Taking Cultural Backgrounds Into Account for Suicide Prevention

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Suicide-prevention programs geared toward specific communities are more effective than treatment-as-usual.

Taking Cultural Backgrounds Into Account for Suicide Prevention
Taking Cultural Backgrounds Into Account for Suicide Prevention

There is a significant need for culturally adapted, empirically-supported interventions for suicidal individuals. Given that risk and protective factors for suicide can vary across different populations, suicide prevention programs should meet the needs of a particular ethnic group by considering the target population's culture, beliefs, practices, norms, and customs.

It is critical for researchers and mental health professionals to work together to evaluate the strengths and weaknesses of the evidence for suicide treatment while considering clinician, patient, and contextual factors.

In general, there are limited studies evaluating interventions and treatments effective at reducing suicidal behavior, which includes suicide ideation, attempts, and deaths. The reasons often cited for this dearth are the significant challenges inherent in investigating suicidal behavior and program efficacy. For example, the low base rate of suicidality makes it difficult to obtain the necessary sample sizes to adequately evaluate outcomes.

In spite of these limitations, there is a burgeoning body of research examining population, community, and individual level interventions specifically targeting suicidal behavior. Effective strategies include means restriction and media blackouts (population), gatekeeper training and physician education (community), and pharmacotherapy and psychosocial interventions (individual). Yet, many developers of these prevention programs fail to consider suicide-related cultural characteristics when designing their interventions.

As the population of the United States changes to become more diverse, suicide-specific prevention efforts should incorporate other cultural values and factors into interventions that are different from those associated with a Western, biomedical, and Eurocentric perspectives.

Accordingly, researchers should focus their attention on rigorously evaluating culturally centered interventions and treatment adaptations that show promise at reducing the risk for suicide in various ethnic groups. Multiple frameworks exist to aid in the development and/or adaptation of culturally tailored evidence-based psychosocial treatments to fit the needs of specific ethnic groups. Unfortunately, clinical trials assessing the outcomes of suicide prevention programs in ethnic minorities are noticeably lacking.

This gap in the literature led to the development of the Grady Nia Project (Nia) and Compassion and Meditation Program (CAMP), which are two randomized controlled trials (RCTs) offered through Grady Health System and the Emory Department of Psychiatry and Behavioral Sciences in Atlanta.

Under the direction of Nadine Kaslow, PhD, the goals of both of these evidence-based programs are to implement and disseminate interventions that address the needs of suicidal, low-income, African American men and women in a culturally sensitive manner.

Named for the Kwanzaa term meaning “purpose,” Nia is a culturally competent 10-session, group-based, manualized intervention designed to reduce risk factors and enhance protective factors associated with suicidal behavior among African American women in abusive partnerships.

Given the established association between intimate partner violence (IPV) and suicidal behavior,1 suicide prevention programs targeting abused women are warranted. Guided by the Theory of Triadic Influence (TTI),2 Nia addresses both proximal and distal influences of not only intrapersonal risk and protective factors, but also social/situational and cultural/ environmental influences as well.  

The intervention promotes a strong recognition of the cultural context of African American women's experience of IPV by fostering their intrapersonal qualities, addressing negative effects of trauma many have experienced, enhancing their interpersonal strengths, assisting them in negotiating access to mental health care, increasing their access to social support, and building supportive community collaborations.3

Results from the RCTs evaluating Nia vs. treatment-as-usual indicated that the Nia women reported more rapid decreases and greater symptom reduction in regards to general overall distress, depression, and suicidality. Moreover, several other suicide-related risk factors (e.g., hopelessness) were reduced and protective factors (e.g., existential well-being) were enhanced.4

These findings suggest that Nia may improve coping skills and resilience among abused, African American women while decreasing their risk for suicide.                          

Moreover, CAMP, a recently adapted six-session, group-based prevention program, employs the Cognitively-Based Compassion Training (CBCT) protocol5 with inner-city, low-income African American male and female suicide attempters.

CBCT is derived from the Tibetan Buddhist (lojong) mind-training tradition and was secularized to benefit a wider range of recipients.6 Although the majority of mindfulness-based investigations have been tested on Caucasians with relatively high socioeconomic status, theoretical predictions and pilot studies have suggested that these interventions may be well-suited for low-income African Americans.7

Like other widely used mindfulness-based interventions, CBCT employs a form of meditation and promotes the enhancement of mindfulness and attention. However, a major focus of CBCT that makes it different from other mindfulness interventions is that it applies a cognitive and analytical approach fostering empathy, equanimity, connectedness, and compassion in an effort to prevent future suicidal behaviors.

It is thought that CBCT may help reduce suicidality by increasing one's tolerance of maladaptive cognitive patterns and emotional states by decreasing experiential avoidance through a nonjudgmental and accepting approach using more mindful attention and awareness.8

Participants in a RCT received six culturally-adapted CAMP training sessions, while those in the treatment-as-usual group participated in six support sessions. Although CAMP is relatively new and the program is still in the process of being evaluated, anecdotal feedback has been obtained, in which several themes emerged:

  • Patients found the group activities to be very invigorating and useful in helping them understand challenging concepts, such as equanimity.
  • They enjoyed the homework exercises as it helped them to reinforce what they learned in the training.
  • They appreciated the class discussion and the meditation training, which helped them become more self-compassionate and compassionate towards others.

As an innovative meditation-based suicide prevention program, CAMP appears to show promise as an effective treatment option for low-income, suicidal African American men and women. However, more work is needed to evaluate the efficacy of this culturally-tailored program to determine its impact on suicidal behavior as compared with treatment-as-usual.

In sum, both Nia and CAMP demonstrate the importance of culturally-competent interventions to prevent suicidal behavior. Although preliminary quantitative and qualitative data have supported the efficacy of these two projects, additional longitudinal research is necessary to advance our understanding of evidence-based, culturally-informed practices.

Hopefully, these outcomes encourage further efforts in designing, implementing, and evaluating culturally-sensitive approaches that improve the well-being of minority populations at-risk for suicide. However, the development of culturally-informed suicide prevention programs need to not only be supported, but should be a priority in order to save lives.

Dorian A. Lamis, PhD, is an assistant professor in the Department of Psychiatry and Behavioral Sciences at Emory University School of Medicine.

References

  1. Devries KM, et al. Intimate partner violence and incident depressive symptoms and suicide attempts: A systematic review of longitudinal studies. PLoS Medicine. 2013; doi:10.1371/journal.pmed.1001439.
  2. Flay BR and Petraitis J. The theory of triadic influence: A new theory of health behavior with implications for preventive interventions. Advances in Medical Sociology. 1994;4:19-44. 
  3. Davis SP, et al. The Grady Nia Project: A culturally competent intervention for low-income, abused and suicidal African American women. Professional Psychology: Research and Practice. 2009; 40:141-147.
  4. Kaslow, NJ, et al. Suicidal, abused African American women's response to a culturally-informed intervention. Journal of Consulting and Clinical Psychology. 2010:78:449-458. 
  5. Ozawa-de Silva B, et al. Compassion and ethics: Scientific and practical approaches to the cultivation of compassion as a foundation for ethical subjectivity and well-being. Journal of Healthcare, Science and the Humanities. 2012. 2:145-161. 
  6. Pace T. Effect of compassion meditation on neuroendocrine, innate immune and behavioral responses to psychosocial stress. Psychoneuroendocrinology. 2009;34:87-98.  
  7. Dutton MA. Mindfulness-based stress reduction for low-income, predominantly African American women with PTSD and a history of intimate partner violence. Cognitive and Behavioral Practice. 2013;20 3-32. 
  8. Luoma JB and Villatte JL. Mindfulness in the treatment of suicidal individuals. Cognitive and Behavioral Practice. 2012;19:265-276.
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