Suicide Prevention and Intervention: Considering Cultural Differences
Mental health and suicide prevention services must be tailored creatively to the needs of each culture.
More than 1 million individuals worldwide die by suicide annually.1 Although suicide exists in every country, religious group, and age group, suicidal behavior is “differently determined and has different meanings in different cultures.”2 Yet, despite the clear role of culture in suicidal behavior, it is often neglected by clinicians.3
Certain risk factors — depression, anxiety, and mental illness — are common in all cultural groups, Sherry Molock, PhD, associate professor of psychiatry, George Washington University, Maryland, told Psychiatry Advisor. But these factors may present and be conceptualized differently across different cultures. Mental health and suicide prevention services must be tailored creatively to the needs of each culture.
Is Suicide Always Taboo?
Unlike US culture as a whole, “Asian cultures condone and accept the practice of suicide as legitimate in the context of familial shame, interpersonal conflict, and for altruistic reasons,” observed Aruna Jha, PhD, LCSW, research assistant professor, University of Illinois at Chicago. “When informed of a death by suicide, Asians are more likely to say it was understandable.”
“Asian cultures tend to be other-focused and community-based,” she told Psychiatry Advisor. “If people think their family will be dishonored by their behavior, they see suicide as a legitimate option.”
In contrast, among blacks suicide is taboo. “Suicide is seen as a sin, and the spiritual and cultural norms are often regarded as protective,” Dr Molock observed. “But those same norms may prevent people from getting help because even suicidal ideation is regarded as taboo.”
Barriers to Seeking Help for Suicidal Ideation
Fewer members of racial and ethnic minorities than members of the general population seek help for mental health, even after controlling for factors such as lack of health insurance and socioeconomic status.4
“Shame and stigma prevent Asian Americans from acknowledging mental illness,” said Dr Jha, who is the founder of the Asian American Suicide Prevention Initiative. “Often, mainstream providers who are not sensitized to Asian cultural values are unable to bypass the shame-based resistance that Asians have toward seeking help and discussing mental illness or suicidality.”
Among blacks, stigma is likewise a barrier to seeking help. “African Americans are less likely to think it is acceptable to seek help from a mental health professional because it can be viewed as a personal or spiritual weakness,” Dr Molock said. Instead, blacks are more likely to turn to family members, friends, or clergy. Moreover, “young men are socialized not to talk about feelings, fear, or being vulnerable.”
Suicide in Adolescents and Young Adults
In both the Asian American and the black communities, the incidence of suicide among adolescents and young adults is high. Suicide is the third leading cause of death for young black males ages 15 to 24 years. Blacks die by suicide a full decade earlier than the general population, with an average age of 32 vs 44.5
Racial discrimination is an important reason for this, Dr Molock said. “Police violence against young black men has been traumatizing, and graphic footage has increased that trauma.” In addition, “many youngsters who live in impoverished communities or are exposed to violence have a sense of fatalism and feeling devalued.”
Asian American college students have markedly higher suicidal ideation and completed suicide rates than do non-Asian students.6 “As youth individuate from families and absorb more American values of individualism, they can feel ostracized by parents who may suggest that they have betrayed the culture by adopting American ways,” Dr Jha said. “College students report that this is a significant source of stress that can lead to the desire to end life.”
Additionally, “the image of the ‘model minority' also creates stress for Asian American youth. They are under immense pressure to excel academically, leading to a sense of family betrayal if they acknowledge academic struggles to their parents.” Parents often choose careers or majors for their children, “and even today, many young women are pressured into arranged marriages, which can lead to suicidality.”
Engaging Asian American Families
Many US clinicians may not understand that “individuals from family- and community-centric cultures are not comfortable in an environment with individual self-determination.” Psychoeducation of family is particularly important. “However, the patient may request that no one be informed of the clinical discussion,” Dr Jha said.
The clinician's assessment and intervention “have the objective of empowering the individual within the context of the family and community.” So the first step is to get permission to bring in the parents or spouse. “In my experience, this is relatively easy, because most suicidal individuals actually hope someone will help them communicate with their family.” It is up to the clinician “to recognize this unstated or stated wish. ‘What if I were to help you have the conversation with your parents/spouse?'”
Since suicidal individuals feel disempowered, “you cannot risk taking choice away from them completely,” Dr Jha warned. “Ultimately, the choice to die is at least one thing they have control over.” So if a parent or family member is not immediately available, “arrange with the patient to wait. ‘I know you want it all to end, but how do you feel about tabling the decision until you have had this conversation?'”
The clinician “may need to take an active role in mediating the conversation. ‘Would you allow me to explain it to them?' This gives the choice back to the patient and also buys time.” Dr Jha not only facilitates the conversation but also educates families regarding the nature of suicidal thought patterns and models the way to conduct a conversation about them.
“Parents have reported relief and a higher level of stability after this type of mediated consult,” Dr Jha reported.
Suicide Prevention Among Blacks
While suicide remains a significant problem among blacks, there are “important protective factors, including a supportive environment, family support, peer support in younger people, and belonging to a faith-based community,” Dr Molock reported.
“Providers can talk to pastors,” suggested Dr Molock, who is the co-pastor of the Community Church in Accokeek, Maryland. She reported that in one Baptist church that she used to attend, “we went from not being able to talk about suicide at all, to sermons and Bible study on the subject, to asking for family support for a suicide.”
Dr Molock added that despite taboos against suicide and “concerns regarding sexual behavior and orientation, churches still do a phenomenal job working with youth” because of the commitment to “make sure the next generation thrives.”
Tips for Clinicians Working With Asian Americans and Blacks
Understand the patient's language. “If language is a problem, it is essential to find a really good interpreter who understands not only what the patient and clinician are saying, but who can interpret the patient's words from a culturally nuanced perspective,” Dr Jha advised.
Address reluctance to seek help. “The clinician is in a unique position to be an influential person in the patient's life,” Dr Molock stated. “So spend a little extra time exploring the patient's view about help-seeking. This is the opportunity to educate people about mental health counseling.”
She emphasized the importance of using the word “counseling” vs “therapy” when working with blacks. “Therapy seems more serious and more associated with being ‘crazy.' But counseling is less threatening.”
If patients require psychotropic drugs, it helps to compare the medications to insulin or antihypertensive agents. “I use the word ‘stabilize' regarding the role of medication, because it is similar to insulin that ‘stabilizes' blood sugar or antihypertensive agents that ‘stabilize' blood pressure levels,” she said.
Talking about suicide does not precipitate suicide. Broaching the subject of suicide “allows things to come out into the open so people can get the help and resources they need,” Dr Molock said. Dr Jha added, “there is often a feeling of relief when a suicidal person can openly talk and feel understood and supported.”
Help patients navigate the healthcare system. “It is overwhelming for a person in a crisis to figure out facilities, insurance coverage, copays, and scheduling,” Dr Molock observed, encouraging clinicians to “create a structure to help the patient navigate these issues.” Clinicians who do not have time to personally provide this service should consider recommending colleagues, such as social workers or patient advocates, or online resources, such as Zocdoc.7
A recent article in The Washington Post noted that racial and ethnic diversity has increased in the United States.8 Clinicians will increasingly be called upon to provide “culturally sensitive services that can be effective in treating and possibly preventing episodes of acute mental illness” and suicide.9
- Mishara BL. Suicide prevention: international efforts and cultural themes. Presented at the 7th World Suicide Prevention Day. New York, NY: United Nations Headquarters. September 10, 2009. https://www.iasp.info/wspd/pdf/2009_wspd_president_un_speech.pdf. Accessed January 18, 2017.
- Lester D. Suicide and culture. WCPRR. 2008;51-68. http://www.wcprr.org/pdf/03-02/2008.02.5168.pdf. Accessed January 18, 2017.
- Colucci E. The cultural facet of suicidal behaviour: its importance and neglect. Australian E-Journal for the Advancement of Mental Health. 2006;5(3):234-246. http://www.tandfonline.com/doi/abs/10.5172/jamh.5.3.234. Accessed January 18, 2017.
- Broman C. Race difference in the receipt of mental health services among young adults. Psych Serv. 2012;9:38-48.
- Suicide Prevention Resource Center. Suicide among racial/ethnic populations in the United States: Blacks. www.sprc.org/sites/default/files/migrate/library/Blacks%20Sheet%20August%2028%202013%20Final.pdf. Accessed: January 11, 2017.
- American Psychological Association. Suicide among Asian-Americans. www.apa.org/pi/oema/resources/ethnicity-health/asian-american/suicide.aspx. Accessed: January 11, 2017.
- Zocdoc. Available at: https://www.zocdoc.com. Accessed: January 13, 2017.
- Keating D, Karklis L. The increasingly diverse United States of America. The Washington Post. November 25, 2016. www.washingtonpost.com/graphics/national/how-diverse-is-america/. Accessed: January 13, 2017.
- UPenn Collaborative on Community Integration. Community Integration Tools. Cultural competence in mental health. Available at: http://tucollaborative.org/pdfs/Toolkits_Monographs_Guidebooks/community_inclusion/Cultural_Competence_in_MH.pdf. Accessed: January 13, 2017