Articles and Publications
Cultural Competency
Author: Donna H. Barnes, PhD, (ed.)
Originally Published In , August 2004 DOWNLOAD PDF
Cultural Competency
Developing Strategies to Engage Minority Populations in
Suicide Prevention
Report from the NOPCAS Task Force
Edited by Donna Holland Barnes, Ph.D.
2003 / 2004
CONTENTS
INTRODUCTION?????????????????????...3
Mission and Vision
Target Populations
UNDERSTANDING COMMUNITITES OF COLOR ???????.6
Internal Complexities
Health Statistics and Suicide Rates
Models of Health and Illness
Approaches to Intervention
Causal and Contributing Factors of Suicide in Minority
Populations
Cultural Competencies required to Intervene
SUMMARY????????.???????????????...18
APPENDIX?.???????????????????????19
Task Force Members
References
Suicide Deaths, Substance Abuse Treatment Admissions Mental
Illness Hospitalization Data and Suicide Attempt Data by
State (2000)
INTRODUCTION
The National Organization for People of Color Against
Suicide (NOPCAS) was contracted by the Suicide Prevention
Resource Center (SPRC) to develop ways to engage minorities
in suicide prevention, intervention, and postvention
initiatives. Under the contract, NOPCAS developed a task
force of Latinos, African Americans, Asians, and American
Indians to help develop a plan for SPRC. For the first
phase of the project, the task force met for two days in
August 2003 to identify specific characteristics that
distinguish each of the sub-communities that comprise the
minority community, and to discuss strategies to
communicate effectively with each sub-community.
Due to the difficulty of this undertaking, the task force
decided to develop a document that would outline the issues
involved in engaging communities of color. The task force
determined that phase II of the project would address
effective engagement methods in more detail.
Suicide prevention and intervention initiatives for
minority groups must be tailored to ensure social justice,
ethnical acceptability, and effectiveness (IOM, 2003;
Dumas, 1999). This document will address the complexities
associated with defining each ethnic group represented in
the task force. The document will hopefully provide readers
with a better understanding of the challenges we face in
communicating more effectively with specific communities,
and what we might do to address the challenges.
Cultural competence results from a developmental process
that depends on the continued acquisition of knowledge, the
development of skills and ongoing evaluations of progress
(Diller, 1999). Hence, there is a necessity for ongoing
training.
Mission and Vision
The Suicide Prevention Resource Center is designed to help
intervention agents, researchers, and educators obtain and
use unique skills and practices that are necessary to
become sensitive to cultural differences.
As a result, the NOPCAS task force is dedicated to
developing an understanding among intervention specialists
and agencies of culturally sensitive prevention and
intervention strategies. This approach will better serve
specific minority communities, and can improve the
effectiveness of efforts to include other ethnic groups in
program initiatives.
Target Populations: Demographic Complexities When
Identifying Communities
Racial and ethnic minority populations are increasing
throughout the United States. The U. S. Census (2000)
indicates that the nonwhite population is expected to
exceed 50 percent by 2050. There is a widespread consensus
that health interventions should be tailored for specific
populations (IOM, 2003).
The ordinary use of the term ?community? refers to more
than a set of people who occupy analogous locations in
social or institutional structures. The term also refers
to a group of people who share common interests and
understand those interests in the same way. For
example, ?communities of color? or the ?Hispanic community?
can be used to indicate members of a common geographic
location, or members of communities that share
characteristics other than location. In fact, members of
ethnic groups can have highly developed forms of
association apart from geographic affiliation, such as
language, lifestyles, religious belief systems, and
attitudes and behaviors. These forms of association can
vary in terms of dialect, tribe, religious beliefs, and
class levels, resulting in a ?distributed cognition,? or a
thinking that is distributed across an entire group of
people beyond one area, block or city. The following will
suggest who comprises the communities in each ethnic
minority group.
Latinos
Latinos, also known as Hispanics, have a population that
now reaches more than 37.4 million in the United States.
According to the U.S. Census (2000) 66.9 percent of Latinos
are of Mexican ancestry, a population that includes U.S.-
born Mexican Americans (also known as Chicanos) whose
families may have been in the Southwest for many
generations, as well as many recent Mexican immigrants
(Tatum, 1997). Central and South Americans make up 14.3
percent and Puerto Ricans make up 8.6 percent of the Latino
population while 3.7 percent are of Cuban ancestry. The
remaining 6.5 percent are of ?other Hispanic? origins.
The Latino community is unique in its diversity, and in the
relatively young age of its members. These factors are
critical to understanding the community, over and above
reasons that members of the community may have immigrated
into the United States. While the majority of U.S. society
is growing older, the Latino community is growing younger.
Its rapid growth and younger age can be attributed in great
part to immigration. According to the latest census,
Latinos are now the largest minority population, comprising
13 percent of the population (37.4 million), and accounted
for half of the nation?s population growth between 2000 and
2002. It is a young population, forming households in
numbers similar to rates associated with the ?baby boomers.?
African-Descent and/or Black Americans
African-Descent and/or Black Americans constitute
approximately 36 million people in the United States or 13
percent of the civilian noninstitionalized population. This
population also consists of African Carribbeans, African
Hispanics and Africans-second generations. This does not
include the additional 2 million people who identified
themselves as ?multiracial? in the 2000 census, or who
identified themselves as being black and at least one other
race.
The majority of blacks - close to 19 million - live in the
South, which saw its black population increase by 3 million
people since 1990. Ten southern states now have black
populations exceeding one million members. Texas,
California, and New York each have black populations
exceeding two million members.
The overwhelming majority of Americans of African ancestry
are descendants of slaves, who were forcibly brought from
western Africa to the Americas during the 18th and 19th
centuries. In addition, since the end of World War II, a
significant number of people of African ancestry have
immigrated to the U.S. from the Caribbean and Africa. Due
to the unique conditions posed by slavery, many African
Americans cannot trace direct cultural ties to African
ethnic groups (Franklin and Moss, 1988)
The Black population grew at a faster pace between 1990 and
2000 than the total U.S. population, and tends to be
younger, more concentrated in the South and in central
cities than the majority population (McKinnon, 2003).
However, the population is made up of numerous cultural
variations.
Asian Americans and/or Pacific Islanders
Though Asian Americans and/or Pacific Islanders do not
constitute a large proportion of the U.S. population,
according to the US Census report (2003), there are 12.5
million Asians (4.4 percent of the U.S. population) and
nearly 900,000 Pacific Islanders (0.3 percent). ?Asian?
refers to those having origins in the Far East, Southeast
Asia or the Indian subcontinent, including Cambodia, China,
India, Japan, Korea, Malaysia, Pakistan, the Philippines
Islands, Thailand, and Vietnam. ?Pacific Islander? refers
to those having origins in Hawaii, Guam, Samoa, or other
Pacific Islands.
Asians and Pacific Islanders tend to be concentrated in the
West, but they are much more urban than other non-Hispanic
White communities. Ninety-five percent of all Asians and
Pacific Islanders live in metropolitan areas.
Although cultural ties exist among the different AA/PI
communities, it is important to recognize the differences
among the groups. Asian Americans and Pacific Islanders
represent very diverse populations in terms of ethnicity,
language, culture, education, income level, English
proficiency, and sociopolitical experience. As many as 43
different ethnic groups make up the Asian-American group,
and the majority were born overseas (Lee, 1998). Their
population is projected to grow to 20 million by the year
2020. Asian Americans and Pacific Islanders, as groups,
speak over 100 languages and dialects with an estimated 35
percent living in linguistically isolated households. It is
reported that no one age 14 or older speaks English ?very
well? (President?s Advisory Commission on Asian Americans
and Pacific Islanders, 2001).
American Indians and Alaska Natives
The population of American Indians and Alaska Natives
totaled 4.1 million in the 2000 Census. This represents
more than 560 different cultural communities federally
defined as sovereign entities, in which the United States
has a government-to-government relationship (Tatum,
1997). ?American Indian? or ?Alaska Native? describe
individuals whose origins are in North and South America
(including Central America) and who maintain tribal
affiliation or community attachment. There are an estimated
200 Native groups that are not recognized by the U.S.
government. Each of these cultural communities has its own
language, customs, religion, economy, historical
circumstances, and environment (p. 144).
The majority of the federally recognized American Indians
live in the southwest. Over half of the population lives
in urban areas to be near jobs and schools. Too narrow a
focus on cultural differences that exist between the Indian
and nonIndian cultures may tend to obscure other important
differences that exist between American-Indian Tribes.
Because there are over 250 different languages spoken
within the community - customs, including patterns of child
rearing; attitudes towards health and illness; family
structure and roles vary widely from tribal group to tribal
group. This is true even for tribes within the same
geographic region, such as in Oklahoma, which hosts 38
different tribes and the largest Indian population in the
United States. Varying levels of acculturation, urban
versus rural lifestyles, and interracial marriages are some
factors that contribute to diversity in this population.
The history of American Indians includes a variety of Anglo
intrusions into American-Indian society, including through
systems that have influenced traditional tribal systems of
education, law, and religion.
UNDERSTANDING COMMUNITIES OF COLOR
Internal Complexities
How do you sort people? Attempts to communicate suicide
prevention and intervention messages to diverse populations
can be complicated. What are the primary constructs? Do
we consider color of skin, shared heritage, cultural
beliefs, and religious beliefs?
In fact, there are various belief systems, religions
practices, and behavioral patterns that must be considered
for each ethnic population. Because suicide prevention and
intervention initiatives focus on behavioral change - i.e.,
developing practices to minimize suicidality - the primary
construct should be behavioral. It is important to be
clear of the targeted behavior to be changed, and to
understand what controls such behavior, such as attitude,
perceived norms, or personal agency (IOM, 2003).
Where community or cultural history and experiences drive
behavior, it is necessary to be aware of the fact that one
ethnic community may have many distinct populations with
various historical relationships to the United States. For
example, Mexican Americans have a different history than
Puerto Ricans or Dominicans. The same is true of multiple-
generation African-Americans descended from U.S. residents,
and those descended from recent African immigrants. Some
diverse populations were incorporated into U.S. society
against their will, such as Mexican Americans, African
Americans, and American Indians, while other groups were
not, such as African Caribbeans, Dominicans and
Nicaraguans. While reducing populations to race or ethnic
background can be insensitive, it can also limit the
ability to recognize unique histories within a population,
which in turn can undermine the effectiveness of strategies
to reach diverse communities.
One of the major defining issues within groups is
acculturation?an appreciation for (and contact with) the
dominant culture and a form of assimilation. While most
ethnic groups work at assimilating with the dominant
culture, and are encouraged to do so because it helps
maintain positive relationships?more attention needs to be
focused on conflictive issues that develop once
acculturated. For example, many individuals in certain
groups who are proficient in English tend to disassociate,
or leave behind, family members who are not. This can lead
to loss of family bonds and support. Similarly, studies
have shown a correlation between acculturation and elevated
suicide rates among young black males (Willis, et al,
2003). The lack of a strong sense of identity in relation
to the dominant group can become a key risk factor for
suicidal behavior. However, this is not found to be true
for U.S. born Mexican Americans compared to those who are
Mexican-born (Sorenson and Golding 1988).
Because an individual is from a diverse population does not
mean that he or she is not socially competent in more than
one culture. Nor does it mean he or she is not comfortable
with the majority culture. Bicultural and acculturated
individuals might be served in the same manner as majority
participants, but preventive interventions for suicidality
could be tailored to meet the needs of those who are less
fluent with the majority culture, as suggested by some
researchers. For example, it could be argued that poverty
and language prevent communities from being familiar with
and proficient within the dominant culture.
Health Statistics and Suicide Rates
Table 1 ? Percentages of 10 leading causes of death by
race, both sexes, all ages
(2000)
Black (%) Latinos (%) Asian (%)
American Indian (%)
Diseases of heart 27 24 26 22
Malignant Neoplasm 22 20 27 17
Cerebrovascular Disease 07 06 10 05
Chronic lower respiratory 03 03 04 04
Accidents/unintentional injuries 05 09 05
12
Diabetes melitius 05 05 04 06
Influenza and pneumonia 02 03 04 03
Homicide 03 03 -- --
Nephritis 03 -- 02 02
Suicide -- -- 02 03
Human Immunodef Virus(HIV) 03 -- -- --
Chronic liver disease -- 03 -- 05
Certain conditions perinatal period -- 02 02
--
The aforementioned statistics are based on general race
categories with the understanding that Hispanics can be of
any race, but are included in the charts as a separate
category. Thus, from a statistical point of view, we are
lumping groups of people together blindly without
respecting the complexity within the broad categories of
Asians and Asian Americans, Africans and African Americans,
Latino and Hispanics, and American Indians and Alaskan
Natives. The statistics do not capture the complexity that
arises when comparing sub-communities. Developing exact
information that describes the various sociocultural
processes of each ethnic category is a challenge at best.
In fact, some research indicates such information cannot be
fully developed at the present time because the
circumstances under which diversity matters within diverse
populations cannot be determined (IOM, 2002).
Latinos
There has been little research on suicide in the Latino
community. As a result, statistical data necessary to
understand suicide among Latinos is limited. In 2001,
Latinos had a suicide rate of 5 per 100,000 compared to
over 19 per 100,000 for Whites. However, in the 2003 Youth
Risk Behavioral Surveillance System, Latino students (10.6
percent) were more likely than White students (6.9 percent)
to have reported a suicide attempt. Also, Latino students
were more likely to have made a suicide plan (17.6 percent)
than White males (16.2 percent). Latino female students
(5.7 percent) were significantly more likely than white
female students (2.4 percent) to attempt suicide and
require medical attention.
Researchers have found that among Latinos with mental
disorders, fewer than 1 in 11 contact mental health
specialists, while fewer than 1 in 5 contact general health
care providers. Among Latino immigrants with mental
disorders, fewer than 1 in 20 use services from mental
health specialists, while fewer than 1 in 10 use services
from general health care providers (Mental Health, 2001).
One study found that 24 percent of Hispanics with
depression and anxiety received appropriate care, compared
to 34 percent of Whites. Another study found that Latinos
who visited a general medical doctor were less than half as
likely as Whites to receive either a diagnosis of
depression or antidepressant medicine.
African-Descent and/or Black Americans
The rate of suicide among African Americans has
historically been lower than that of Whites, however, the
rate of suicide among young Black males increased
substantially from 2.1 to 4.5 per 100,000 in the 1980s.
The suicide rates increased the most for Blacks 10 - 14
years of age (MMWR, 1998). The trend reversed in the mid-
1990s, and the suicide rate among young African-American
males aged 15 - 24 years has steadily declined since
1994. The suicide rate for African-American women has
been 2 per 100,000 for the past two decades. African
American women have the lowest rate of suicide among all
ethnic groups in the United States.
Asian Americans and/or Pacific Islanders
Current data on suicide in Asian American communities
indicates rates of 5.5 percent for all age and ethnic
subgroups (McIntosh, 2002). However, the data may be
underreported, as it is calculated on the total Asian-
American population, whereas suicide may be prevalent to a
greater degree in particular ethnicities within the Asian-
American category. For instance, suicide rates in a 20
year span (1970 - 1990) rose 54 percent for Japanese
American teenagers and 36 percent for Chinese-American
teenagers (Ridgon, 1991).
In 2000, suicide ranked as the second leading cause of
death among Asian and Pacific Islander males ages 15 - 24
in the United States, according to the 2002 National Vital
Statistics Report. Asian-American women ages 15 - 24 have a
slightly higher rate of suicide than Whites, Blacks, and
Hispanics in the same age group. Asian-American children
and adolescents are considered by mental health providers
to be highly prone to depression.
In a national survey, 30 percent of Asian-American girls in
grades 5 - 12 reported suffering from depressive symptoms.
Also, Asian-American girls reported the highest rates of
depressive symptoms compared to White, Black and Hispanic
girls (Chung, 1998). Asian-American teenage boys were more
likely than their White, Black, and Hispanic peers to
report physical or sexual abuse. Asian-American children
received less mental health care than Whites, Blacks, and
Hispanics (Ku & Mantani, 2000).
American Indians and Alaska Natives
As in the general population, injuries account for 75
percent of all deaths among American
Indians and Alaska native children and youth. During 1989?
1998, injuries and violence
were associated with 3,314 deaths among AI/AN youth under
19 years of age. Motor vehicles
were the leading cause of death, followed by suicide,
homicide, drowning, and fires.
Death rates of all causes were higher among males than
females. Prevention strategies
should focus on the leading cause of injury-related deaths
in each AI/AN community, such
as motor-vehicle crashes, suicides, and violence (MMWR,
2003). America Indians have the
highest rate of suicide among all ethnic groups in the
United States with a rate of 14.8 per
100,000 reported in 1998. Rates were highest in Tucson,
Arizona and Alaska?five to seven times higher than the
overall U.S. rates. The Aberdeen region, which covers
North and South Dakota, Nebraska, and Iowa, also registered
similarly high suicide rates.
Models of Health and Illness
Communities of color and their sub-communities view
distress differently, and in ways that are nonwestern in
perspective. What are some of the factors that lead to
mental wellness and illness?
Latinos
There is a stigma attached to mental illness in the Latino
community. In fact, while physical illness in the Latino
community is culturally acceptable, mental illness is not.
Latinos often describe physical symptoms to express mental
distress. Consequently, many mental health problems are
treated in mainstream health clinics and hospitals. They
are often labeled with somatic complaints. Cultural
modalities, such as Penas, sustos, or malo are accepted
within the culture to express extreme pain and distress.
These conditions are often combined with physical pain as
well.
Given that individuals from different cultures may have
different views of mental illness, their views of treating
mental illness may also vary from mainstream culture.
Often, non-Western cultures rely on more informal means of
treatment, including reliance on healers instead of
physicians. In the Latino culture Curanderos or
Spiritualist Folk Healers are often preferred to medical
doctors. Congress and Lyons write that the use of
Curanderos is more consistent with the Latino?s holistic
view of the mind and body as one. The use of herbal
treatments instead of, or in addition to health care
treatment is another phenomenon in Latino culture. Culture
highly influences perceptions about mental illness.
African-Descent and/or Black Americans
The psychology of African-Americans, as represented
in models of mental health, has undergone various stages of
development over the past 100 years. There are two main
models that have been used to explain the psyche of blacks?
?inferiority? models and ?deprivation/deficit? models. The
common thread of these models is one of European
superiority (White and Parham, 1990). Africans and African
Americans have historically been viewed in all aspects of
human life as ?less than? their European counterparts.
Psychological stress and difficulties were viewed by the
dominant culture mainly as arising out of the impact of the
culture and deficits of the individual. For Europeans the
impact of the individual?s personal and/or family medical
history was taken into consideration when assessing
psychological stress and difficulty (p.10).
In more recent times, mental health professionals have
provided alternative ways of viewing the mental health of
African Americans. Specifically, they have examined the
impact and imposition of European culture on what is
traditionally considered African-American culture and
African heritage. In this light, the damage that was done
by destructive social forces of the slavery experience was
deemed to be harmful and pervasive to the mental well-being
of people of African descent. In addition, ongoing racism
that arises from constant discrimination can bring forth
less than optimal well-being or mental illness. This
process leads to ?dehumanization,? ?deculturalization?
and ?despiritualization.? Therefore, understanding suicide
from this context places internalized oppression and
discrimination as the central culprits that can lead to
depression and suicide. Interventions to address these
problems should focus on addressing the impact of
internalized oppression and discrimination on the affected
individuals and the African-American community at large,
and should be ethnocentric in nature.
Asian Americans and/or Pacific Islanders
Traditional forms of medicine in most Asian countries?e.g.,
Ayurveda in India and Chinese Medicine in China - increases
the likelihood that Asian-American immigrants will continue
to use a mixture of traditional and modern medical
practices for the treatment of various illnesses. In
traditional medicine, there is no separation of mind and
body. Therefore, mental illness often manifests itself
with physical symptoms. This presents significant
challenges to the health care provider who must understand
the psychosomatic origins of various symptoms and provide
adequate care. Further, mental illness is often perceived
as manifestations of evil, consequently a mentally ill
individual runs the risk of being labeled a ?bad? person.
This lack of understanding motivates many individuals and
families to hide the symptoms of mental illness and delay
seeking appropriate help until they are in a state of acute
emergency.
American Indians and Alaska Natives
American-Indian Tribes and Alaska Natives now have the
opportunity to run programs for their communities that have
typically been managed by the Indian Health Service and the
Bureau of Indian Affairs. Many tribes have already
exercised this option, which they consider necessary to
address specific cultural needs. However, some tribes
still prefer to let the federal agencies manage services
related to health and educational needs. The self-
determination efforts have yet to be evaluated, but the
cultural aspect of services can be implemented based on
each tribe?s preferences.
It is argued that subsequent generations of American
Indians suffer from a response entitled historical
unresolved grief (Brave Heart & DeBruyn, 1998).
Generations of American Indians have a pervasive sense of
pain from what happened to their ancestors, and have
undergone incomplete mourning of those losses. Closer
examination of suicide studies reveals implicit unresolved,
fixated, or anticipatory grief about perceived abandonment,
as well as affiliated cultural disruption (Berlin, 1987;
Claymore, 1988).
The assimilation of American-Indian children into a society
that is not their own has had a tremendous impact on tribal
structure. Every American-Indian child who became educated
had to repudiate much of his or her own cultural
background - even though it was clear to the government
that the benefits of White civilization were not, even when
accessible, consistently preferred by American Indians. For
example, parenting skills that would have been learned
within the family structure were lost. In addition, native
languages were soon forgotten, making communication with
elders difficult or impossible. Although it is not
possible to quantify all of the changes that have occurred
among the tribes, one thing is certain - major changes have
taken place among the tribes that have survived.
American Indian communities face many social and economic
problems, including suicide. The profound grief related to
the loss of a loved one is made somewhat easier in the
American Indian community because the entire community
unites to mourn the loss, and to support the survivors.
Native Americans are now more open to research carried out
in their communities, provided they participate in the
interpretation of research findings.
Causal and Contributing Factors of Suicide in Minority
Populations
Role of Immigration and Acculturation
? Acculturative stress results from the adjustments
and conflicts that are inevitable when migrating to a new
country.
? This stress has been correlated with psychological
disorders, lowered self-esteem, isolation, and changes in
appetite and behavior (Roysircar-Sodowsky & Maestas, 2000).
? Acculturative stress has been significantly
associated with depression and suicidal ideation in
minority college students (Jha, 2001).
Sense of Alienation and Marginalization:
? Barriers to treatment among Hispanics are often
created because of their inability to speak English.
? Attitudes that reflect alienation from the majority
and a sense of marginalization are associated with
increased depression and, thereby, suicidal ideation in
immigrant and American-born minorities.
? Takahashi and Berger, (1996) indicated that an
intense desire among Japanese to belong to a group, or to
become a part of the establishment may be associated in a
high number of Japanese suicides. While this tendency may
protect individuals from isolation on one hand, individuals
who do not fit in the groups tend to feel ostracized and
suicidal on the other.
? Perhaps what is unique about Asian-American suicide
is how the perception of isolation from a group affects an
individual?s emotions and behaviors.
Role of Racism and Prejudice
? Individuals who experience racism can suffer from
feelings of self-consciousness, difficulties in
relationships, and isolation (Poussaint and Alexander,
2000; Root, 1992; Bush, 1978).
Approaches to Intervention
There are a number of approaches we can examine to gain a
better understanding of the different suicide intervention
strategies required for different ethnic groups. In fact,
some groups have more developed strategies than others.
Latinos
One of the main barriers within this culture is language.
Intervention cannot occur without communication. We also
cannot address unique cultural challenges associated with
suicide if they are not understood. Because translation is
critical, a standard interpretation of technical language
relating to suicide is necessary. Furthermore, because
language relates to much more than words, the
interpretations must translate the cultural concepts and
ideas associated with suicide to in a way that captures the
community?s core principles.
For example, a video was used in one hospital emergency
room to help explain treatment available for Latino females
who attempted suicide. The video served as an effective
intervention tool, and was designed to improve adherence to
outpatient therapy, including utilization of staff and
family therapy. The video resulted in lower rates of
suicide reattempts and suicidal reideation among adolescent
Latino females (Rotheram-Borus, 2000).
African-Descent and/or Black Americans
The cultural dynamics in this population show an increasing
set of problems, including unemployment, delinquency,
substance abuse, and teenage pregnancy, in addition to
suicide, and especially among young Black males (Gibbs,
1984). For this reason, a variety of primary or universal
prevention programs are needed that focus on: (1) better
secondary education, (2) employment, (3) sex education and
family planning, (4) delinquency prevention, and (5) drug
prevention and counseling (Lester,1998). Gibbs (1997) also
notes that it is critical to increase life options for
black youth?especially males?by raising high school
graduation rates and implementing job training programs.
Other successful strategies for early intervention include
increased use of mental health clinics in inner cities and
school programs to help establish strong coping skills. In
addition, mental health workers and school personnel need
to recognize the effects of racism on blacks, and be aware
of ?perceiving? paranoia or over diagnosing schizophrenia
in African Americans. Counselors need to become familiar
with social agencies and resources in inner cities and
become acquainted with black culture beyond such things as
music and food to incorporate behavior and attitude. It is
also critical to involve Black role models in these
preventive intervention programs, and in the treatment of
Black suicidal patients (Lester, 1998).
Strategies should also involve treatment availability and
determining which medications and counseling techniques are
most effective for managing seriously suicidal individuals
(Lester, 1998). The key here is to develop a close
relationship with the mental health professionals and
facilities within the communities.
Asian Americans and/or Pacific Islanders
There is not enough empirical research to determine
guidelines for managing suicidality among Asian Americans.
Studies that critically examine the efficacy of traditional
approaches to suicidality among Asian Americans have
focused on commonly noted trends, such as age and gender
differences, but have not examined differences in suicide
trends between foreign-born and U.S.-born Asian-American
population. They also have not focused on such things as
the effect of the length of stay in the United States.
These are crucial elements that should be addressed in
order to formulate action plans and provide future
directions for research.
There is an urgent need to review and revise how suicide
cases are reported, and how ethnicities are classified and
documented. For example, a number of suicide victims
registered under the ?Other Asian? category in Cook and Du
Page counties in Illinois between 1991 - 2001 were found to
be of Asian-Indian descent. Statistical reports can help
identify ?high-risk? or ?high-need? populations and provide
clearer directions of evolving trends, thereby allowing
intervention and preventive strategies to target specific
groups and group needs. Furthermore, Asian Americans have
often been grouped together with Pacific Islanders, (e.g.,
Hawaiians, Guamanians, Samoans, etc.) by the federal
government for convenience in statistical accounting. There
are major differences between Asian Americans and the
Pacific Islanders and between various populations among
Asian Americans. The need to report data on specific Asian
ethnic groups has been highlighted by many researchers as
critical to present a more accurate and complete
statistical picture, and to understand ?trends? (Baker, F.
M. 1994; Leong & Lau 2001).
American Indians and Alaska Natives
It is not fully known what types of strategies are needed
to address suicide in American Indian communities. However,
a number of complicating factors in enhancing mental
wellness must be addressed, such as a high treatment
dropout rate among American Indians and a hesitancy to
enter treatment. These problems are rooted in a historical
distrust of the majority population to a large degree, and
to the shortage of American Indian health providers
(Kindya, 2003). Because of the sovereignty of Native
American Tribes, it is essential to work with the
leadership of the community to conduct suicide prevention
research. But the benefits to the community must be made
clear before American-Indian communities will agree to such
research, and community members must be engaged as active
members of the research team (Fisher, et al., 1998).
One successful program included collaboration between the
Indian Health Service, the Centers for Disease Control and
Prevention, and the University of New Mexico to support an
adolescent suicide prevention program implemented by a
small Western Athabaskan American Indian tribe in rural New
Mexico. This was a multicomponent program based on the idea
of youth natural helpers who were trained to respond to
other young people in crisis, to notify mental health
professionals, and to help provide health education in
schools and the community. Other program components
included outreach to families following a suicide or
traumatic death, immediate response and follow-up for
reported at-risk youth, community education about suicide
prevention, and suicide-risk screening in mental health and
social service programs. Evaluation data showed a
reduction of suicidal acts (suicide and suicide attempts)
in the target population after the program was implemented.
The American Indian/Alaska Native Community Suicide
Prevention Center and Network expanded the program to
target all Native-American/ Alaska-Native communities
throughout the country. Adults and youth from various
geographic areas of the country were identified and trained
to respond to requests from communities on topics such as
crisis response, development of suicide intervention and
prevention programs, data collection, establishing
surveillance systems, developing crisis response teams,
program evaluation, and conducting postvention services
(MMWR, 1998).
Another culturally relevant intervention program was
administered to a Zuni Pueblo population in New Mexico
using a social cognitive development model. At the Zuni
Public High school, a life skills development curriculum
was structured around seven major units: (1) building self-
esteem, (2) identifying emotions and stress, (3) increasing
communications and problem-solving skills, (4) recognizing
and eliminating self-destructive behavior, (5) receiving
suicide information, (6) receiving suicide intervention
training, and (7) setting personal and community goals. A
unique feature and strength of the curriculum was that it
was specifically tailored to be compatible with Zuni norms,
values, beliefs, and attitudes (LaFromboise and Howard-
Pitney, 1995).
Cultural Competencies Required to Intervene
The basis of this section is to answer the question, who
can intervene within a specific community? The notion of
whether one is viewed as an insider or outsider is
important, as is the need to codify the role of those who
are best suited to intervene in a community.
?Insiders? may include primary health care providers (who
share the patient?s cultural and linguistic background),
community advocates, local alternative healers such as
herbalists, acupuncturists, and clergy. Insiders can be
those who are viewed as experts or those who have the trust
and confidence of the patient and or community.
?Outsiders? are generally health care providers who do not
share the patient?s culture and language. Outsiders are
also those who have difficulty gaining the trust and
confidence of the specific community.
Latinos
The ultimate in cultural sensitivity is to strive to
accept, understand, respect, and affirm the unique culture
and values of each family. The best way to engage any
family is to respect and work within their beliefs and
values.
? Speak the language and dialect of the community.
? Be of the same ethnic and cultural subgroup as the
community to ensure common meanings and experiences are
shared.
? Be aware that different generations of the same
community may have different primary languages. Address
this issue before deciding which language to use for a
specific intervention.
? Emphasize that genetic causes of schizophrenia
intensifies feelings of discrimination. Some communities
may feel stigmatized or shamed by seeking support.
Individuals within the community may be uncomfortable with
or mistrust mainstream facilities or programs. They may
see these programs as unresponsive to their needs, or as
threatening to their immigration status or government
benefits.
African-Descent and/or Black Americans
Some individuals in certain Black sub-communities are
considered, in general, to be ?classic outsiders? when it
comes to the implementation of preventive interventions in
the African- American community. ?Professional helpers? or
change agents who are members of the dominant (White)
culture are often labeled as outsiders, and encounter
barriers to entry into the African-American community as a
result (Kaufman, 1994).
Successful suicide prevention strategies in the Black
community can include (1) political, institutional and
personal neutrality, thus avoiding obligations to a sponsor
or a patron who might promote bias in observations and
alter ways of behaving; (2) follow the ?rules? or customs
of the Insiders; and (3) identify several key informants
who are generally accepted and liked by other Insiders, and
who can advise, teach and direct the Outsider in ways of
behaving and interpreting events.
According to Kaufman (1994), community evaluation of
actions and interaction by outsiders begins to erode social
myths and stereotypes compelling each side to see the other
as fellow human beings, while also guarding against
possible rejection. Strategies in interactions are based
on the premise that it is important to be genuine and to
avoid ?trying too hard? to be accepted.
Sharing personal stories and belongings, making commitments
and creating mutual obligations create a deeper awareness
of one another. Using insider idiomatic expressions
develops a form of settling in and signifies the capacity
of the outsider and insiders to relax, enjoy, care for,
explore and be with each other. For example, while the
boundaries of friendship can become clearer when outsiders
and those in the community exchange jargon during light
banter, this and similar techniques presupposes
understanding and acceptance, according to Kaufman.
Another barrier identified by Jordan, et al (2001) refers
to the organizational context. They indicate that
collaboration with community agencies involves special
challenges. These challenges center around the fact that
most Black community-based social service agencies
are ?underfunded, understaffed and overtaxed by the
multiplicity and the severity of community needs? (Mincy,
1994; Wiener, 1994). Therefore, the limited resources
available for implementing interventions impose actual or
perceived constraints on the efforts and assistance that
community-based agencies can offer.
Jordan, et al., (2001) offer a comprehensive process to
address these barriers. The process has five components
which include the following:
? Create a foundation for trust.
? Focus on community needs.
? Establish forum for community feedback and
involvement.
? Create autonomy.
? Help train future professionals.
Asian Americans and/or Pacific Islanders
Integration of primary health and mental health services
can be beneficial for Asian-American patients who
experience tremendous barriers to accessing mental health
specialists. (Best Practice Model: Primary Care and
Mental Health Bridge Program at the Charles B. Wong
Community Health Center). Research has shown that
integrating mental health services into the primary health
care setting can increase access to services, leading to
increased diagnosis and treatment. Unfortunately, many
primary health care providers are ill-equipped to deal with
mental health issues such as suicide and depression.
It is important to recognize that most cultures do not
clearly differentiate physical, emotional, and spiritual
problems, perhaps because this is a Western concept.
Describing symptoms through somatic and spiritual
complaints may lead to less social rejection and less loss
of self-esteem. Utilization of community leaders, such as
ministers, priest, root healers, herbalists, diviners, and
natural caregivers is key in this situation.
American Indians and Alaska Natives
While an ?insider? among American Indians and Alaska
natives would typically be a tribal member, anyone who is
respectful of those in the community and shows sensitivity
to cultural issues will find acceptance. Outsiders will be
viewed as any other group would view that person. Be
sincere, honest, and ethical. Most service providers will
be put to the test before trust is earned. Most tribes
and/or communities will be provided an orientation as to
what is acceptable for the tribe, but much will be learned
by being sensitive. This is probably true for all minority
communities.
It will typically be assumed in the community that
permission has been obtained from the community or tribe to
provide services or intervention activities. As a result,
providers should always go to the leadership of the
particular tribe to get permission to provide intervention
services.
SUMMARY
How do you engage communities of color and communities that
are culturally different? It is important to develop
knowledge of who is in the community and is most
influential to the particular group you are trying to
reach. Each community is complex. If you are trying to
reach Asian Americans, what exactly does that mean? There
are various Asian-American communities. Know which groups
are in your community. Does your community consist of
Japanese, Chinese, Cambodians, East Indians, or others?
This phase I project was both difficult and simple. On the
one hand, it is difficult to sort people and differentiate
sub-communities. On the other hand, many of the barriers
to reaching minorities were similar such as the role of
immigration and acculturation for some Asians, Latinos, and
African Caribbeans. Racism and Prejudice were also shown
to be universal contributing factors among all four groups.
There are also critical questions associated with race,
ethnicity and culture. Should populations be sorted by the
skin color, by religious practices, or by lifestyles?
Getting various ethnic groups involved in traditional
preventive intervention programs takes planning.
Programmers must (1) know who is in the community, (2)
identify the influential leaders, (3) create the right
environment by inviting members of the community to the
planning table and listening to what they have to offer,
and (4) recognize the value of their alternative ways of
preventive intervention procedures.
Furthermore, individuals who are biracial and/or
assimilated must decide for themselves which culture they
will follow when seeking treatment for mental disorders. Do
they seek treatment through the system of the dominant
culture or do they use the approaches of their ethnic
traditions. And, which ethnic practice should be used for
a multi-racial individual, for example, one who is part
Japanese, part Hawaiian and part American Indian? Internal
complexities are widespread among minority groups and
should be recognized and discussed when approaching a
community of color.
Finally, successful suicide prevention interventions in
diverse communities require a sophisticated understanding
of the complex dynamics of ?otherness,? or feelings
of ?outsiderness? and ?insiderness.? Unless this
understanding is combined with a deep appreciation of the
political, social and psychological phenomena, even very
sincere and well-intentioned efforts to promote social
change or healing are easily thwarted.
APPENDIX
Task Force Members
Craig Boatman, Ph.D. (Facilitator)
University of Maryland
Baltimore County
Baltimore, MD
Boatman@UMBC.EDU
Lisa Jordan, Ph.D. (Co-Facilitator)
University of Maryland
Baltimore County
Baltimore, MD
ljordan@UMBC.EDU
Majose Carrasco
NAMI
2107 Wilson Blvd, Suite 300
Arlington, VA 22201-3042
703-524-7600
majose@nami.org
Alex Crosby, MD
Morehouse School of Medicine
Department of Community Health & Preventive Medicine
720 Westview Dr., SW
Atlanta, GA 30310
404-752-1620
Yvonne Davis
921 Buena Vista, SE, Apt B201
Albuquerque, NM 87106
505-242-4629
Ymdmt@aol.com
Marlene Echohawk, Ph.D.
Behavioral Health Program
12300 Twinbrook Parkway
Rockville, MD 20852
301-443-2589
MEchohaw@HQE.IHS.GOV
Mercedes Hernandez, Ph.D.
425 University Boulevard East
Silver Springs, MD 20901
301-439-1396
mdh@gwu.edu
Aruna Jha, Ph.D.
University of Illinois at Chicago
850 W. Jackson, Suite 400
Chicago, IL 60607
312-355-4433
arunajha@uic.edu
Cleo Manago
AMASSI
160 South LaBrea Avenue
Inglewood, CA 90301
310-419-1969
cleo@amassi.com
Darlene Nipper, MS
NAMI
2107 Wilson Blvd, Suite 300
Arlington, VA 22201-3042
703-524-7600
Darlene@nami.org
Patrick Sanchez
National Latino Behavior Health
506 Welch Avenue
Berthoud, CO 80513
970-532-7210
Patrick.sanchez@prodigy.net
Henry Westray, MS
18 Jolie Ct
Randallstown, MD 21133
410-767-5650
WestrayH@DHMH.STATE.MD.US
Consultants
Maria A. Oquendo, MD
Columbia University
Department of Neuroscience at New York State Psychiatric
Institute
1051 Riverside Drive
N.Y., NY 10032
moquendo@neuron.cpmc.columbia.edu
Joseph D. Hovey, Ph.D.
Director, Program for the Study of Immigration & Mental
Health
The University of Toledo
Toledo, OH 43606
419/530-2693; (fax) 419/530-8479
jhovey@utoledo.edu
Sherry Molock, Ph.D.
9007 Doris Dr.
Ft. Washington, MD 20744-2414
301-248-9495
smolock@gwu.edu
Other Contributors
Meera Rastogi, Ph.D.
Archana Basu, MA
Masa Nakata, MA
Susan Kim, MPH
Penny Lun, MA
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