The Racial-Cultural Framework

Overview of the Framework

The RCF consists of three interrelated components that are further categorized into nine principles (see Table 1). We propose a key question that each of the three components addresses: What? (Component 1, a focus on constructs), Who? (Component 2, a focus on populations), and How? (Component 3, a focus on interventions). What follows is a discussion of the three components and nine principles.

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Table 1.

The Racial-Cultural Framework for Addressing Suicide-Related Outcomes in Communities of Color.

Component	Questions	Principles
Constructs	What constructs should be emphasized in theories and research addressing suicide-related outcomes in communities of color?	1. Examine the contributions of systemic inequities and oppression (e.g., racism) to suicide-related outcomes
		2. Address the complex ways in which cultural constructs serve as risk and protective factors in suicide-related outcomes
		3. Assess culturally relevant lay beliefs and attitudes about life, death, and suicide-related outcomes
Populations	Who (which communities of color) should be given more attention in suicide theory, research, and practice?	4. Disaggregate data on suicide-related outcomes to identify ethnic subgroups that have been neglected in previous suicidology work
		5. Adopt an intersectionality perspective (e.g., intersections of race and gender) to address suicide-related outcomes in communities of color
Interventions	How should suicide preventive interventions in communities of color be conducted and what should be the focus of these interventions?	6. Adapt culturally relevant suicide preventive interventions
		7. Collaborate with communities of color to devise, implement, and evaluate suicide preventive interventions
		8. Increase access to treatment resources
		9. Incorporate environment-centered suicide preventive interventions

Principle 1: Examine the Contributions of Systemic Inequities and Oppression

Consistent with recent counseling psychology scholarship that emphasizes ecological perspectives on psychological distress, we propose that oppressive environments and systemic inequities are salient risk factors for suicide-related outcomes among people of color (Buhin & Vera, 2009). Although multiple forms of oppression may predict suicide-related outcomes, we focus on racism and racial inequities because of their central relevance to the lives of people of color (Sue, 2003). A growing number of scholars have theorized that racism is an important risk factor for suicide related among people of color (Joe et al., 2008; Utsey, Hook, & Stanard, 2007; Wong & Poon, 2010). Using Durkheim’s (1897/1951) theory of suicide, racism can be conceptualized as an antecedent to suicide-related outcomes because it represents societal rejection or failure to integrate successfully into society (Mullen & Smyth, 2004). Similarly, racism can be viewed as generating a sense of failed belongingness, which is, in turn, a risk factor for suicide-related outcomes (Wong & Poon, 2010). Perceived racism has been found to be associated with suicide ideation among Asian American adults (Cheng et al., 2010), gay and bisexual Latino American men (Diaz, Ayala, Bein, Henne, & Marin, 2001), and Native American adolescents (Walls, Chapple, & Johnson, 2007). Collectively, these studies addressed individual forms of racism (Thompson & Neville, 1999).

Racism and racial inequities can also occur at the macro level in the form of racial income inequalities, racial segregation, and other types of systemic inequities (Buhin & Vera, 2009; Sue, 2003). For instance, Alcántara and Gone (2007) proposed that the legacy of colonization may help explain the relatively high rates of suicide in Native American communities. Drawing from criminology research and theoretical models, two studies found support for a racial inequality suicide thesis—Black American male and Latino American suicides were elevated in geographical areas with greater Black–White and Latino–White economic inequalities, respectively (Burr, Hartman, & Matteson, 1999; Wadsworth & Kubrin, 2007). Racial economic inequality may engender resentment, hopelessness, and eventually, self-destruction because it violates the principles of equal opportunity and fair play (Burr et al., 1999).

In another study, Kubrin, Wadsworth, and DiPietro (2006) applied Wilson’s (1996) deindustrialization thesis to the study of suicides among Black American men. Wilson proposed that the decline in U.S. manufacturing industries since the 1960s was particularly detrimental to less educated Black American male city dwellers who traditionally worked in manufacturing industries. Consistent with this thesis, Kubrin et al. found that in cities with a lower proportion of individuals employed in manufacturing jobs, Black American men experienced greater economic disadvantages (e.g., higher joblessness and poverty rates), which predicted higher Black American male suicide rates. In contrast, urban industrial composition did not affect White American economic disadvantages and White American male suicide rates. Together, these studies underscore the importance of examining macro-level, ecological manifestations of racial inequities as antecedents of suicide-related outcomes.

In terms of future directions, we encourage counseling psychology researchers to pay greater attention to developing and testing theories that address the link between racism and suicide-related outcomes in communities of color. In addition to individual forms of racism, counseling psychologists are urged to address macro-level manifestations of racism and racial inequities as suicide risk factors. However, research on macro-level risk factors has typically been conducted by sociologists, epidemiologists, and public health researchers (e.g., Burr et al., 1999; Neeleman, 2002) rather than by psychologists. Because the study of macro-level suicide risk factors often requires the investigation of geographical regions, such research may require psychologists to use multilevel research designs that include the effects of geographical contexts (such as neighborhoods and metropolitan areas) on suicide risks. In this regard, one promising line of inquiry may be to test both individual and macro experiences of racism; for instance, researchers can test whether individual experiences of racism mediate the link between people of color’s residence in highly segregated neighborhoods and suicide risk (cf. Acevedo-Garcia, Lochner, Osypuk, & Subramanian, 2003).

Principle 2: Address the Complex Ways in Which Cultural Constructs Serve As Risk and Protective Factors

We encourage researchers to address the complex ways in which culture can serve as both risk and protective factors for suicide-related outcomes in communities of color. Culture has had an increasingly prominent role in suicidology scholarship (Goldston et al., 2008; Lester, 2008; Shropshire, Pearson, Joe, Romer, & Canetto, 2008). Most studies on culture and suicide-related outcomes can be classified into two areas—(a) demographic differences and (b) acculturation and enculturation.

Principle 3: Assess Culturally Relevant Lay Beliefs and Attitudes About Life, Death, and Suicide

Counseling psychologists are encouraged to incorporate culturally relevant lay beliefs and attitudes about life, death, and suicide in their development of theories and research relevant to suicide-related outcomes among people of color. Such beliefs and attitudes include those about the meanings, causes, and consequences of suicide-related outcomes, death, and reasons for living, as well as beliefs about how to cope with suicide (Braun & Nichols, 1997; Canetto, 2008; Rogers & Whitehead, 2008).

An examination of culturally relevant lay beliefs and attitudes is useful for several reasons. Suicide preventive interventions that incorporate the lay beliefs held by key stakeholders in a community of color will likely be perceived as more credible within the community (e.g., May, Serna, Hurt, & DeBruyn, 2005). In addition, an investigation of such beliefs and attitudes may help identify culturally relevant strengths that buffer against suicide risk, a focus that is consistent with counseling psychology’s emphasis on human strengths (Walsh, 2003). In this regard, it may be useful to assess people of color’s reasons for living that protect them from suicide. For instance, studies have shown that Black and Latino Americans more strongly endorsed survival and coping beliefs and moral objections to suicide as reasons for living than White Americans (Ellis & Range, 1991; Oquendo et al., 2005). These findings may help identify culturally relevant protective factors that are salient in specific communities of color, although as discussed below, studies on reasons for living are not without limitations.

An investigation of culturally relevant lay beliefs about life, death, and suicide may also form the basis for the development of new culturally sensitive suicidology theories (Lester, 2006). Although lay beliefs about suicide are not identical to scientific theories, they may contain an element of truth that may explain suicide-related outcomes (Walker, Lester, & Joe, 2006). For instance, some scholars have observed that in many Asian cultures, suicide is viewed as a solution to intractable interpersonal problems rather than as a consequence of mental illness (Range et al., 1999; Shiang, 2000). Consistent with these notions, a study of Asian American college students lay beliefs about why Asian American college students might develop suicide ideation found that the overwhelming majority of responses described interpersonal causes, especially family problems (Wong, Koo, et al., 2011). In addition, LaFromboise and Bigfoot (1988) theorized that Native American cultural beliefs about the interconnections between the human and spirit worlds may reduce fears about death and suicide. Such beliefs can be incorporated in the development of suicidology theories relevant to communities of color.

Furthermore, culturally relevant lay beliefs and attitudes may provide insight into how communities of color cope with suicide-related outcomes as well as how their loved ones might respond to them. In a qualitative study of Black American pastors’ views on suicide, Early and Akers (1993) found that suicide was viewed as an unthinkable sin, a rejection of one’s Black identity, and as a “White thing” that is foreign to Black culture. Although these attitudes may serve as a buffer against suicide for Black Americans, they may also attach a high level of stigma to suicide-related outcomes. Consequently, Black Americans who hold these attitudes toward suicide, yet struggle with suicidal tendencies, may be reluctant to seek help or disclose their suicide ideation to others.

With regard to future research directions, we encourage more qualitative studies on people of color’s lay beliefs and attitudes toward life, death, and suicide (Leach & Leong, 2008). Qualitative research may provide a more nuanced understanding of the subjective meanings that people attribute to suicide-related outcomes (Chung, 2010). In addition, we encourage counseling psychologists to develop culturally relevant measures of reasons for living for specific communities of color. There are other culturally salient dimensions of reasons for living not examined in existing measures. For instance, current measures of reasons for living do not assess commitment to one’s tribe and commitment to one’s racial identity, dimensions that may be culturally relevant protective factors for some Native American tribes (e.g., Lester, 1997) and for Black Americans (Early & Akers, 1993), respectively.

Principle 4: Disaggregate Data to IdentifyEthnic Subgroups’ Suicide-Related Outcomes

Much of previous multicultural research on suicide-related outcomes has focused on specific racial groups (e.g., Latino Americans; Zayas et al., 2009) or comparisons between racial groups (e.g., Black vs. White Americans; Abe et al., 2006). Similarly, the CDC (2011) compiled national suicide data based on five “racial” categories: White, Black, American Indian/Alaskan Native, Asian Pacific Islander, and Other (combined) as well as the “ethnic” category of Hispanics. Unfortunately, these categories do not allow for the examination of variations among ethnic subgroups (e.g., Chinese, Haitian, and Mexican American) within these categories. Accordingly, disaggregation of data on suicide-related outcomes is needed to identify specific ethnic subgroups that are at higher risk for suicide-related outcomes. What follows is a brief review of research that has adopted a disaggregation strategy to address ethnic subgroup differences in suicide-related outcomes.

Among the three largest Latino American ethnic subgroups—Mexican, Puerto Rican, and Cuban Americans—research has consistently shown Puerto Rican Americans to be at higher risk for suicide attempts and ideation than Mexican Americans or Cuban Americans (Baca-Garcia et al., 2011; Fortuna et al., 2007; Ungemack & Guarnaccia, 1998). Among Asian Americans, suicidal deaths, ideation, and attempts of Chinese and Japanese Americans tend to be higher than other subgroups such as Vietnamese and Filipino Americans (Cheng et al., 2010; Lester, 1994). Research on Black Americans have found that Caribbean Black American adults had higher rates of suicide attempts and ideation than African American adults (Joe, Baser, Breeden, Neighbors, & Jackson, 2006; R. J. Taylor, Chatters, & Joe, 2011). In contrast, among Black American adolescents, African Americans had higher rates of suicide ideation and attempts than Caribbean Black Americans (Joe, Baser, Neighbors, Caldwell, & Jackson, 2009). Research on Native Americans has also demonstrated dramatically different rates of suicide-related outcomes among Native American tribes and tribal subgroups (Garroutte et al., 2003; Middlebrook, LeMaster, Beals, Novins, & Manson, 2001). For example, May and Van Winkle (1994) found that the number of suicide per 100,000 from 1957 to 1979 was 33.06 for Apache, 20.30 for Pueblo, and 7.45 for Navajo. Moreover, Novins et al. (1999) found that among three Native American tribes, the correlates of adolescents’ suicide ideation were different; indeed, there was no single correlate of suicide ideation common to the three tribes.

Overall, these findings underscore the importance of disaggregating suicide-related outcome data to identify specific ethnic subgroups that may have elevated rates of suicide-related outcomes (e.g., Puerto Rican Americans) or diverse risk and protective factors. Nevertheless, the disaggregation of suicide data presents a challenge because the CDC (2011) currently does not publish national suicide data based on ethnic subgroups. To advance suicidology theory, research, and practice related to communities of color, counseling psychologists may need to advocate for public policy changes to enable suicide data on specific ethnic subgroups to be more readily available.

Although the foregoing literature review suggests the existence of ethnic subgroup differences in suicide-related outcomes within communities of color, the reasons for these differences need to be further explored. Some scholars speculate that differences in cultural and spiritual beliefs may account for these ethnic subgroup differences (Leong, Leach, Yeh, & Chou, 2007; May & Van Winkle, 1994; Novins et al., 1999). For instance, Novins et al. (1999) attributed differences in suicide-related outcomes among Native American tribes to differences in beliefs about death and suicide, interpersonal relationships, self-concept, and social support. Future research should explore suicide-related outcomes of ethnic subgroups and identify relevant mediators of these subgroup differences. Such research can, in turn, form the basis for culturally relevant suicide preventive interventions for specific ethnic subgroups.

Principle 5: Adopt an Intersectionality Perspective

In addition to the disaggregation of data on ethnic subgroups, we encourage counseling psychologists to adopt an intersectionality perspective when addressing suicide-related outcomes. The intersectionality perspective originated from the works of feminists of color and critical race theorists who found that people’s experience of discrimination and privilege could be amplified or diminished depending on the intersections of their diverse identities (e.g., gender, race, and sexual orientation; Cole, 2009). For example, Crenshaw (1994) argued that Black American women experience disadvantages in ways that are qualitatively different from both White American women and Black American men. An intersectionality perspective in suicidology can help identify subgroups within communities of color that deserve further attention as well as acknowledge the unique, intersecting contributions of multiple forms of oppression to suicide-related outcomes (Diaz et al., 2001). We focus in particular on the intersections of race/ethnicity with age, gender, sexual orientation, and socioeconomic status.

Principle 6: Adopt Culturally Relevant Suicide Preventive Interventions

We encourage counseling psychologists to use culturally relevant suicide preventive interventions with communities of color (Joe et al., 2008). Cultural relevance refers to interventions that incorporate the cultural practices, beliefs, values, norms, and customs that form the core of a community (Barrera & Castro, 2006; Castro, Barrera, & Martinez, 2004). Culturally relevant interventions are essential because risk and protective factors for suicide-related outcomes differ across culture (see our discussion of Principle 2), which limits the generalizability of suicide preventive interventions used in White-majority populations. Moreover, the use of preventive interventions that are congruent with the cultural norms of a community increases the credibility of the interventions within the community (Reese & Vera, 2007).

There is a growing body of literature about culturally relevant suicide preventive interventions for Native American communities (Hamilton & Rolf, 2010; Middlebrook et al., 2001). LaFromboise and colleagues (LaFromboise & Howard-Pitney, 1995; LaFromboise & Lewis, 2008) developed the Zuni Life Skills Development Program, a suicide preventive intervention that focused on life skills training for high school students in a New Mexico Zuni reservation. The intervention was tailored specifically to address Zuni cultural manifestations of symptoms associated with suicide. Furthermore, the curriculum commenced with an invocation from a Zuni leader who reminded students that their lives were their most important possession. LaFromboise and Howard-Pitney (1995) found that high school students who attended the program had lower levels of suicide probability than a no-intervention group. In another study, May and colleagues (2005) monitored a population-based suicide preventive program for adolescents and young adults above 15 years in a New Mexican Athabaskan tribal reservation. The program included a multifaceted range of culturally relevant interventions (e.g., community education for adults, school-based curriculum, and clinical services) that targeted suicide risk factors specific to the tribe. The authors found a significant decrease in suicide attempts and gestures from 1988 to 2002.

In a third study, Muehlenkamp, Marrone, Gray, and Brown (2009) created a culturally relevant multidimensional campus-based prevention program for Northern Plains Native American college students that included educational (e.g., gatekeeper training) and cultural/spiritual components. Grounded in the notion that connecting students with traditional Native American cultural practices strengthened their resilience against suicide, a spiritual advisory committee was formed to coordinate and provide cultural and spiritual ceremonies (e.g., talking circles, sweat lodge ceremonies, and cleaning ceremonies) to these Native American college students. Hence, the program provided students direct access to cultural and spiritual activities that were integrated into their university life. The authors found that Native American students who participated in the program reported greater suicide knowledge.

There are a few culturally relevant interventions for Black American communities that have focused on women and youth. In a church-based suicide prevention program directed at Black American youth (Molock, Matlin, Barksdale, Puri, & Lyles, 2008), the authors proposed that a suicide educational curriculum be integrated with communication mediums that have cultural relevance to the Black American church. For instance, sermons and Sunday school lessons would emphasize the importance of seeking professional mental health for suicide-related outcomes. Another intervention involved an outpatient 10-session, group-based intervention for suicidal, low-income Black American women who were survivors of intimate partner abuse (Davis et al., 2009). The intervention was developed with appropriate consideration of contextual factors for this population. Black American women are often not inclined to seek help from institutions responsible for their oppression, and many feel that counselors do not understand the context in which they live. To address these concerns, the preventive intervention integrated the transtheoretical stages of change model by Prochaska, DiClemente, and Norcross (1992) with sensitivity to gender, culture, and systemic barriers (Heron, Jacobs, Twomey, & Kaslow, 1997). The intervention included collaborations with community agencies that supported women and incorporated the use of Afrocentric theory and Black feminism/womanism to empower participants (Davis et al., 2009). Although all intervention participants had attempted suicide within the year prior to their participation, only 13% attempted suicide within a year of their participation. In addition, almost 90% of participants reported extremely high or high levels of satisfaction with the intervention.

Unfortunately, there is limited peer-reviewed documentation of suicide preventive interventions for Asian, Pacific Islander, and Latino American communities. Therefore, we encourage counseling psychologists to develop culturally relevant suicide preventive interventions for these communities as well as for Black American men, a group that has demonstrated increasing rates of suicide attempts over the past few decades (Joe, 2010). Furthermore, an important limitation of most suicide preventive interventions (including culturally relevant suicide preventive interventions for communities of color) is the general lack of empirical evidence that these interventions reduce rates of suicide deaths (Joiner et al., 2009). For instance, after the introduction of a population-based suicide preventive program for Native American youth, May and colleagues (2005) found a reduction in suicide gestures and attempts but not suicide deaths. Accordingly, more research is needed to demonstrate the effectiveness of culturally relevant interventions in reducing suicide death rates. Another limitation of culturally relevant suicide preventive interventions is the need for greater theoretical grounding. Joe et al. (2008) observed that without a good theory, it is difficult to determine which aspect of a suicide preventive intervention is responsible for the desired outcomes. Therefore, we encourage counseling psychologists to take the lead in developing theory-based suicide preventive interventions for communities of color.

Principle 7: Collaborate With Communities of Color

Integral to the formulation and implementation of culturally relevant suicide preventive interventions in communities of color is collaboration with leaders and members of the community (Sullivan et al., 2001). Whereas cultural relevance addresses the content of a suicide preventive intervention, we propose that collaboration is a critical means through which an intervention becomes culturally relevant. Communities that lack social and economic power are often the focus of well-intentioned interventions developed by people outside the community with little input from community stakeholders (Fondacaro & Weinberg, 2002). Such interventions are less likely to be culturally relevant and to be supported by community members. In contrast, culturally relevant suicide prevention programs involve collaboration between researchers and community stakeholders to create and implement interventions that integrate the needs of the community, culture, and evidence-based programs (Skaff, Chesla, Mycue, & Fisher, 2002).

Collaboration with community stakeholders helps establish egalitarian partnerships with local communities (Reese & Vera, 2007). Collaboration facilitates the implementation of culturally relevant interventions because people within a community can provide insight into the cultural values of their community (Reese & Vera, 2007). In other words, members of a community are viewed as experts on their own culture and understand their community’s values, history, and coping strategies. In addition, involving community members in all phases of the preventive intervention builds new strengths by empowering community stakeholders to be agents of change within their own communities (Romano & Hage, 2000; Skaff et al., 2002). The active involvement of community members in preventive interventions also increases the likelihood that the intervention would be supported by the community over time, which, in turn, increases participation in the intervention (Hage et al., 2007).

Collaboration can take place at several phases of a preventive intervention, including (a) identifying important leaders, members, and stakeholders; (b) designing a preventive intervention; (c) implementing the preventive intervention; and finally (d) evaluating the intervention (Lerner, 1995). Several suicide preventive interventions for Native American communities illustrate the value of researcher–community collaborations. Two preventive interventions documented in our foregoing discussion (Principle 6) involved widespread collaborations between researchers and tribal members. Extensive input was sought from Zuni tribal members in the development of the Zuni Life Skills Development Program through the use of focus groups (LaFromboise & Lewis, 2008). For example, input from tribal members led to a title change of the program from Zuni “suicide prevention” to Zuni “life skills development.” Similarly, collaboration between researchers and tribal members in the development of the suicide preventive programs for an Athabaskan tribe involved more than 50 interactive group discussions on the problems to address in the community (May et al., 2005). Moreover, the implementation of the intervention involved people from different facets of the community, including schools, neighborhoods, and local mental health professionals to provide services in nonstigmatizing environments. For example, neighborhood volunteers were selected as “natural helpers” to provide counseling to clients who preferred to receive help from trusted laypeople. In a third study, researchers conducted a community-based participatory project to examine suicide-related outcomes in White Mountain Apache adolescents and young adults (Mullany et al., 2009). In collaboration with tribal leaders, researchers explored suicide rates and methods among community members between 2001 and 2006. Tribal leaders made the executive decisions about the data to collect and the data they wanted released. Researchers supported these requests by developing and standardizing measures, collecting data, and conducting data analysis (Mullany et al., 2009).

To summarize, we encourage counseling psychologists to establish collaborative partnerships with community stakeholders in their design, implementation, and evaluation of culturally relevant suicide preventive interventions for communities of color. Given the benefits of collaboration, researchers can also assess whether the quality of researcher–community collaboration mediates the effectiveness of suicide preventive interventions. In addition, researchers can also test whether collaboration increases the social validity of suicide preventive interventions (i.e., the extent to which community members and participants approve of the intervention).

Principle 8: Increase Access to Treatment Resources

Research has consistently revealed racial disparities in the use of crisis and psychotherapeutic services, with White Americans using these services at higher rates than people of color. In an assessment of a school-based suicide prevention program, Kataoka, Stein, Lieberman, and Wong (2003) found that Latino American high school students who were at high risk for suicide were underidentified for follow-up crisis interventions relative to White American students, despite previous documentation of higher suicide attempt rates among Latino American youth. In addition, after contact with the suicide prevention program, Latino American students were less likely than non-Latino American students to seek follow up for mental health services outside of school (Kataoka, Stein, Nadeem, & Wong, 2007). Similarly, Freedenthal (2007) found that among suicidal adolescents, Latino and Black Americans had a reduced likelihood of using mental health services relative to White Americans. Overall, people of color have reduced access to mental health services, are less likely to receive services even if access is available, and receive poorer quality of care in comparison with White Americans (U.S. Department of Health and Human Services [DHHS], 2001). Possible reasons for racial disparities in the use of professional mental health services include the stigma of suicide and mental illness, the lack of culturally and linguistically competent services, and a lack of financial resources (U.S. DHHS, 2001). For instance, among people of color living at or below the poverty line, the main avenue for care is through emergency services during times of crisis rather than through mental health services (Heron et al., 1997).

Reducing barriers and racial disparities in access to treatment resources for suicide-related outcomes is consistent with counseling psychologists’ growing interest in social justice research and practice (Toporek, Gerstein, Fouad, Roysircar, & Israel, 2006). In particular, we highlight two preventive interventions that have commonly been used to increase the use of mental health services by suicidal individuals—suicide screening and gatekeeping.

Suicide screening is a common suicide preventive strategy to identify those at risk for suicide. Respondents who score above a particular threshold on these screening tools are deemed to be at risk for suicide and are identified for follow-up interventions. Several studies have explored the utility of suicide screenings in schools, which often involves the administration of a screening tool to as many students as possible (e.g., Brown & Grumet, 2009; Peñta & Caine, 2006; Scott et al., 2009). Screening tools typically involves questions on participants’ mental health symptoms (e.g., depression and anxiety). However, among people of color (relative to White Americans), mental illnesses are poorer predictors of suicide-related outcomes, whereas interpersonal factors (e.g., family relationships) are better predictors of suicide-related outcomes (see Principle 2; for example, Abe et al., 2006). Hence, in addition to assessing mental illness symptoms, suicide screening tools that are used in communities of color may need to be adapted to include culturally salient risk factors, such as interpersonal isolation and family conflicts.

In addition to suicide screening, gatekeeping is another commonly used suicide preventive intervention. Gatekeeping involves training and encouraging people in contact with potentially suicidal individuals to identify suicide warning signs and to refer them to professional help (Paris, 2006). Gatekeeping may help increase the use of mental health services because research has shown that the majority of people who seek counseling services were prompted by someone to seek counseling (Vogel, Wade, Wester, Larson, & Hackler, 2007). Gatekeeping interventions used in communities of color are most effective when directed at social network members whom individuals are most comfortable seeking help from. For instance, previous research indicated that Black American youth who attended church regularly preferred young adult gatekeepers (Molock et al., 2007); therefore, Molock et al. (2008) proposed that a concerted effort should be made to recruit young adults for a church-based gatekeeping program for Black American youth. In another study, Chu, Hsieh, and Tokars (2011) found that relative to Latino Americans, Asian Americans were less likely to seek help for suicide ideation from all types of professional sources except medical professionals; therefore, the authors proposed training medical professionals to recognize suicide warning signs among Asian American patients and to make appropriate referrals to counseling when necessary.

Overall, we urge counseling psychologists to explore ways to increase access to treatment resources in communities of color. There is more evidence on the existence of racial disparities in the use of treatment resources than on why these disparities exist. Therefore, we encourage research to identify mediators of racial disparities in the use of mental health services among suicidal individuals.

Principle 9: Incorporate Environment-Centered Interventions

In line with our emphasis on macro-level sources of suicide-related outcomes (see Principle 2), we encourage counseling psychologists to use environment-centered suicide preventive interventions with communities of color. Such interventions shift the focus of attention from psychological problems to macro-level causes of suicide-related outcomes. Examples include interventions directed at the media and advocacy to introduce public policies that address macro-level risk factors.

The media can play a powerful but dangerous role in promoting suicide contagion by glorifying suicide or providing excessive information about the methods used by people to die by suicide (Jobes, Berman, O’Carroll, Eastgard, & Knickmeyer, 1996). That is, media portrayals of fictional as well as actual suicides can provide a social model for subsequent suicide and suicide attempts (Gould, 2001; Pirkis & Blood, 2001). Studies have found that television portrayals of suicides have led to increased rates of suicide deaths and attempts using the same methods portrayed (Gould, Jamieson, & Romer, 2003). Moreover, suicide contagion tends to be most prevalent among people who share similar life experiences and demographic characteristics as suicide decedents portrayed in the media (Gould, 2001).

Given the danger of media-influenced suicide contagion, educating media professionals about responsible portrayals and reporting of suicides is an important means of suicide prevention. Gould (2001) recommended that media reports of suicide should avoid portraying suicide as heroic or romantic, exercise care with publishing pictures of suicide decedents, avoid providing detailed descriptions of suicide method and site, and provide information about local treatment resources. Gould also reviewed evidence showing that suicide rates in Austria and Switzerland declined after media guidelines on the reporting of suicides were introduced. Although such guidelines have been widely disseminated to media professionals (Gould et al., 2003), it is unclear whether professionals who work for ethnic minority media organizations (e.g., journalists who write for a Mexican American newspaper) are familiar with these guidelines. The challenge of media contagion is compounded by the rise of the Internet as an important source of news. One recent study found that a significant proportion of websites on Asian American suicide-related outcomes provided either inaccurate or inappropriate (e.g., descriptions of suicide methods) information about suicide deaths (Park, Kwok, Yan, & Wong, 2010). Accordingly, counseling psychologists can help prevent suicide contagion by educating professionals involved in ethnic minority media on guidelines for responsible media reporting of suicides.

Although the media can be a source of suicide contagion, it can also be a means of suicide prevention through PSAs. A PSA could target a community of color to raise awareness about suicide and reduce stigma about seeking mental health services (Leong, Leach, & Wong, 2011). For example, a PSA on a radio station for Vietnamese Americans could provide information about suicide warning signs, access to help services, and other information about suicide prevention using language that accurately represents cultural conceptualizations of suicide (Leong et al., 2011; Olson & Wahab, 2006). Such information can also serve a gatekeeping function by encouraging members of the community to refer people to appropriate help resources (Joiner et al., 2009).

In addition to engaging the media, counseling psychologists can also advocate for public policies that reduce macro-level suicide risk factors in communities of color. Given our foregoing discussion of the link between racial economic inequality and suicides (see Principle 1), it is possible that environment-centered public policies that reduce racism and racial inequities (Buhin & Vera, 2009) may also prevent suicides in communities of color. For instance, counseling psychologists can advocate for socially just macroeconomic policies that reduce racial economic inequality. Another example of a macro-level factor that has implications for public policy is the ethnic and immigrant density of geographical locations. As our foregoing discussion of Principle 2 demonstrates, low immigrant and ethnic minority concentration in a geographical area may be a risk factor for higher suicide rates in communities of color (Neeleman & Wessely, 1999; Wadsworth & Kubrin, 2007). Such findings raise questions about the wisdom of refugee resettlement policies that encourage the dispersing of refugees across geographical areas to reduce the density of refugee concentration in a particular area (Desbarats, 1985). Accordingly, counseling psychologists can educate government leaders and public policy makers about suicidology research that can inform immigration and refugee resettlement policies.

Another public policy that can reduce macro-level suicide risk factors in communities of color is suicide means restriction. Research has shown that reducing access to certain suicide means (e.g., firearms and bridges) has been followed by a reduction in suicide rates (Daigle, 2005). For instance, a Canadian study that used interrupted time-series analyses concluded that a new law on firearms restriction may have been responsible for a reduction in suicide rates (Carrington & Moyer, 1994). Means restriction is effective because many people have a preference for a suicide method; hence, people with restricted access to a suicide means may not necessarily turn to alternative means of suicide (Daigle, 2005). There is evidence that the means by which people choose to die differ across race and that certain communities of color may have preferred methods of suicide (Lainer, 2010; Lester, 1994). Stack and Wasserman (2005) found that Black Americans were more than 2 times as likely as White Americans to use violent means of suicide (e.g., hanging and firearms). Another study showed that from 1979 to 1997, the rates of firearm suicides among Black American males aged 15 to 24 years increased more than their White American male counterparts (Joe & Kaplan, 2002). In a third study, Asian American suicide decedents were found to use hanging at higher rates than White American decedents (Shiang et al., 1997). Accordingly, counseling psychologist can identify suicide means that are salient in specific communities of color and, where appropriate, advocate for restriction of access to these means.

Perhaps the most glaring limitation in the literature on environment-centered suicide preventive interventions is the lack of research on the effectiveness of such interventions in communities of color.

For instance, we are not aware of any published research that has evaluated preventive interventions related to media-influenced suicide contagion, the use of PSAs, and suicide means restrictions in communities of color. We encourage counseling psychologists to address these areas in future research.