Journal of American Indian Education
Volume 36 Number 1
SUICIDE AMONG AMERICAN INDIAN YOUTH: THE ROLE OF THE SCHOOLS IN PREVENTION
Arlene Metha and L. Dean Webb
Every one hour and 46 minutes somewhere in the United States one young person takes his or her life. Suicide is now the third leading cause of death of 15-24 year olds in the United States (Centers for Disease Control, 1995). Every year almost 5,000 young people aged 10-24 years old take their own lives (CDC, 1995). Of these, the highest suicide rates are found among American Indian youth (see Table 1). Not only do young American Indian males commit suicide at rates almost twice that of other racial groups, the rates increase with age far more dramatically than those of other groups. It should be noted, however, that suicide rates do vary widely among the various tribes, ranging from 6 per 100,000 among the Chippewa, to 130 per 100,000 among the Blackfeet (Group for the Advancement of Psychiatry (GAP) as cited in Lipschitz, 1995).
As alarming as are the statistics on completed suicides, evidence suggests that the number of actual suicides may in fact be far greater than the number reported. The social, cultural, or religious stigma attached to suicide, the belief that insurance might be forfeited, and the difficulty in determining whether some accidents (e.g., pedestrian deaths, vehicular deaths, and barbiturate poisonings) are actually accidents or suicides, and the desire to avoid publicity have resulted in both the intentional and the unintentional under-reporting of suicides. Estimates of the under-reporting have been as high as 80 percent (Phillips & Ruth, 1993).
While the number of youth suicides is in itself of such a magnitude
as to create a major national health concern, this concern is compounded
by the evidence that for every completed suicide there are as many as
20 (Washington State Department of Health, 1995) to 50-100 attempts
(Spirito, Hart, Overholser, & Halverson, 1990). Grossman, Milligan,
and Deyo (1991) analyzed data from the 1988 Navajo Adolescent Health
Survey of 7,254 students grades 6 through 12 on the Navajo reservation
and found that 971 students (15 percent) had attempted suicide. A higher
incidence (23 percent) was reported by Manson, Beals, Dick and Duclos
(1989) in their study involving American Indian students attending a
boarding school in the southeastern United States. Yet an even higher
rate of suicide attempt (30 percent), a rate significantly higher than
that for youth in the general population, was found by Howard-Pitney,
LaFromboise, Basil, September, and Johnson (1992) among Zuni adolescents
at a pueblo in New Mexico. In addition, Gartrell, Jarvis and Derksen
(1993) reported that seven percent of the 12 and 13 year old Alberta
Indians in their study had attempted suicide, as had 16 percent of the
14 year olds, and 25 percent of those over 15 years of age.
Suicide Rates for Youth 10-24 Years of Age, by Race and Ethnicity: 1990
(Rates in suicides per 100,000)
Researchers who have studied the problem of youth suicide have concluded that suicide is a complex, multi-causation phenomenon (Blumenthal, 1990). The research on largely non-minority populations has suggested a number of variables ranging from biochemical/genetic to behavioral which place youth at risk for suicide. The risk factors which appear to be the more dominant include: a history of suicide attempt (Lewinsohn, Rohde, & Seeley, 1994; Spirito et al., 1990); the suicide of a close friend or relative (Lewinsohn et al., 1994; Wagner, Cole, & Schwartzman, 1995); depression and other psychiatric disorders (Andrews & Lewinsohn, 1992; Brent, 1995; Marciano & Kazdin, 1994; Moscicki, 1995); hopelessness (Beck, Steer, Beck, & Newman, 1993; Joiner & Rudd, 1996; Lewinsohn et al., 1994); low self-esteem (Lewinsohn et aL, 1994; Marciano & Kazdin, 1994; Stivers, 1990); deficit coping and problem-solving skills (Asarnow, Carlson, & Guthrie, 1987; Rotheram-Borus, Trautman, Dopkins, & Shrout, 1990; Wilson, Stelzer, Bergman, Kral, Inayatullah, & Elliott, 1995); substance abuse (Andrews & Lewinsohn, 1992; Garrison, McKeown, Valois, & Vincent, 1993); and negative life events (e.g., pregnancy, contracting a sexually transmitted disease, break-up with boyfriend/girlfriend, physical or sexual abuse, death or divorce in the immediate family, legal or disciplinary problems, unemployment [parent], illness, or school problems) (Asarnow et al., 1987; Brent, Perper, Meritz, Baugher, Roth, Balach, & Schweers, 1993; Wagner et al., 1995).
The research on risk factors associated with American Indian youth
indicates that many of those same variables place them at risk for suicidal
behavior. For example, Grossman et al. (1991) found a history of mental
health problems, family history of a suicide or suicide attempt, weekly
consumptions of hard liquor, past physical or sexual abuse, alienation
from family and community, and poor self-perception of health to be
risk factors for suicide attempt among Navajo youth. Manson et al. (1989)
found the risk factors for suicide among American Indian students at
a boarding school to be having either relatives or friends who have
attempted suicide, greater depressive symptomatology, greater quantity
and frequency of alcohol use, and little family support. Manson et al.
(1989) also summarized the literature on suicide among American Indian
and Alaska Natives identifying the following risk factors: frequent
interpersonal conflicts; prolonged, unresolved grief, chronic familial
instability; depression; alcohol abuse and dependence; family history
of psychiatric disorder-particularly alcoholism, depression and suicide;
physical illness; previous suicide attempt; frequent encounters with
the criminal justice system; and multiple home placements.
The research of Howard-Pitney et al. (1992) investigated the psychosocial variables that might impact suicide ideation and suicide attempt among Zuni adolescents. Correlates of suicide ideation were found to be drug use, depression, hopelessness, stressful life events and psychological distress. Correlates of suicide attempt included the same variables, as well as suicide ideation and poor coping skills. On the other hand, social support, a positive attitude toward school, and good communication skills were negatively correlated with suicide ideation, and a positive attitude toward school and good communication skills were negatively related to suicide attempt. Lastly, Gartrell et al.'s (1993) study of seventh, eighth, and ninth graders on seven reserves in Alberta reported elevated levels of suicide ideation for American Indian adolescents with low psychological wellbeing, no father in the household, and a history of suicide in the household. Risk factors for suicide attempt were low psychological well-being, heavy alcohol use, and no father in the household.
One set of suicidal risk factors that are somewhat unique to American
Indians focus on the stressors they experience as a result of social
disintegration and cultural conflict (Berlin, 1985; Hochkirchen &
Jilek, 1985). As with other risk factors, these risk factors have a
differential impact among tribes. As Lipschitz (1995, citing the GAP)
Lower suicide rates are found to prevail in tribes like the Navajo, who have succeeded in maintaining a separatist cultural identity, and in those like the Cree, who have evolved a cultural, economic, and political integration with the dominant society over the course of their long period of contact. Both forms of adaptation allow these tribes to provide a supportive milieu that sustains identity consolidation in their young people. In other groups the separatist and integrationist paths have failed to prevent the disruption of cultural values. Concurrently, members of these marginalized groups have not been able to adopt values from the prevailing American culture in ways that preserve their social pride and personal self-esteem. The social alienation, identity confusion, and self-hate that they experience are reflected in their high rates of alcoholism and suicide. (p. 163)
And, as LaFromboise and Bigfoot (1988) so pointedly note, for many American Indians "'whose lives have been affected by the governmental goal of assimilating them into the general ethos of American life, suicide could be construed as the ultimate act of freedom" (p. 139). The researchers also note that the identity conflict or ambiguity has perhaps its most profound impact as the American Indian child enters adolescence, a developmental stage that in almost all children is characterized by varying degrees of psychological turmoil, and that the negative life stressors which have been found to place all youth at risk for suicide-loss of a family member by death or separation, long-term poverty, parental unemployment, and underachievement in school-are far more prevalent in the lives of American Indian youth than those in the larger society.
LaFromboise and Bigfoot (1988) also discuss specific cultural values
and beliefs that may contribute to suicidal behavior among American
Indian youth. For example, the cultural value placed upon self-control
often results in American Indian youth both internalizing psychological
pain, and the feeling that death is not to be feared but is an active
process where the individual can exercise control over the preparation
for death. The values of social responsibility and reciprocity may also
contribute to imitative behavior, while the idealization of the deceased,
including those who have committed suicide, during giveaway ceremonies
may tempt others to join the deceased and be similarly honored. American
Indian beliefs in reincarnation and the reciprocity of influence between
the human and spirit worlds serve as an interpretive system when deciding
whether or not to self-destruct and may reduce some of the fear surrounding
While prevention of the needless death of so many of our young people is the responsibility of the entire community, it is without question that the schools must assume a major role in the suicide prevention efforts of the community. The assumption of this role seems particularly incumbent upon those schools which serve American Indian youth. Few others have the opportunity of school personnel to interact daily with young people and to observe the changes in their behavior, to understand the stressful situations they encounter, or to respond to their subtle or direct cries for help (Smith, 199 1).
Suicide prevention is often discussed in terms of three levels or domains.
Some typologies refer to primary, secondary, and tertiary prevention;
others prevention, intervention, and postvention.
For students this information is often included as part of a general
health curriculum and will typically include additional material on
how to respond to a a troubled peer. While this type of curriculum is
not targeted to students at any a specific level of suicide risk or
to any particular risk factors, having even this brief overview can
be a matter of life or death to many troubled youth. Because adolescents
have little experience with life and few well-developed coping skills,
they do not realize that their feelings of depression are usually limited
in duration and a are not a sign of inadequacy. And, because a peer
is the most common confidant of a suicidal youth, they need to know
how to recognize suicide warning signs a and where and how to get professional
assistance for a troubled peer. They also need to understand the myths
and misconceptions about suicide, to take warnings signs seriously,
and to break a confidence to save a life (Ryerson, 1991).
Parents also desperately need this information. According to one expert on youth suicide, "(P)arents are often inexperienced with or ignorant about the emotional difficulties of adolescents. Reluctant to acknowledge emotional difficulies ties in their own child, they frequently deny the seriousness of a teenager's despair until it is too late" (Ryerson, 1991, pp. 100-101). While it is often difficult to reach and obtain the participation of parents or guardians at suicide awareness sessions, aggressive outreach programs involving phone chains, using community leaders as speakers, and even raffles have been used with varying degrees of success I (Ryerson, 1991). These and any other strategies that offer the potential to increase family involvement should be used to remind parents and guardians that their children's lives are at risk.
Training for faculty and staff should be mandatory and should be provided
[(to all those adults who come in contact with students, including custodial,
secretarial, and transportation staff. Such training can last from two
hours to two days. However, a common practice is to provide a one day
in-service for the entire faculty and staff, and a second day for those
who are to serve on the school or ;(school district crisis response
team (discussed below). It should be emphasized -1 that the purpose
of this training is not to train faculty or staff to provide counseling
or risk-assessment services; these services should only be provided
by per;(sons with expertise in these areas (Capuzzi, 1994).
However, before any students are involved in these intervention programs,
the necessary first step is the identification of those at greatest
risk for suicide. This can be accomplished in several ways. As already
noted, all school staff should be trained to recognize the warning signs
of suicide. If a staff member does have concerns about a youth that
might be at risk for suicidal behavior, the staff member should express
his or her concern to the student (do not be afraid to ask the student
directly if he or she has entertained thoughts of suicide), attempt
to establish rapport with the student, and facilitate a meeting with
the school counselor or a crisis team member as quickly as possible
Identification of youth at risk for suicide can also be accomplished by a formal multistage process to determine the level of risk. The first step would involve the administration of a short instrument, such as the Suicide Ideation Questionnaire (Reynolds, 1988), to identify those at risk for suicide. Students found to be at high risk should then be referred for additional assessment using a more intensive instrument such as the Evaluation of Imminent Danger for Suicide (Bradley & Rotheram-Borus, 1990) or the Measurement of Adolescent Potential for Suicide (Eggert, Thompson, & Herting, 1994), which are administered in a face to face interview by a trained counselor, psychologist, psychosocial nurse specialist, or other mental health professional. Those identified as being at imminent danger for suicide should be referred for additional evaluation and intervention by mental health professionals. Those not requiring emergency intervention should be provided the appropriate counseling intervention.
As suggested previously, intervention programs can be directed at the treatment of specified risk factors (e.g., substance abuse prevention or depression management), the development of specific skills (e.g., problem-solving skills, decision-making skills, or coping skills), or the enhancement of protective factors [e.g., family cohesion, positive school experience, or positive friendships (Rubenstein, Heeren, Housman, Rubin, & Stechler, 1989)]. One such program, a life/social skills training program developed by LaFromboise and Howard-Pitney (1995) for use with Zuni high school students shows promise for use with other populations of American Indian youth. Life/social skills training programs are intended to teach the social competencies and fife skills needed to support positive social, emotional and academic development. The curriculum employed with the Zuni students included 7 major units: self-esteem building, identifying emotions and stressors, communication and problem-solving skills training, recognizing and eliminating self-destructive behavior, suicide information, suicide intervention, and personal and community goal setting. The curriculum was presented three times a week throughout the year (over 30 weeks). According to the developers, each lesson included "the standard skills training techniques of providing information about the helpful or harmful effects of certain behaviors, modeling of target skills, experimental activities and behavioral rehearsal for skill acquisition, and feedback for skill refinement" (LaFromboise & Howard-Pitney, 1995, p. 48 1). The life/social skills training was found to be effective in reducing hopelessness and suicide probability as well as improving anger management, and problem-solving.
The curriculum was designed to be compatible with the norms of Zuni tradition including its values, beliefs, and attitudes; sense of self, space, and time; communication styles; and forms of recognition. Extensive community input was sought during the development of the curriculum.
The first step in postvention is the appointment of a crisis management team, typically composed of the principal or assistant principal, guidance counselors, the school nurse, classroom teachers, and the school psychologist. The role of the crisis management team is to develop and put in place the actions and activities that follow the suicide of a student. The typical postvention program would proceed as follows (Cappuzi, 1994; Wenckstem & Leenaars, 1991):
(1) Verify any report of a suicide with the police department or medical
examiner. If confirmed, notify central administration.
School-based suicide prevention programs that are shaped and designed to be compatible with local American Indian norms, values and traditions are sorely needed. All prevention efforts should be comprehensive and should include a wide variety of input from the community and families. Where appropriate, adaptation to specific tribes and customs should be made.
Each time a young person takes his or her life it dramatically affects the lives of at least six to eight other significant individuals-with sometimes permanent consequences to productivity, self-esteem, or physical or mental health (Maris & Silverman, 1995).
However, the real tragedy of youth suicide is not in the suffering and pain felt by the survivors, but in the fact that it is a needless waste of human potential, of a life that will never be realized. Suicide is typically not the result of a single event. It is the end in a series of events, emotions, and beliefs that have placed the individual at risk for suicide. But youth suicide does not have to happen. People and institutions can play a vital role in altering the individual's perception of those events, emotions, and beliefs. Schools, in particular, are in a strategic position to intervene and help at a variety of levels.
Andrews, J. A., & Lewinsohn, P. M. (1992). Suicidal attempts among older adolescents: Prevalence and co-occurrence with psychiatric disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 31, 655-662.
Asarnow, J. R., Carlson, G. A., & Guthrie, D. (1987). Coping strategies, self-perceptions, hopelessness, and perceived family environments in depressed and suicidal children. Journal of Consulting and Clinical Psychology, 55, 361-366.
Beck, A. T., Steer, R. A., Beck, J. S., & Newman, C. F. (1993). Hopelessness, depression, suicidal ideation and clinical diagnosis of depression. Suicide and Life-Threatening Behavior, 23, 139-145.
Berlin, 1. N. (1985). Prevention of adolescent suicide among some Native American tribes. Annals of the American Academy of Adolescent Psychiatry, 12, 77-93.
Blumenthal, S. J. (1990). Youth suicide: Risk factors, assessment, and treatment of adolescent and young adult suicidal patients. Psychiatric Clinics of North America, 13, 511-558.
Bradley, J., & Rotheram-Borus, M. J. (1990). Evaluation of imminent danger of suicide: A training manual. Tulsa, OK: National Resource Center for Youth Services
Brent, D. A. (1995). Risk factors for adolescent suicide and suicidal behavior: Mental and substance abuse disorders, family environmental factors, and life stress. Suicide and Life-Threatening Behavior, 25, 52-63.
Brent, D. A., Perper, J. A., Meritz, G., Baugher, M., Roth, C., Balach, L., & Schweers, J. (1993). Stressful life events, psychopathology, and adolescent suicide: A case control study. Suicide and Life-Threatening Behavior, 23, 179-187.
Capuzzi, D. (1994). Suicide prevention in the schools: Guidelines for middle and high school settings. Alexandra, VA: American Counseling Association.
Centers for Disease Control (CDC) (1995). Suicide in the United States 1980-1992. Atlanta, GA: Author.
Eggert, L. L., Thompson, E. A., & Herting, J. R. (1994). A measure of adolescent potential for suicide (MAPS): Development and preliminary findings. Suicide and Life-Threatening Behavior, 24, 359-381.
Felner, R. D., Adan, A. M., & Silverman, M. M. (1992). Risk assessment and prevention of youth suicide in schools and educational contexts. In R. W. Maris, A. L. Berman, J. T. Maltsberger, and R. 1. Yufit (Eds.), Assessment and prediction of suicide (pp. 420-447). New York: Guilford Press.
Garrison, C. Z., McKeown, R., Valois, R., & Vincent, M., (1993). Aggression, substance use, and suicidal behaviors in high school students. American Journal of Public Health, 81, 840-874.
Gartrell, J. W., Jarvis, G. K., & Derksen, L. (1993). Suicidality among adolescent Alberta Indians. Suicide and Life-Threatening Behavior, 23, 366-373.
Grossman, D. C., Milligan, B. C., & Deyo, R. A. (1991). Risk factors for suicide attempts among Navajo adolescents. American Journal of Public Health, 81, 870-874.
Hochkirchen, B., & Jilek, W. (1985). Psychosocial dimensions of suicide and parasuicide in Amerindians of the Pacific Northwest. Journal of Operational Psychiatry, 16, 24-28.
Howard-Pitney, B., LaFromboise, T. S., Basil, M., September, B., & Johnson, M. (1992). Psychological and social indicators of suicide ideation and suicide attempts in Zuni adolescents. Journal of Consulting and Clinical Psychology, 60, 473-476.
Joiner, T. E. Jr., & Rudd, M. D. (1996). Disentangling the interrelations between hopelessness, loneliness, and suicidal ideation. Suicide and Life-Threatening Behavior, 26, 19-26.
LaFromboise, T., & Howard-Pitney, B. (1995). The Zuni life skills development curriculum: Description and evaluation of a suicide prevention program. Journal of Counseling Psychology, 45, 479-486.
LaFromboise, T. D., & Bigfoot, D. S. (1988). Cultural and cognitive considerations in the prevention of American Indian adolescent suicide. Journal of Adolescence, 11, 139-153.
Lewinsohn, P. M., Rohde, P. & Seeley, J. R. (1994). Psychosocial risk factors for future adolescent suicide attempt. Journal of Counseling and Clinical Psychology, 62, 297-305.
Lipschitz, A. (1995). Suicide prevention in young adults (Age 18-30). Suicide and Life-Threatening Behavior, 25, 155-170,
Manson, B. Beals, J., Dick, R., & Duclos, C. (1989). Risk factors for suicide attempts among Indian adolescents at a boarding school. Public Health Reports, 104, 609-614.
Marciano, P. L., & Kazdin, A. E. (1994). Self-esteem, depression, hopelessness and suicidal intent among psychiatrically disturbed inpatient children. Journal of Clinical Child Psychology, 23, 151-160.
Maris, R. W. & Silverman, M. M. (1995). Postscript: Summary and synthesis. Suicide and LifeThreatening Behavior, 25, 205-209.
Moscicki, E. K. (1995). Epidemiology of suicidal behavior. Suicide and Life Threatening Behavior, 25, 22-35.
Phillips, D. P., & Ruth, T. E. (1993). Adequacy of official suicide statistics for scientific research and public policy, Suicide and Life-Threatening Behavior, 24, 307-319.
Reynolds, W. M. (1988). Suicide Ideation Questionnaire: A professional manual. Odessa, FL: Psychological Assessment Resources.
Rotheram-Borus, M. J., & Trautman, P. D., Dopkins, S. C., & Shrout, P. E. (1990). Cognitive styles and pleasant activities among female adolescent suicide attempters. Journal of Consulting and Clinical Psychology, 58, 554-561.
Rubenstein, J. L., Heeren, T., Housman, D., Rubin, C., & Stechler, G. (1989). Suicidal behavior in "normal" adolescents: Risk and protective factors. American Journal of Orthopsychiatry, 59, 59-71.
Ryerson, D. (1991). Suicide awareness in schools: The development of a core program and subsequent modifications for special populations or institutions. In A. A. Leenaars & S. Wenckstem, S.( Eds.), Suicide prevention in schools (pp. 99-120). New York: Hemisphere Publishing.
Smith, J. (1991). Suicide intervention in schools: General considerations. In A. A. Leenaars & S. Wenckstem, S.(Eds.), Suicide prevention in schools (pp. 3-15). New York: Hemisphere Publishing.
Spirito, A., Hart, K., Overholser, J., & Halverson, J. (1990). Social skills and depression in adolescent suicide attempters. Adolescence, 25, 543-552.
Stivers, C. (1990). Promotion of self-esteem in the prevention of suicide. Death Studies, 14, 303-327.
Wagner, B. M., Cole, R. E., & Schwartzman, P. (1995) Psychosocial correlates of suicide attempts among junior and senior high school youth. Suicide and Life-Threatening Behavior, 25, 358-372.
Washington State Department of Health. (1995). Youth Suicide Prevention Plan for Washington State. Olympia, WA: Author.
Wenckstem, S., & Leenaars, A. A. (199 1). Suicide postvention: A case illustration in a secondary school. In A. A. Leenaars & S. Wenckstem, S.( Eds.), Suicide prevention in schools (pp. 18 1 195). New York: Hemisphere Publishing.
Wilson, K. G., Stelzer, J., Bergman, J. N., Kral, M.
J., Inayatullah, M., & Elliott, C. A. (1995). Problem solving, stress,
and coping in adolescent suicide attempts. Suicide and Life-Threatening
Behavior, 25, 241-252.