When she was working with American Indian communities in the Pacific Northwest to identify and build support for adolescents at risk for suicide, June Strickland, PhD, RN, did not call the endeavor a “suicide prevention project” or refer to the young people as “troubled.” Instead, she and her colleagues called the effort a “youth wellness program,” and when she met with parents, she spoke of their children’s “gifts”--special qualities that happened to make them more sensitive and more susceptible to absorbing pain. These carefully chosen words carried meaning because American Indian cultures emphasize positive concepts to promote healing. A negative approach focusing on brokenness would have failed.
This reframing of the issue was just one of the many ways the program was tailored to fit the tribal communities. Strickland, who is a member of the Cherokee tribe, bonded with the youths through traditional cultural activities, such as making baskets and working with clay, and she became part of the communities, visiting the hospital when a mother delivered a baby or someone was sick. She gave each of the young people a little pottery flower she made with her phone number on the back, so they could call her whenever they wished. She shared wisdom from her people, but also encouraged the teens to talk to their elders to learn about their own tribe’s traditions. The effort involved the whole community. Tribal leaders helped develop protocols and held celebrations to honor the youngsters.
The results were dramatic: Suicide risk and ideation decreased after just one year. Ten years later, Strickland, an associate professor of psychosocial and community health at the University of Washington School of Nursing, still gets calls from the young people, and she remains involved in the communities through other projects, including cancer prevention.
Her work, which was part of a larger suicide prevention project in the Seattle area in the 1990s, is an example of a culturally appropriate approach to suicide prevention and of the key role minority nurses can play in helping to restore hope in high-risk communities of color.
In recent years, racial and ethnic disparities in suicide rates--especially among young people--have become an urgent public health crisis. Statistics paint a grim picture:
• American Indian and Alaska Native (AI/AN) people have the highest suicide rates of any minority population in the country. Suicide is the second leading cause of death for young AI/AN people ages 15 to 24, with a rate 2.4 times that of the overall U.S. population.
• Asian American and Pacific Islander (AAPI) women ages 15 to 24 kill themselves at a higher rate than other women of the same age group, and AAPI women over age 65 have the highest suicide rates among seniors of all races.
• In 2005, a greater percentage of Hispanic high school girls reported thinking about, planning or attempting suicide than white or African American girls.
• Suicides among young African American men have risen alarmingly. The suicide rate for black men in general is almost seven times higher than for black women.
Preventing suicide is a task for every nurse, not just those who specialize in mental health. Because they spend so much time with patients, nurses are in a unique position to recognize when people are in trouble and to intervene, according to the Suicide Prevention Resource Center (SPRC), a joint project of the Substance Abuse & Mental Health Services Administration (SAMHSA) and the Education Development Center (EDC).
“Community nurses, public health nurses, school nurses and home health nurses are in the best position of any discipline to intervene, because they’re naturalists in those environments,” says Faye Gary, EdD, RN, FAAN, Medical Mutual of Ohio Professor of Nursing for the Care of Vulnerable and At-Risk Populations at Case Western Reserve University’s Frances Payne Bolton School of Nursing in Cleveland. “They’re not strangers.”
A variety of complex factors put Americans of color at risk for suicide. Nurses who understand the cultural and community contexts of their patients’ lives are better equipped to recognize warning signs and introduce interventions.
The dissolution of the family support system is among the risk factors for Hispanic adolescents after their families immigrate to the United States, says Mary Lou de Leon Siantz, PhD, RN, FAAN, assistant dean for diversity and cultural affairs at the University of Pennsylvania School of Nursing and director of the Migrant Health Program at the university’s Center for Health Disparities Research. Hispanic culture emphasizes group cooperation for the good of the family, while the majority American culture emphasizes working hard to get ahead as an individual, she explains. Adolescents break away from their parents sooner here than in countries such as Mexico, and the cultural clash can be hard on both teens and their families.
Today’s anti-immigration sentiment also takes a toll, says Siantz, who is a past president of the National Association of Hispanic Nurses. “It doesn’t matter how long you’ve been here,” she maintains. “There’s so much animosity [against Hispanics] that teens are almost embarrassed to speak Spanish. Through school and friends, they further break ties from heir families.”
Cultural stigma about mental illness can be still another risk factor for this population, because it can prevent depressed people from seeking the help they need. “[Mental illness] is thought of as the curse of the devil and comes with great guilt,” Siantz notes. “A person [suffering from depression] might tell himself, ‘Obviously I did something terrible and it’s my fault.”
Because of this stigma, which is also very strong in the Asian community, patients are unlikely to say they’re depressed but instead will complain of physical ailments, such as stomach pains and headaches, or symptoms such as nervousness and sleeplessness. Even if patients at risk for suicide do reach out for help, health care providers can miss the warning signs if they don’t speak the patient’s language or lack cultural sensitivity.
Culture clash, high expectations and the pressures of being perceived as “the model minority” all help explain the high rates of suicide among young Asian American women, says Linda Beeber, PhD, RN, CS, a professor of psychiatric nursing at the University of North Carolina at Chapel Hill. Earlier in her career, she worked at a psychiatric clinic where she provided care to young immigrant women from Korea, Japan and China who struggled with depression and contemplated suicide. Many of them came to the U.S. to study or be with their spouses and found themselves torn between two cultures without support from their families, all the while under great pressure to succeed. Some, for instance, worked all day in a laboratory doing graduate work, then had to assume the traditional female role at home. “They had difficulty bringing those two worlds together,” Beeber explains.
Asian Americans and Pacific Islanders are much less likely than Caucasians to talk about their mental health concerns to friends, family or health care providers, according to the SPRC. They tend to view emotional problems as shameful and are less likely to seek mental health treatment than other racial and ethnic groups.
American Indian and Alaska Native youth have the highest suicide rates of any young people, although rates vary from tribe to tribe. Extreme poverty, lack of job opportunities, substandard housing and substance abuse are all significant risk factors. In many AI/AN communities, cultural destruction and forced assimilation to the majority culture have weakened traditional bonds of tribal unity and parental influence--important support systems that can help safeguard kids from depression and suicide.
Meanwhile, suicide among young African American men does not get enough attention from researchers, Gary believes. In 2005 the suicide rate for black Americans of all ages was 5.25 per 100,000 people--about half the overall U.S. rate of 10.75 per 100,000, according to the Centers for Disease Control and Prevention. However, the suicide rate for young black men between the ages of 20 and 24 was 18.2 per 100,000--almost twice the rate for the overall U.S. population and more than three times the rate for black Americans as a whole.
Some researchers believe that suicide rates for both African American and AI/AN young people are actually undercounted, theorizing that some young men living in despair and poverty deliberately put themselves in harm’s way to get themselves killed. For example, they may abuse drugs and alcohol, drive recklessly or even provoke police into shooting them. This is sometimes referred to as “hidden suicide.”
According to the U.S. Department of Health and Human Services’ Office of Minority Health (OMH), reversing the trend of rising suicide rates in communities of color “will require a renewed and revitalized approach, one that involves the courage to switch gears.” Addressing the problem will require multiple resources and a willingness to form partnerships that extend beyond the health care profession.
“We need to look at suicide in minority communities through the context of socioeconomic factors, such as acute poverty, joblessness, deindustrialization and drug abuse,” says Roberta Waite, EdD, MSN, RN, CS, assistant professor of nursing at Drexel University in Philadelphia.
There are no easy answers and a one-size-fits-all approach won’t work. The OMH emphasizes the importance of culturally and linguistically competent suicide prevention programs, early interventions and the involvement of families and entire communities. And this is exactly where minority nurses can make their most important contributions--through culturally sensitive research, clinical care and, especially, community outreach.
“We need to make the general public aware and alert individuals about [the problem], but the efforts must be specific to communities rather than something designed for everybody,” Gary says.
“You’ve got to spend time with folks in the community,” Beeber agrees. “You have to become a known entity.”
Beeber is currently the principal investigator of a community-focused research study that is testing in-home interventions to reduce depression in low-income mothers of infants and toddlers and improve young children’s mental health. The study has two components: The HILDA Project serves primarily low-income African American and Caucasian mothers in several North Carolina communities and in Syracuse, N.Y., while the Alas (Spanish for “wings”) Project targets Spanish-speaking mothers in four North Carolina counties. In both programs, psychiatric nurses visit the mothers weekly for five months, helping them develop coping skills to face difficult issues, improve their parenting skills and increase their use of social support resources.
“We’ve seen that through the interventions, the moms can reduce their depressive symptoms,” Beeber reports. “The programs reach mothers who probably would not be reached by traditional mental health [services].”
This would not happen, though, without strong community partnerships. The researchers work hand-in-hand with Early Head Start, a federally funded program for low-income families with infants and toddlers. Early Head Start staff, who have already established relationships with the families, screen mothers for symptoms of depression and encourage them to participate in the HILDA and Alas projects. The research team also works with Latino and African American community organizations, and through the years Beeber has established trust through many hours of community volunteer work.
Nurses must get involved in the community to reach people where they live their daily lives. For example, Ruby Murphy, RN, MS, a case manager for mental health emergency services at Jackson Memorial Hospital’s Mental Health Hospital Center in Miami, educates people in the local black community about depression through church health fairs. This is an ideal venue because many African Americans rely on prayer and spiritual support to deal with emotional problems and because the church is a hub of the community. Through this outreach work, Murphy teaches individuals and families how to recognize signs of depression and what to do if they think they or someone else is suffering from this illness.
Gary advises nurses to learn about the conditions and resources in the communities in which they work. “How do people feel about the resources, and do they use them? Who are the natural caregivers and community brokers? What is the rhythm of the community?”
By forming partnerships with these community resources, nurses can make information about mental health care and suicide prevention available at housing projects, day care centers, schools, barbershops and beauty salons, neighborhood youth centers--wherever people go in the course of their day-to-day activities.
Above all, community-based suicide prevention initiatives must be ongoing and consistent, Gary says. “You don’t go in and do it for a year, and then leave.”
On the individual patient care level, being culturally knowledgeable can give nurses an advantage in recognizing minority patients who may be at risk for suicide and in intervening early enough to save their lives.
In her research on depression among African American women, Waite found that understanding the cultural context of patients’ lives could lead to earlier detection of the disease. She studied how African American women articulate, conceptualize and cope with depression. Because of cultural and social norms, many of the women hid their depression from family and friends. The study reported one participant saying, “Being strong is seen as good. If I said I was depressed, people would say, ‘You’re a better person than that.’ You are labeled, and if you are perceived as ‘crazy,’ they do not want any part of you.”
Strickland’s Cherokee cultural background helped her connect with youth in the Pacific Northwest tribal communities, but she also delved deeper to learn more about the stressors and protective factors in the young people’s lives. One girl, for instance, reported deep anger over the rape of the land and the historical trauma her people had suffered for generations. The teens also spoke of the healing power of going to water, spending time in the mountains and talking to their grandmothers.
Of course, it is unrealistic to expect nurses to have a thorough understanding of every culture. But treating patients with cultural sensitivity and respect can do a lot to help fill in the gaps.
“There are so many nuances in culture,” Gary says. “You can’t know it all, but if you respect yourself and what you have to offer and also respect the individual and family, then you’ll manage.”
Any nurse, not just those specializing in mental health, can refer depressed patients for help, and should do if there is even a hint that a patient is at risk for harming himself or herself, says Murphy. Nurses must be familiar with the warning signs for suicide and sharpen their assessment and interviewing skills so that they know how to ask the right questions. “Good communication skills are imperative, because they can be life-saving,” she stresses.
Nurses should not shy away from broaching the subject of suicide if they think a patient might be at risk--even if suicide is a taboo subject in the patient’s culture, experts say. In focus groups for Beeber’s Alas Project, Latina mothers said they would confide in nurses about feelings they would not share with family members or friends.
“It takes courage on the part of nurses to bring up the subject of suicide, but you have to ask the questions in the context of a relationship,” Beeber says. “I can’t emphasize enough that you have to have a relationship with people because that’s the only way you’re going to hear how they really feel.”
A patient-centered approach is critical, Waite believes. Too often, health care providers approach problems with an “I know what’s best for you” attitude, instead of taking time to listen to the patient’s perspective.
“You need to connect with patients where they are,” she says. “If the patient thinks praying for 15 minutes a day helps, then you start working from there.”
National Strategy for Suicide Prevention
Suicide Prevention Resource Center
National Institute of Mental Health
National Organization for People of Color Against Suicide
Indian Health Service Community Suicide Prevention Website
American Association of Suicidology
Suicide Prevention Action Network USA
American Foundation for Suicide Prevention
Warning signs of suicide include:
Observable signs of serious depression:
• Unrelenting low mood
• Anxiety, psychic pain and inner tension
• Sleep problems
Increased alcohol and/or other drug use
Recent impulsiveness and taking unnecessary risks
Threatening suicide or expressing a strong wish to die
Making a plan:
• Giving away prized possessions
• Sudden or impulsive purchase of a firearm
• Obtaining other means of killing oneself, such as poisons or medications
Unexpected rage or anger
Source: American Foundation for Suicide Prevention