Understanding Indigenous Suicide Through a Theoretical Lens: A Review of General,Culturally-Based,and Indigenous Frameworks

Abstract

Many American Indian/Alaska Native (AI/AN) communities throughout North America continue to experience the devastating impact of suicide. Theoretical explanations of suicide from a psychological, sociological, cultural, and Indigenous perspective all differ in focus and applicability to AI/AN communities. These diverse theoretical frameworks and models are presented herein to examine the potential applicability, strengths, and limitations in understanding AI/AN suicide. In providing these perspectives, continued discussions and empirical examinations of AI/AN suicide can guide informative, culturally-informed suicide prevention and intervention efforts.

Keywords

American Indian Alaska Native Indigenous suicide

Suicide continues to disproportionately impact many North American Indigenous (i.e., American Indian, Alaska Native, First Nations, Aboriginal, Métis, Inuit) communities (Centers for Disease Control and Prevention, 2010). Although there is variability in suicide mortality rates by specific community, AI/ANs as a whole are dying by suicide more than any other group in the U.S. (Drapeau & McIntosh, 2015). This devastating trend is also evident in Canada, where suicide rates are two times higher than the general population for First Nations communities and six to eleven times higher among Inuit communities (Kirmayer et al., 2007). Additional concern centers on high suicide mortality rates of Indigenous youth and young adults. Suicide deaths among AI/ANs ages 15 to 24 are nearly two times higher than all other ethnic groups in the U.S. (CDC, 2010) and three to six times higher same-aged peers among Aboriginal youth in Canada (Kirmayer et al., 2007).

Within suicidology, prominent scholars argue that the development and testing of empirical models of suicide is a critical avenue in decreasing suicide deaths (Joiner, 2005; O’Connor & Nock, 2014). Over the last decade, contemporary models of suicidal behavior have accumulated empirical support. Many of these models unfortunately lack information regarding cultural development and applications. Specifically, AI/AN contexts and worldviews are not incorporated, leaving a gap in understanding and decreasing AI/AN suicide.

In order to decrease AI/AN suicide deaths, the development and testing of culturally sound models of suicide is paramount. To make progress on this endeavor, researchers and communities face unique obstacles. First, North American Indigenous communities are heterogeneous, with 567 federally recognized tribes in the U.S. (Bureau of Indian Affairs, 2016), state-recognized tribes, tribes without federal or state recognition, and more than 600 First Nations/Aboriginal/Indian bands in Canada (Statistics Canada, 2013). Suicide death rates greatly vary across tribes and researchers must consider tribal and geographic variability to explore how culture impacts health (Beals, Manson, Mitchell, Spicer, & the AI-SuperPFP Team, 2003).

Along with disparate rates of suicide by tribe, model development is difficult given sparse existing research on AI/AN suicide. Wexler and colleagues (2015) recently highlighted that in the past decade, only 20 empirical articles investigated risk and protective factors in AI/AN suicide. Further, a substantial amount of AI/AN suicide research has looked at individually focused risk factors and interventions without regard for unique historical, social, and cultural factors (Wexler et al., 2015). This is problematic, as there are cultural variations in likelihood that an individual at risk for suicide will communicate, how symptoms of suicide are expressed, as well as differences in means for suicide (Chu, Goldblum, Floyd, & Bongar, 2010).

Outside of developing AI/AN suicide models from the ground up, there has been hesitation to apply/modify Western theories that emphasize psychological and intrapersonal suicide factors to AI/AN communities (Wexler et al., 2015). However, decolonizing (i.e., reinstatement of ways of life/land to Indigenous peoples; Tuck & Yang, 2012) research “does not mean and has not meant a total rejection of all theory or research or Western knowledge” (Smith, 1999, p. 41). Instead, decolonizing research to better suit Indigenous populations is concerned with placing Indigenous knowledge at the forefront for understanding and using theories based on Indigenous viewpoints and needs (Smith, 1999; Walter & Anderson, 2013). In addition, theoretical frameworks need to be critically and vigilantly analyzed prior to use with Indigenous peoples (Smith, 1999).

Given the claim that theory and model development is important in understanding and preventing suicidal behavior (Joiner, 2005; O’Connor & Nock, 2014), we conducted a systematic literature review on PsycINFO with the key terms “Indigenous”, “American Indian”, “Native American”, “Alaska Native”, “First Nations;” “theory;” and “suicide” to exclusively yield empirical research (both qualitative and quantitative) on Indigenous suicide that has been either influenced by theory or proposed a theory of Indigenous suicide based upon empirical data. This search yielded 39 total peer-reviewed articles, and we excluded six articles not focused on North American Indigenous populations, five book reviews or commentaries, six review articles without empirical data, four that included Indigenous peoples in the study sample, however, were not focused on Indigenous suicide as a study aim, and four articles that did not examine suicide-related outcomes. This resulted in 14 empirical studies (Chiurliza, Michaels, & Joiner, 2016; Cole et al., 2013; Davenport & Davenport, 1987; Hill, 2009; Mehl-Madrona, 2016; O’Keefe & Wingate, 2013; O’Keefe et al., 2014; Rasmus, Charles, & Mohatt, 2014; Tingey et al., 2014; Travis, 1984; Travis, 1990; Walls, Chapple, & Johnson, 2007; Young, 1991; Young & French, 1995) that utilized aspects of theory (either established theory or culturally guided theory informed from empirical data) with suicide-related outcomes in North American Indigenous communities. It is notable that slightly more than half of these articles have been published in the last decade, while the others were published in the 1980s and 1990s.

The current paper aims to better situate an understanding of AI/AN suicide by examining a variety of theories. First, general suicide models (psychological and sociological theories) will be explored in the context of Indigenous populations. The psychological and sociological theories included below are some of the “most prominent and influential explanations of suicidal behavior” (Joiner, 2005, p. 42). The well-known psychological and sociological theories included below also have empirical support of theoretical key components that have been examined within Indigenous communities. Second, given the importance of examining culture and ethnicity on the impact of suicide (Chu et al., 2010; O’Connor & Nock, 2014; Wong, Maffini, & Shin, 2014), culturally-focused suicide theories and their applicability to Indigenous suicide will be discussed. Finally, AI/AN theories of health, wellness, and/or suicide will be discussed. We also present a table summarizing the main tenets of each theory, as well as whether they have been applied to better understand suicide in Indigenous communities.

General Models of Suicide

Durkheim’s Sociological Theory of Suicide

Durkheim presented a complex sociological perspective according to which suicide could not be fully explained by psychological factors, religious affiliations, geographic location, or climate (Durkheim, 1951). A major premise of this theory is that, “[s]uicide varies inversely with the degree of integration of the social groups of which the individual forms a part” (Durkheim, 1951, p. 209). Durkheim identified three forms of suicide in his analysis of this pattern: egoistic, altruistic, and anomic suicide. Egoistic suicide occurs when one experiences excessive individualism in communities with low social integration (Davenport & Davenport, 1987; Lester, 1995). Altruistic suicide is rooted in feelings of detachment from society when high social integration is present, while anomic suicide is enacted during periods of social change or in societies with low social regulation (Davenport & Davenport, 1987; Lester, 1995). Durkheim presented a fourth form of suicide which follows this pattern, which he termed fatalistic suicide. However, this fourth type is omitted from his main text and discussed in a footnote due to little relevance and few examples. Fatalistic suicide is conceptualized as the opposite of anomic suicide, and is said to occur as a result of overly high social regulation (Durkheim, 1951; Niezen, 2015).

There have been few theoretical applications and studies providing empirical support for the constructs of egoistic and fatalistic suicide among AI/AN populations (Davenport & Davenport, 1987) compared to altruistic and anomic suicide. Altruistic suicide was theorized to occur among AI/ANs through self-sacrifice (e.g., during battle, elder self-sacrifice to help his/her community; Davenport & Davenport, 1987). Suicide attempts and deaths resulting from family shame or other factors (Davenport & Davenport, 1987) continue to be particularly salient for AI/ANs aged 15 to 24 (CDC, 2010; May, 1987). Anomic suicide has been applied to AI/AN suicide (Niezen, 2015; Zitzow & Desjarlait, 1994) given negative social and cultural changes (i.e., contact, colonization, removal, and assimilation tactics). These changes have impacted family, community, culture, health, self and tribal identity and may be compounded by prejudice, discrimination, and low socioeconomic status (Davenport & Davenport, 1987; May & Van Winkle, 1994). Further, these historical changes likely resulted in intergenerational trauma, which may be passed down to tribal descendants (Brave Heart & DeBruyn, 1998).

One empirical study documented the trend of suicide rates varying inversely with social integration in diverse tribal communities (May & Van Winkle, 1994). Results showed tribes with high social integration and few changes due to modernization had low suicide rates. However, tribes with high social integration and rapid changes had elevated suicide rates (May & Van Winkle, 1994). The application of Durkheim’s theory to AI/AN peoples has been debated, given its exclusion of culture, suicide method, and suicide clusters (Niezen, 2015).

Suicide clusters are defined as a high number of self-inflicted deaths that occur in both temporal and geographical proximity (Gould, Wallenstein, & Davidson, 1989). This results in the idea that suicide can be contracted from others through an “epidemic” analogous to disease (Niezen, 2009). Such episodes of self-destruction may be explained through contagion effects, where one self-inflicted death related to emotional problems results in dramatic increases in depression and anxiety among surviving community members, some of whom go on to imitate suicidal acts (Niezen, 2009). Several Indigenous communities in the U.S. and Canada have been recognized for experiencing suicide clusters (e.g., Mullany et al., 2009; Niezen, 2009). Media coverage often selectively portrays these communities as impoverished, depressed, and suicidal (Niezen, 2009). However, comparison of national suicide statistics with those of Aboriginal communities dispels the myth that suicide clusters are the norm for Aboriginal populations (for a review, see Niezen, 2009).

It is unclear how suicidal acts produce contagion effects; however, concentrated areas with high suicide rates are likely influenced by shared ideas and values (Niezen, 2009). Suicide clusters offer a unique paradox – those who die by suicide are often driven by feelings of loneliness, and surviving others may identify with these feelings of loneliness. This paradox creates a pathological sociability in which the idea of self-destruction becomes normalized (Coleman, 1987; Niezen, 2009). Notably, not all who experience distress act upon it using self-destruction. Kral (1994) suggests that “the only direct cause of suicide is the idea of suicide and ways to do it, and that in order to better understand suicide we need to know more about how ideas are spread throughout society and become part of an individual’s repertoire” (p. 253). Taken together, understanding how suicide as an option becomes internalized is particularly relevant for suicide clusters due to the likely influence of collective ideas (Niezen, 2009). Niezen (2009) provides an example of how Aboriginal youth groups may form around binge drinking and progressively move toward greater severity of self-harm, possibly to the point where “death itself becomes a focus of belonging” (p. 190).

Escape Model of Suicide

The Escape Model (Baumeister, 1990) posits that suicide attempts occur when individuals try to escape negative views of the self, negative affect; in this model, life problems and short-term escape by death is desired over long-term consequences associated with death. First, an individual is more likely to attempt suicide when he/she has unrealistic expectations, experiences recent problems with negative outcomes, and encounters setbacks or stressors. The theory suggests that if these experiences are to produce a suicidal outcome, they should lead to negative internal attributions of the self. Thus, negative views about oneself are created or worsened via negative internal attributions and self-condemnation for negative external outcomes (Baumeister, 1990). Third, comparison of self to others creates aversive and excessive self-awareness, leading to inadequate, incompetent, or guilty feelings. Fourth, acute and negative affect (e.g., depression, anxiety, dejection) results from unfavorable comparison to past self-standards and high standards of others. Fifth, an individual will try to escape by numbing and cognitive deconstruction (Baumeister, 1990). If escape is not possible, a strong desire to end negative affect will be experienced. Finally, an individual may experience reduced inhibition by way of cognitive deconstruction and presents an increased willingness to attempt suicide to escape the self, negative emotions, and life problems (Baumeister, 1990).

To the authors’ knowledge, no study has applied the Escape Model to examine suicide among AI/AN populations. However, components of this theory have been examined to understand Indigenous suicide. Specifically, stressful and negative life events (Dinges & Duong-Tran, 1994; Yoder, Whitbeck, Hoyt, & LaFromboise, 2006), negative self-attributions/low self-esteem (Yoder et al., 2006), depression, anxiety, or anger (Cole et al., 2013; Keane, Dick, Bechtold, & Manson, 1996; Walls et al., 2007), and pain habituation and decreased fear of suicide death (Chiurliza et al., 2016; O’Keefe & Wingate, 2013) have been associated with suicide-related outcomes in AI youth or adult samples.

Psychache Theory of Suicide

Introduced by Shneidman (1996), this suicide theory posits that intolerable psychological pain is central to suicidal desire. Psychache is defined as intense psychological pain (e.g., feelings of sadness, guilt, shame, and/or loneliness) that manifests when basic psychological needs are unmet. When psychache is perceived as unbearable, an individual likely views suicide as an escape (Schneidman, 1996). Apart from psychache, other factors influence the perception that acute psychological pain is insufferable. When high levels of psychache, stress, and agitation interact, an individual is likely to desire suicide death (Schneidman, 1996). Accumulated empirical analysis suggests that self-reported psychache has been related to elevated suicide ideation in inpatients, homeless individuals, and incarcerated youth, and prospectively predicted suicide ideation in college students (Patterson & Holden, 2012; Pereira, Kroner, Holden, & Flamenbaum, 2010; Troister, Davis, Lowndes, & Holden, 2013; Troister & Holden, 2012).

Psychache as an overall theory has yet to be explicitly studied in AI/AN communities. However, one study of 54 Canadian Aboriginal individuals reported a common theme of wanting to “stop the pain” as a reason for attempting suicide (Mehl-Madrona, 2016). In addition, many of the contributing factors leading to psychache have predicted suicide-related outcomes in AI/ANs. Feelings of social isolation and extreme loneliness have been related to increased suicide ideation in AIs (Hill, 2009; O’Keefe et al., 2014). Feelings of shame have also been associated with suicide attempts in tribes across North America (Mehl-Madrona, 2016; Pine, 1981). Research has also demonstrated that perceptions of stress in AI/AN youth influence suicidal desire (Strickland & Cooper, 2011) and that increased stressors are related to suicide ideation in Midwest and Canadian AI adolescents (Walls et al., 2007). If applied to AI/AN populations, the stress-related concept included in this theory would benefit from the inclusion of culturally-specific stress-related concepts including discrimination, acculturative stress, historical trauma, and economic/financial disadvantages, as each have been associated with AI/AN suicide (Lester, 1995, 1999; Tucker, Wingate, O’Keefe, Hollingsworth, & Cole, 2016; Walls et al., 2007). Further, culture-bound notions of stress for Indigenous communities should be addressed if viewed from this framework (e.g., lack of alignment and conflict between Indigenous and Western values and implications for future, see Wexler, 2009).

Interpersonal Theory of Suicide

The Interpersonal Theory of Suicide (ITS; Joiner, 2005) was developed to explain how an individual becomes at risk for a lethal or near lethal suicide attempt. Three distinct constructs are included in this model: perceived burdensomeness, thwarted belongingness, and acquired capability. Perceived burdensomeness describes the real or imagined perception that one is ineffective in life and a burden. Thwarted belongingness refers to feelings of social disconnection and loneliness. The simultaneous experience of these two constructs is argued to create suicidal desire (Van Orden, Witte, Gordon, Bender, & Joiner, 2008). The model also considers how an individual must be able to inflict self-harm and be fearless about death as a result of life experiences that increase pain tolerance and fearlessness (acquired capability). When an individual cumulatively experiences all three constructs, he/she is deemed to be at the highest risk of suicidal behavior or death (Joiner, 2005).

Research has recently applied the ITS to examine Indigenous suicide. One study found that perceived burdensomeness, and the interaction of perceived burdensomeness and thwarted belongingness, were associated with increased suicide ideation in an AI sample (O’Keefe et al., 2014). In another study, perceived burdensomeness was found to mediate the relationship between depression symptoms and suicide ideation among AIs (Cole et al., 2013). Of note, thwarted belongingness was not a significant predictor of suicide ideation in the aforementioned studies. O’Keefe and colleagues (2014) suggested the ITS construct of thwarted belongingness may not accurately assess cultural understandings and experiences of belongingness in AI/AN peoples. In a strengths-based study of AI/ANs, high hope and optimism were associated with decreased thwarted belongingness and perceived burdensomeness (O’Keefe & Wingate, 2013). Continued research on the cultural appropriateness of the ITS constructs and assessment with AI/ANs is needed, as it may assist in understanding and preventing AI/AN suicide (O’Keefe et al., 2014).

Cognitive Model of Suicide

The Cognitive Model of Suicidal Behavior (Wenzel & Beck, 2008; Wenzel, Brown, & Beck, 2009) adopts a diathesis-stress approach to suicidal behavior, positing that those who attempt suicide have dispositional vulnerability factors that place them at suicide risk. These factors include, but are not limited to, impulsivity, deficient problem-solving, overgeneralized memory, trait-like maladaptive cognitive styles, personality factors (e.g., neuroticism, perfectionism), and acquired capability to enact suicide (Wenzel & Beck, 2008; Wenzel, Brown, & Beck, 2009). These dispositional factors confer greater suicide risk when activated by life stressors, resulting in cognitive processes associated with psychiatric disturbances (i.e., maladaptive content and biased information-processing) and suicide-specific cognitive processes (i.e., hopelessness, feeling life is unbearable, attentional fixation on suicide-relevant cues). These two separate cognitive processes interact to culminate in a suicide attempt when it is perceived that distress associated with both cognitive processes is overwhelming (Wenzel & Beck, 2008; Wenzel, Brown, & Beck, 2009).

This model of suicide has not been explicitly studied with AI/ANs; however, research has found feelings of hopelessness are likely to play an integral role in AI/AN suicide (Pharris, Resnick, & Blum, 1997; LaFromboise & Howard-Pitney, 1995; Manzo, Tiesman, Stewart, Hobbs, & Knox, 2015). Given that hopelessness is a central component in the Cognitive Model of Suicidal Behavior (Wenzel & Beck, 2008; Wenzel, Brown, & Beck, 2009) and past research has demonstrated hopelessness is related to suicide-related outcomes in some AI/AN communities, it may be a relevant theory to continue to explore.

Culturally-Based Models of Suicide

The Racial-Cultural Framework

The Racial-Cultural Framework (RCF; Wong et al., 2014) details a model for conceptualizing and preventing suicide in people of color. The RCF is structured in terms of three interrelated components, each comprised of specific guiding principles. The first component consists of culturally-relevant constructs to be considered in understanding suicide in people of color with the following principles: 1) individual and macro-level discrimination plays a role in the development of suicidal behavior; 2) theoretical models of suicide are vital, especially those including acculturation and enculturation, individual constructs (e.g., acculturative stress), macro-level constructs (e.g., ethnic density in location); and 3) the understanding of cultural beliefs regarding suicide, life, and death is important for highlighting who is at-risk versus protected from suicide (Wong et al., 2014). The second component identifies the need for increased research, theory, and clinical practice, and is guided by two principles: 1) disaggregation of suicide-related outcome data is necessary to identify minority groups at the highest risk for suicide; and 2) an intersectional perspective in which ethnicity is considered in conjunction with age, gender, and socioeconomic status is needed to understand suicide prevalence. The final construct details suicide prevention steps in communities of color with four guiding principles: 1) culturally relevant prevention methods should be adopted; 2) researchers and providers should collaborate with community members where they are working; 3) increased access to care is vital in preventing suicide in communities of color; and 4) interventions applied should be environment-centered, considering both individual (i.e., therapy) and macro-level (e.g., increasing media awareness) prevention efforts (Wong et al., 2014).

The RCF provides important directions for the development of culturally relevant theory regarding AI/AN suicide. Component one identifies future research directions with AI/AN populations, including overt and subtle forms of discrimination experiences and their impact on suicidal behavior. In addition, perceptions of discrimination, acculturative stress, historical trauma, financial disadvantage, and racial microaggressions are all minority stressors that have been linked to AI/AN suicide risk (Lester, 1995, 1999; O’Keefe, Wingate, Cole, Hollingsworth, & Tucker, 2015; Tucker, Wingate, O’Keefe, Hollingsworth, & Cole, 2016; Walls et al., 2007). Additionally, little research exists regarding ethnic/cultural identification in specific AI/AN communities, which may have differential effects on suicide-related outcomes (Rieckmann, Wadsworth, & Deyhle, 2004). Component two of the RCF can be reflected in the vital understanding that suicide-related predictors and outcomes are not consistent due to tribal heterogeneity. Research indicates beliefs regarding death, life, and suicide likely varies greatly between tribal communities (Pine, 1981). The adoption of an intersectional understanding (i.e., emphasizing the co-construction of identity in terms of dimensions: age, gender, socioeconomic status, culture, etc.) of suicide risk in AI/AN communities may be fruitful given variability across communities (Drapeau & McIntosh, 2015). Related to the third component, there are prime examples of AI/AN community suicide prevention programs implemented on the basis of cultural soundness. The American Indian Life Skills Development Curriculum (LaFromboise, 1996) and the White Mountain Apache Tribally Mandated Surveillance System (Cwik et al., 2014; Mullany et al., 2009) were developed by communities and researchers to understand and decrease suicide within the given community. Culturally-focused suicide prevention efforts need to continue to be developed with tribal communities given the successful aforementioned programs.

Models Focused on Indigenous Well-Being and Suicide Prevention

American Indian Life Skills Intervention and Indigenist-Stress Coping Model for Youth Suicide Prevention

For AI/AN peoples, ecological factors (e.g., historical trauma), social factors (e.g., family discord), and individual factors (e.g., psychological disorder) may lead to stress. These stressor(s) may lead to cognitive difficulties, including effective problem-solving (LaFromboise & Fatemi, 2011). According to the Indigenist Stress-Coping Model (Walters, Simoni, & Evans-Campbell, 2002) traumatic stressors, (e.g., discrimination, lifetime trauma, historical trauma), are associated with negative health outcomes, including substance use problems and depression. Cultural buffers (e.g., familial and community support, spirituality, ethnic identity) weaken the impact of the traumatic stressors while strengthening mental health outcomes. The Indigenous-Stress Coping Model for Youth Suicide Prevention (LaFromboise & Fatemi, 2011) further posits that avoidant versus approach coping is an important mediating variable, Avoidant coping may lead to feelings of hopelessness and suicide-related outcomes. Approach coping, which encourages the conscious processing and reframing of emotions in the face of stressors, may lead to positive, resilient outcomes. This theoretical model led to The American Indian Life Skills Intervention (LaFromboise & Howard-Pitney, 1995), a school-based multifaceted approach to reducing risky behaviors (e.g., suicide). Psychoeducation with teachings on adaptive coping skills, community and individual skills for overall well-being are delivered in a curriculum to adolescents.

The American Indian Life Skills Intervention (LaFromboise, 1996) has been adapted for U.S. tribes and is included in the Substance Abuse and Mental Health Services Administration’s (SAMHSA) National Registry of Evidence-Based Programs and Practices (NREPP). This model was empirically tested with a group of Southwest tribal students with positive results for those who received the intervention, including better suicide intervention skills and lower feelings of hopelessness compared to those without the intervention (LaFromboise & Howard-Pitney, 1995).

Historical Trauma

One Indigenous understanding of suicide is that it is the consequence of a loss of balance and obliteration of cultural ways resulting from colonization (Duran & Duran, 1995). The relatively recent emergence of the term historical trauma has offered new concepts to characterize intergenerational processes of grief and negative health outcomes of the legacy of European contact and colonization (Brave Heart, 1999a, 1999b; Brave Heart & DeBruyn, 1998). Kirmayer and colleagues (2014) have argued that understanding intergenerational trauma and its impact on mental health is complex and “requires a broader view of identity, community, adaptation, and resistance as forms of resilience” (p. 313). Negative health outcomes including depression, substance abuse/dependence, domestic violence, and suicide have been theoretically linked to internalized oppression from genocidal acts committed against AI/AN populations at the time of European contact, and to ongoing dynamics of marginalization in the present (Brave Heart & DeBruyn, 1998). Current forms of ongoing oppression and adversity within Indigenous communities should also be included in discussions of historical trauma (e.g., “postcolonial distress”; see Kirmayer et al., 2014).

One study investigated the impact of historical trauma on a Northwest tribe with focus groups and interviews with community elders and parents (Strickland et al., 2006). Of note, one-third of the parent participants’ children were assessed to be at risk for suicide. During interviews, elders conversed about historical trauma and its effects on the community. When asked what caused youth suicide, community responses explained that youth were leaving tribal identity behind to survive in mainstream society (Strickland et al., 2006). Further, elders and parents advocated for community suicide prevention strategies that include cultural activities and parenting strategies that incorporate traditional values.

Another recent empirical investigation inquired about the frequency of thoughts pertaining to historical trauma, ruminative thinking, and suicide ideation among 140 multi-tribal college students (Tucker et al., 2016). Results showed that thinking about historical trauma was associated with a ruminative thinking style. A mediation analysis indicated that increased historical trauma thinking was indirectly related to suicide ideation through rumination. This is the first empirical study to support a connection between historical trauma and suicide-related outcomes among AI/AN peoples.

Cultural Continuity

The cultural continuity model (Chandler & Lalonde, 1998) is premised on the notion that individuals have a need to persist as selves (self-continuity). Adolescents may become vulnerable in disruption of self-continuity through physical, emotional, and cognitive changes that correspond with development. The theory of self-continuity was extended to the concept of cultural continuity related to social changes within Indigenous communities, and an ability to connect traditional past, contemporary context, and future (Chandler & Lalonde, 1998). The construct of cultural continuity is composed of community control and sovereignty over lands, government, education, public protective services (i.e., fire protection, police), healthcare services, child and family services, presence of community cultural centers, and participation of women in local governance reflecting matrilineal cultural values (Chandler & Lalonde, 1998, 2008). Critiques of cultural continuity theory include re-labeling this construct “local control”, emphasizing adaptability of culture within communities, and lack of accounting for potential covariates (e.g., empowerment, collective efficacy, self-esteem; see Kirmayer et al., 2007).

Chandler and Lalonde (1998, 2008) found that suicide mortality rates per 100,000 were lower among First Nations communities in British Columbia with self-governance and sovereignty of lands and land claim negotiation involvement, education, public protective services, healthcare, community cultural centers, female participation in government, and local child and family services. A recent qualitative study of Aboriginal Canadian individuals who had attempted suicide related themes to personal and cultural continuity (Mehl-Madrona, 2016). These studies are grounded in theory and highlight that aspects of mastery over self and tribal community may be strengths against suicide. Further, the cultural continuity model supports efforts in developing culturally-driven mental health promotion (e.g., Kirmayer, Sheiner, & Geoffroy, 2016). It would be beneficial for future research to explore whether results are replicated in tribal communities outside of British Columbia and ways to increase community control and sovereignty as a suicide prevention/intervention strategy.

Cuqyun Model of Protective Factors for Alaska Native Youth

The Cuqyun Model (see Allen, Mohatt, Beehler, & Rowe, 2014; Allen, Mohatt, Fok, et al., 2014) is a culturally-guided theory of alcohol abuse and suicide prevention among Alaska Native (AN) youth. This model is composed of multiple levels of individual (e.g., self-mastery), family (e.g., cohesion), community (e.g., support), social (e.g., peer influences in alcohol use), and cultural factors (e.g., reflection about ways of life) that interact to prevent alcohol abuse and suicide risk. In addition, reasons for living is an important component associated with individual, family, and community factors, and may be a more culturally appropriate avenue to assess suicidality than direct questions (e.g., are you feeling suicidal).

This model was tested with culturally and community-developed measures among AN youth raised in remote communities (Allen, Mohatt, Fok et al., 2014). The culturally-tailored measures included individual characteristics (i.e., self-efficacy and mastery over self, family, and friends), family characteristics (i.e., family cohesion, expression, and resolving conflict), community characteristics (i.e., support and opportunities within the community), and peer influences (i.e., dishearten and condemn substance use). Outcome measures included reflection on the consequences of alcohol use and reasons for living. Structural equation modeling demonstrated an acceptable model fit, suggesting this model may be important in examining suicide protective factors for AI/AN communities (Allen, Mohatt, Fok et al., 2014).

Transactional-Ecological Approach to Suicide

Suicidal behaviors are often understood and treated at the individual level. However, recent research suggests this perspective may be culturally inappropriate for suicide prevention and intervention among AI/AN communities because it does not consider systemic, contextual, communal, or historical contexts and processes that contribute to suicide risk (for a review, see Wexler et al., 2015). Identifying risk and protective factors through a biopsychosocial lens was proposed as a fruitful avenue in detecting and preventing suicide among AI/ANs (Alcántara & Gone, 2007). Alcántara and Gone (2007) developed a transactional-ecological framework for AI/AN suicide. This approach targets problematic interactions between people and their environments, and also targets broad antecedent conditions (e.g., family mental health history) that may lead to unfavorable outcomes (e.g., substance abuse), which then may ultimately heighten one’s risk for suicide. In this perspective, pathology is not an individual experience, but impacts whole communities through a culmination of stressors, the environment, and sociocultural conditions. The goal of this approach is to reinstate healthy developmental pathways at the community level to prevent negative outcomes (e.g., suicide deaths) rather than treat individual disorders (Alcántara & Gone, 2007).

Although AI/AN suicide prevention programs have been implemented to address broad antecedent conditions and contextual roles, few studies have evaluated these programs and they may be limited in rigor and generalizability (Alcántara & Gone, 2007; Middlebrook, LeMaster, Beals, Novins, & Manson, 2001). One study within a small AI community over a 15-year period found a dramatic decrease in suicidal behavior after implementing a community-based intervention model (May, Serna, Hurt, & DeBruyn, 2005). Another study employed a qualitative, longitudinal approach to understand risk factors among Apache youth who attempted suicide (Tingey et al., 2014). In line with a transactional-ecological model, results identified individual factors (e.g., emotion recognition/dysregulation), family factors (e.g., family support), community factors (e.g., burden, stigma), and societal factors (e.g., contagion) as associated with suicide attempts.

Another AI/AN community program includes CARES (Collaborations for At-Risk youth Engagement and Support), an alternative approach to gatekeeper training consistent with the transactional-ecological framework. This program does not specifically focus on suicide but aims to strengthen the local support network to reach persons-in-need before a crisis occurs. CARES generates ideas based on experiences and stories of local community members, including family, youth natural helpers, and gatekeepers, all assist those at risk for suicide (Wexler, White, & Trainor, 2015). In line with these approaches, an AI college student suicide prevention model was developed using the medicine wheel as a guiding framework (Muehlenkamp, Marrone, Gray, & Brown, 2009). The medicine wheel originates from the Lakota tribe (Dapice, 2006) and is divided into four interconnected sacred components: mental, physical, emotional, and cultural/spiritual. This model encourages social connections between AI students, tribal communities, and college campuses, and aims to integrate spirituality/culture into academia to enhance resilience (Muehlenkamp et al., 2009). This model has shown preliminary effectiveness among AI college students with results showing increased suicide knowledge via gatekeeper training and significant improvements in problem-solving (Muehlenkamp et al., 2009).

Discussion

The current paper provides an overview of several general (psychological and sociological models), culturally-based theories/frameworks, and models of AI/AN health and wellness, to broaden comprehension of AI/AN suicide and better guide AI/AN suicide prevention (see Table 1 for summary of each theory and applicability to Indigenous suicide). Each of the reviewed models/frameworks hold unique strengths and limitations in their ability to contribute to the development, implementation, and testing of AI/AN suicide-related outcomes.
Table 1.
Summary of General, Culturally-Based, and Indigenous Frameworks.

Model Author Basic Premise Applied to Indigenous Populations

Sociological Theory of Suicide Durkheim (1897) Four forms of suicide are proposed, which are related to social integration. 1) Egotistic (occurs when an individual has low social integration). 2) Altruistic (occurs when there is high social integration and an individual feels detached from society). 3) Anomic (occurs during high periods of negative/positive social change). 4) Fatalistic (occurs in societies with high social regulation). Yes

Escape Model of Suicide Baumeister (1990) An individual is likely to attempt to die by suicide when he/she tries to escape from his/her problems. No

Psychache Theory of Suicide Shneidman (1996) An individual is likely to view suicide as an escape if their “psychache”, or intense psychological pain is perceived as being unbearable. No

Interpersonal Theory of Suicide Joiner (2005) Perceptions of being a burden (perceived burdensomeness) and feelings of social disconnection (thwarted belongingness) create a desire to die by suicide. An individual also develops the ability to inflict self-harm through life experiences (acquired capability). Experiencing these three constructs simultaneously places one at the highest risk of a lethal or near-lethal suicide attempt. Yes

Cognitive Model of Suicide Wenzel & Beck (2008) and Wenzel, Brown, & Beck (2009) Individuals who attempt suicide have dispositional vulnerability factors that place them at risk of psychopathology and suicidal behavior. Life stressors exacerbate the vulnerability factors, resulting in negative cognitive processes, such as ruminative thinking styles. A suicide attempt occurs when the distress associated with the cognitive processes are perceived as overwhelming. No

Racial-Cultural Framework Wong, Maffini, and Shin (2014) This framework details conceptualizing and preventing suicide in people of color. It includes three interrelated components, each comprised of specific guiding principles. The components include culturally-relevant constructs considered when attempting to understand suicide; identifying populations where increased research, theory, and clinical practice is needed; and suicide prevention efforts in communities of color. No

American Indian Life Skills Intervention LaFromboise and Howard-Pitney (1995) This intervention is a multi-faceted, school-based approach to reduce risky behaviors among American Indian adolescents, including suicide. This is achieved through psychoeducation and teaching adaptive coping skills, as well as other community and individual skills for overall well-being. Yes

Historical Trauma Brave Heart (1999a; 1999b; 2000); Brave Heart and DeBruyn (1998); Duran and Duran (1995) Though it is not associated with a specific model, historical trauma is a recently identified concept that refers to intergenerational grief and the impacts of European contact and colonization on health. Historical trauma is shown to be positively related to negative mental health outcomes, including depression, substance abuse/dependence, domestic violence, and suicide. Yes

Cultural Continuity Chandler and Lalonde (1998) This is a culturally-grounded theory that has been used with First Nations youth in British Columbia, Canada. This theory posits that cultural continuity is achieved through an ability to connect traditional past, contemporary context, and future events. Continuity if further enhanced through sovereignty over lands, government, public services, community cultural centers, and healthcare. Yes

Cuqyun Model of Protective Factors for Alaska Native Youth Allen et al. (2006) This is a culturally-guided theory of alcohol abuse and suicide prevention for Alaska Native youth. This model is composed of multiple levels of individual (e.g., self-mastery), family (e.g., cohesion), community (e.g., support), social (e.g., peer influences in alcohol use), and cultural factors (e.g., reflection about ways of life) that interact to prevent alcohol abuse and suicide risk. Yes

Transactional-Ecological Approach to Suicide Alcántara and Gone (2007) This approach targets problematic interactions between people and their environments. According to this approach, pathology impacts whole communities through a culmination of stressors, the environment, and sociocultural conditions. The goal of this approach is to reinstate healthy developmental pathways at the community level to prevent negative outcomes (e.g., suicide deaths), rather than to treat individual disorders. Yes

General suicide theories have seldom been applied to AI/AN communities. We briefly described Durkheim’s Theory of Suicide (Durkheim, 1951) and the Interpersonal Theory of Suicide (Joiner, 2005) which have been theoretically applied or empirically tested with AI/AN communities. However, Durkheim’s theory has not been applied to AI/AN populations since the 1990s and investigations of the cultural appropriateness of the Interpersonal Theory of Suicide constructs have yet to be conducted. These theories hold promise for understanding AI/AN suicide given that they are well-established (i.e., assessment measures available and literature detailing theory testability). Unfortunately, a shortcoming of these major theories of suicide focus on individual cognitive and affective experiences without specific mention of sociocultural influences that may influence AI/AN suicide. Given the cultural variability in suicidality (Chu et al., 2010) and prevention of continued individual-level suicide literature in AI/AN communities (Wexler, Chandler, et al., 2015), these theories should be approached cautiously and with attention paid to tribal/community adaptability, if warranted.

We also described a culturally grounded suicide theory, the Racial-Cultural Framework (RCF; Wong et al., 2014). The applicability of the RCF to AI/AN communities was explicitly addressed and indicates how culture underlies and impacts suicidality, certainly a unique strength for its potential application to understanding AI/AN suicide. AI/AN researchers highlight the importance of historical, social, and cultural realities of AI/AN communities in understanding health-related outcomes (Wexler & Gone, 2012). In addition, both theories included individual, social, and environmental components unique to people of color that may impact suicide-related outcomes (e.g., cultural meaning of life/death/suicide, racism, and importance of social environment). As this model/framework was not developed specifically with AI/AN communities in mind, unique AI/AN experiences that may influence suicide risk/resilience are absent. For example, “No other ethnic group in the United States has endured greater and more varied distortions of its cultural identity than American Indians” (Mihesuah, 1996, p. 13). These distortions of Indigenous culture have serious consequences for health and wellness. Pervasive stereotyped images of AI/AN peoples (e.g., the Chief Wahoo baseball mascot, Disney’s Pocahontas) have been associated with lower self-esteem and community worth, and decreased academic achievement goals among AI youth (Fryberg, Markus, Oyserman, & Stone, 2008). Any theory of suicide for AI/AN peoples should address the impact of historical trauma, continued colonization via discrimination, and how these social and cultural issues cannot be removed from discussions of suicide among AI/AN communities (Smith, 1999).

The theories of AI/AN health and wellness described in this review are distinctive in that they specifically assert the importance of historical, social, and cultural influences that impact health. In addition, many of these theories/models contain cultural and spiritual components. A holistic approach in understanding health is an important strength of these models and holds promise to better comprehending AI/AN suicide. In some respects, AI/AN and Western worldviews regarding mind, body, and spirit may differ or conflict (Duran & Duran, 1995). People in AI/AN communities tend to view mind, body, and spirit as interconnected and not separate entities. These holistic models are congruent with traditional Indigenous worldviews, which emphasize culture, spirituality, and relationship with self, others, and the environment as sources of knowledge and well-being (Wilson, 2008). It is also worth noting that the general suicide theories highlighted in this paper include various components related to Indigenous views of suicide. Indigenous ways of knowing are not simply about understanding concepts, but also highlight the interweaving of physical and non-physical relationships surrounding those concepts (Wilson, 2008). These frameworks are guided by Indigenous epistemologies and are in line with a call for defying dominant ways of thinking/systems that have oppressed AI/AN peoples, asserting sovereignty and self-determination in research and healthcare (Lucero, 2011).

Conclusion

The present paper reviewed several general suicide theories, culturally-based theories of suicide, as well as Indigenous theories of wellness and suicide prevention to lead to a future culturally-grounded conceptualization of AI/AN suicide. The recognition of strengths, limitations, gaps, and perspectives in how these theories can be applied to Indigenous suicide is important given the continued high suicide death rates that aggregated data yield combined with the lack of empirical research guided by or guiding theory. With this knowledge in hand, it is hoped that continued research on a comprehensive understanding of AI/AN suicide leads to expedited prevention efforts to reduce suicide deaths throughout North American Indigenous communities.

Model	Author	Basic Premise	Applied to Indigenous Populations
Sociological Theory of Suicide	Durkheim (1897)	Four forms of suicide are proposed, which are related to social integration. 1) Egotistic (occurs when an individual has low social integration). 2) Altruistic (occurs when there is high social integration and an individual feels detached from society). 3) Anomic (occurs during high periods of negative/positive social change). 4) Fatalistic (occurs in societies with high social regulation).	Yes
Escape Model of Suicide	Baumeister (1990)	An individual is likely to attempt to die by suicide when he/she tries to escape from his/her problems.	No
Psychache Theory of Suicide	Shneidman (1996)	An individual is likely to view suicide as an escape if their “psychache”, or intense psychological pain is perceived as being unbearable.	No
Interpersonal Theory of Suicide	Joiner (2005)	Perceptions of being a burden (perceived burdensomeness) and feelings of social disconnection (thwarted belongingness) create a desire to die by suicide. An individual also develops the ability to inflict self-harm through life experiences (acquired capability). Experiencing these three constructs simultaneously places one at the highest risk of a lethal or near-lethal suicide attempt.	Yes
Cognitive Model of Suicide	Wenzel & Beck (2008) and Wenzel, Brown, & Beck (2009)	Individuals who attempt suicide have dispositional vulnerability factors that place them at risk of psychopathology and suicidal behavior. Life stressors exacerbate the vulnerability factors, resulting in negative cognitive processes, such as ruminative thinking styles. A suicide attempt occurs when the distress associated with the cognitive processes are perceived as overwhelming.	No
Racial-Cultural Framework	Wong, Maffini, and Shin (2014)	This framework details conceptualizing and preventing suicide in people of color. It includes three interrelated components, each comprised of specific guiding principles. The components include culturally-relevant constructs considered when attempting to understand suicide; identifying populations where increased research, theory, and clinical practice is needed; and suicide prevention efforts in communities of color.	No
American Indian Life Skills Intervention	LaFromboise and Howard-Pitney (1995)	This intervention is a multi-faceted, school-based approach to reduce risky behaviors among American Indian adolescents, including suicide. This is achieved through psychoeducation and teaching adaptive coping skills, as well as other community and individual skills for overall well-being.	Yes
Historical Trauma	Brave Heart (1999a; 1999b; 2000); Brave Heart and DeBruyn (1998); Duran and Duran (1995)	Though it is not associated with a specific model, historical trauma is a recently identified concept that refers to intergenerational grief and the impacts of European contact and colonization on health. Historical trauma is shown to be positively related to negative mental health outcomes, including depression, substance abuse/dependence, domestic violence, and suicide.	Yes
Cultural Continuity	Chandler and Lalonde (1998)	This is a culturally-grounded theory that has been used with First Nations youth in British Columbia, Canada. This theory posits that cultural continuity is achieved through an ability to connect traditional past, contemporary context, and future events. Continuity if further enhanced through sovereignty over lands, government, public services, community cultural centers, and healthcare.	Yes
Cuqyun Model of Protective Factors for Alaska Native Youth	Allen et al. (2006)	This is a culturally-guided theory of alcohol abuse and suicide prevention for Alaska Native youth. This model is composed of multiple levels of individual (e.g., self-mastery), family (e.g., cohesion), community (e.g., support), social (e.g., peer influences in alcohol use), and cultural factors (e.g., reflection about ways of life) that interact to prevent alcohol abuse and suicide risk.	Yes
Transactional-Ecological Approach to Suicide	Alcántara and Gone (2007)	This approach targets problematic interactions between people and their environments. According to this approach, pathology impacts whole communities through a culmination of stressors, the environment, and sociocultural conditions. The goal of this approach is to reinstate healthy developmental pathways at the community level to prevent negative outcomes (e.g., suicide deaths), rather than to treat individual disorders.	Yes

Footnotes

Acknowledgements

We are greatly appreciative of local American Indian communities for allowing us to be involved and participate in events, as well as invite us to provide suicide prevention resources/training. In addition, we thank the undergraduate research assistants and American Indians into Psychology research fellows who have contributed in valuable ways to our laboratory at Oklahoma State University. Lastly, we are grateful to the tribal community members, clinicians, policymakers, and researchers who are collectively working towards reducing suicide-related outcomes throughout Indian Country.

Declaration of Conflicting Interests

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

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Victoria M. O’Keefe, Ph.D. is an Assistant Professor in the Center for American Indian Health and Department of International Health (Social and Behavioral Interventions Program) at Johns Hopkins Bloomberg School of Public Health. She is a member of the Cherokee and Seminole Nations of Oklahoma. Dr. O’Keefe’s primary research interest is in developing culturally grounded, strengths-based, suicide prevention/intervention programs with North American Indigenous communities utilizing tribally-engaged research methodologies. She is also interested in social, historical, and cultural determinants that relate to health outcomes (e.g., microaggressions, historical trauma) and utilizing qualitative and quantitative methodologies to develop and evaluate intervention programs in collaboration with and implemented/sustained by Indigenous communities.

Raymond P. Tucker, Ph.D. is an assistant professor in the Department of Psychology at Louisiana State University. Dr. Tucker’s research interest is broadly in the area of suicide prevention, with parallel veins of work in historical and current cultural factors that influence suicide risk and resilience in underrepresented populations and novel etiological and maintaining factors of suicidal ideation and suicide attempts in the broader population. His recent published works focus on the relationship between transition-related medical intervention, minority stressors, and self-injurious thoughts and behaviors in transgender veterans and the incorporation of historical trauma into theoretical models of suicide in Indigenous populations.

Ashley B. Cole, M.S., is a doctoral candidate in Clinical Psychology at Oklahoma State University, and is currently completing her Psychology Residency at the University of Mississippi Medical Center in Jackson. Ms. Cole’s research broadly examines suicidality in the context of theoretical and cultural models. Specifically, her published work investigates causes and correlates of suicidal behavior, focusing on cultural, interpersonal, and cognitive risk and protective factors in ethnic/racial minority groups. Populations of particular interest include Indigenous and African American populations. Recently, Ms. Cole’s research has expanded to include proximal risk for suicidality, including alcohol and substance use as acute risk factors in predicting suicide attempt characteristics, and examining differences in these characteristics among ethnic/racial minority groups.

David W. Hollingsworth, Ph.D. is an assistant professor in the Department of Psychology at Fairfield University. Dr. Hollingsworth researches interpersonal risk and protective factors of suicide among ethnic minority groups. His recent published works include examining the Interpersonal Theory of Suicide, racial microaggressions, and hope in African Americans.

LaRicka Wingate, Ph.D. is an Associate Professor in the Department of Psychology at Oklahoma State University. Her research has focused on African American and American Indian suicide, interpersonal risk factors for suicide, and positive psychology/protective factors against suicide. Dr. Wingate’s research continues to focus on ethnic minority suicide and on the study of specific risk and protective factors that may be particularly salient to ethnic minority populations, such as racial/ethnic discrimination, racial microaggressions, historical loss, acculturation, intersectionality, help-seeking behaviors, hope, and grit.

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