin, we (L. W., T. L., and J. P. G.) compiled a list of potential participants with expertise in AI/AN suicide prevention who met the following inclusion criteria: (1) peer-reviewed publications related to Indigenous suicide, (2) experience doing empirical research focused on Indigenous suicide, and (3) long-term research (at least 5 years) in the field. After reviewing published articles, reports, and conference abstracts, we identified a list of authors with active AI/AN suicide research supported by the National Institute of Mental Health and National Institute on Drug Abuse, the primary sponsors, and by the National Institute of Alcohol Abuse and Alcoholism. We also circulated the list to the AI/AN Taskforce to elicit additional names. In finalizing the invitee list, we tried to have representation of scholars who are Indigenous themselves, and to include scholars from multiple disciplines including public health, psychology, psychiatry, sociology, education, and anthropology. Next, we contacted individuals by e-mail to determine their interest in participating in a meeting

to encourage dialogue among a multidisciplinary group of researchers about AI/AN suicide and prevention and to conceive of next steps for addressing and reducing suicide and suicidal behavior in tribal communities.

Before attending the workshop, each invited attendee was asked to prepare a short 1- to 3-page statement that (1) outlined the nature of the problem of suicide from their perspective, (2) described current gaps in the knowledge or barriers to research that hinder progress toward suicide prevention in AI/AN communities, and (3) identified promising ways to advance the field and reduce the prevalence and severity of AI/AN suicide and suicidal behavior. These questions formed the basis of each attendee’s short presentation at the meeting. The entire first day involved these presentations, which were given in a round-robin style with questions and discussion after each presentation. On the second day, participants were asked 2 questions regarding their reflections on the previous day’s discussions: (1) what appears to be the most productive research pathways to reduce suicidal behavior in AI/AN communities, and (2) what crucial information is still missing from investigators’ understanding of these issues as they pursue research to prevent AI/AN suicide? Key ideas were recorded and prioritized, again using a round- robin, synthesizing approach. The prioritized ideas were preliminarily agreed on and organized into the themes reflected in this article. A draft article outline was circulated to the group to ensure that it accurately reflected the meeting outcomes, and particular participants, based on expertise, were responsible for drafting particular sections. The sections were pulled together and circulated to all meeting participants for their review and feedback by

the lead author, and the article was then revised several times, incorporating all participants’ feedback until all authors reached consensus. Last, the article was circulated to the AI/AN Taskforce co-chairs for their review, and their suggestions were also included. Project: Discussion Question Assignment

CURRENT KNOWLEDGE OF THE PROBLEM

US researchers have identified several risk and protective factors6 for AI/AN suicide, many of which conceptualize suicide as a problem originating at an individual level rather than a societal one.7 Studies have described the co-occurrence of suicidal behaviors and alcohol and drug use in many AI/AN communities, documenting that more than half of the AI/AN people who have exhibited suicidal behavior were intoxicated at the time.8-11 Childhood adversity is also associated with AI/AN suicidal behavior and ideation.12 Young AI/AN men—in particular those who are unemployed, do not complete schooling, or both—and those with a history of trauma are at greater risk for suicide attempts.13-16 Compared with other ethnocultural groups, AI/AN youths have more severe problems with anxiety, victimization, substance abuse, and depression,1718 which may contribute to suicidality. Research has also linked perceived discrimination and acculturation stress with AI/AN suicide ideation.19-21 Previous research has identified potential targets for intervention at multiple levels, including increasing coping skills, reducing the stigma of mental health services, and building community infrastructure for prevention and health promotion,9,14 yet there is little guidance about how to effectively implement prevention programs in AI/AN contexts.22’23 Unique challenges in Indigenous communities include distrust of formal services, ongoing marginalization, poverty, underemployment, lack of basic services, and collective disempower- ment.24-26 In addition, rural AI/AN communities often lack the resources to ensure safety (e.g., absence of law enforcement on rural reservations and AN villages), do not have access to mental health services,27’28 or do not use the mental health services that are available.29

Research has shown that existing systems of acute care for at-risk and suicidal people are poorly utilized by AI/AN people.22,30,31 In fact, the majority of AI/AN youths never receive any form of behavioral health care, despite behavioral problems, signs of mental distress 32,33 or active suicide ideation.29,34 In 1 study, 65% of ANs who were referred to mental health services because of suicide attempts either did not initiate or complete care.16 When Indigenous people do receive treatment, their care may be culturally inappropriate because of the individualistic and clinic-based intervention offered by primarily non-Native counselors.35-37 These services tend to address primarily psychological rather than social, cultural, and spiritual issues that are often seen as more relevant for suicide prevention in AI/AN communities.24,38-43 Similarly, standard treatment practices do not address the key perceived contributors to AI/AN suicide, ignoring issues such as historical oppression, intergenerational trauma, and ongoing marginalization44-47 In addition, when there is a need for involuntary hospitalization in cases of imminent risk, the intervention itself, which is often offered far from home in rural communities, can further alienate or distress Indigenous people 48,49 Taken together, previous research has underscored the need for practical and collaborative research on intervention and prevention strategies that are culturally consonant and that can have more sustainable impacts. Project: Discussion Question Assignment

AMERICAN INDIAN/ALASKA NATIVE SUICIDE RESEARCH

To determine current trends in AI/AN suicide research, we performed a PubMed search using the terms American Indian or Alaska Native and suicide for peer-reviewed academic sources and empirical research published from 2004 to 2014. The search produced 30 articles, of which we excluded 10 commentaries and reviews. We documented each of the remaining 20 articles’ focus on deficit- or strengths-based variables or methods, orientation (e.g., participatory or investigator directed), and level of outcome (individual or community). Of these 20 articles, 90% (n= 18)1-18 measured only individual-level factors, 60% (n = 12)1_5’7~9,12,14,17,19 focused on deficits or risks, and only 30% (n = 6)47~51 described doing the research in collaboration with AI/AN groups. Some of these trends, such as focusing on individual-level processes and outcomes and limited information about community involvement in project development and implementation, were found in another recent literature review focused on existing AI/AN alcohol, tobacco, and other drug and suicide prevention intervention literature. In addition, the recent review by Allen et al.49 noted a need for increased focus on the process aspects of this work rather than only on outcomes and for use of local knowledge and theory to frame and guide intervention. Project: Discussion Question Assignment