Volume 36 Number 1
Fall 1996

The Problem

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.

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) explains:

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 death.

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.

Prevention
Whatever the title, normally the first level of prevention in a school-based prevention program involves raising the awareness of students, parents, and the school staff about the problem of youth suicide and the behavioral signs, physical symptoms, and stress indicators typically associated with youth at risk for suicide, and providing them information about community mental health resources and referral procedures.

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).

Intervention
Because of the high incidence of suicide among American Indian youth, it has been suggested by several researchers that the schools which serve these youth should focus their prevention efforts on the next level of prevention, that which seeks to identify those youth most at risk and to target programming toward the modification of those conditions which make them vulnerable to or protect them against suicide (Grossman et a]., 199 1; LaFromboise & Howard-Pitney, 1995). These programs address what are presumed to be the antecedent conditions of suicide (as well as other at risk behaviors), and make no mention of suicide in their titles (Felner, Adan, & Silverman, 1992). They include life-skills programs, decision-making skills programs, self-esteem building, stress reduction, socialskills training, anger and aggression management, coping skills programs, and problem-solving skills training.

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 (Capuzzi, 1994).

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.

Postvention
Postvention programs attempt to respond to the emotional and psychological impact of a suicide on those remaining. The goal of postvention is to support faculty, staff, and students with the grieving process and to prevent further suicides. The postvention program should be developed and in place in every school before a suicide has occurred, not after.

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.
(2) Inform faculty and staff of the suicide. Ideally such information should be given at a meeting of the entire faculty and staff. If this is not possible, then faculty and staff should be telephoned or notified by a member of the crisis team who would go to each classroom or office to inform teachers/staff. Every effort should be made to prepare teachers to assist students before any engagement of students. It is also critical that the reactions of staff to the suicide be addressed before the staff can be expected to assist students.
(3) Inform, individually and in person, close friends or relatives of the victim.
(4) Contact the victim's family to offer condolences and support. Inform them of the planned postvention efforts and, if possible, obtain the family's assistance in identifying friends or relatives in other schools who may need assistance.
(5) Prepare a written statement. Such a statement, should provide the facts of the suicide without any detailed description, a recognition of the sorrow and distress the death will cause, and information about resources available to help students with their grief or other emotions. If possible, this information should be transmitted on a class by class basis by members of the crisis response team ,or by a member of the team paired with a teacher. Opportunity must also be provided for students to share their feelings in the supportive environment of a small group
(6) Respond to inquiries from the community. It is important that a system be in place to handle inquiries from the media, parents, and the larger community. One member of the administration or mental health staff should be designated as the official spokesperson. However, all staff, and especially school secretaries who are often the point of first contact, should be briefed on how appropriately respond to inquiries. While school personnel need to respond accurately and professionally to all inquiries, the school should avoid becoming the principal source of information. It should be made clear that releasing details about the suicide is the responsibility of the medical examiner or other authority. In responding to any inquiries an explanation should be made of the efforts being made to help students deal with the tragedy, as well as information provided about where troubled youth or their families can obtain assistance.
(7) Communicate with parents. A letter should be sent to the parents of classmates of the victim providing them with information about the suicide, alerting them to be sensitive to their child's response, and encouraging them to contact the school if they have any personal concerns or observe any behavioral changes in their child.
(8) Provide counseling services. Prevention in the postvention context includes individual and group counseling for those most impacted by the suicide, as well as those who may be at increased risk because of the suicide. Postvention prevention may also include the provision of additional suicide awareness/prevention workshops for school staff, students, and parents. However, such training should not be instituted until after the initial phase of the crisis is past.
(9) Provide follow-up consultation. Approximately two to three months after the suicide the suicide prevention team should hold a meeting to assess the effectiveness of postvention efforts and, as necessary, to revise the program for the future. Provisions should also be made to insure that follow-up counseling and outreach initiatives continue as long as needed.

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).