Suicide Prevention in Indigenous Communities Proceedings of a Workshop (2022) / Chapter Skim
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Proceedings of a Workshop
Proceedings of a Workshop
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In some Indigenous communities, death by suicide has reached epidemic proportions with an increase from 21.5 per 100,000 in 2015 (Leavitt et al., 2018) to 23.9 per 100,000 in 2020 (Ehlman, 2022)
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The April 22, 2022, webinar provided an overview of suicide trends and suicide prevention efforts among Indigenous communities.2 Webinar participants discussed the differences between and among groups and tribes geographically, culturally, and linguistically. Additionally, participants discussed how cultural knowledge, practices, and ceremonies contribute unique strengths and serve as protective factors that act in parallel with behavioral health intervention and suicide prevention programs.
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;3 to raise the physical, mental, social, and spiritual health of Indigenous people to the highest level; and to ensure that comprehensive, culturally appropriate personal and public health services are available and accessible to Indigenous communities. The IHS provides comprehensive primary health care and disease prevention, including suicide prevention, to approximately 2.6 million Indigenous people in approximately 574 federally recognized tribes in 37 states (IHS, 2022)
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. BOX 2 Suggestions from Individual Workshop Participants to Advance Suicide Prevention in Indigenous Communities Improving culturally appropriate approaches to identifying, managing, and preventing suicides and suicide clusters • Engage with tribal communities and seek guidance from Indigenous leadership and scholarship to protect communities' values.
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• Empower Indigenous communities to engage in research and encourage researchers to partner with Indigenous people across the study continuum. (Allen, Dillard, Shaw)
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. Ivey-Stephenson shared data of an analysis that compared descriptive characteristics and circumstances precipitating suicide among non-Hispanic Indigenous people compared to non-Hispanic Whites across the 18 states that were included in the National Violent Death Reporting System, between the years 2003 and 2014.
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Figure 1 2020 leading causes of death by age groups, 10–14 and 45–54, in the Indigenous population. SOURCE: Ivey-Stephenson presentation, 2022 7
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In conclusion, Ivey-Stephenson said the CDC is working with tribes to reduce risk and increase protective factors to prevent suicide among Indigenous communities (NCIPC, 2022)
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President Nez stressed that many people in Indigenous communities continue to live with the effects of colonization and intergenerational and historical trauma. He also explained that all tribes are different, and urged tribal communities and leaders to utilize the unique Indigenous ways of life to develop effective suicide prevention strategies to reduce suicide ideation, attempts, and deaths and to restore harmony to their nations.
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is pervasive, not only in mental health but also in physical health, leading to disparities in chronic diseases, which in turn impact life potential," Warned stressed. Additionally, there are social conditions and local contexts that place Indigenous communities at greater risk for exposure to ACEs, which can result in disrupted neurodevelopment and subsequent social, emotional, and cognitive impairment that in turn lead to adoption of health risk behaviors, early onset of disease and disability, and social problems and early death, such as from suicide (Felitti et al., 1998, 2019)
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The researchers found that compared with non- Indigenous communities, I ndigenous people displayed a higher prevalence of ACEs, including abuse, neglect, and household d ysfunction, and had a higher total number of ACEs. For both Indigenous communities and non-Indigenous communities, having six or more ACEs significantly increased the odds for depression, anxiety, PTSD, severe alcohol misuse, and smoking compared with individuals with no ACEs (Warne et al., 2017)
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. BOX 4 Tribal Strengths and Cultural Aspects for Wellness Promotion and Suicide Prevention Miigis Gonzalez, a member of the Lac Courte Oreilles Ojibwe community in Northern Wisconsin and an assistant scientist for the Johns Hopkins Bloomberg School of Public Health Center for American Indian Health; Michelle Kahn-John, a member of the Diné Navajo Nation from Big Water Clan, a research fellow at Johns Hopkins School of Nursing, and psychiatric mental health nurse practitioner; and Evon Peter, a Neetsaii Gwich'in and Koyukon from Vashrąįį K'ǫǫ, Alaska, and senior research scientist at the Center for Alaska Native Health Research at University of Alaska, Fairbanks, discussed ways in which Indigenous cultures and language serve as protective factors and means to improve well being among Indigenous peoples (Gonzalez et al., 2017)
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Kahn-John agreed that speaking Indigenous language can be a protective factor. She also emphasized that cultural wisdom within Indigenous communities exists in stories, language, beliefs, ceremony, and traditional cultural practices (Kahn-John et al., 2021)
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Therefore, he suggested that evidence-based interventions in Indigenous communities may be more successfully accomplished by incorporating culturally appropriate practices. He urged those developing and implementing interventions to include more Indigenous people in leadership as knowledge and culture bearers.
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Gone explained that once there is substantial evidence of proven benefits for a given intervention across numerous studies, that evidence can be incorporated into formal clinical practice guidelines. Evidence Base for Mainstream Suicide Interventions Gone explained that there are different forms of suicide interventions, and not all mainstream suicide interventions have been shown to work.
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Evidence Base for Indigenous Suicide Interventions Gone said that robust intervention outcome research is challenging and therefore rare in Indigenous communities. He explained this point by sharing the findings of two systematic reviews.
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He suggested four questions that would need to be answered concerning evidence-based suicide interventions for Indigenous communities: 1. How confident are Indigenous populations that mainstream evidence based suicide interventions deserve special recognition and promotion in their communities?
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Examples of Suicide Intervention Models in Indigenous Communities Several speakers presented an overview of a range of current suicide intervention models and strategies across diverse Indigenous communities. Zero Suicide Sadé Heart of the Hawk Ali, of the First Nations Mi'kmaq from the Sturgeon Clan, and tribal lead for the Zero Suicide initiative, said that Zero Suicide is a way to improve suicide care within health and behavioral health systems.
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Although current available data estimate that 31 percent of Two-Spirit youth attempt suicide, Indigenous communities currently do not effectively collect data on this identity or sexual orientation and suicide rates among Two-Spirit and LGBTQ people (Trevor Project, 2020)
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. Ali said that the Zero Suicide initiative has published a companion toolkit, Best and Promising Practices for the Implementation of Zero Suicide in Indian Country, which indigenizes the Zero Suicide framework and serves as a resource for cultural adaptation of the Zero Suicide toolkit for health systems 10 See https://zerosuicide.edc.org/about/framework (accessed August 21, 2022)
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. serving Indigenous communities.11 The toolkit contains recommendations for the implementation of Zero Suicide in Indian Country, forms and tools others have used in their own implementation, and videos featuring a variety of Indigenous health systems that have committed to the implementation and indigenization of the Zero Suicide framework for their communities.
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When asked by a participant about what changes might increase uptake of Zero Suicide in Indian Country, and what advocates could do to assist in this aim, Ali responded that it is essential to find ways to talk to the communities and frame the conversation in respectful ways. Celebrating Life Novelene Goklish and Francene Larzelere, who are both from the White Mountain Apache Tribe and are research associates at the Center of A merican Indian Health at Johns Hopkins Bloomberg School of Public Health, presented on the Celebrating Life Suicide Prevention Program in the White Mountain Apache community.
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Larzelere shared the findings of a study that evaluated the impact of the Celebrating Life program among the White Mountain Apache of Arizona (Cwik et al., 2016)
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"Dedication to the community has shown that a surveillance system works, in-person follow-up works, and connecting to individuals on a oneon-one basis is key in suicide prevention and can greatly assist with accurate data collection," Larzelere emphasized. The White Mountain Apache Tribe is currently working with other Indigenous communities to implement similar interventions.
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Coordinated Care Model and Medication Management Lieutenant Commander Teresa Grund, lead faculty at Indian Country ECHO, and certified psychiatric pharmacist who practices as an advanced practice clinical pharmacist in a behavioral health medication management clinic at the Red Lake IHS in Minnesota, discussed opportunities to use an interdisciplinary health care team approach to suicide prevention, and the role of pharmacists in individual-level suicide prevention efforts. Many Indigenous health care facilities are located in remote areas, which limits access to mental and behavioral health care.
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She said that while most mainstream suicide prevention approaches tend to be very focused on individual risk factors and treatments for individuals who are in crisis, the research on social disparities in many Indigenous communities points to the need to think about community-level contexts, and in turn, 14 Self-administered tools for assessing depression. 15 See http://www.pc-cares.org/about (accessed August 21, 2022)
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Honoring Native Life Teresa Gomez, a tribal member of the Pueblo of Isleta and program manager of the Honoring Native Life program16 at the University of New Mexico (UNM) Department of Psychiatry and Behavioral Sciences in the Division of Community Behavioral Health, said that this program was established in March 2011 when the New Mexico state legislature passed legislation establishing what is called the Clearinghouse for Native American Suicide P revention.
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Gomez noted that throughout the years, Honoring Native Life has hosted several statewide summits, bringing together hundreds of people, including youth, tribal leadership, and partners, and behavioral health staff to discuss important issues such as community readiness, crisis response planning, and suicide prevention practices. In partnership with the New Mexico Department of Indian Affairs, the program offers trainings that are community based and focused on screenings, community readiness, and supporting tribal communities (Indian Affairs Department, 2021)
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, formerly, Zuni Life Skills. AILS is a community-driven, school-based, and culturally sensitive suicide prevention program for American Indian adolescents of the Zuni Pueblo.
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Nation and an assistant professor at Johns Hopkins University. Wetsit said that the Little Holy One project is a community-based participatory research project that resulted from previous research conducted at Fort Peck, which showed that historical trauma is associated with suicidal ideation in adolescents (Brockie et al., 2015; Willmon-Haque and BigFoot, 2008)
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Little Holy One is a starting point for future intervention in Fort Peck, Brockie concluded. RESEARCH IN INDIGENOUS COMMUNITIES Denise Dillard, an Inupiaq Eskimo, and the director of research for Southcentral Foundation, and Jennifer Shaw, who is of Ashkenazi Jewish and French-Canadian descent, and a medical anthropologist and senior researcher at Southcentral Foundation, discussed lessons learned from conducting research with Indigenous communities and described suicide prevention research conducted at Southcentral Foundation.
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32 Figure 5 Fort Peck Assiniboine and Sioux tribes: Timeline of collaborative activities. SOURCE: Brockie presentation, May 13, 2022.
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Respondents also raised specific cultural concerns along with global ethical concerns, as well as the potential promise of research in improving the health of Indigenous people. Dillard said that researchers derived key lessons from the study about transparency, accessibility, and seeking community and participant input.
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. One study evaluated the accuracy of an electronic health record-based algorithm, developed by the Mental Health Research Network, for predicting suicide risk among Indigenous people in primary care settings (Shaw et al., 2022)
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In addition, the implementation should balance safety concerns with privacy concerns to ensure timely intervention and to sustain patients' trust in the health system. Data Governance in Indigenous Communities and Community Wellness Stephanie Russo Carroll, of Ahtna and Sicilian descent, a citizen of the Native Village of Kluti-Kaah, and assistant professor as well as associate director of the Native Nations Institute at the University of Arizona, discussed the links between Indigenous governance, data sovereignty, the environment, and community wellness.
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Focusing on greater data sharing alone creates a tension for Indigenous Peoples who are also asserting greater control over the applica tion and use of Indigenous data and Indigenous knowledge for collective benefit. In response to this, academics and practitioners in the International Indigenous Data Sovereignty Interest Group within the Research Data Alliance led the development of the "CARE Governance for Indigenous Data Governance" (Collective Benefit, Authority to Control, Responsibility, and Ethics)
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allows Indigenous Peoples to access their data and share their data on their own terms (Carroll et al., 2021)
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, spoke about policy opportunities to advance suicide prevention efforts across Indigenous communities. Native Behavioral Health Access Improvement Act Honorable Smith said that generations of trauma and systemic underfunding of tribal housing, health, education, and other programs have caused serious harm to Indigenous communities in the United States.
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One grant requirement is to follow up with youth who are discharged from emergency departments or from inpatient units because of suicide attempts in order to reduce the significant risk of future attempts. Several studies have been conducted to examine the impact of the GLS State and Tribal Youth Suicide Prevention Grant Program on suicide mortality in counties that have implemented the program (Godoy Garraza et al., 2015, 21 See https://www.ihs.gov/sdpi/ (accessed August 21, 2022)
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They compared 525 counties exposed to the GLS program activities with unexposed matched control counties on county-level suicide mortality rates among youth ages 10 to 24. One year after implementing program activities, youth suicide mortality rates were 0.9 per 100,000 deaths lower among exposed counties than control counties.
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The second program that McKeon described was the Native Connections Grant Program, also referred to as Tribal Behavioral Health grants. This five-year grant program is available only to federally recognized tribes, tribal organizations, and tribal consortia to help Indigenous communities identify and address the mental health needs of Native youth.
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Combining estimates of suicide rates and other data overlooks the distinct identities among Indigenous communities and the ways people take care of and protect each other. Wexler emphasized that Indigenous communities are diverse and can have significantly different practices, leadership structures, ways of supporting spirituality, and languages.
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. It is essential to acknowledge harms and move toward a more equitable system, Wexler said, concluding that "It is important to begin to move from risk-only research to understand the strengths of communities, think of research as ceremony and process creation with the inclusion of local leaders and voices to improve empowerment, self-determination, and community development, and honor scientific and Indigenous knowledge." WRAP-UP Brockie reflected that this workshop on suicide prevention in Indigenous communities convened experts who are currently doing work across Indigenous communities to examine suicide risk and protective factors in Indigenous populations, discuss culturally appropriate and effective suicide prevention policies and programs, explore existing data systems and how data can be used for tracking suicide rates, and consider gaps and challenges in providing the continuum of care services for substance use and mental health disorders in multiple health care settings across Indigenous communities.
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2022. Protective factors as a unifying framework for strength-based intervention and culturally responsive American Indian and Alaska Native suicide prevention.
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Zero Suicide, Education Development Center. https://zerosuicide.edc.org/evidence/outcome-story/ chickasaw-nation-departments-health-and-family-services (accessed August 15, 2022)
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2019. Long-term impact of the Garrett Lee Smith Youth Suicide Prevention Program on youth suicide mortality, 2006–2015.
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March 8, 2021. New Mexico Indian Affairs Department partners with honoring Native life to host a suicide prevention training series for behavioral health providers in tribal communities.
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2021. Suicide interventions for American Indian and Alaska Native populations: A systematic review of outcomes.
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2020. The Trevor Project Research Brief: American Indian/Alaskan Native Youth Suicide Risk.
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2015. Impact of the Garrett Lee Smith Youth Suicide Prevention Program on suicide mortality.
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2008. Violence and the effects of trauma on American Indian and Alaska Native populations.
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