Cross-Cultural and Cognitive-Affective Models of Suicide Risk

Abstract

Only a handful of empirical investigations have identified culturally salient markers of suicide risk within samples of African American young adults. To address this gap, our study examined the intercorrelations among cultural congruity, defectiveness schemas, and multiple indices of suicide risk for African American (n = 207) and European American (n = 208) students attending a primary White institution. Cultural congruity was negatively associated with reports of interpersonal and behavioral suicide risk for both African and European American students. However, ethnic differences in the magnitude of these relationships emerged. Specifically, as predicted, for African Americans, lower levels of cultural congruity were more strongly related to greater interpersonal factors associated with a desire to die. Finally, the relationships between cultural congruity and multiple indices of suicide risk were partially mediated by defectiveness schemas for both African and European American students, suggesting a useful intervention target for students. These results also have implications for suicide screening, prevention, and intervention strategies directed toward African American students.

Keywords

cultural congruity defectiveness schemas suicide risk

Although theorists strongly assert that the interaction between ethnicity and environmental stress serves as a trigger for suicide behaviors, few researchers offer cross-cultural comparisons that delineate how suicide risk varies across ethnic groups. Instead, the bulk of the suicide literature considers risk from a European American perspective with little thought directed toward identifying suicide markers unique to predominant ethnic groups in the United States (Langhinrichsen-Rohling, Friend, & Powell, 2009). Inattention to processes that consider how the interactive effects of ethnicity and environmental stress promote suicide has impeded the development of culturally sensitive screening, prevention, and intervention efforts (Chu, Goldblum, Floyd, & Bongar, 2010), especially in regard to African American youth aged 18 to 24 for whom suicide is the third leading cause of death (Centers for Disease Control and Prevention, 2012).

African American suicide remains inadequately understood (Walker, Wingate, Obasi, & Joiner, 2008) perhaps due to misinterpretations of mortality statistics and self-report assessments that suggest that African Americans (5-6/100,000) have a considerably lower rate of suicide compared to European Americans (12/100,000; American Association of Suicidology, 2011). Interpreting mortality statistics and self-report ratings as an assessment of risk can be misleading in two important ways. Namely, the accuracy by which suicides are recorded is subject to underreporting and misclassifying errors (Chu et al., 2010; Rockett et al., 2010). For instance, ethnic minorities are more likely to engage in “hidden ideation,” a concept coined by Chu et al. (2010) to describe the tendency to conceal the desire and willingness to engage in suicide behaviors on self-report questionnaires and interviews. Mortality statistics also offer a restricted definition of suicide that considers only one outcome, the act of taking one’s own life. Instead recent theory recommends that suicidal behavior be defined along a continuum (Lewinsohn, Langhinrichsen-Rohling, Langford, & Rohde, 1995). The continuum begins with thoughts of death and dying and a desire to engage in risk-taking behaviors. It progresses to suicide ideation, plans to attempt suicide, and eventually suicide attempts. Identifying individuals who are engaging in behaviors at early points along the continuum (e.g., intervening with risk-taking and interpersonal correlates of suicide behavior) has been identified as an important screening and prevention strategy; especially since suicide completion is a relatively low base rate behavior (Langhinrichsen-Rohling, Klibert, & Williams, 2011).

Examining risk outcomes at earlier points on the suicidal trajectory is also consistent with culturally sensitive practices of suicide assessment. According to Chu et al.’s (2010) cultural model of suicide, consideration for alternative forms of suicide thought and intent (i.e., social discord, risk-taking behavior) is an essential step in explicating cultural variation of suicide risk in and among different ethnic groups. Few researchers, to date, have investigated ethnic disparities on interpersonal and risk-taking components of suicide. Preliminary evidence from these studies indicate that few meaningful differences exist on interpersonal and behavioral measures of suicide risk between African American and European American youth (Davidson & Wingate, 2011); however, more research is needed to confirm these findings.

Integrative Theory of Suicide Risk

Suicide risk consists of a constellation of factors that increase the willingness by which an individual will consider and engage in suicide attempts (Langhinrichsen-Rohling et al., 2011). Based on the recommendations of Klibert, Langhinrichsen-Rohling, Luna, and Robichaux (2011), it is important to assess suicide risk from an integrative perspective that considers constructs related to suicidal desire and the capability to enact self-injury. Joiner’s (2005) Interpersonal Theory of Suicide and Lewinsohn et al.’s (1995) Suicide Proneness Model work in concert to produce a robust means of assessing suicide risk, especially for ethnically diverse groups (Davidson & Wingate, 2011). Joiner’s Interpersonal Theory is a tripartite model of the processes underlying the development and maintenance of suicidal behavior (Van Orden, Cukrowicz, Witte, & Joiner, 2012). According to Joiner’s theory, sustained co-occurrence of two core interpersonal factors, thwarted belongingness and perceived burdensomeness, contribute to the development of a desire for death by suicide. Thwarted belongingness represents an unmet need related to a person’s sense of connectedness to familial, social, and cultural groups, whereas perceived burdensomeness represents failed attempts to achieve a sense of effectiveness or social competence in one’s primary support network (Van Orden et al., 2012). Although these factors are salient features in a moderate proportion of suicide notes (Joiner et al., 2002) and demonstrate the capability to predict suicide ideation (Christensen, Batterham, Soubelet, & Mackinnon, 2013), they are not thought to be sufficient to provoke lethal suicide behavior (Van Orden et al., 2012).

Instead, interpersonal factors only contribute to lethal suicide behavior when they simultaneously occur with Joiner’s (2005) third component to suicide risk, an acquired capability to enact self-injury. An acquired capability is characterized by a heightened degree of pain tolerance and fearlessness that work in tandem to deactivate preservation instincts and perceptions of alarm associated with suicide behavior (Van Orden, Witte, Gordon, Bender, & Joiner, 2008). Joiner posits that prolonged exposure to painful (physical and emotional) and provocative events over time can habituate an individual to the necessary levels of pain tolerance and fearlessness to initiate and complete a lethal suicide attempt. Painful behaviors directly affiliated to suicide, such as self-injury and previous suicide attempts, are the most efficient means of cultivating an acquired capability; however, indirect risky behaviors (e.g., violence, sensation seeking) that occur with greater frequency are also important in the development of an acquired capability (Smith & Cukrowicz, 2010). For instance, substance use, often a same day correlate of suicide, may facilitate the necessary fearlessness to attempt to end one’s life.

The latter position mirrors the work of Lewinsohn et al. (1995), who theorized and empirically investigated an individual’s propensity to engage in future suicide behavior. According to Rohde, Lewinsohn, Seeley, and Langhinrichsen-Rohling (1996), most instruments assess suicide behaviors that occur at a high threshold of severity (e.g., suicide attempts). Such focus often neglects consideration of life-threatening/risky behaviors (e.g., substance abuse, self-injury, social deviance), all of which are salient factors in the etiology of youth suicide (Esposito, Spirito, & Overholser, 2003). These behaviors may also be important prevention targets. In addition, most assessments possess strong associations with cognitive, affective, and interpersonal components of suicide, overlooking research suggesting that these components are neither necessary nor sufficient in predicting actual suicide attempts (Holden, Mendonca, & Serin, 1989). In response to these limitations, Lewinsohn et al. (1995) developed the Life Attitudes Schedule (LAS) and Life Attitudes Schedule–Short Form (LAS-SF) as a means to capture unique components of suicide behavior not otherwise accounted for by cognitive, affective, and interpersonal components. Item content of the LAS and LAS-SF was designed to extract clusters of subtle or covert life-threatening behaviors, as well as behaviors that are overtly suicidal (Rohde, Seeley, Langhinrichsen-Rohling, & Rohling, 2003). Included within these clusters are a number of behaviors (e.g., smashing a fist into a window, going on drinking sprees) that are known to promote associated features (e.g., greater levels of pain tolerance and fearlessness; Joiner, 2005) of an acquired capability to enact self-injury. In support of this theory, suicide prone behaviors have been shown to correlate with recent suicide ideation and a history of suicide ideation and attempts (Langhinrichsen-Rohling & Lamis, 2008).

Traditional symptoms of suicide (e.g., hopelessness, depression, etc.) are not as salient in the prediction of future suicide behaviors among African Americans when compared to European Americans (Abe, Mertz, Powell, & Hanzlick, 2006), making it difficult to use most existing assessment strategies aimed at identifying risk. In addition, differing expressions of suicide may be steeped in unique cultural dynamics, intentions, and motivations (Klibert et al., 2011), which in turn, may contribute to complications in risk assessment strategies. Thus, it is important to examine interpersonal (desire to die) and behavioral (suicide proneness) components of suicide behavior in conjunction with one another to generate a more robust and culturally sensitive assessment of suicide risk.

Identifying Culturally Salient Markers to Suicide Risk

For African Americans, quality of life is often determined by perceptions of cultural fit between individuals’ personal values and the values espoused within the environment they operate (also known as cultural congruity; Gloria & Robinson-Kurpius, 1996). Many challenges exist for African Americans seeking high levels of cultural congruity in the United States, as institutions prevalent in U.S. society often endorse a monocultural framework that is consistent with European American, masculine, and middle-class values (Gloria, Hird, & Navarro, 2001). Notably, microaggressions, marginalization, and acculturation difficulties are all prominent stressors that African Americans disproportionally encounter in their attempts to adapt to majority dynamics (Constantine, Smith, Redington & Owens, 2008; Venzant-Chambers, 2009). Prolonged exposure to such challenging stressors facilitates a sense of cultural incongruity marked by feelings of underappreciation and lower levels of cultural, social, and psychological wellness (Constantine & Watt, 2002; Pieterse, Todd, Neville, & Carter, 2011), which has the potential to generate interpersonal and behavioral risk to suicide.

Specifically, dissonance between cultural values and environmental pressures to assimilate may engender overwhelming emotional distress highlighted by a sense of isolation or burdensomeness (e.g., De Hoyos & Ramirez, 2007; Walker, 2007). Some previous work has supported this position. For instance, Chao, Mallinckrodt, and Wei (2012) examined co-occurring presenting problems in 1,777 African American counseling center clients. Results indicated that ethnically induced distress was positively related to a number of interpersonal concerns associated with thwarted belongingness, including difficulties connected with familial relationships, peer relationships, forming new friendships, and homesickness. Similarly, Constantine, Robinson, Wilton, and Caldwell (2002) found that cultural incongruity was positively associated with burdensomeness features including perceptions of ineffectiveness regarding membership in social groups.

Similarly, an inhospitable and unwelcoming environment may also foster engagement in life-threatening and risky behaviors common among individuals with an acquired capability to die by suicide. Psychosocial detriments associated with cultural incongruity (e.g., discrimination) have been shown to consistently predict increases in unhealthy behaviors over time for African Americans (Gibbons, Gerrard, Cleveland, Wills, & Brody, 2004). Gibbons et al. (2012) extended our understanding of these associations by experimentally examining the relationships among racial discrimination, impulse control, and features of substance use. Their results highlighted an indirect relationship between racial discrimination and substance use through reduced impulse control, suggesting that the cumulative effects of discrimination reduce the potential to employ effective self-control strategies, which in turn precipitates a greater proclivity to engage in more risky and life-threatening behaviors (e.g., substance use). Taken as a whole, these results suggest that operating in a culturally incongruent environment may have detrimental effects that may increase risk to suicide. However, direct relationships between cultural congruity and indices of suicide risk have yet to be established for African American adults.

Defectiveness as a Potential Mediator

Multicultural theories posit that the relationship between cultural stressors and psychopathological outcomes may be mediated through cognitive-affective variables (Pyke, 2010; Szymanski, Kashubeck-West, & Meyer, 2008). The literature on internalized oppression supports this position, citing the insidious effects hostile environments have on an individual’s perception of self and how these perceptions provoke negative psychological outcomes (Szymanski et al., 2008). Culturally incongruent environments may contribute to and perpetuate chronic feelings of self-blame, disgust, and disrespect that distort one’s self-concept (Pyke, 2010). Interestingly, similar clusters of cognitive-affective variables underlie Young, Klosko, and Weishaar’s (2003) defectiveness schema, which reflects broad and pervasive themes of insecurity and inferiority. Considering that the common estimates of self-worth (e.g., self-esteem measures) do not consider a diverse range of cognitive and affective components associated with perceptions of self-concept, defectiveness schemas may be a more robust mechanism to explain the relationship between cultural incongruity and psychological difficulties among African Americans. Moreover, Klibert, Barefoot, Smalley, and Warren (2014) found evidence suggesting that defectiveness schemas predict moderate to large amounts of variance in both interpersonal and behavioral components of suicide risk over time. In combination, these findings provide theoretical evidence for the potential mediational role of defectiveness schemas in explaining the relationships between cultural congruity and indices of suicide risk.

Current Study

The purpose of the current study was to investigate gender and cross-cultural differences (African American vs. European American students) in suicide risk. Research citing gender and ethnic differences in suicide rates has been hampered by underreporting errors (Rockett et al., 2010). To address this limitation, researchers (i.e., Chu et al., 2010) have endorsed conducting studies to examine gender and ethnic differences on alternative measures of suicide desire and intent that may more accurately capture culturally sensitive expressions of risk. As a result, the first goal of the current study was to examine gender and ethnic differences on two unique measures of suicide risk (interpersonal factors associated with a desire to die and suicide proneness). Additionally, an emerging line of research has focused on the identification of culturally salient correlates of suicide risk across ethnic groups. Classic correlates of suicide risk (e.g., depression, hopelessness) appear less predictive of future suicide behavior for African American versus European American students (Abe et al., 2006). As a result, it is important that researchers identify culturally salient correlates to African American risk so that more culturally sensitive practices associated with suicide prevention and intervention can be developed and refined. Given this need, the second goal of the current study was to examine the relationships between cultural congruity and two measures of suicide risk for African American as well as European Americans students. Also considering the large percentage of African Americans students who report experiencing a discriminating event (98.5%; Prelow, Mosher, & Bowman, 2006) and the deleterious effects of acculturative stress on mental health (Walker, 2007), there may be some ethnic variation by which cultural congruity is related to indices of suicide risk. As a result, the third goal of the study was to examine ethnic differences in the associations between cultural congruity and indices of suicide risk. Finally, theorists suggest that models of suicide have not been framed from a multicultural context (Chu et al., 2010), which again limits the development of culturally sensitive prevention and assessment strategies to suicide. Multicultural theories (i.e., Pyke, 2010) posit that culturally incongruent environments may influence the development of cognitive-affective themes of inferiority and insecurity, which in turn may promote negative psychological outcomes. To date, no known study has examined the fit of this model to predict suicide risk in a sample of ethnically diverse students. To address this gap, the fourth goal of the current study was to examine cultural congruence-suicide risk relationships in the context of a third mediating variable, defectiveness schemas, in a sample of African American students.

Given the current literature, the hypotheses for the current study were the following: (a) minimal differences in self-reported measures of suicide risk (i.e., interpersonal factors associated with a desire to die, suicide proneness) would be reported between African American and European American college students; (b) cultural congruity would be inversely related to reports of interpersonal and behavioral risk for both African American and European American students; (c) the relations between cultural incongruity and suicide risk would be stronger for African Americans as compared to European Americans; and (d) defectiveness schemas would at least partially mediate the relationships between cultural congruity and the indices of suicide risk, especially for African American students.

Method

Participants

Participants included 487 (293 women and 194 men) students from a Primary White Institution (PWI) in the southeastern region of the United States. All interested students were invited to participate in the study through the university’s subject pool and received one course credit for their time. The age of the participants ranged from 18 to 26, with an average age of 19.55 (SD = 1.46). In terms of ethnicity, only participants who self-identified as European American and African American were included in the analyses. Two hundred and eight participants self-identified as European American (57.5%), and 207 participants self-identified as African American (42.5%). These characteristics, including the preponderance of women, are similar to the demographics of this university’s psychology participation pool.

Measures

Life Attitudes Schedule–Short Form (LAS-SF)

The LAS-SF (Lewinsohn, Langhinrichsen-Rohling, Rohde, & Langford, 2004) is a 24-item true-false questionnaire designed to measure behaviors known to increase the likelihood of future suicide ideation, attempts, and completions. Total LAS-SF scores range from 0 to 24, with higher scores indicating greater suicide proneness. The LAS-SF total score has demonstrated solid internal consistency (α = .78) with college student samples (Lewinsohn et al., 2004) and high construct validity as evidenced by moderately high relationships with measures of risky behaviors and reports of previous suicide attempts among college students (Rohde et al., 2003). Similarly, in the current study, the LAS-SF total score (α = .74) demonstrated adequate internal consistency.

Interpersonal Needs Questionnaire (INQ)

The INQ (Van Orden et al., 2008) is a 12-item questionnaire. It was designed to measure an individual’s desire to die as reflected by a perceived lack of connection to others as well as by overwhelming feelings of burdensomeness. Participants were asked to indicate the extent to which each statement was recently true for them using a 7-point Likert-type scale (1 = Not at all true for me to 7 = Completely true for me). INQ total scores range from 0 to 84, with higher scores indicating greater interpersonal factors associated with a desire for death by suicide. Considering that the most dangerous form of suicide desire arises from the simultaneous presence of thwarted belongingness and perceived burdensomeness (Van Orden et al., 2012), an INQ total score was calculated and used within the current study. Klibert et al. (2014) found high internal consistency (α = .92) and test-retest reliability (α = .68) for the INQ total score in college student samples. In addition, the INQ total score has demonstrated excellent construct validity with measures of perceived stress and suicide proneness across time (Klibert et al., 2014). In the current study, the INQ total score (α = .92) demonstrated high internal consistency.

Cultural Congruity Scale (CCS)

The CCS (Gloria & Robinson-Kurpius, 1996) is a 13-item measure designed to assess for the perceived fit between an individual’s cultural values and traditions and the cultural climate of the environment in which he/she operates. The CCS asks participants to rate their perceptions of cultural fit with their campus climate (e.g., “I feel that my language and/or appearance make it hard for me to fit in with other students”) on a 7-point Likert-type scale (1 = Not at all, 7 = A great deal). Total scores on the CCS range from 13 to 91, with higher scores indicating greater perceived cultural congruity. The CCS has been shown to have adequate reliability (α =.82) and excellent construct validity with measures of help-seeking behavior (Gloria et al., 2001; Gloria, Robinson Kurpius, Hamilton, & Willson, 1999) among diverse samples of college students. In the current sample, the CSS total score demonstrated solid internal consistency (α = .79).

Young Schema Questionnaire–Long Form 2nd Revision (YSQ-L2)

The YSQ-L2 (Young, 2005) consists of 205 items that measure pervasive and debilitative themes of cognitive-affective functioning. In total, the YSQ-L2 contains 15 early maladaptive schema subscales. However, for the purposes of this study, only the defectiveness schema subscale score (n = 15) was calculated. Individuals were asked to respond to a series of statements by rating their agreement/disagreement using a 6-point Likert-type scale. Total scores on the defectiveness schema subscale range from 15to 90, with higher scores indicating greater adherence to cognitive-affective themes associated with insecurity and inferiority. The defectiveness schema subscale has demonstrated solid internal consistency (α = .84) and high construct validity with academic, social, and emotional adjustment difficulties in college students (Cecero, Beitel, & Prout, 2008). In the current sample, the defectiveness schema demonstrated high internal consistency (α = .92).

Procedure

Data were collected anonymously through an online survey. Undergraduates voluntarily provided their informed consent before responding to the set of questionnaires. Participants took approximately 50 minutes to complete the online survey. On completion of the survey, all participants were taken to a debriefing page where they were offered free to low cost mental health services and thanked for their participation. Ethical guidelines were followed in the collection of these data, and institutional review board approval was obtained prior to data collection.

Data Analytic Plan

To test our hypotheses, the following data analytic strategies were executed. First, a 2 (gender) × 2 (ethnicity) factorial MANOVA was conducted to determine if there were group differences on the two measures of suicide risk. Next, tests of zero-order correlations were examined to determine the relationships among the study’s variables separately by ethnic group (African American vs. European American). Zero-order correlations were then analyzed using Fisher’s r to z analyzes to determine significant differences in the strength of the obtained relationships for African American versus European American students. Finally, a series of ordinary least square multiple regressions were analyzed to assess the mediating effects of defectiveness schemas on the cultural congruity-suicide risk relationships for African American and European American students separately. In total, four mediation models were evaluated based on the general guidelines outlined by Baron and Kenny (1986). Specifically, mediation is established when four conditions are met: (a) the predictor variable (cultural congruity) must be significantly related to the outcome variable (suicide risk); (b) the predictor variable (cultural congruity) must be significantly related to the proposed mediating variable (defectiveness schemas); (c) the proposed mediating variable (defectiveness schemas) must be related to the outcome variable (suicide risk) when controlling for the predictor variable (cultural congruity); and (d) the significant relationship between the predictor variable (cultural congruity) and the outcome variable (suicide risk) must be attenuated by the proposed mediating variable (defectiveness schemas). If these conditions are met, two types of mediating effects are possible, full and partial mediation. Full mediation is indicated when a proposed mediating variable completely attenuates the relationship between the predictor and outcome variable. Alternatively, partial mediation occurs when the presence of the proposed mediator accounts for a significant portion, but not all, of the covariance between the predictor and outcome variables. As a supplement to the regression models, Sobel’s z tests (1982) were conducted to determine if the proposed mediator accounted for a significant portion of the covariance between the predictor and outcome relationships.

Results

Mean Difference and Correlational Analyses

Mean Differences on Suicide Risk

A 2 gender (women vs. men) × 2 ethnicity (African American vs. European American) MANOVA was conducted to investigate ethnic differences among the two suicide indices (i.e., interpersonal factors associated with a desire to die and suicide proneness). Results yielded a significant overall main effect for ethnicity Wilks’s Λ(1, 480) = 3.31, p = .037, η² = .02. However, nonsignificant effects for gender, Wilks’s Λ(1, 480) = .92, p = .14, η² = .01, and the gender by ethnicity interaction, Wilks’s Λ(1, 480) = .99, p = .791, η² = .01, were revealed. For ethnicity, there was significant main effect on suicide proneness, F(1, 482) = 5.47, p< .05, η² = .01, such that African American students (M = 5.22, SD = 3.31) reported engaging in less life-threatening behaviors than did European American students (M = 5.98, SD = 3.65). Overall, ethnicity main effects were not obtained for self-reported interpersonal factors associated with a desire to die.

Univariate Correlations

Zero-order correlations were computed to examine the relationships among cultural congruity, defectiveness schemas, and indices of suicide risk for African American and European American students independently. Means, standard deviations, and the intercorrelations among the study’s main variables are presented in Table 1. Intercorrelations revealed medium effect sizes for both African American and European American students. All of the intercorrelations examined were in the expected directions.

Table 1.

Means, Standard Deviations, and Intercorrelations Among Measures of Cultural Congruity, Defectiveness Schemas, and Suicide Risk in European and African Americans Students.

Variable	1	2	3	4	M	SD
1. Cultural Congruity	—	−.55**	−.44**	−.60**	75.75	12.64
2. Desire to Die	−.37**	—	.55**	.64**	20.34	11.46
3. Suicide Proneness	−.32**	.50**	—	.51**	5.22^††	3.31
4. Defectiveness Schemas	−.36**	.60**	.45**	—	28.29	12.42
M	75.28	20.33	5.98^††	28.98
SD	10.45	10.98	3.65	11.91

Note: Mean scores and correlations in bold represent data for African American students.

Correlation is significant at the .01 level.

††

Significant mean differences between African American and European American students at .05 level.

Ethnic Differences Among Univariate Correlations

Based on the literature, it was expected that lower rates of cultural congruity would be associated with greater reports of insecurity and inferiority and higher levels of suicide risk for African American students more than for European American students. To test these hypotheses, Fisher’s r to z analyses were performed to determine if significant differences existed in the magnitude of these relationships between ethnic groups. Results are presented in Table 2. Of note and as predicted, lower rates of cultural congruity were more strongly related to greater reports of interpersonal factors associated with a desire to die and cognitive-affective themes of insecurity and inferiority for African American as compared to European American students. There was no difference in the strength of the cultural congruity-suicide proneness relationship between ethnic groups.

Table 2.

Comparison of Correlational Coefficients Between Cultural Congruity and Measures of Suicide Risk and Defensiveness by Ethnic Group.

Correlations	African American cultural congruity	European American cultural congruity	r to z score	p Value
Desire to Die	−.55 (n = 203)	−.37 (n = 277)	2.44	<.05
Suicide Proneness	−.44 (n = 204)	−.32 (n = 279)	1.49	>.05
Defectiveness Schemas	−.60 (n = 204)	−.36 (n = 279)	3.30	<.01

Mediation Models

All variables were associated to a significant degree, meeting Baron and Kenny’s (1986) four conditions to construct mediation models. As a result, four series of ordinary least square multiple regressions were conducted to examine the potential mediating effects of defectiveness schemas on the relationships between cultural congruity and indices of suicide risk for African American and European American students. Considering that two indices of suicide risk (interpersonal factors associated with a desire to die and suicide proneness) were under investigation, two separate mediation models were constructed for each ethnic group. The results of the path analyses are presented in Figure 1.

Figure 1.

Results of indirect and direct paths for African Americans in Models 1(a) and 1(b). Results of indirect and direct paths for European Americans in Model 2(a) and 2(b).

For African American respondents, the inclusion of the defectiveness schema attenuated (Δβ = .31; Sobel’s Z = 7.83, p< .01) the relationship between cultural congruity and interpersonal factors associated with a desire to die by suicide. However, even after considering the impact of defectiveness schemas, the relationship between cultural congruity and interpersonal factors associated with a desire to die was still significant (β = −.24, p< .01), suggesting partially mediated effects. The linear combination of cultural congruity (b = −.24, p< .01) and defectiveness schemas (b = .51, p< .01) predicted 47% of the variance in interpersonal factors associated with a desire to die by suicide in the final step of the path model, F(2, 200) = 88.78, p< .01. Similar results were revealed in examining the relationship between cultural congruity and suicide proneness in African American students. Notably, defectiveness schemas significantly reduced the strength of the path between cultural congruity and suicide proneness (Δβ = .24; Sobel’s Z = 6.64, p< .01). Again, defectiveness schemas only partially mediated this relationship as the direct path between cultural congruity and suicide proneness remained significant (β = −.20, p< .01) even after accounting for the mediating effects. The linear combination of cultural congruity (b = −.20, p< .01) and defectiveness schemas (b = .40, p< .01) predicted 30% of the variance in suicide proneness scores in the final step of the path model, F(2, 201) = 42.89, p< .01.

Defectiveness schemas also attenuated the path between cultural congruity and interpersonal factors associated with a desire to die by suicide (Δβ = .19; Sobel’s Z = 5.73, p<.01) for European American students. Likewise, considering that the direct path between cultural congruity and interpersonal factors associated with a desire to die by suicide (β = −.18, p< .01) was significant after controlling for the mediated effects, only partial mediation was obtained. The linear combination of cultural congruity (b = −.18, p< .01) and defectiveness schemas (b = .54, p< .01) predicted 39% of the variance in interpersonal factors associated with a desire to die by suicide in the final step of the path model, F(2, 274) = 86.74, p< .01 (as compared to 47% of the variance for African American students). Last, the direct path between cultural congruity and suicide proneness was also significantly reduced in the path analysis (Δβ = .14; Sobel’s Z = 5.11, p< .01) after controlling for the effects of defectiveness schemas. However, the model only revealed partially mediated effects as the relationship between cultural congruity and suicide proneness (β = −.18, p< .01) was still significant after accounting for defectiveness schemas. The linear combination of cultural congruity (b = −.18, p< .01) and defectiveness schemas (b = .38, p< .01) predicted 23% of the variance in suicide proneness scores in the final step of the path model for European American students, F(2, 276) = 41.43, p< .01 (as compared to 30% of the variance for African American students).

Discussion

The current literature reports mixed findings regarding variation in self-reported suicide risk between African American and European American college students. As a result, the current study examined mean differences between African American and European American students on two highly regarded indices of suicide risk. Overall, on a positive note, both African American and European American students reported low levels of interpersonal factors associated with a desire to die and suicide proneness. Moreover, only minimal differences in suicide risk emerged between African American and European American students. For instance, African Americans expressed similar levels of interpersonal factors (thwarted belongingness and perceived burdensomeness) when compared to European Americans, confirming previous findings (Davidson & Wingate, 2011). In addition, African American students (M = 5.22) reported significantly lower suicide proneness scores compared to European American students (M = 5.98), though the difference may not hold much practical significance (η² = .01). Taken as a whole, these findings suggest that African Americans express suicide risk almost as frequently as European Americans among samples of college students and support Davidson and Wingate’s (2011) empirical results suggesting that few, if any, meaningful differences in self-reported suicide risk exist between African American and European American students.

However, these findings stand in contrast to a large body of literature suggesting that African Americans are at a decreased risk for suicidal behavior (e.g., attempts, completions; Wenzel et al., 2011). How researchers measure suicide risk may be an important factor in explaining these discrepancies. It is important to note that in our study and other similar studies (e.g., Davidson & Wingate, 2011) suicide risk was measured by more subtle and indirect assessments. This is an important contribution to the literature as most empirical investigations of ethnic disparities in suicide assess risk examine more direct behaviors (e.g., suicide ideation and attempts). According to Chu et al. (2010), use of direct suicide assessments may underdetect risk for ethnic minorities because such practices engender little consideration for cultural sanctions (e.g., shame) that might influence willingness to disclose. Instead, ethnic minorities may be more willing to express symptoms of suicide risk on indirect and subtle measures because these assessment strategies may help minimize potential stigma, shame, and/or embarrassment. In keeping with this position, our findings provide support for diversifying the means by which clinicians assess suicide in African Americans to include subtle and indirect measures.

Correlates of Suicide Risk by Ethnic Group

Another limitation in the suicide literature is the lack of empirical attention toward identifying culturally salient correlates of suicide risk for ethnically diverse populations (Walker et al., 2008). To address this gap, the current study examined associations between cultural congruity and two indices of suicide risk in a sample of African American and European American students. As expected, perceptions of cultural incongruity within one’s social environment were significantly related to estimates of interpersonal (e.g., thwarted belongingness and perceived burdensomeness) and behavioral (e.g., engaging in life-threatening behaviors) risk for both African American and European American students. These findings are consistent with previous research (e.g., Pieterse et al., 2011; Walker, 2007) suggesting that African Americans students are at a greater risk to engage in life-threatening behaviors when they perceive their environment as culturally restrictive and oppressive. Moreover, if African American students experience prolonged exposure to culturally unwelcoming and hostile conditions, they may increase the frequency and intensity by which they engage in life-threatening behavior, which may then amplify the probability of engaging in risk behaviors (e.g., fearlessness and pain tolerance) needed to enact lethal self-injury. Continued research in this area will be important in order to identify the impact of prolonged exposure to culturally incongruent environments on the relationship between life-threatening behaviors and the ability to enact a lethal suicide attempt.

Interestingly, perceptions of cultural incongruity were also related to higher estimates of suicide risk for European American students. While estimates of cultural congruity have been traditionally collected from samples of ethnic minorities, this finding suggests that cultural congruity may also be important in understanding the development and exacerbation of mental health difficulties for European American students. Rather than comparisons of fit based on race, cultural congruity examines fit based on ethnicity, a concept that includes many cultural aspects (nationality, language, ancestry, etc.) along which European Americans may vary considerably. In keeping with this position, it is recommended that cultural congruity be considered in future research designed to predict mental health difficulties in European American students.

Ethnic Variation in Correlates to Suicide Risk

Culturally incongruent environments often exert their influence on behavioral and emotional health outcomes. However, the insidious effects of cultural incongruity may fluctuate based on minority group status—with individuals self-reporting as members of a minority group experiencing greater consequences in comparison to majority group members. Consistent with this position, the obtained findings revealed some ethnic group differences in the relationships among cultural congruity, defectiveness schemas, and indices of suicide risk. For instance, relationships between cultural incongruity and interpersonal factors associated with a desire to die were stronger for African Americans students than for European American students. This same pattern was obtained for the relationship between cultural incongruity and defectiveness schemas. In combination, these results suggest that unstable perceptions of cultural fit may be more detrimental in terms of cultivating a sense of belongingness, social competence, and positive self-image for African American students as compared to European American students enrolled at a PWI. One potential explanation for these differences is fluctuations in cognitive appraisal processes. According to Lazarus and Folkman (1984), secondary appraisal processes associated with the identification and implementation of coping resources are crucial in the development of interpersonal and affective outcomes. Unfortunately, African American students may experience more difficulties in accumulating culturally salient coping resources (e.g., social support) to endure unwelcoming and inhospitable climates compared to European American students. Thus, when faced with stressors associated with cultural incongruity, African American students may experience more decrements in interpersonal and affective components known to buffer suicide risk because of restricted opportunities to identify and implement effective coping resources on college campuses.

Mediation Models of Suicide Risk

Consistent with our hypothesis, defectiveness schemas emerged as a significant mediator in the relationships between cultural congruity and indices of suicide risk for African American students. These findings are consistent with internalized oppression models (Pyke, 2010) and suggest that feelings of insecurity and inferiority partially account for the detrimental effects of low cultural congruity on suicide risk. For example, an African American student who perceives that he/she must alter his/her cultural values to achieve the resources needed to excel in college may be at a greater risk to cultivate and exacerbate feelings of insecurity around others and hypersensitivity to rejection. These feelings of insecurity and inferiority, in turn, may increase interpersonal (e.g., low belongingness and social competence) and behavioral (e.g., alcohol consumption) risks to suicide. These findings are comparable to other studies investigating the link between cultural-related stressors and suicide (Davidson, Wingate, Slish, & Rasmussen, 2010). Our results extend previous research on culturally relevant theories of suicide by highlighting the role of cognitive-affective variables as a salient factor in explaining the relationships between cultural congruity and suicide risk, especially among African American students. However, it is important to note that defectiveness schemas only partially mediated the relationships between cultural congruity and suicide risk indices; suggesting that other factors may be equally important in understanding how perceptions of cultural congruity are related to a diverse range of suicide markers for African American students. Identifying other factors that mediate or moderate these relationships will be important in future studies.

Practical Implications Regarding Suicide Prevention and Intervention

In light of these findings, the current study offers practical implications that have the potential to promote higher levels of well-being, particularly among African American students attending a PWI. Most important, university officials must recognize that effective suicide prevention requires proactive investment from all levels of administration and staff. There are a diverse range of activities and experiences that are specifically designed to facilitate cultural congruence that administrative officials can integrate into the fabric of the core curriculum and the health resources offered to enrolled students. One way to promote cultural appreciation at the university level is to ensure that the adopted core curriculum and first-year educational experiences are culturally inclusive. Researchers have concluded that the development and adoption of required multicultural and social justice training leads to increases in self-exploration through the context of cultural identity and the expansion of personal relevance of multicultural principles (Iijima-Hall, 1997; Warren, 2006). In addition, teaching student service workers how to promote and advocate for psychological well-being through sociocultural contexts may increase cultural congruity among African American students, as well as among European American students who perceive themselves as incongruent with their environment. As an example, teaching effective and culturally sensitive practices associated with mentoring, coping with discrimination, career counseling, and accumulating social support resources may help residence hall advisors, academic counselors, and other student support workers meet the diverse needs of African American students.

Our results also offer some unique insights into the assessment of suicide risk and provision of therapeutic services to African American students. First, screening and evaluation of suicide risk needs to consider the interactive effects of unwelcoming social climates and resulting internalized self-attributions in the expression of suicide risk. Second, our results highlight the importance of adopting culturally congruent practices to treatment. We caution against the exclusive use of traditional psychotherapeutic approaches in treatment because they often fail to consider culturally salient experiences associated with the presenting problem (Bernal & Sáez-Santiago, 2006). Instead, it may be useful to implement postmodern practices as a culturally sensitive method of reducing risk. For instance, narrative practice is a client-led approach that is designed to examine the intersection between prominent life experiences and the formation of identity conclusions. In this way, African American students are offered opportunities to gain insights on how oppressive experiences have altered their perceptions of self. Clinicians can use the insights gained to flush out unique outcomes, neglected aspects of the individuals’ cultural identity, and reinvigorate cultural supports that may help buffer against the desire and/or ability to enact suicide behaviors.

Limitations and General Conclusions

It is important to note the potential limitations of this research. First, our findings were generated through an evaluation of self-report measures, which are susceptible to social desirability demands and response biases. To increase the validity in the obtained relationships, it will be important for researchers to reexamine the connection between cultural congruity and suicide risk using behavioral measures. Second, few of the participants in this sample reported experiencing interpersonal processes associated with a desire to die and engaging in suicide prone behavior, limiting the ability to generalize these findings to other populations. Investigations of these models would benefit from research efforts directed toward more clinical samples of college students (e.g., students receiving services from university counseling centers). Finally, the current project used a cross-sectional design that, over time, did not consider the relationships between cultural congruity and suicide risk. Longitudinal research will be needed to consider the degree to which cultural congruity is predictive of suicide risk over time.

Nonetheless, our findings highlight some unique insights concerning suicide risk for African American students. This is important because cultural processes associated with African American risk are not well represented in conventional models of suicide. Our findings highlight mediated, via defectiveness, associations between cultural processes and indices of suicide risk for both groups of college students, although more strongly for African American students. Overall, consideration for the interaction between cultural experiences and negative self-attributions may enhance the utility in ongoing suicide prevention and intervention efforts, especially among African American students.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

References

Abe

Mertz

K. J.

Powell

K. E.

Hanzlick

R. L.

(2006). Characteristics of Black and White suicide decedents in Fulton County, Georgia, 1988-2002. American Journal of Public Health, 96, 1794-1798. doi:10.2105/AJPH.2005.08213

American Association of Suicidology. (2011). U.S.A. suicide: 2005 official final data. Retrieved from http://www.ct.gov/dmhas/lib/dmhas/prevention/cyspi/aas2005data.pdf

Baron

Kenny

(1986). The moderator-mediator variable distinction in social psychological research:Conceptual strategies and statistical considerations. Journal of Personality and Social Psychology, 51, 1173-1182. doi: 10.1037/0022-3514.51.6.1173

Bernal

Sáez-Santiago

(2006). Culturally centered psychosocial interventions. Journal of Community Psychology, 34, 121-132. doi:10.1002/jcop.20096

Cecero

Beitel

Prout

(2008).Exploring the relationships among early maladaptive schemas, psychological mindedness, and self-reported college adjustment. Psychology and Psychotherapy: Theory, Research and Practice, 81, 105-118.

Centers for Disease Control and Prevention. (1997). Web-based injury statistics query and reporting systems (WISQARS). Atlanta, CA: National Center for Injury Prevention and Control. Retrieved from http://www.cdc.gov/ncipc/wisqars/default.htm

Chao

Mallinckrodt

Wei

(2012). Co-occurring problems in African American college clients reporting racial discrimination distress. Professional Psychology: Research and Practice, 43, 199-207. doi:10.1037/a0027861

Christensen

Batterham

P. J.

Soubelet

Mackinnon

A. J.

(2013). A test of the interpersonal theory of suicide in a large community-based cohort. Journal of Affective Disorders, 144, 225-234. doi:10.1016/j.jad.2012.07.002

Chu

J. P.

Goldblum

Floyd

Bongar

(2010). The cultural theory and model of suicide. Applied and Preventive Psychology, 14, 25-40.

10.

Constantine

M. G.

Robinson

J. S.

Wilton

Caldwell

L. D.

(2002). Collective self-esteem and perceived social support as predictors of cultural congruity among Black and Latino college students. Journal of College Student Development,43, 307-316.

11.

Constantine

M. G.

Smith

Redington

R. M.

Owens

(2008). Racial microaggressions against Black counseling and counseling psychology faculty: A central challenge in the multicultural counseling movement. Journal of Counseling and Development, 86, 348-355.

12.

Constantine

M. G.

Watt

S. K.

(2002). Cultural congruity, womanist identity attitudes, and life satisfaction among African American college women attending historically Black and predominantly White institutions. Journal of College Student Development,43, 184-194.

13.

Davidson

C. L.

Wingate

L. R.

(2011). Racial disparities in risk and protective factors for suicide. Journal of Black Psychology, 37, 499-516. doi:10.1177/0095798410397543

14.

Davidson

C. L.

Wingate

L. R.

Slish

M. L.

Rasmussen

K. A.

(2010). The great black hope: Hope and its relation to suicide risk among African Americans. Suicide and Life-Threatening Behavior, 40, 170-180. doi:10.1521/suli.2010.40.2.170

15.

De Hoyos

L. R.

Ramirez

. (2007). The relationship between shame and acculturation among Latino/Chicano students: Implication for social work education. Journal of Ethnic & Cultural Diversity in Social Work: Innovation in Theory, Research, & Practice, 15, 147-166. doi:10.1300/J051v15n01_07

16.

Esposito

Spirito

Overholser

(2003). Behavioral factors: Impulsive and aggressive behavior. In Spirito

Overholser

J. C.

(Eds.), Evaluating and treating adolescent suicide attempters: From research to practice (pp.113-145). San Diego, CA: Academic Press. doi:10.1016/B978-012657951-2/5008-X

17.

Gibbons

F. X.

Gerrard

Cleveland

M. J.

Wills

T. A.

Brody

(2004). Perceived discrimination and substance use in African American parents and their children: A panel study. Journal of Personality and Social Psychology, 86, 517-529. doi:10.1037/0022-3514.86.4.517

18.

Gibbons

F. X.

O’Hara

R. E.

Stock

M. L.

Gerrard

Weng

Wills

T. A.

(2012). The erosive effects of racism: Reduced self-control mediates the relation between perceived racial discrimination and substance use in African American adolescents. Journal of Personality and Social Psychology, 102, 1089-1104. doi:10.1037/a0027404

19.

Gloria

A. M.

Hird

J. S.

Navarro

R. L.

(2001). Relationships of cultural congruity and perceptions of the university environment to help-seeking attitudes by sociorace and gender. Journal of College Student Development,42, 545-562.

20.

Gloria

A. M.

Robinson-Kurpius

S. E.

(1996). The validation of the Cultural Congruity Scale and the University Environment Scale with Chicano/a students. Journal of Behavioral Sciences, 18, 533-549.

21.

Gloria

A. M.

Robinson Kurpius

S. E.

Hamilton

K. D.

Willson

M. S.

(1999). African American students’ persistence at a pre dominantly White university: Influences of social support, university comfort, and self-beliefs. Journal of College Student Development, 40, 257-268.

22.

Holden

R. R.

Mendonca

J. D.

Serin

R. C.

(1989). Suicide, hopelessness, and social desirability: A test of an interactive model. Journal of Consulting and Clinical Psychology, 57, 500-504. doi:10.1037/0022-006X.57.4.500

23.

Iijima-Hall

C. C.

(1997). Cultural malpractice: The growing obsolescence of psychology with the changing U.S. population. American Psychologist, 52, 642-651. doi:10/1037/0003-066X.52.6.642

24.

Joiner

T. E.

(2005). Why people die by suicide. Cambridge, MA: Harvard University Press.

25.

Joiner

T. E.

Pettit

J. W.

Walker

R. L.

Voelz

Z. R.

Cruz

Rudd

M. D.

Lester

(2002). Perceived burdensomeness and suicidality: Two studies on the suicide notes of those attempting and those completing suicide. Journal of Social and Clinical Psychology, 21, 531-545.

26.

Klibert

Barefoot

Smalley

K. B.

Warren

J. C.

(2014). Suicide schemas: Longitudinally examining the relationships among perceived stress, defectiveness, and indices of suicide risk. Manuscript submitted for publication.

27.

Klibert

Langhinrichsen-Rohling

Luna

Robichaux

(2011). Suicide proneness in college students: Relationships with gender, procrastination, and achievement motivation. Death Studies, 35, 625-645.

28.

Langhinrichsen-Rohling

Friend

Powell

(2009). Adolescent suicide, gender, and culture: A rate and risk factor analysis. Aggression and Violent Behavior,14, 402-414.

29.

Langhinrichsen-Rohling

Klibert

Williams

(2011). Gender considerations in college students’ suicidal behavior. In Lamis

D. A.

Lester

(Eds.), Understanding and preventing college student suicide (pp. 47-64). Springfield, IL: Charles C. Thomas.

30.

Langhinrichsen-Rohling

Lamis

D. A.

(2008). Current suicide proneness and past suicidal behavior in adjudicated adolescents. Suicide and Life-Threatening Behavior, 28, 415-426. doi:10.1521/suli.2008.38.4.415

31.

Lazarus

R. S.

Folkman

(1984). Stress, appraisal, and coping. New York, NY: Springer.

32.

Lewinsohn

P. M.

Langhinrichsen-Rohling

Langford

Rohde

(1995). The Life Attitudes Schedule: A scale to assess adolescent life-enhancing and life-threatening behaviors. Suicide and Life-Threatening Behavior, 25, 458-474.

33.

Lewinsohn

P. M.

Langhinrichsen-Rohling

Rohde

Langford

R. A.

(2004). Life Attitudes Schedule (LAS): A risk assessment for suicidal and life-threatening behaviors (Technical manual). Toronto, Ontario, Canada: Multi-Health Systems.

34.

Pieterse

A. L.

Todd

N. R.

Neville

H. A.

Carter

R. T.

(2011). Perceived racism and mental health among Black American adults: A meta-analytic review. Journal of Counseling Psychology, 58, 1-9. doi:10.1037/a0026208

35.

Prelow

H. M.

Mosher

C. E.

Bowman

M. A.

(2006). Perceived racial discrimination, social support, and psychological adjustment among African American college students. Journal of Black Psychology, 32, 442-454. doi:10.1177/0095798406292677

36.

Pyke

K. D.

(2010). What is internalized racial oppression and why don’t we study it? Acknowledging racism’s hidden injuries. Sociological Perspectives, 53, 551-572. doi:10.1525/sop.2010.53.4.551

37.

Rockett

I. R. H.

Wang

Stack

De Leo

Frost

J. L.

Ducatman

A. M.

. . .Kapusta

(2010). Race/ethnicity and potential suicide misclassification: Window on a minority suicide paradox? BMC Psychiatry, 10, 35.

38.

Rohde

Lewinsohn

P. M.

Seeley

J. R.

Langhinrichsen-Rohling

(1996) The Life Attitudes Schedule Short Form: An abbreviated measure of life-enhancing and life-threatening behaviors in adolescents. Suicide and Life-Threatening Behavior, 26, 272-281.

39.

Rohde

Seeley

J. R.

Langhinrichsen-Rohling

Rohling

M. L.

(2003). The Life Attitudes Schedule-Short Form: Psychometric properties and correlates of adolescent suicide proneness. Suicide and Life-Threatening Behavior, 33, 249-260.

40.

Smith

P. N.

Cukrowicz

K. C.

(2010). Capable of suicide: A functional model of the acquired capability component of the interpersonal-psychological theory of suicide. Suicide and Life-Threatening Behaviors, 40, 266-275. doi:10.1521/suli.2010.40.3.266

41.

Sobel

M. E.

(1982). Asymptotic intervals for indirect effects in structural equation models. Sociological Methodology, 13, 290-312.

42.

Szymanski

D. M.

Kashubeck-West

Meyer

(2008). Internalized heterosexism: A historical and theoretical overview. The Counseling Psychologist, 36, 510-524. doi:10.1177/0011000007309488

43.

Van Orden

K. A.

Cukrowicz

K. C.

Witte

T. K.

Joiner

T. E

. (2012). Thwarted belongingness and perceived burdensomeness: Construct validity and psychometric properties of the Interpersonal Needs Questionnaire. Psychological Assessment, 24, 197-215. doi:10.1037/a0025358

44.

Van Orden

K. A.

Witte

T. K.

Gordon

K. H.

Bender

T. W.

Joiner

T. E

. (2008). Suicidal desire and the capability for suicide: Tests of the interpersonal-psychological theory of suicidal behavior among adults. Journal of Consulting and Clinical Psychology, 76, 72-83. doi:10.1037/0022-006X.76.1.72

45.

Venzant-Chambers

T. T.

(2009). The “receivement gap”: School tracking policies and the fallacy of the “achievement gap.” Journal of Negro Education, 78, 417-431.

46.

Walker

R. L.

(2007). Acculturation and acculturative stress as indicators for suicide risk among African Americans. American Journal of Orthopsychiatry, 77, 386-391. doi:10.1037/0002-9432.77.3.386

47.

Walker

R. L.

Wingate

L. R.

Obasi

E. M.

Joiner

T. R.

(2008). An empirical investigation of acculturative stress and ethnic identity as moderators for depression and suicidal ideation in college students. Cultural Diversity and Ethnic Minority Psychology,14, 75-82. doi:10.1037/1099-9809.14.1.75

48.

Warren

C. S.

(2006). Incorporating multiculturalism into undergraduate psychology courses: Three simple active learning activities. Teaching of Psychology, 33, 105-109. doi:10.1207/s15328023top3302_5

49.

Wenzel

Berchick

E. R.

Tenhave

Halberstadt

Brown

G. K.

Beck

A. T.

(2011). Predictors of suicide relative to other deaths in patients with suicide attempts and suicide ideation: A 30-year prospective study. Journal of Affective Disorders,132, 375-382. doi:10.1016/j.jad.2011.03.006

50.

Young

J. E.

(2005). The YSQ-S2 Young Schema Questionnaire, Short Form. In Young

J. E.

(Ed.), Schema Therapy complete packet: Workshop handouts (Unpublished manuscript). New York, NY: Schema Therapy Institute.

51.

Young

J. E.

Klosko

J. S.

Weishaar

M. E.

(2003). Schema therapy: A practitioner’guide. New York, NY: Guilford Press.