The Cultural Theory and Model of Suicide

G Model APPSY-76; No.of Pages 17 ARTICLE IN PRESS Applied and Preventive Psychology xxx (2011) xxx–xxx Contents lists available at SciVerse ScienceDirect Applied and Preventive Psychology journal homepage: www.elsevier.com/locate/app Review The cultural theory and model of suicide Joyce P. Chu ∗ , Peter Goldblum, Rebecca Floyd, Bruce Bongar Palo Alto University, 1791 Arastradero Road, Palo Alto, CA 94304, USA a r t i c l e i n f o a b s t r a c t A growing body of research has demonstrated important variations in the prevalence, nature, and correlates of suicide across ethnic and sexual minority groups. Despite these developments, existing clinical and research approaches to suicide assessment and prevention have not incorporated cultural variations in any systematic way. In addition, theoretical models of suicide have been largely devoid of cultural influence. The current report presents a comprehensive analysis of literature describing the relationship between cultural factors and suicide in three major ethnic groups (African Americans, Asian Americans, and Latinos) and LGBTQ1 sexual minority groups. We utilized an inductive approach to synthesize this variegated body of research into four factors that account for 95% of existing culturally specific risk data: cultural sanctions, idioms of distress, minority stress, and social discord. These four cultural factors are then integrated into a theoretical framework: the Cultural Model of Suicide. Three theoretical principles emerge: (1) culture affects the types of stressors that lead to suicide; (2) cultural meanings associated with stressors and suicide affect the development of suicidal tendencies, one’s threshold of tolerance for psychological pain, and subsequent suicidal acts; and (3) culture affects how suicidal thoughts, intent, plans, and attempts are expressed. The Cultural Model of Suicide provides an empirically guided cohesive approach that can inform culturally competent suicide assessment and prevention efforts in future research and clinical practice. Including both ethnic and sexual minorities in our investigations ensures advancement along a multiple identities perspective. © 2011 Elsevier Ltd. All rights reserved. Article history: Received 1 July 2011 Received in revised form 23 November 2011 Accepted 23 November 2011 Keywords: Culture Suicide Theory Ethnicity Sexual orientation Asian American Latino African American LGBTQ Contents 1. 2. 3. 4. 5. Cultural variations in suicide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Existing theoretical models for suicide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The present study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.1. Cultural sanctions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.2. Idioms of distress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.3. Minority stress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.4. Social discord . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Cultural Model of Suicide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.1. Three principles of the Cultural Model of Suicide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusions and implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00 00 00 00 00 00 00 00 00 00 00 00 00 6. 7. 1. Cultural variations in suicide A lack of uniformity in suicide rates and risk across cultural groups points to the public health importance of incorporating cultural factors in the study of suicidology. Though overall suicide rates are higher in White males than most other racial/ethnic groups (e.g., 22.60 per 100,000 for White males compared to 5.78 for Asian/Pacific Islanders, 5.22 for African Americans, and 5.17 for Hispanics during 2004 to 2008) (CDC, 2009), an examination of 1 “LGBTQ” populations are also referred to as “sexual minorities.” LGBTQ is an abbreviation for lesbian, gay, bisexual, and transgender or transsexual individuals, and people questioning their sexual orientation. ∗ Corresponding author. Tel.: +1 650 814 8376; fax: +1 650 433 3888. E-mail addresses: [email protected] (J.P. Chu), [email protected] (P. Goldblum), rfl[email protected] (R. Floyd), [email protected] (B. Bongar). 0962-1849/$ – see front matter © 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.appsy.2011.11.001 Please cite this article in press as: Chu, J. P., et al. The cultural theory and model of suicide. Applied and Preventive Psychology (2011), doi:10.1016/j.appsy.2011.11.001 Meyer. Durkheim (1897). suicidality.7%. plan. Sexual minority status has proven to be particularly important in matters of suicide (McDaniel et al. data on culture and suicide have not been grounded in guiding theory (Leenaars. Bronfenbrenner. Though it is useful to know that older age for Asian Americans. 2009). McDaniel et al. 2008). or low family cohesion among African Americans particularly predict suicide risk in these respective cultural minority groups. 2001.41 per 100. Beck. In a diversifying world. neither of these recent works carry these cultural themes further to provide a overarching framework for cultural suicide assessment and management. et al. Leong and Leach (2008). Though depression is strongly predictive of suicide. & D’Augelli. J. Within the mainstream suicide literature.11. acculturative stress among Latino adolescents. researchers have increasingly recognized the importance of approaching cultural work from a multiple identities perspective (e. they can be mutually exclusive with one recent study finding that as many as one-third of Asian Americans who attempted suicide reported no history of depression or anxiety (Cheng et al. Third. for example. D’Andrea & Daniels. First.” (Leach & Leong. 2001. 2007) and elevated rates in Asian American elderly females (Shiang et al. 2009. Yeh. Risk factors unique to LGBTQ individuals. and efforts are needed to integrate sexual and ethnic minority research into a broader multiple identities model. 2010). Mo´ 1994. 2007. Joe & Kaplan. / Applied and Preventive Psychology xxx (2011) xxx–xxx specific ethnic subgroups and trends shows particular areas of elevated risk. 2010). Additionally. 7. Brown. However. Jones & McEwen. that determine a blueprint for action and influence the events that trigger suicidal behaviors. Friend. & Steer. 2000). and Powell (2009). Second. lesbian. 2005. 2000). 2005).g. Lester. the interpersonal theory of suicide (Joiner. Other studies have also showed higher rates of suicide attempts in Asian American compared to White students (Leong.G Model APPSY-76. 2008. however. suicidal tendencies. Heron.000) than any other racial or ethnic group among females ages 65 and older during 2004 to 2008 (CDC. Berchick.g.1016/j. Researchers have drawn attention to this problem stating that “there is no current or past theory development with regard to suicide among racial ethnic minority groups in the U. expression. and 9. single culturally specific risk correlates have not been systematically organized around underlying principles that would allow for ease of comprehension. 1985).. on the other hand.2011. icant suicide precipitants (Canetto & Sakinofsky. 2008. 3 The term cultural minority in this article is an inclusive referring to both ethnic or racial minority and sexual minority (LGBTQ) individuals. Please cite this article in press as: Chu. attempts. Socialization theory and cultural scripts theory also provide some basis for conceptualizing the importance of culturally signifscicki. Thompson. 1990. 1998.S. 2005) can be used to extend cultural understandings of suicide beyond the individual to the relationship. Sociological theories. 2007. Steer. Applied and Preventive Psychology (2011). 2. 1996).9%. Yet. The combination of low acculturation and parent–child conflict predict greater risk for suicide among Asian American outpatient youths (Lau. One meta-analysis showed lifetime attempt rates four times higher in gay/bisexual males compared to heterosexual males (King et al. and bisexual (LGB) people are at greater risk for suicidal behaviors2 than heterosexual people.. and behaviors of suicide are influenced by cultural variation and ethnic and sexual minority group status (Lester... cognitive-behavioral theories on hopelessness (Beck. 314). 2001. neither comprehensively account for the ways in which cultural factors or context influence suicide. Zane. & Chou. 2001). McDaniel. Existing theoretical models for suicide Fourth. yet. P. Goldston et al. and suicide rates are growing quickly among African American adolescent males (Day-Vines. Anthropological theories or interpersonal clusters of suicide are highlighted 2 The terms suicidal behavior.. & Kaslow. These cultural minority group3 variations in suicide rates are complemented by research finding risk factors that are culturally distinctive and risk factors with different strengths of association to suicide. Stice & Canetto. scientific findings represent a large array of single suicide risk correlates spread across numerous minority groups. gay.. For example. 2008). these reviews largely reiterate knowledge about each separate cultural group with limited efforts at comprehensive synthesis.. Though Durkheim’s sociological theories and the cultural scripts and socialization theories of Canetto or Mo´ scicki provide important advances. direct some attention to cultural aspects of suicide. and society. Recent data also suggest that transgender people carry the highest suicide risk of any demographic with up to one third making at least one lifetime suicide attempt (see Haas et al. 2008). correlates. (2009) advances our knowledge about gender differences in ethnic adolescent groups along several levels of categorization. and Langhinrichsen-Rohling.0%. include concealment of sexual identity or internalized homonegativity (heterosexism) (e. This literature.. Leach. socialized by one’s cultural context. (2008). Durkheim’s thesis is that suicide is related to broken or excessive integration with social networks and too much or too little regulation of emotions by cultural standards and norms. and there is a substantial and well-documented increased risk for attempts among young gay men (King et al. circles the question of cultural context in his theory about the role of social integration and social regulation in suicide. Without question... a growing body of literature on diversity and suicide confirm that the nature. there has been a lack of integration between ethnic and sexual minority literatures. The cultural theory and model of suicide. No. it can be difficult for clinicians to recall these complex combinations of findings in the minutes or hours one has to assess and manage high risk situations. 2003).appsy. has been subject to four major problems. community. Thus far. 1990. respectively) (CDC. Van Heeringen & Vincke. Kovacs. Van Orden et al. Leach and Leong (2008). 2009).P. Low family cohesion and support from extended communities are particularly important in matters of suicide for African Americans (Compton.001 . or acculturative stress. doi:10. It is important for future syntheses of culture and suicide knowledge to amass empirical data directly related to suicidal behaviors. 2001). & Myers. of Pages 17 2 ARTICLE IN PRESS J. religion.. Recent advances have been made in reviewing cultural group differences in suicide by Leach (2006). whereas acculturative stress predicts suicidal ideation among Latino adolescents (Hovey & King. and psychodynamic theories of desire for escape from psychological pain (Baumeister. internalized homonegativity among LGBTQ. Cultural scripts are beliefs about suicide. Among sexual minority populations.g. Jernewall. (2008) does attempt integration by identifying cross-cutting themes for ethnic adolescent groups such as the role of collectivism. & Garrison. for example. and Langhinrichsen-Rohling et al. p. 2009). 2002). 2011 for review). 1998). intent. but more broadly in terms of other cultural identities such as sexual orientation. existing theories of suicide do not apply well across cultures. Leenaars (2009). several theoretical perspectives have been proposed including the cognitive theory of suicide (Wenzel & Beck. 1997). 2008). 2009). and Lester (2009) discuss how the ecological model (e. Purcell. and suicide are utilized in this article as encompassing the complete range of suicidal ideation. Shneidman. and few directly or comprehensively explain cultural variations in suicide (Lester. Stewart. existing reviews and discussions of suicide among cultural minority groups often extrapolate knowledge about suicide from data on related constructs such as depression or general psychological distress.. Chu et al. and completions. Goldston et al. Latina high school students report a higher percentage of suicide attempts than their White or African American peers (14. defining “culture” not just as race and ethnicity. Asian Americans had higher suicide rates (6. and those that measured suicide-related constructs such as depression or schizophrenia instead of direct assessment of suicidal behaviors were also eliminated. Each culturally specific research finding related to suicidal behaviors was counted separately. 5. book chapters. Cultural sanctions can dictate the acceptability of suicide as a solution for one’s problems. 240 individual empirical research findings were identified as culturally specific and empirically related to suicidal behaviors among African Americans. Cultural sanctions Our culture and suicide literature review found that cultural context influences the acceptability of two constructs that bear significance on suicide risk: (1) acceptability of suicide as an option and (2) unacceptability and shame associated with life events. 4. The present study In their seminal text on suicide among ethnic groups. Several studies have shown that appraisal of suicide as unacceptable or amoral predicts a lower likelihood Please cite this article in press as: Chu. A definition of the four cultural factors are defined in Table 1. Latinos. Our literature review focused only on empirical data directly related to suicidal behavior rather than constructs like depression. et al. From these 144 articles. For example. and factor names were assigned based on consensus between the two lead raters. 3. We propose that a model specific to the processes of suicide risk is needed to encompass the full spectrum of cultural variations in suicide. Examination of commonalities in the data revealed that 12 of these 240 research findings were classified in the “other” category of variables unduplicated and thematically unrelated to other identified findings. synthesizing existing data on culture and suicide to generate patterns and commonalities in the interplay of cultural factors with suicidology. from 1991 to 2011. and LGBTQ. and affect whether one considers suicide as a viable solution.1. Specifically. (3) Minority stress. values. The four groups chosen represent the largest minority populations in America and also are the most commonly studied within culture and suicide research. Results The final literature search and exclusionary criteria process yielded 144 empirical articles for review. Asian American. Latinos. They call for the development of a framework that can be utilized to guide future work in this field.. In addition. they were not included in the literature review or extracted variable list. Asian Americans. and LGBTQ groups. No. in particular. of Pages 17 ARTICLE IN PRESS J. Any research findings that were unduplicated or unrelated to other empirical works were placed in an “other” category.” These terms were paired with searches for each respective cultural minority group: African American. Variables that showed no difference between a minority group and the mainstream (predominantly White heterosexual) suicide literature were excluded from the final extracted list of culturally specific findings. a literature review was conducted on suicide research in four cultural minority groups in North America. norms. All empirical works were read by a team of eight graduate research assistants and one clinical psychologist to extract variables empirically related to suicide. Latinos. we conducted a comprehensive suicide literature analysis amongst four major cultural minority groups: African American. data were compared by two lead research team members to ascertain commonalities and patterns amongst the research findings. literature was limited to those published in the last twenty years. We utilized an inductive approach. Search terms related to suicidology included “suicide. or customs held by ethnic and sexual minority groups that have been shown to influence suicide. Studies performed outside North America. The cultural theory and model of suicide. Leach and Leong (2008) highlighted both the pervasive underinclusion of ethnic minorities in suicide research. J. In order to provide an empirical synthesis of culture and suicide data based on current scientific knowledge. This “bottom-up” inductive approach assures that our resulting Cultural Model of Suicide is empirically based and able to guide future research and practice. Additionally. Latinos. cultural factors are defined to include beliefs. and sexual minorities within four categories of cultural factors related to suicide.001 . Applied and Preventive Psychology (2011).” and “suicidology. For example. Without theoretical grounding or organization around variegated research findings. Patterns induced from this literature were then used to inform theory. categorized according to these four cultural suicide factors.1016/j. the suicidology field has been unable to provide systematized recommendations to advance cultural suicide science and practice. if one study found racial differences in cocaine and alcohol use in suicide decedents. and concentrated on culture-specific findings distinct to each cultural group (rather than culture non-specific findings) to further this article’s goal of developing a model that addresses the unique ways in which culture affects the developmental suicide process. if past suicide attempts and hopelessness (two common risk factors) were equally related to suicide for both a cultural minority group and the mainstream literature. The term cultural sanctions – defined as messages of approval or acceptability supported by one’s culture – encompasses these two categories (see Table 2 for a summary of the literature). Research findings were grouped based on related themes.P. and (4) Social discord. variables within the same study that were similar in operational definition were counted as one research finding. The following sections describe the culture and suicide literature. Asian Americans. and LGBTQ groups. Asian Americans. thus. Following the extraction of culturally specific factors in the literature for African Americans. research findings that reported the prevalence or incidence of suicidal behaviors among cultural minorities were excluded. they were counted as one culturally specific finding under the category of substance use. 5.appsy. and sexual minorities (LGBTQ). it is possible to consider the vast majority (95%) of the culture and suicide literature from 1991 to 2011 for African Americans. The current article furthers extant reviews of the cultural suicide literature by providing an empirical synthesis of data directly related to suicidal behavior into a theoretical model inclusive of both sexual and ethnic minorities. Our study addressed categories separate from simple minority status as an ethnic or sexual minority individual. The remaining 228 research findings (listed in Tables 2–5) were encompassed within four common cultural categories of suicide risk: (1) Cultural sanctions. and literature review results are depicted in Tables 2–5. doi:10. Latino. / Applied and Preventive Psychology xxx (2011) xxx–xxx 3 as examples that have extended suicide beyond the individual.” “suicidal. PubMed. and the absence of theory on culture and suicide. Methods Utilizing PsycInfo. Including both ethnic and sexual minorities in our investigation ensures advancement along a multiple identities perspective. Asian American. the Psychology and Behavioral Sciences Collection.11. P. practices. and the Health Source: Nursing/Academic Edition databases. Chu et al.2011. The intention of this selection process was to examine culturally specific risk factors related to suicidal behaviors only. In essence. such is the aim of this article. supporting the need for a specific cultural theory for suicide. Review articles.G Model APPSY-76. or conceptual papers were excluded from our final literature review to limit the search to empirical works only. (2) Idioms of distress. It was necessary to include minority status groups with sufficient available data related to culture and suicide. All of these authors emphasize the need for theory development. it was possible for one empirical article to yield more than one qualifying finding. and necessary than that of a heterosexual adolescent. 2008) • Commitment to religious beliefs about suicide as a non-viable solution to problems.. 2009). Lizardi. 2007) • How religious Central American immigrants perceived themselves was unrelated with ideation (Hovey. Colemon. is a common purveyor of cultural sanctions regarding the acceptability of suicide with variations among different religions (e.001 . Cohen. Watt & Sharp. Barksdale.g. Li. acceptable. 1999. Greening & Stoppelbein. Matlin. African Americans • Attempts related to higher suicide acceptability and lower religious well-being (Anglin et al.. Spann. Many studies neglect to measure the distinctions between. 2000b) • Infrequent church attendance.G Model APPSY-76. 2010) • Lower religiosity and spiritual well-being predicted attempts in Black low-income adults (Kaslow et al. 2004. Olvera. Higher scores on moral objections and negative attitudes about suicide have been cited as possible reasons for lower overall prevalence rates of suicide among African American communities (Bender. 2000a. and low perceived influence of religion related with increased ideation among Mexican immigrants (Hovey. found that orthodox religious beliefs and devotion (elements related to cultural sanction aspects of religion) rather Please cite this article in press as: Chu. & Stueve. 2008. & Puri. but not extrinsic religiosity or church attendance. 2003) Literature with more than one cultural minority group • Greater tolerance towards suicide related to higher ideation among Black. Religion.2011. 2001). Bolden.. and weak. 2005. 2000b. these two components of religion in their statistical analyses (Burr et al. acceptable. These views of suicide as more acceptable for homosexual teens were the strongest among homosexual participants themselves. community. Yaffee. Fitzpatrick. 2004) • Views of suicide as unacceptable predicted lower ideation in Black female college students (Marion & Range. 2000. 2002) Asian Americans • Shame/disgrace related to a family member precipitated suicide in two Asian American decedents (Blinn. Olvera. Richardson-Vjlgaard. & Kaslow. a cultural identity of its own. O’Donnell. Latino. and White urban low-income high school students (Marcenko. Utsey. 2007. 2006) • Blacks higher than Whites on moral objections to suicide and survival/coping beliefs (Morrison & Downey. Morrison & Downey.. and necessary than of a heterosexual teen. Neeleman. & Stanley. particularly among homosexual participants (Molloy et al.appsy. Hartman. 2001) • Moral objections to suicide and survival and coping beliefs negatively related to suicidal behavior for Latinos and non-Latinos (Oquendo et al. unsound. 2005) Sexual minorities (LGBTQ) • Suicide of a homosexual teen seen as more justified.P. & Friedman. Cohen et al. Lee. 2005) • Attendance of religious services was unrelated to attempts for Black and White teens (Watt & Sharp. 2000a) • Use of religion as a coping mechanism associated with ideation in Whites and Latinos (Olvera. 1998) • In contrast to Whites and Latinos. 2008. Canino.. several other studies have found a lack of systematic association of religiosity with suicide among cultural minority groups (Fortuna. 1993) • Black teens who perceived belonging to a spiritual community had lower odds of ideation (Fitzpatrick et al. 2008) • Black pastors in a southern U. low perception of religiosity. 2002. et al. 1997) Latino/as • Frequency of church attendance unrelated to suicide attempts or ideation (Fortuna et al. O’Donnell. Hovey. for example. 2009). Piko. 2005). Burr. McLaren. 2006) • Church attendance lowered suicide ideology more among Whites than Blacks (Stack & Wasserman. 2000) • Blacks had lower acceptance of suicide (an indicator of orthodox religious beliefs and devotion rather than practice and affiliation) than Whites (Neeleman et al. Gabriel. Molloy.. 2007).. 2003) • Church attendance and level of activity in church unrelated to ideation or attempts in Black high school students (Molock et al. & Miller. Sribnev.. of Pages 17 4 ARTICLE IN PRESS J. Wessely. or friends Table 1 Description of four major categories of culturally specific risk. 2004. 2005. community viewed suicide as an unacceptable sin and a “White thing” alien to Black culture (Early & Akers. Chu et al. Walker. & Casimir. Blacks with depression did not report a negative relationship between moral objections and ideation (Richardson-Vjlgaard et al. & Williams. & Alegria. Kaslow et al. Hovey.11.S. No. or alienation from family. Phillips. Marion & Range. Fishman. 2000) • Church membership related to decreased probability of Black male suicide (Burr et al. These inconsistent findings may be explained by which of two main operative components of religion were assessed within each study: the extrinsic social support function of attending religious services versus the intrinsic cultural sanctions imposed by religion on suicide. Oquendo. Neeleman et al. 1998). 2000. lack of integration. doi:10. predicted lower perceived risk in Black and White teens (Greening & Stoppelbein.. or mix together. Tsang... & Lewis... Applied and Preventive Psychology (2011). 2007) • White heterosexual participants viewed the decision to engage in suicidal behavior following coming out as unacceptable. (1998). 2001. 2003) • Self-conscious thoughts about others’ evaluation of one’s body predicted attempts in transgendered youth (Grossman & D’Augelli. lower levels of religiosity have been associated with greater suicidality (Anglin et al... 2006.. 2004. Yet. 1999) • Religiosity related to lower suicidality in Black and White elderly (Cohen et al. Kaslow et al..1016/j.. particularly by androgynous participants (Cato & Canetto. & Metteson. 1999. suggesting that greater acceptance of suicide as a viable solution may pose risk for suicide in some LGBTQ subgroups. 2002) • Black male but not female suicide decedents less likely than non-suicide decedents to attend church (Joe. The cultural theory and model of suicide. 2002).. 2008. 2003) and Latinos (Oquendo et al. Wardlaw. Culturally specific risk category Cultural sanctions Idioms of distress Minority stress Social discord for suicidal behavior among African Americans (Anglin. Sher. 2006. P. and McLachlan (2003) additionally found that the suicide of a homosexual adolescent is seen as more justified. 1995) • Low religious or spiritual well-being predictive of ideation and attempt in Black adults (Walker et al. 2005) • Greater negative attitudes towards suicide and intrinsic religiosity in Blacks than Whites (Bender. & Kleinman. 1999) • Religiosity marginally related to ideation among Black and Latino teens (O’Donnell et al.... with some evidence suggesting that this protective effect applies only to attempts and not ideation for African Americans (Richardson-Vjlgaard et al. In numerous studies. Buddhism or Taoism as associated with more accepting appraisals of suicide than Catholicism or Judaism) (Leach. 2005. / Applied and Preventive Psychology xxx (2011) xxx–xxx Table 2 Cultural sanctions: summary of culturally specific suicide literature. 2004) Description Acceptability of suicide as an option Unacceptability and shame associated with life events One’s likelihood to express suicidality The way suicide symptoms are expressed Chosen methods or means of attempting suicide Stresses cultural minorities experience because of social identity or position including: • Acculturation as moderated by ethnic identity and density • Discrimination-related strain • Social disadvantages Conflict. J. Most studies that directly compare the relative effects of the cultural sanction versus social support elements of religion find that cultural sanction is more influential for suicide.. 2009) • Religious coping style unassociated with reduction of suicidal risk in Black teens (Spann et al. Molock. Perez. traditional risk assessment would instead focus directly on depressive symptoms or suicidal thoughts. & Barksdale. Especially in light of the phenomenon of hidden ideation among ethnic minorities. are less likely to express suicidal ideation than Whites. 2000). 2002).. Rodriguez. ethnic minorities (consisting of 17 Asian Americans. One study found that completed suicides were more likely to involve aggression towards others in African American than White suicide decedents (Abe et al. Puri. & Wang. Steinberg. low appraisal of suicide as a viable solution to problems. self-perception of religiosity. Ducatman. Cato and Canetto (2003) found that predominantly White heterosexual individuals viewed sexual minorities’ decisions to engage in suicidal behavior following coming out and being rejected by family as unacceptable. Barker. Roberts. & Garcia.appsy. and weak. Vanderwerker et al. Culture and suicide research shows differential patterns in the following idioms of distress: (1) likelihood to express suicidality. Clearly. & DiClemente. 2003). Self-conscious thoughts that may be related to internal shame about others’ evaluation of bodily appearance were shown to be predictive of attempts in transgendered youth (Grossman & D’Augelli. The cultural theory and model of suicide. 2008). Idioms of distress It is well-recognized that there are cultural variations in the manifestation or expression of psychological symptoms – a phenomenon coined “idioms of distress” (American Psychiatric Association. Applied and Preventive Psychology (2011). 1997). 2007). Karch.2011. a concept called “hidden ideation.. 2003). Interestingly. One contradictory study of Mexican immigrants found that church attendance. 2009. Taken together. 2008). 1 Latino) were less likely to disclose their suicidal thoughts on a questionnaire than when queried in an in-person intake interview. Ethnic minorities. Bell. unsound. J. withdrawal. anger.. or Latino adolescents (Else. aggression. suicidal behavior itself can be a life event that is viewed as unacceptable. Yet. One study found that African Americans who successfully complete suicide exhibit idioms of distress opposite to that of hidden ideation. one study found that aggression and conduct-related symptoms identified a different subset of suicidal ethnic minority adolescents than depressive symptoms (Feldman & Wilson.. or irritability may be alternate expressions of suicidal thoughts or intent among African Americans. Disclosure of suicide was more strongly predictive of a suicide act among African American than White decedents. Filipino and Hawaiian youth. Walker. as African American suicide decedents were found to be less likely than Whites to leave a suicide note (Abe. loss of face common in Asian American cultures – the shame experienced when an event has occurred that is unacceptable or intolerable to social relationships–has been discussed as an influential factor in mental health-related issues (Zane & Yeh. & Fukuda. 2002. Rockett. 2001. Classic signs of suicide such as hopelessness.P. Lodico.. 2008). Stack. doi:10. & Wei. 2004. Attending religious services was also found to be unrelated to suicidal behavior among African Americans (Molock. 1997). but not church attendance. risk-taking behavior. 2006). Yao. 2002) and unrelated to ideation and attempts among Latinos (Fortuna et al. Even the role of mental illness in suicide varies according to cultural group.g. was related to lower perceived suicide risk.. & Obasi. Yang. Stack & Wasserman. however. (2) the way suicide symptoms are expressed. No. but also in the manner in which they are expressed. such ideas have remained largely non-empirically tested conjecture. for example. Eastern cultures) (Ryder. for example. Pearson. suicide can be a culturally acceptable solution to alleviate the burden of shame or sin levied on one’s family or community (Beautrais. of Pages 17 ARTICLE IN PRESS J. 2006. compared to their White counterparts (Morrison & Downey. suggesting that frequent expressions of suicidal symptoms may constitute a more serious indication of risk among African American individuals. Depression and anxiety disorders in particular may be less strongly related to suicide among African Americans than Whites. These disapproving attitudes may create additional sources of stress for suicidal LGBTQ individuals. hari-kari in Japanese culture or suttee in Hindu cultures). more frequent expressions of suicide may not extend to written expression. Such shameful life events can precipitate suicidal ideation or behaviors. Cultural sanctions can also shape which life events or experiences are considered shameful. Greening and Stoppelbein (2002) discovered that among a community sample of African American adolescents. & Yi. particularly in interdependent cultural minority groups. These externalized expressions of distress would not typically be detected as a flag for suicide risk by clinicians trained in traditional suicide query. Goebert. Coombs. are more likely to be expressed in psychological terms in Western cultures compared to more somatic terms in other cultures (e. African Americans at the highest risk level talked about suicidal tendencies more often in the time preceding their suicidal act (Willis. 2007). Latino and African American are less likely than White suicide decedents to have a diagnosed mental disorder whereas African Americans are more likely to have schizophrenia and Whites depression or bipolar disorder in the presence of death by suicide (Abe et al. Watt & Sharp. 2010. In fact. and influence of religion on one’s life all predicted lower suicidal ideation (Hovey. 2009). 1993. Alabi.G Model APPSY-76. Violence. Among Asian Americans. 2002.. 2007). though research has shown inconsistent results (Greening & Stoppelbein. 1997. Juon & Ensminger. & Hanzlick. Specifically. 2009. 2000). Rockett et al. / Applied and Preventive Psychology xxx (2011) xxx–xxx 5 than religious practice and affiliation indicated lower acceptance of suicide in African Americans compared to White adults. & Potenza. or low self-worth may be less predictive of suicide for African Americans compared to Whites (Perkins & Hartless. 2009).1016/j. Hernandez.001 . 2005.2. Wu. Kung. 1995. Zhu. 5. Additionally. 2006. Please cite this article in press as: Chu. & Strine.. Powell. et al. Though examinations of shamerelated experiences as suicide risk factors in cultural minority populations are sparse. Direct assessment of suicidal ideation and attempt may under-detect suicide risk in ethnic minority adolescent males in particular who are less likely than ethnic minority females (including African American. and (3) the chosen methods or means of attempting suicide (see Table 3 for a summary of the literature). Asian American. Kaslow et al. & Cockerham. Chu et al. Gutierrez. Carloton. one study examining narrative data from the San Francisco Medical Examiner’s office found that shame or disgrace related to a family member was the precipitating event for suicide completions of two Asian American individuals (Blinn. Drentea.” In a study examining outpatient clients at a university counseling center. P. detecting alternative expressions of risk will be especially crucial in culturally competent suicide assessment. Cultural variations in idioms of distress also apply to manifestations of suicide. risk-taking behavior via gambling is more likely to be associated with suicide attempts than in Whites (Barry. and Latinos) to directly report suicidal thoughts or attempts (Langhinrichsen-Rohling et al.. It is notable that only a small handful of studies have studied the phenomena of hidden ideation or heightened disclosure of suicidal symptoms preceding a suicidal act.g. Lian. 2007). Olshen. Depression symptoms. Matlin. The literature indicated the existence of cultural variation not only in the likelihood that suicide symptoms are expressed. 2008.. Willis et al. this limited evidence suggests that cultural sanctions about suicide serve a prominent function in determining risk for suicidal behaviors. 2008). Other non-empirical works have theorized that in some cultures (e.11. 2009).g. Donnelly & Kim.. additional research is needed to extend and clarify these preliminary findings. 24 African American. 2000a). The tendency to keep suicidal thoughts private has been hypothesized as common in Asian American cultures where emphasis on minimization of shame may enhance the value of “suffering in silence” when feeling suicidal (e.. Mertz. 2010) • Greater proportion of Black than White decedents’ households contained firearms. 2010) • Predominant methods used in completed suicides in San Francisco: firearms (30% of Blacks. & Potenza. Bae. • Asian Americans and Latinas had lower percentages of alcohol-involved suicide poisoning acts at a hospital than White females (Miller et al. 2002) • Black men twice as likely as White men to use firearms to complete suicide (Joe. 2003) Asian Americans • Asian American more likely than White gamblers calling a gambler helpline to report attempts (Barry. 2004) • Non-fatal self-harm poisonings in the emergency room included 71/100. 26% of Whites). exerting pressure on peers. 2010) • Firearm suicides increased at a greater rate from 1979-1997 among Black than White males (Joe & Kaplan. and committing physical violence (Else et al. / Applied and Preventive Psychology xxx (2011) xxx–xxx Table 3 Idioms of distress: summary of culturally specific suicide literature. 35% suffocation. and comparatively more psychotropic drugs (Shiang et al.000 – for Latinos (Prosser. 1993) Please cite this article in press as: Chu. violence. Literature with more than one cultural minority group • Aggression and conduct-related symptoms identified a different subset of ethnic minority teens than depressive symptoms (Feldman & Wilson. respectively). 1993) • Blacks more likely than other races to suicide by firearm (Price et al. Asian American. Black decedents lower on alcohol use. and ecstasy usage than Blacks and Whites (Luncheon. Blacks less likely to use substances just prior to suicide. and Whites had less cocaine but more antidepressants and opiates (Karch et al. 2002) • White decedents predominately used gunshot. 2003) • 80% of Russian roulette suicide decedents were Black compared to 30. 2007) • Attempts among hospitalized teen girls were typically impulsive.. et al. 4% alcohol abuse. Sue. 1996) • Latino patients with serious mental illness made less lethal attempts than non-Latinos (Oquendo et al. attempts related with risky behaviors related to drugs. 2007) • Aggression (high assault behavior) and drug use (cocaine) related to suicidal behaviors in Blacks (Juon & Ensminger. 27% of Asians). and 3%... 65 per 100.appsy. 2006) Sexual minorities (LGBTQ) • LGB youth attempters worried more about excessive alcohol use. and undercontrolled behaviors unrelated to risk among Asian youth (Lau et al. Clarke.9 times more likely than Whites to use cocaine immediately before committing suicide (Marzuk et al.6%) (Unikel et al. 7% cars. 1997) • Suicidal Filipino and Native Hawaiian youth had higher rates of intimidating. jumping (20%). 1992). and Latino teen males less likely than females to utilize direct rather than indirect reports of ideation and attempts (Langhinrichsen-Rohling et al.. Whites used drugs. of Pages 17 6 ARTICLE IN PRESS J. 1997). Attempt methods included: 70% drug overdose.11. 2009) • Impulsive. 2010) • Hopelessness linked to lower reasons for living in Whites but not Blacks. 1998) • Weaker association of hopelessness with suicide for Black than White adolescents (Perkins & Hartless. African Americans • Black more likely than White suicide decedents to hurt others in a suicide but less likely to report depression or leave a suicide note (Abe et al.. et al.9%). Asian decedents used drugs only. Steinberg. Higher underenumeration of comorbid mood disorders and higher overenumeration of schizophrenia evident on Black and Latino than White suicide death certificates (Rockett et al. and property destruction.2011. the lowest – 23/100.8%) and wrist cutting (27.. 7% knives.001 . Marcus. Talking about suicide before death was a more frequent and a stronger risk factor for Blacks (Willis et al. 29% suffocation.. 2010) • Percentage of decedents with alcohol use/dependence was high in Latinos and low in Blacks (MMWR. 2005) • Fewer Black than White college students use alcohol or illicit drugs while making an attempt (Molock et al.8%). and safety (Olshen.000 for Whites. antisocial. overdose (28% of Whites) (Shiang. P. Wu. Gil. • White suicide decedents more likely to have depression or bipolar disorder.. doi:10. Zoewenstein.G Model APPSY-76. 2005). Blacks decedents more likely to have schizophrenia. overdoses.P. • Blacks low on depression reported higher risk than Whites low on depression. & Pines.. (Blinn. 4%. The cultural theory and model of suicide. overdose (13.. disordered eating. et al. with a stated wish to die (Razin et al. 1999) Latino/as • Different patterns of suicide methods evident among Hispanic male decedents (48% firearms. & Singh.. Zimmerman. 2001) • Risk-taking behaviors more likely to be related to attempts in Black than White teens (Hernandez et al. non-lethal. other than Blacks with a less “African-centered” world view (Walker et al.. 2004) • Suicide methods different between Cuban-born (42% hanging and 48% gunshot) versus American-born (74% gunshot) Cuban elderly male decedents (Llorente. verbalization of low self-worth. Eisdorder. 2004) • Suicide deaths related with heavy drinking and depression in Whites but not Blacks (Kung et al. & Zarate. et al. Completed suicide in Blacks was related to hallucinating and violent threats but unrelated to withdrawal.1%). 7% poisoning) compared to Hispanic females (29% firearms. hanging (31% of Latinos. J. 2007) • Unprotected receptive anal intercourse associated with attempts in Asian American transgendered women (Operario & Nemoto. Blacks were three times more likely than Whites to use revolvers in suicides (Stack & Wasserman. 2009) • Ethnic minority clients at a college clinic disclosed ideation less than Whites (Morrison & Downey. 2006) • Black.. Joe. 1997) • Asian decedents less likely than Whites to use a firearm (Sorenson & Berk. 2002) • Blacks had the highest rates of misclassification of potential suicide deaths (Phillips & Ruth. 2005) • Being Latino was not related with firearm suicide deaths (Price et al. 2008) • Anxiety disorders predicted suicidality in White but not Black elderly patients (Vanderwerker et al. • Comorbid psychopathology more than twice as likely to be documented on death certificates of Whites than Black and Hispanic males (8%. 1993) • Depression related to risk among Black female but not male suicide decedents (Joe. isolating/excluding. No.1016/j. 2009) • Latina female teens at risk for suicide who used drugs had higher lifetime cocaine. 1994) • Firearms accounted for 66–72% of suicides in Blacks under 19 years old. Asian Americans used hanging. 6% razor blades. Applied and Preventive Psychology (2011).000 for Blacks. 2000) • Among Black and Latino high school students. 2007... 27% poisoning) (CDC. alcohol.7% of a control suicide decedent group. alcohol use more frequent with White decedents (Garlow. threatening. 2007) • Suicide deaths of Black police officers have a high risk of being misclassified as undetermined (Violanti. but more frequent for Black than White adult decedents (Garlow et al.. 1993). Chu et al.. 2008) • Methods of suicide for Blacks included staying late in dangerous neighborhoods and using a pillow in the face (Brown & Grumet.. gunshot wound (19. methamphetamine. 2004) • No difference between Black and White substance dependent attempters on hostility personality (Roy... Latino more likely than Black and White decedents to have substance abuse without comorbid mental health problems.. 2002) • Cocaine use more frequent for White than Black teenage decedents. 1997) • Attempts in Black adults related with more aggression and substance use (Kaslow et al.3 and 1. 2009) • Asian Americans’ chosen suicide methods were hanging (27. 2009) • Cocaine use more frequent in Black decedents. 2008) • Latino and Black suicide decedents 3. acting suspicious. 1998) • Deviancy-delinquency more strongly predicted attempts for White than Blacks and Latino adolescents (Vega. Antidepressants and stimulants were used less and cocaine used more among Black than White decedents. 2007). and 2% guns (D’Augelli & Hershberger.... 2009) • Blacks and Hispanics had higher suicide misclassification relative to Whites (Rockett et al.. 1991) • Preferred method among Mexican female students was pills (41... Perrone.. followed by strangulation (18–20%) (MMWR. 2002) • Depressive symptoms more weakly related to suicide history for White than Black undergraduates (Gutierrez et al. (Greening & Stoppelbein. among Latinos and Asian Americans. Price. Thompson. Sorenson & Shen.. 1993). ˜ 2010. and discrimination show the most consistent relationship with increased suicide risk for sexual minority groups (Clements-Nolle. Moderating variables of ethnic density or ethnic identity explain this variability. suicidality is also expressed via externalized symptoms of substance abuse. McNiel.. Kaslow et al. These minority positions often afford disadvantages. Díaz. 5. 2003). & Weiss. a handful of studies show the opposite effect of lower acculturated individuals carrying higher suicide risk (Cho. Marzuk et al. In contrast. acculturation affords unique challenges associated with adapting and balancing cultures of origin with American culture. African American adults and Latinos are more likely than Whites to have cocaine in their system at the time of a suicideprecipitated death. whereas alcohol. These environmental stresses have been called acculturative stresses. 2009)... 2006. 2006). jumping. McClure. 1996. along with immediate removal of means in the presence of any level of suicide risk (American Psychiatric Association.. et al. 2003). Suicide deaths among Black police officers in particular have a high risk of being misclassified as undetermined (Violanti. 1991).. 2004. Mainstream suicide assessment and management literature recommends routine assessment of access to means of suicide. & Williams.S. Though the majority of the culture and suicide research from the past twenty years shows that greater acculturation (e. 1996. 2001). QuinteroSalinas. are less likely to use substances just prior to a completed suicidal act (Molock. Minority stress Minority stress refers to the stresses cultural minorities experience because of their social identity or position (Meyer. 2008.3. & Holzer. and opiates are more common among Whites (Garlow. 1994. Substance abuse as an omnibus category is related with impulsivity and higher risk for self-harm among mainstream populations (Rowan. 2009... 2005. Kennedy. or stresses that can contribute to vulnerability for suicide (see Table 4 for a summary of the literature).2011. 2009. are inconsistent within the literature. Rockett et al. Korean. Gil. 1993). The relationship trends of acculturation with suicidality. 2002. It is important to note that cultural subgroup variation exists in idioms of distress. 1997. 2008. Weaver. Shiang et al. Takeuchi. In stark opposition to African American and White groups. & Zayas. The majority of this research has focused on the need to assess for the most common method of suicide in Western countries – firearms – as the gold standard of care and the most common suicide method chosen among Whites (e. 1998. Bein. or a null relationship between acculturation and suicide (Lau et al. stimulants. particularly for individuals who experience weakened ties to their culture of origin. CDC. 1998. & Katz. one’s chosen idiom of distress for methods or means of attempting suicide varies according to cultural minority group. 2004. Willis et al. A frequently discussed idea of African Americans enacting “victim-precipitated homicide” or “suicide by cop” as a method of suicide has remained non-empirically verified but could contribute to the underdetection and misclassification of suicides as homicide (Langhinrichsen-Rohling et al.. or poisoning have been found to be preferred means of suicide attempt or completion over firearms (Blinn.. 2008). born) ethnic minorities.G Model APPSY-76.appsy. and beliefs about one’s cultural group. and the proximal level represents the internalization of negative events. but some evidence indicates that suicide in Latinos may be more likely to present with substance use problems only rather than with comorbid mental health and substance use problems (Karch et al. suffocation. Other studies point to alternate methods of suicide attempts that would not be captured by typical suicide assessment such as staying late in dangerous neighborhoods for African Americans (Brown & Grumet. and preferred method for suicide point to the importance of incorporating variant idioms of distress into routine suicide assessment and management efforts. The culture and suicide literature. African Americans. Joe. 2010. Lawrence. of Pages 17 ARTICLE IN PRESS J. and encompass discrimination-related strains. 1999). 1992. No. Pumariega. 2002. 1997). Mistreatment.. 2010. 2009). or anger. 2005). (2010) additionally found that African Americans and Latinos had higher suicide misclassification rates than Whites. & Warheit. Shiang. Wadsworth and Kubrin (2007) found that second generation Latinos are faced with increased suicide risk only when compared to first generation immigrants who live in areas of high ethnic density where there are other ethnically similar residents. The distal level refers to negative events such as discrimination or daily hassles. Chu et al. Vega. some investigators have conjectured that stresses relayed in the U. MMWR. Lacy. Phillips and Ruth (1993) found that African Americans had the highest rates of suicide deaths misclassified as other causes such as pedestrian deaths or accidental barbiturate poisoning. Linskey. 2010). Sorenson & Shen. Álvarez-Sánchez. compared to an overwhelming 70% majority who overdosed on drugs (D’Augelli & Hershberger. 2009). aggression. 2004.001 . Duldulao. immigrants who are isolated from other ethnically similar individuals. Bright. cultural environment during the acculturative process. Obasi. 2007. P. or engagement in unsafe sexual practices among Asian American transgendered women (Operario & Nemoto. however. Willis et al. Juon & Ensminger. Marion & Range. Teti. one study found that only 2% of LGB youth who made attempts utilized a gun. 2007. Wingate. Minority stresses occur at two levels. 2006. Marcus. Willis et al. For ethnic minorities. especially among Latino men (Croyle. Walker.. Garlow. with some studies showing higher or more rapidly growing suicide rates by firearms in African American compared to White populations (Joe & Kaplan. Parhar. Kaplan... 2003). Ethnic or racial identity may also moderate the relationship between acculturation and suicide. 2003. 1998. Distinct cultural variations in drug of choice are also evident. Ungemack & Guarnaccia. 2007) or African Americans where pro-Black attitudes serve a protective effect against suicide (Bell. Kimbrough. Zayas. MMWR. on the other hand. & Gorzalka. & Heninger. Applied and Preventive Psychology (2011). Marx. Southeast Asian.11. In an examination of death certificates.. Fortuna et al. stigma. shows that focusing assessment on firearms would not capture the range of suicide methods utilized by some ethnic and sexual minority subgroups. 2007. Purselle. Kuhlberg. constitute the primary mechanism of heightened suicide risk (Borges et al. Asian American decedents more frequently utilize psychoactive drugs whereas Whites use not only psychoactive drugs but also alcohol (Miller. 1993). Shiang et al. Swanson. / Applied and Preventive Psychology xxx (2011) xxx–xxx 7 Similar to the externalization of suicide expression via violence. & Please cite this article in press as: Chu. The cultural theory and model of suicide. Turner. 2007.g. manner of expression. Finally. Stack & Wasserman. doi:10. stereotypes.P.g. J.. Given that acculturation appears to confer suicide risk among second generation (U. Zayas. 2007. Shiang et al... 2009). & Ross. second generation individuals) is related with increased suicidality in Latinos and Asian Americans (Baumann.S. 2004. firearms are actually the most frequently utilized means of suicide. & Hall. & Hong. 2002. Henne. 2003. 2003). and recent immigrants.. 2002).. the presence of other ethnically similar individuals may help to preserve ties to cultures of origin or provide social support that can buffer the stresses of immigration. & Drake. 1997). Samra. These striking differences in likelihood to disclose. 1992. & Kaplan. Karch et al. harassment. Zimmerman. however. Price et al. & Cabassa. In essence. with one study finding that non-Filipino and Hawaiian Asian American youth (including Chinese. and Japanese). 1997. Additionally. In African American groups. Pena et al..1016/j. 2002. methods such as hanging.. 2003). Cheng et al. 1997. Sorenson & Berk. LGB youth attempters have worries about excessive alcohol use (D’Augelli & Hershberger. Ayala. do not express suicide violently or impulsively (Lau et al. Razin et al. antidepressants. & Joiner. discrimination. 2001). et al. perceived poor life chances. 2009) • Acculturation uncorrelated with ideation in Black female college students (Marion & Range. Ethnic identity associated with reduced attempts. joblessness) shaped suicide by influencing motivation among Whites versus gun availability among Blacks (Kubrin & Wadsworth. or unsure sexual orientation in Black and Latino high school students (Olshen.heterosexual younger. 2007) • Latina teen attempters and non-attempters were similar in acculturation (Zayas et al.-born Mexican Americans. poor grades) more strongly related to attempts for Whites but not Blacks (Watt & Sharp.. 2005. 2002) Latino/as • 2nd more likely than 1st generation Latina teens to have an attempt history (Baumann et al.. No..-born Mexican Americans than Mexicans (Borges et al. Low income related to ideation and attempts for Puerto Ricans. & Pilkington.87 times and 3+ generation were 3. 1994) • Suicide attempts related to higher victimization and visible/behavioral aspects of sexual identity among sexual minority male youth (Savin-Williams & Ream.. born Asian American women at greater risk for ideation. Attempts more than two times as high in low-income than high-income Asian Americans (Duldulao et al. 2009) Sexual minorities (LGBTQ) • At-school victimization was more strongly related to suicidality for LGB youth than heterosexual youth (Bontempo & D’Augelli. 2002) • Gay-related stressors more common among attempters than nonattempters among gay and bisexual adolescent males (Rotheram-Borus et al. P. (Ungemack & Guarnaccia. Immigrants at lower risk only when living in high ethnic density areas. 1998) • Acculturative strains (acculturative conflicts.57 times more likely than 1st generation Latino youth to have an attempt history.. especially for males (D’Augelli et al.. and language conflicts) interacted with cocaine/crack to predict attempts in 7th/8th grade Latino teens (Vega. younger age. Unemployment. 1998a) • Acculturative stress related to elevated ideation in Mexican American students (Hovey.1016/j. 1996) • Unlike heterosexual youth. 1999) • Reports of mistreatment (including anti-gay verbal harassment. time pressure finances. and physical violence) associated with ideation among gay and bisexual men (Huebner et al. mediated by divorce/separation. • School safety protective against ideation and attempts in 9th–12th graders.11.. Zimmerman. social acceptability.. 1995) Literature with more than one cultural minority group • Same-sex attraction predicted attempts in Black. plans.S. 2008) mediated this relationship (Pena • Latina teens attempters had parents born outside of the U. / Applied and Preventive Psychology xxx (2011) xxx–xxx Table 4 Minority stress: summary of culturally specific suicide literature. and immigrant women. Perceived discrimination associated with ideation and attempts (Cheng et al. 2006) • Early openness about sexual orientation was associated with gay-related suicide attempts. 2009) • Identification with heritage culture related to increase risk among European. J. 2004) • Life hassles (social cultural difficulties. Gil. and Asians than Whites (Clarke et al. 2000) • Status strains (not going to college. and were more comfortable disclosing sexual orientation than non-attempters (D’Augelli & Hershberger. language proficiency) correlated with attempts (Fortuna et al.S.. this effect of acculturation not applicable for Blacks and Asian Americans (Sorenson & Shen. felt more people now about their sexual identity. 1993) • Acculturation associated with attempts among Latino adolescents (Vega. African Americans • Black suicide attempters more likely to be homeless than nonattempters (Anglin et al. Puerto Rican.S. 2004) • Attempts related to homosexual.. high school dropouts. and attempts than US born men. 2005). 2008). female-headed households.001 . et al.. 2007) • Acculturation (U. lower income.. 2001) • LGB Latinos at greater risk for attempts than LGB Whites (Meyer et al. 2006) • Association of sexual orientation with suicidality mediated by violence/victimization behaviors for female high school students (Garofalo et al. 2005) • A trend of a positive relationship between pro-black attitudes and suicidal ideation (Bell. and unequal economic resources related to risk (Wadsworth & Kubrin. 2008) • Latino and Asian gay/bisexual more likely than heterosexual men to report recent attempts (Cochran et al. • Community areas with greater Latino economic disadvantage (poverty. 2009) • Low socioeconomic status related to 2× higher attempts in Filipino and Native Hawaiian youth (Else et al. and criminal and psychiatric problems (Razin et al.... 2004) • In gay and bisexual men. 2010) • Risk higher among early immigrant and U.. 1999) • Blacks at higher risk for attempts were more likely to be less educated (Joe.. 1993) • Most attempts in LGB youths followed awareness of same-sex feelings and preceded disclosure of sexual orientation to others (Augelli. Higher education related to ideation in Mexicans. welfare receipt. extended families on public assistance.. social victimization) was a risk factor for attempts in Blacks (Kaslow et al. 2006) • Black attempters reported lower ethnic identity than nonattempters (Kaslow et al. 2003) • U. born Asian Americans... Warheit. 2003) • Completed suicide among 3 homosexual teens did not directly follow episodes of stigmatization (Shaffer et al. Waldon. being a sexual minority in a hostile environment was a suicide risk factor (Paul et al. and education.. 2007) • Acculturation and low agreement about immigration decisions related to ideation in Latino migrants (Hovey.appsy. 2008) • Outness related to less suicidality via lower psychological distress for Black and White but not Asian American and Latina lesbian and bisexual women (Morris. doi:10.. Gil. & Rothblum. 2007) • Foreign-born at lower suicide risk than U... Chu et al. 2003) Asian Americans • U.2011. 2008) • Low-status occupations related to higher suicide rates for Whites but not Blacks (Wasserman & Stack. 2002) • In Mexican Americans. work..P. Kaslow et al. 2003) • High acculturative stress or low ethnic identity moderated increased ideation among Black college students who reported depression symptoms (Walker et al. 1993) • Suicide rates higher among immigrant than U... Hershberger.. 2009) • 2nd generation were 2.. less medically healthy mothers.G Model APPSY-76. were handling this knowledge for longer.S. 2007) • Strong relationship between social discrimination and ideation among gay and bisexual Latino men.. Applied and Preventive Psychology (2011). bisexual.S. 2009) • Mexican orientation (not acculturation) related to lower self-harm for men but not women (Croyle.. and South Asian immigrants in Canada (Kennedy et al.S. 2002) • Black less likely than White decedents to be educated beyond high school (Willis et al. low social acceptance. of Pages 17 8 ARTICLE IN PRESS J. perceived discrimination. born Latinos. 1991) • Mexican American more likely than Mexican secondary students to report elevated ideation (Swanson et al. 2001) • Income disparities elevated risk more for Blacks.. Hispanic and White boys and Black and White girls (Borowsky et al. 1992) • Latina adolescents with and without history of attempts did not differ in acculturation (Turner et al. 2006) • Bullying mediated a positive relationship between gender-role nonconformity and suicidality among gay male youth (Friedman et al. The cultural theory and model of suicide.. et al. Chinese. Please cite this article in press as: Chu. 2002) • Gender-based discrimination and victimization were associated with attempted suicide among transgender individuals (Clements-Nolle et al.. mediated by social isolation and low self-esteem (Díaz et al. Black sexual minority youth were not at lower suicide risk than White counterparts (Walls et al. nativity. lower education.S. 1996) ˜ 2003) • Acculturative stress related to ideation among Mexican migrant farm workers (Hovey & Magana. 2010) • Korean international students experienced more ideation than their more acculturated counterparts (Cho. and Cuban Americans. immigrant men. 2005) • Social disadvantage (poverty. 2001) • Engaging in same-gender sex but not ethnic identity was a correlate of ideation among Black and Latino low-income youth (O’Donnell et al. knew they were non. born reported higher rates of ideation than non-U. • LGB youth attempters more “out” in general. 1998b) • Acculturative stress related with ideation in Central American immigrants (Hovey... Repeated drug use ˜ et al..S. nonprofessional employment) associated with more suicides (Nielsen & Martinez.. 2005) • No differences in suicidality based on acculturation among depressed youths (Lau et al.. 2000b) • Acculturative stress (as measured by perceived discrimination) related with ideation in 1st and 2nd generation Latino teens (Hovey & King. acculturation related to risk. 2007) • Higher occupational and income inequalities between Blacks and Whites and lower socioeconomic status related with increased suicide risk in Black males (Burr et al. LGB youth scored lower than non-LGB on school safety (Eisenberg & Resnick. Poverty related to risk for Mexican. Korr.. Ortega. 1999). Watt & Sharp. conflict in the form of family rejection or alienation from friends and a social community plays an important role in suicidality (e. 2007). Woods. 2001. 2004. suicide is related with social discord predominantly in the form of family conflict (Cheng et al.. 1994). 2006. Colantonio. lack of support. Hicks. Savin-Williams & Ream. Particularly among LGBTQ youth. Koeske. Mays. depression over the death of a family member. 2007. Grossman. 1999. lack of integration. Rhodes. The opposite of family discord – perception of being supported by one’s parents – predicted lower suicidal ideation in Korean American students (Cho. 2001. The cultural theory and model of suicide. 1999.001 . 2004. conferring an 8. the culture and suicide literature indicates that acculturation as moderated by ethnic identity and ethnic density. O’Donnell. Ungemack & Guarnaccia. Acculturation was a moderating factor with lower acculturated more vulnerable than higher acculturated Asian American youth to increased suicide risk in the presence of parent–child conflict. 2007. The effects of family rejection on suicide appear strong. 1997). 2001. & Stueve. or having a low-status occupation are less predictive of suicide for African Americans than Whites (Wasserman & Stack. Silvestre. / Applied and Preventive Psychology xxx (2011) xxx–xxx 9 Marin. Dietrich. Low educational attainment. Rebchook. one study found that weak sense of community belonging more strongly exacerbated suicidality among Asians than Whites in Canada (Clarke et al. with bullying and at-school victimization as particular concerns for LGB youth (Bontempo & D’Augelli. Hovey & King. and marital dysfunction were common in the presence of death by suicide (Blinn. 2010. Ungemack & Guarnaccia.g. ˜ 2003. Garofalo. Wisneski. It is possible that these suicidal LGB individuals who were more “out” to the people in their lives for a longer period of time experienced more long-standing discrimination or harassment. Huebner. Acculturative stress or life hassles. Kuhlberg.g. Friedman. 2003). & Esparza. and social disadvantages all serve as minority stress factors that increase suicide risk among ethnic and sexual minority individuals.. Having a socially supportive community in the form of gay-straight alliances or LGB support groups in schools has been related to decreased suicide risk for sexual minority youth (Goodenow. & Westheimer. with less satisfying homosexual friendships. Willis et al. 2002. 2008).. Ireland. 2002. Freedenthal. 1998. & Takeuchi. low socioeconomic status. D’Augelli & Hershberger. 2006). Asian Americans with low income and socioeconomic status are over two times as likely as Asian Americans with high incomes to attempt suicide (Duldulao et al.. & Sanchez. Like Asian Americans. Other authors have suggested that social disadvantage shapes suicide for African Americans at more severe levels of disadvantage via increased availability of guns.. O’Donnell et al. This relationship between family discord and suicide may be mediated by the low self-esteem. for example. Inequalities in income. has been found as associated with suicide risk among Latinos (Hovey.. Else et al. one idea is that African Americans have developed a hardiness to lower status stresses due to endurance of years of inequality (e. and felt that more people in their lives were aware of their sexual minority status than LGB people who have not attempted suicide. and loss of friends due to one’s sexual orientation placing LGB youth at greater risk for suicide (D’Augelli.appsy. lower social acceptance. Burr et al. Vega. 1995. Pena. were handling this knowledge and were open about sexual orientation for a longer time. RotheramBorus. et al. 2006. Guiao ˜ 2003..g. In addition to family conflict as a risk factor for suicide. Paul et al. and that the converse construct of social support – family connectedness and adult caring – can protect against suicidal ideation and attempts (Eisenberg & Resnick. 2000b. 2000). 1995).. Olvera. & Zimmerman. Walker et al. Conflict with parents appear Please cite this article in press as: Chu. 2001. however..4 times higher likelihood of attempted suicide in 224 White and Latino LGB young adults with high levels of family rejection compared to similar peers with low or no family rejection (Ryan. 1994. & Rosario.. Wardlaw. 2005. J. 2009. & Escobar. 2009. alienation) characterize the interpersonal troubles that place ethnic and sexual minorities at suicide risk (see Table 5 for a summary of the literature). which in several studies include discrimination as a part of its operational definition.. 2003). 1998). Fisher. or increased difficulties one may experience when family conflict arises via an increase in acculturative stress (Hovey & King. In fact. 2008). Razin et al. & Resnick. community) in intersection with several types of discord (e. McBee-Strayer & Rogers.g.. internalizing behaviors. family discord or alienation from the family creates the hopelessness and helplessness that is linked with suicidal behaviors. & Kegeles. Wolf. P. Overall. Queralt. 1982). Szalacha. O’Donnell. family. D’Augelli et al. 2000. ˜ & Zayas. Applied and Preventive Psychology (2011). Cheng et al. Parides. disparities in income elevate suicide risk more for Blacks. & Sites. Huebner. Though the specific reason for this inoculated response to status-related strains is unknown. 2009). Hovey & Magana. Hunter. 1993) and two studies with African Americans (Kaslow et al.. D’Augelli. Narrative analysis of death records for Asian Americans who completed suicide showed that themes involving family discord or loss such as burden of care for others. However. Asians and South Asians compared to Whites (Clarke. & Gould.1016/j... suggesting that suicide risk may result from a cumulative effect of discrimination experiences (Shaffer. family shame or disgrace. Chung (2003) found that among eight Asian American females with a history of suicidality. Joe. unemployment. Wadsworth & Kubrin. 5... 2008. Social network categories (e. 2009).. Apospori. King. Among Asian Americans.. Alegria. 2010). Diaz. Chu et al. 1996. Fortuna et al. this mediation effect was not present for Whites (Kubrin & Wadsworth. 2008). Van Heeringen & Vincke. studies have shown that ejection from the home was more prevalent among suicidal individuals (RotheramBorus et al. 2005. 2005). 2008). and socioeconomic inequalities among Blacks were related with higher risk for suicide attempts (Anglin et al. 2004. doi:10. (2010) found a direct and independent association between high levels of perceived discrimination with suicidal ideation and suicide attempts for Asian Americans. 1998b.2011. A final source of minority stress related to suicide falls under the category of social disadvantages.. Alienation from one’s social community also plays an important role. Cochran.. Hovey & King. 2009). 1993. 2010). Burr et al. 1999.. 1996. and Salter (2005) and D’Augelli and Hershberger (1993) found that LGB individuals who have attempted suicide knew they were LGB at a younger age.. Double minority status may confer additional minority stresses with research finding heightened suicide risk among individuals who identity as both sexual and ethnic minorities (Borowsky. 1993. Walls et al. In addition. some evidence suggests that status-related strains such as not going to college. Kaslow et al. conflict. For LGBTQ individuals. 2006. receiving welfare. 1996. Meyer. 2002. No. 2006. Warheit. Hovey & Magana. 2008). 2005. One case study of three homosexual adolescent decedents provided preliminary evidence that suicide did not directly follow a life event involving stigmatization. Wissow. there are culturally specific variations in the types of social factors that play a role in suicide risk for ethnic and sexual minority groups.. Gil. 2002.4. and poverty were also correlates of suicide among Latinos (Nielsen & Martinez. In addition. Kuhlberg et al. 2002).11. Social discord Lack of social support is a general source of suicide risk in the mainstream literature. Family conflict in the form of intergenerational conflict may be particularly impactful for Asian American youth. discrimination experiences. Lau et al. Medina & Luna.G Model APPSY-76. Walls.. 2003). 1991. homelessness. social discord as a suicide risk factor among Latinos is also embedded in family conflict or lack of family connectedness (Borowsky et al. Schwartz. (2002) found that Asian American youth with high levels of parent–child conflict had a 30-fold increase in risk for suicidal behaviors. & Goodman. of Pages 17 ARTICLE IN PRESS J.P. Garofalo et al. 2006) • Higher parent–adolescent conflict in Latina teen attempters than non-attempters. running away. 2003) • Low marital integration (divorced.2011. Clarke. 2000b) ˜ 2003) • Less effective social support and greater family dysfunction related to ideation in Mexican migrant farm workers (Hovey & Magana. et al..11. but less likely to have recent family death (Willis et al.. friends. and low parental caring predictive of suicide risk in Latino teens (Garcia et al. attempts precipitated by conflicts with their mother or boyfriend. 2002) • Absence of marital ties related to suicidality in Puerto Ricans and Mexican Americans. Molock. Chu et al. 2006) • Family problems related to ideation for Latino and White youth (Olvera. having mistrustful mothers who have fewer friends. a positive relationship between acculturation and suicide risk was explained by support networks disrupted by divorce or separation (Ungemack & Guarnaccia. No. 1993) • In Latina teens.. Latino LGB men reported the highest family rejection (Ryan et al.. 2008) • Intergenerational conflict yielded a 30-fold increase in risk for Asian American youth. and have a seriously ill family member. of Pages 17 10 ARTICLE IN PRESS J. especially for males (D’Augelli et al. was a resiliency factor for ideation and attempts in Black and Latino youth (O’Donnell et al.. 1997) • Social support a protective factor for attempts for Blacks (Kaslow et al... Marcus. 1996) • Perceived social support (including family... 2006) • Sexual minority teens in schools with LGB support groups reported lower victimization rates and attempts than those in other schools (Goodenow et al. 2003) • Asians more likely than Whites to report weak sense of community belonging. and marital dysfunction (Blinn. The cultural theory and model of suicide. Attempts related with recent loss of friends.. 2007) • Low social integration and frequent mobility were risk factors in Blacks. which exacerbated suicidality (Clarke et al. • Acculturative stress as measured by presence of conflicts in social. 2001) • Black substance dependent attempters had lower childhood emotional neglect scores than Whites (Roy. parental conflict. 1995) • Ineffective social support (not low family functioning or unavailability of social support) correlated with ideation in Central American immigrants (Hovey. 2002) • Parental efforts to discourage gender atypical behavior associated with gay-related attempts. less parental awareness of sexual orientation. et al. living separately from parents. 1998) • Maternal affection protected against suicidal behavior in Mexican female students (Unikel et al. alienation from family. predicted attempts in Latina teens (Baumann et al.. Applied and Preventive Psychology (2011).. 2009) Sexual minorities (LGBTQ) • Loss of friends because of sexual orientation was related to attempts in LGB youth (D’Augelli. family shame or disgrace. Being in a mother-alone or absent family. 1994) • Relational strain (feeling that parents/adults don’t care about them) predicted attempts more in Blacks than Whites (Watt & Sharp.. Involvement in LGB organizations unrelated to attempts (D’Augelli & Hershberger. Depression mediated these relationships (Compton et al. 1995) • Less satisfying homosexual friendships related to risk for homosexual and bisexual youths (Van Heeringen & Vincke. 2009) Please cite this article in press as: Chu. 2003) • Seeking support from friends/family negatively related to attempts for Black and White adults (Nisbet. 1993) • LGB youth with attempts related to sexual orientation issues had more close friends who died from suicide than LGB youth with attempts unrelated to sexual orientation (D’Augelli et al.appsy. 2001) • Family closeness but not peer support. or pain and frustrations from romantic relationships created hopelessness and helplessness among 8 Asian females with suicidal history (Chung.. 2001) • Family connectedness and adult caring protective against ideation and attempts in 9–12th graders. family cohesion negatively related to ideation and past attempts (Guiao & Esparza. 1996) • Among Black teens. and environmental contexts related with ideation in 1st and 2nd generation Latino teens (Hovey & King.. Larger household was a unique protective factor for Black males (Borowsky et al. fewer ongoing paternal relationships.. 2002) • In Black but not White suicidal teens. et al... 2002) Latino/as • Mother-daughter reciprocal empathy and engagement negatively related to internalizing and externalizing behaviors which. & Walton. and being negatively described by their mothers (Razin et al.P. female-headed households) increased probability of Black male suicide (Burr et al. 2007) • Low parental availability to talk. familial.. family cohesion.. 1994) • Completed suicide among 3 homosexual teens did not directly follow lack of support (Shaffer et al. Joe. lower perceived family support associated with ideation (Joe. LGB youth scored lower than non-LGB on both protective factors (Eisenberg & Resnick. 2001) ˜ et al. 2002) • Black more likely than White decedents to have their community complain about them. 2000) • Presence of gay-straight alliances in schools associated with decreased risk for sexual minority youth (Walls et al.g. widowed) stronger predictor of risk for Whites than Blacks (Stack.. talk frequently with friends/relatives. community violence associated with ideation and attempts via depressive symptoms and aggressive behavior (Lambert et al. African Americans • Qualitative interviews indicated that community solidarity and collectivism decrease (and silence increases) in situations of suicide in the Black community (Barnes...001 .1016/j. social embeddedness.G Model APPSY-76. 2005) • Perceived risk related to lower family but not friend support in Blacks and Whites (Greening & Stoppelbein. doi:10. more and earlier loss (fathers in particular). depression over the death of a family member. 2008) • In Mexican teens.. 1996) • A good parental relationship was a suicide protective factor in Latino teen males (Locke & Newcomb. or having separated parents) than non-suicidal counterparts (Queralt.. 2002) • In gay and bisexual adolescent males. problems in romantic relationships. 2003) Negative relationship between social support and suicidality among Black men (Wingate et al. 2005) Asian Americans • Narrative analysis of suicide death records yielded suicide precipitant themes of burden of care for others. 2005) • Among LGB youth. and social support predicted higher attempt rates in low income Black adults. 2005) • Social and interpersonal conflict and family distress related to suicide in 5 Mexican special education students (Medina & Luna. 2010) • Lower social acceptance predicted suicidality in LGB individuals (McBee-Strayer & Rogers. 2006) • Lower mutuality and communication between mother/daughter but not familism more common in Latina adolescent attempters than non-attempters (Zayas et al. P. 2006) • Family disintegration (marital disruption. 2008) • Perception of family support predicted ideation in Black female college students (Marion & Range. in turn. 2008) • Living with 2 biological parents decreased risk for attempts in Latino adolescents (Pena • Latino teen suicide decedents had more family-related stressors (e. 2007. / Applied and Preventive Psychology xxx (2011) xxx–xxx Table 5 Social discord: summary of culturally specific suicide literature. low family connectedness. 2005) • Nonsupportive family and friends related to ideation among Black college students (Kimbrough... attempts associated with ejection from home (Rotheram-Borus et al. 1991) • Mutuality (bi-directional interpersonal responsiveness) between adolescent Latinas and their mothers negatively related to attempts (Turner et al. 2003) • Family discord. 2010) • Family conflict related with attempts among Latinos (Fortuna et al. 1996) • Black adolescents who attempted classified their families as disengaged and deficient in cohesion and adaptability (Summerville et al. Self-esteem and internalizing behaviors mediated the relationship between parent–teen conflict and attempts (Kuhlberg et al. and White girls and boys. 2010) • Perception of being supported by parents predicted lower ideation in Korean American students (Cho. and significant others) predicted lower suicide risk and differentiated depressed Blacks with and without history of suicide attempts (Palmer.. 2004) • LGB young adults with family rejection 8... having more LGB friends and visiting more LGB bars. 1998a. Higher parent–child conflict interacted with lower acculturation to predict risk (Lau et al. 1999) • Low family adaptability.4 times more likely to attempt than those without family rejection. or being unmarried were risk factors for Black males (Juon & Ensminger.. 1997) • Family conflict associated with ideation and attempts (Cheng et al. suicide risk related to loss of friends due to sexual orientation. In Mexican Americans. 2008) Literature with more than one cultural minority group • Perceived parent and family connectedness protective against attempts for Black.. Latino. J. g. caring. of Pages 17 ARTICLE IN PRESS J. & González-Forteza. shame or loss of face to her job loss may experience suicidal ideation. 2003. & Ialongo.. Second. lack of extended social networks and troubles within the family unit such as conflict or feeling unsupported or uncared for are predictive of suicidal behavior (Borowsky et al. / Applied and Preventive Psychology xxx (2011) xxx–xxx 11 particularly salient for Latino youths. For example.2011. job loss) or social in nature (Allison. 1994.. A distinction between collectivistic compared to individualistic cultural practices of Western cultures may explain the culturally specific areas of risk within social discord. Summerville. 2005. 1 presents the Cultural Model of Suicide which represents the integration of our inductively derived cultural suicide factors (cultural sanctions.. Culturally competent suicide risk management with ethnic and sexual minority individuals should include assessment of these different types of social discord. 1 as each step of the Cultural Model is described. 2005. 1987).” In particular. older adults who ascribe the cultural meanings of being useless in the world or a burden to one’s family to chronic physical illness may be more likely to consider suicide (Blinn. Joe. & Cronan. the Cultural Model of Suicide incorporates and expands on existing strengths of the socialization. Barnes (2006) performed qualitative interviews and found that community solidarity and collectivism decrease. 1998. 2000. and religious communities that have traditionally protected African Americans from suicide. The cultural sanctions factor is particularly salient in the mediating mechanism of cultural meaning. Marecek. Skay. 2002. these stressors do not invariably result in suicidal behaviors among these demographics groups. Instead. 2004. 2002.. Continued explication of the Cultural Model of Suicide requires explanation of an expanded theoretical component–that of “cultural meaning. No. a person ascribes certain meanings (box b) to stressors that influence their suicidal consequences of ideation. 2003. Mirowsky & Ross. cultural meanings of suicide can determine whether one chooses to perform a suicidal act. Applied and Preventive Psychology (2011). The first step of the Cultural Model of Suicide–life stressors–is defined as environmental or external events that tax one’s ability to cope and therefore increase one’s vulnerability to mental illness or suicide (Dohrenwend. 1998. cultural scripts.. 2001. Stice & Canetto. and do not encompass the array of cultural factors reviewed in this paper.. and silence increases. Pearlin. Instead. In fact.. Razin et al.appsy. 2003). Copeland-Linder. Markus & Kitayama. in situations of suicide within the African American community.11. 1989). Asian Americans and African Americans). or discrimination. The Cultural Model of Suicide Fig.1016/j. Zayas et al. role strain. a larger household (which constitutes a larger family network) is a unique protective factor (Borowsky et al. 6. First.P. life stressors (box a) do not operate in isolation of one’s interpretation of stressful events and circumstances. research has found social stressors to be more prevalent and impactful for individuals of a cultural minority status (Meyer. Many of these cultural minority groups have been described as collectivistic or interdependent. Thus. Kuhlberg. Social stressors specific to individuals of a stigmatized minority identity–minority stresses–impact the types of stressors that exacerbate risk for suicide. 1999. 2010.g. Rubinstein. minority stress. Willis et al. friend. 2008. connectedness. 2008) or interpersonal problems for females (Canetto. 2008). J. Durkheim. & Zayas. or having community members complain about an individual are related to increase suicide risk (Compton et al. or plan (pathway b1). 1998. Kaslow. doi:10. 2001) whereas being in a family with a single mother or without a mother were suicide risk factors for African American males (Burr et al. being divorced or widowed) is a stronger predictor of suicide risk for Whites than African Americans. intent.. Meyer. Unikel. These theories have been invaluable in establishing that suicidal behavior is culturally determined and regulated (Canetto & Lester.. where self-concept is inclusive of important family. daily hassles. social discord such as lack of community integration or support for LGBTQ individuals or family conflict for Asian Americans and Latinos present as culturally relevant stressors. death of a loved one. Among African Americans. Marion & Range. 2009). Abbate. Cultural meaning operates at two critical junctures in the Cultural Model of Suicide. a seldomly discussed construct–the cultural meanings ascribed to these precipitants–mediates the development of suicidal behavior in response to these stressors.. some scholars have conjectured that recent increases in suicide rates (particular among African American male youth) are indicative of social and economic challenges that have led to a gradual erosion of the informal social supports.. Lambert. research supporting the cultural scripts theory simply identifies culturally significant precipitating stressors like physical health problems for elderly (Stice & Canetto. Social stresses are strains that stem from the social and cultural environment such as poverty. cultural sanctions in the form of shame-inducing events are stressors specific to certain minority groups (i. In contrast. et al. Locke & Newcomb. Second. low social embeddedness. Some empirical evidence supports this notion. community violence. Turner et al. Three culturally specific risk factor categories from our literature review bear weight at this first step of the Cultural Model (box a). Durkheim’s theories are limited in application to the role of social networks only. an Asian American individual who attributes the meaning of unacceptability. situations of frequent mobility (which makes the establishment of extended social networks difficult). 2008. Kerr. 2003). & King. Clarke. Finally. it only briefly mentions and neglects to fully operationalize the cultural meaning of suicide (Canetto & Sakinofsky.e. & Bearinger..001 . The cultural theory and model of suicide. 1997).G Model APPSY-76. another person who reacts to the loss of a job merely as an opportunity to explore other options may be better able to cope and tolerate negative affect (pathway b2). However. First. The reader is encouraged to refer to Fig. intent. Additionally. or poor parental relationships in general. 1997. 1994. with several studies showing that low parental availability. Yet. idioms of distress. or community members that guide decisions and behaviors (e. one characteristic unique to social discord among African Americans is that extended social networks such as extended family or informal social connections play an important role in buffering suicide risk. 1997). 2002). Mo´ scicki. Juon & Ensminger. Cognitive behavioral theories of Please cite this article in press as: Chu. Though the cultural scripts theory is ground-breaking in identifying the importance of cultural scripts and culturally significant precipitating stressors. constructs such as low social integration. as Stack (1996) found that low marital integration (e.g. 2008). Ivey. Juon & Ensminger. Suicide vulnerability from family troubles are not necessarily focused around marital discord. Greening & Stoppelbein. 1999). In addition. Chu et al. 2007. Naughton. Watt & Sharp. 1998. Sieving. Stressors can be personal (e. incorporation of these cultural meanings will be important for a comprehensive cultural model. For female Latina adolescents. and sociological theories of suicide discussed in section 2 of this article (Canetto & Sakinofsky. are associated with increased suicide risk (Garcia. 1997). Gómez-Peresmitré. 2006. 1897. Overall. O’Donnell et al. relationship troubles with their mothers such as decreased mother-daughter reciprocal empathy and engagement or low maternal affection were associated with suicidal behaviors (Baumann. Stice & Canetto. and social discord) into a developmental theoretical framework of suicidal behavior. discord within one’s social network constitutes an important source of suicide risk for cultural minority groups. 1998. 1991). Third... 1998. 1991). Kuhlberg et al. this meaning is influenced by one’s cultural context. Instead. For example. or plan (box c). 2010. educational supports. 1992–1993. P.. and (3) culture affects how suicidal thoughts. household poison.appsy. hopelessness. and a subsequent suicidal act. The third principle states that cultural meanings associated with stressors and suicide affect the development of suicidal tendencies. We comprehensively reviewed literature on cultural variations in suicide for African American. “culture affects how suicidal thoughts. Wenzel & Beck.” this cultural factor addresses how culture dictates the language or method one chooses to express one’s suicidal ideation or intents (i. Results showed that 95% of the culturally specific suicide risk literature were encompassed by four factors: cultural sanctions. depicted in Fig. the literature included remarkably few examinations of cultural meanings of suicide. offers an integration of these inductively derived cultural suicide factors into a theoretical framework of suicidal behavior. 6.. J. or hanging.. in a culture where suicide is viewed as an acceptable and honorable way to relieve one’s family of burden. one’s threshold of tolerance for psychological pain. Three principles of the Cultural Model of Suicide Three theoretical principles encompass the Cultural Model of Suicide. and attempts Please cite this article in press as: Chu.1016/j. P. plans.G Model APPSY-76.e. For example. minority stress.) to determine suicidal behaviors. Specifically. Latino/a. Intent. Coined “idioms of distress..g. No. past suicide attempts. and social discord. and attempts are expressed. doi:10. and cultural sanctions (box a) play a role in the types of factors that contribute to vulnerability for suicidal tendencies like ideation. intent.001 . The second principle states that culture affects the types of stressors that lead to suicidal behavior.P. the third Cultural Model of Suicide principle. one’s threshold of tolerance for psychological pain. intent. The first principle states that culture affects how suicidal thoughts. and attempts are expressed (boxes c and f in Fig. The Cultural Model of Suicide. Asian American. 1). Fig. / Applied and Preventive Psychology xxx (2011) xxx–xxx (a) Life Stressors Minority stress Social discord Cultural sanctions (b) Cultural Meaning of Event Cultural sanctions (about event) (b2) Acceptable event or response Tolerate affect & meaning (b1) Unacceptable event or response (c) Suicidal Ideation. it is well recognized that suicide is determined by multiple factors rather than any single factor in isolation. and sexual minority groups for extraction of common factors. 1.. plans. of Pages 17 12 ARTICLE IN PRESS J. cultural sanctions and messages of acceptability associated with a stressor or a suicidal act (boxes b and d) play a part in the determination of suicidal behavior. Chu et al. Three theoretical principles emerge out of the Cultural Model of Suicide: (1) culture affects the types of stressors and strengths that lead to suicidal behavior. etc. Incorporating the categories and principles of the Cultural Model of Suicide into clinical assessment will yield a broader and more culturally inclusive approach towards risk assessment.1. The cultural meaning and cultural sanctions (box d) that exist for the act of suicide will determine whether one’s tolerance threshold for distress is surpassed and ultimately whether a person acts on suicide intention or impulse (box f). box c) or chosen method of suicidal gesture or attempt (i. Applied and Preventive Psychology (2011).e. The Cultural Model of Suicide. For example. box f). et al. or plan. Notably. future research should be aimed at expanding our understanding of the range of possible cultural meanings attributed to suicidal tendencies. 1. to hide or disclose thoughts. and subsequent suicidal acts. plans. the threshold for a suicidal act may be more easily surpassed (pathway d1) than if suicide is unacceptable and associated with bringing shame to one’s family (pathway d2). In particular. The cultural theory and model of suicide.g. 7. minority stress. 2008). firearm. intent. idioms of distress.2011. (2) cultural meanings associated with stressors and suicide affect the development of suicidal tendencies. suicide discuss that a suicide attempt or gesture (box f) occurs when one’s tolerance level for despair (line e) is surpassed (e. It is important to note that these cultural factors interplay with other risk and protective factors common across majority and cultural minority groups (e.. social discord. intent.11. Conclusions and implications This paper presents the Cultural Model of Suicide which provides a framework to improve the “culturally competent” assessment of suicide risk among cultural minority individuals. Plan Idioms of distress (d) Cultural Meaning of Suicide Cultural sanctions (about suicide) (d1) (d2) Unacceptable Tolerate affect & meaning Acceptable (e) Threshold of Tolerance (f) Suicidal Attempt or Act Idioms of distress Note: Italicized text indicates the current study’s inductively-derived culturally-specific factors. J. As a result of these measurement error sources. (2000).g. 98(9). Wu. N. Future research is needed to further test the utility and predictive validity of this model for different cultural minority individuals. Barnes. Georgia. L. Finally. (1990). American Psychiatric Association..). Additionally. for example. 2000. 97. (1998). it was necessary to compare ethnic and sexual minority science with studies performed with predominantly White heterosexual individuals. unreliable information about sexual orientation from informants or concealed sexual minority identities. A rubric to organize this within-group level knowledge was needed to provide direction for future research and clinical efforts. P. but rather to provide an organizing framework to contextualize and understand within-group data in suicide assessment and management efforts. Suicide as escape from self. Prejudice: The target’s perspective (pp. The American Journal of Public Health. mother-daughter mutuality. religion. Washington. Differences in characteristics of Asian American and White problem gamblers calling a gambling helpline. E. In J. 132–136. A. M. The current state of knowledge also does not allow for approximation of the relative strengths of contribution. However. (2009). (2006). Several limitations must be considered in understanding the current findings. Allison. and constitutes an important advance in the culture and suicide literature. W. as different cultural variations may be evident for other communities (i. & Hanzlick. DC: Author. chemicals or “victim-precipitated suicide”). the extant literature may constitute an overor under-representation of actual cultural variations in suicide.. Arab Americans. K. text revision). (2010).11. 140–150. (2005). Despite these limitations. As such. (2008). Baumeister. and provides the foundation needed for culturally competent research and clinical management of suicide. the Cultural Model of Suicide is subject to several inherent limitations in the measurement of suicide. 83–91. L. King et al. The Cultural Model of Suicide should be interpreted with these cautions in mind. R. the reader should be cautioned in applying the current model to other minority groups or cultural groups outside of North America. Consideration of the Cultural Model’s social discord category may prompt a clinician to include friends rather than family members as social supports in the safety plan of a Latino or Asian American for whom family conflict is a precipitant or trigger for suicide. or misclassification of unintentional injury and homicide among African Americans.. Rockett. M.” may lead a clinician to use multiple assessment modalities with a client prone to hidden ideation. 2001.appsy. the current Cultural Model of Suicide may not apply distinctively to White heterosexual individuals. References Abe. gender.. Please cite this article in press as: Chu. Further. No... K. Journal of Family Psychology.. 90–113. Instead. low in generalizability) that is sacrificed when findings are collapsed across omnibus groups (low cultural specificity. 32(3). Stangor (Eds.. & Coben. The existing literature contains a wide array of individual findings that are difficult to synthesize in the context of complex clinical risk management efforts that often occur within limited periods of time. H. etc. externalized self-destructive reckless behaviors. 1988–2002. Chu et al. S. (2003). to further determine the scope and application of these organizing principles. This paper represents an important step in the consolidation and advancement of the cultural and suicidology literature. For example. 145–170). this paper only reviews literature for three ethnic minority groups and one overarching LGBTQ sexual minority group without addressing the effects of mixed race or intersectional identities. Reporting biases and classification errors can interfere with the accuracy and comprehensive nature of existing cultural suicide studies. 33(2). M. & C. 2006. A. San Diego: Academic Press. Barry. Morrison & Downey. In addition. the current study was unable to specify cultural factors related to other cultural identities such as age. A. Emic investigations of individual cultural minority groups afford richness of within-group understanding (high cultural specificity. American Psychiatric Association. First.g. studies should explore whether the Cultural Model of Suicide’s four risk categories also apply to other cultural minority or mixed identity groups not included in the current investigation. etc. high in generalizability). A. Practice guideline for the assessment and treatment of patients with suicidal behaviors. For similar reasons of methodological design and limited available research. The reader should be aware of variations in the Cultural Model’s cultural factors due to these other cultural identities. Powell. The Aftermath of Suicide among African Americans. risk management should incorporate cultural approaches to suicide in any individual regardless of their group’s overall suicide rate.G Model APPSY-76.. The intention of the current Cultural Model of Suicide was not to replace detailed within-group knowledge. & Potenza. 2008). Diagnostic and statistical manual of mental disorders (4th ed. especially among adolescents who have not come out) have restricted the utility of autopsy data in LGBTQ populations (Halpert.. J.. & Kaslow.2011. though existing culture and suicide research has amassed a substantial literature base. or to specifically ask about means of suicide other than a firearm (e. idioms of distress like hidden ideation among ethnic minorities. J. / Applied and Preventive Psychology xxx (2011) xxx–xxx 13 are expressed. Arlington.e. Swim. 2002. Characteristics of Black and White suicide decedents in Fulton County. T. Including both ethnic and sexual minorities in our investigations ensures advancement in the diversity and suicide field along a multiple identities perspective. VA: Author. Stress and oppressed social category membership. Subsequent research to develop a questionnaire or guide based on the framework of the Cultural Model of Suicide will be invaluable in accomplishing next steps of translating the model for direct clinical application. disability. CNS Spectrums. Psychological Review. Kuhlberg.001 . the current study is the most comprehensive and empirically driven synthesis of the ethnic and sexual minority literature to date. Baumann. 2003). The Cultural Model is particularly useful for idiographic application with clients from ethnic or sexual minority backgrounds.). F. O. Mertz.. In an diversifying world where people increasingly hold more than one cultural minority identity. Journal of Psychology and Theology..1016/j. Gabriel. D. D. can yield underdetection of suicide (Joe & Kaplan. 14(2). Applied and Preventive Psychology (2011). 335–348. R. Willis et al. et al. It is important to note that a culturally attuned approach to suicide risk assessment and management is justified not only in cultural minority groups like LGBTQ youth or Asian American elderly who may have elevated suicide rates relative to the general population. The cultural theory and model of suicide. The Journal of Black Psychology. Familism. future research will need to address the important issue of how the intersection of identities affects suicide risk. K. doi:10. Samora. K.P. 616–624. K.. An additional challenge common to cultural diversity research is the balance between cultural specificity and generalizability. In order to develop a model that incorporates cultural suicide factors not typically assessed and managed within the mainstream literature. American Indians. R.. N.. Of note is the current lack of assessment tools that can aid clinicians in incorporating cultural factors into risk management efforts. Numerous methodological limitations of psychology autopsy studies (e. K. 24(5). The Cultural Model of Suicide gives a common language to understand and classify cultural variation in suicide risk. 2006) and a flexible rather than formulaic approach when utilizing the Cultural Model to assess suicide risk. investigations remain in a relatively nascent stage and may represent only a portion of the ways in which culture interacts with suicide. Suicide acceptability and religious well-being: A comparative analysis in African American suicide attempters and non-attempters. Steinberg. D. the multiple identities approach states that each individual possesses several cultural identities and it is important to recognize that the White heterosexual population also carries a set of distinct cultural values and practices. 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