Advancing Suicide Prevention Research With Rural American Indian a.docx

Advancing Suicide Prevention Research With Rural American
Indian and Alaska Native Populations
| Lisa Wexler, PhD, Michael Chandler, PhD, Joseph P. Gone,
PhD, Mary Cwik, PhD, Laurence J. Kirmayer, MD, Teresa
LaFromboise, PhD, Teresa Brockie, PhD, Victoria O'Keefe,
MA, John Walkup, MD, and James Allen, PhD
As part of the National Action Alliance for Suicide Prevention's
American Indian and Alaska Native (AI/AN) Task Force, a
multidisciplinary group of AI/AN suicide research experts
convened to outline pressing issues related to this subfield of
suicidology. Suicide disproportionately affects Indigenous
peoples, and remote Indigenous communities can offer vital and
unique insights with relevance to other rural and marginalized
groups. Outcomes from this meeting include identifying the
central challenges impeding progress in this subfield and a
description of promising research directions to yield practical
results. These proposed directions expand the alliance's
prioritized research agenda and offer pathways to advance the
field of suicide research in Indigenous communities and beyond.
(Am J Public Health. 2015;105:891-899.
doi:10.2105/AJPH.2014. 302517)
Although the Surgeon General published a call to action to
prevent suicide in 1999,1 national rates of suicide have shown
little improvement, and from 2002 to 2010 suicide moved from
the 11th to the 10th leading cause of death in the United
States2,3 National suicide rates are consistently higher among
White men aged 65 years and older than in younger age
groups.3 However, suicide remains one of the top 5 causes of
death for American adults younger than 45 years and one of the
top 3 for adolescents and young adults.2 Although suicide is
clearly an important public health priority for all Americans, it
is an especially critical issue for American Indians and Alaska
Natives (AI/ANs). North America’s Indigenous peoples have

disproportionately high rates of suicide deaths, attempts, and
ideation, and suicide deaths are approximately 50% higher for
AI/AN people than for White people.1,3 However, AI/AN elder
suicides are quite rare. Suicide is the second leading cause of
death among AI/AN adolescents and young adults, and their rate
of suicide is 2.5 times as high as the national average across all
ethnocultural groups.2 AI/AN young men are particularly
vulnerable4; the Centers for Disease Control and Prevention has
reported that AI/AN youths aged 10 to 24 years have the highest
suicide rates of all ethnocultural groups
in the United States, at 31.27 per 100 000 among male youths
and 10.16 per 100 000 among female youths. To eliminate this
health disparity, research identifying the unique factors
contributing to AI/AN suicide is essential to tailor interventions
to fit the particular cultural and situational contexts in which
they occur.1 Driven by the pressing need to better understand
and reduce AI/AN suicide, the AI/AN Task Force of the
National Action Alliance for Suicide Prevention (NAASP)
created a working group to identify research priority areas that
have the most potential to reduce suicide and suicidal behavior
in AI/AN communities. For this purpose, we (L. W., T. L., and
]. P. G.) worked with Jeff Schulden from the National Institute
on Drug Abuse and LaShawndra Price from the National
Institute of Mental Health to convene a 2-day, multidisciplinary
meeting of suicide researchers in August 2013. The working
group identified 3 undertakings as crucial for advancing
research in this area: the need to (1) summarize current
knowledge about the problem of Indigenous1 suicide, (2)
designate key challenges in Indigenous suicide research, and (3)
propose future directions that might spur innovation in suicide
research among Indigenous people.
Several innovative and promising approaches are currently
unaddressed in the NAASP research agenda.5 We, as Indigenous
suicide research experts, believe that 3 core issues in research
and clinical care are vital for suicide prevention in AI/AN and
other communities. Our suggestions are not meant to be

prescriptive but rather to highlight the ways in which some
dominant approaches can constrain AI/AN suicide research. The
proposed areas of study offer some promising new directions for
AI/AN research and for suicide research more generally.
EXPERT MEETING
We were involved in a 3-stage process of consensus building
about current challenges and future directions for Indigenous
suicide prevention research, and this article is a product of
those efforts. We participated in premeeting reflections and
presented and discussed our perspectives in a 2-day meeting at
the Aspen Institute in Washington, DC, August 19-20, 2013.
After the meeting, authors gave feedback on this article through
5 rounds of editing. We describe the procedures involved in
developing the agenda of the meeting so that readers will be
better able to analyze and make use of the results. To begin, we
(L. W., T. L., and J. P. G.) compiled a list of potential
participants with expertise in AI/AN suicide prevention who
met the following inclusion criteria: (1) peer-reviewed
publications related to Indigenous suicide, (2) experience doing
empirical research focused on Indigenous suicide, and (3) long-
term research (at least 5 years) in the field. After reviewing
published articles, reports, and conference abstracts, we
identified a list of authors with active AI/AN suicide research
supported by the National Institute of Mental Health and
National Institute on Drug Abuse, the primary sponsors, and by
the National Institute of Alcohol Abuse and Alcoholism. We
also circulated the list to the AI/AN Taskforce to elicit
additional names. In finalizing the invitee list, we tried to have
representation of scholars who are Indigenous themselves, and
to include scholars from multiple disciplines including public
health, psychology, psychiatry, sociology, education, and
anthropology. Next, we contacted individuals by e-mail to
determine their interest in participating in a meeting
to encourage dialogue among a multidisciplinary group of
researchers about AI/AN suicide and prevention and to conceive
of next steps for addressing and reducing suicide and suicidal

behavior in tribal communities.
Before attending the workshop, each invited attendee was asked
to prepare a short 1- to 3-page statement that (1) outlined the
nature of the problem of suicide from their perspective, (2)
described current gaps in the knowledge or barriers to research
that hinder progress toward suicide prevention in AI/AN
communities, and (3) identified promising ways to advance the
field and reduce the prevalence and severity of AI/AN suicide
and suicidal behavior. These questions formed the basis of each
attendee’s short presentation at the meeting. The entire first day
involved these presentations, which were given in a round-robin
style with questions and discussion after each presentation. On
the second day, participants were asked 2 questions regarding
their reflections on the previous day’s discussions: (1) what
appears to be the most productive research pathways to reduce
suicidal behavior in AI/AN communities, and (2) what crucial
information is still missing from investigators’ understanding of
these issues as they pursue research to prevent AI/AN suicide?
Key ideas were recorded and prioritized, again using a round-
robin, synthesizing approach. The prioritized ideas were
preliminarily agreed on and organized into the themes reflected
in this article. A draft article outline was circulated to the group
to ensure that it accurately reflected the meeting outcomes, and
particular participants, based on expertise, were responsible for
drafting particular sections. The sections were pulled together
and circulated to all meeting participants for their review and
feedback by
the lead author, and the article was then revised several times,
incorporating all participants’ feedback until all authors reached
consensus. Last, the article was circulated to the AI/AN
Taskforce co-chairs for their review, and their suggestions were
also included.
CURRENT KNOWLEDGE OF THE PROBLEM
US researchers have identified several risk and protective
factors6 for AI/AN suicide, many of which conceptualize
suicide as a problem originating at an individual level rather

than a societal one.7 Studies have described the co-occurrence
of suicidal behaviors and alcohol and drug use in many AI/AN
communities, documenting that more than half of the AI/AN
people who have exhibited suicidal behavior were intoxicated at
the time.8-11 Childhood adversity is also associated with
AI/AN suicidal behavior and ideation.12 Young AI/AN men—in
particular those who are unemployed, do not complete
schooling, or both—and those with a history of trauma are at
greater risk for suicide attempts.13-16 Compared with other
ethnocultural groups, AI/AN youths have more severe problems
with anxiety, victimization, substance abuse, and
depression,1718 which may contribute to suicidality. Research
has also linked perceived discrimination and acculturation stress
with AI/AN suicide ideation.19-21 Previous research has
identified potential targets for intervention at multiple levels,
including increasing coping skills, reducing the stigma of
mental health services, and building community infrastructure
for prevention and health promotion,9,14 yet there is little
guidance about how to effectively implement prevention
programs in AI/AN contexts.22'23 Unique challenges in
Indigenous communities include distrust of formal services,
ongoing marginalization, poverty, underemployment, lack of
basic services, and collective disempower- ment.24-26 In
addition, rural AI/AN communities often lack the resources to
ensure safety (e.g., absence of law enforcement on rural
reservations and AN villages), do not have access to mental
health services,27'28 or do not use the mental health services
that are available.29
Research has shown that existing systems of acute care for at-
risk and suicidal people are poorly utilized by AI/AN
people.22,30,31 In fact, the majority of AI/AN youths never
receive any form of behavioral health care, despite behavioral
problems, signs of mental distress 32,33 or active suicide
ideation.29,34 In 1 study, 65% of ANs who were referred to
mental health services because of suicide attempts either did not
initiate or complete care.16 When Indigenous people do receive

treatment, their care may be culturally inappropriate because of
the individualistic and clinic-based intervention offered by
primarily non-Native counselors.35-37 These services tend to
address primarily psychological rather than social, cultural, and
spiritual issues that are often seen as more relevant for suicide
prevention in AI/AN communities.24,38-43 Similarly, standard
treatment practices do not address the key perceived
contributors to AI/AN suicide, ignoring issues such as historical
oppression, intergenerational trauma, and ongoing
marginalization44-47 In addition, when there is a need for
involuntary hospitalization in cases of imminent risk, the
intervention itself, which is often offered far from home in rural
communities, can further alienate or distress Indigenous people
48,49 Taken together, previous research has underscored the
need for practical and collaborative research on intervention
and prevention strategies that are culturally consonant and that
can have more sustainable impacts.
AMERICAN INDIAN/ALASKA NATIVE SUICIDE
RESEARCH
To determine current trends in AI/AN suicide research, we
performed a PubMed search using the terms American Indian or
Alaska Native and suicide for peer-reviewed academic sources
and empirical research published from 2004 to 2014. The search
produced 30 articles, of which we excluded 10 commentaries
and reviews. We documented each of the remaining 20 articles’
focus on deficit- or strengths-based variables or methods,
orientation (e.g., participatory or investigator directed), and
level of outcome (individual or community). Of these 20
articles, 90% (n= 18)1-18 measured only individual-level
factors, 60% (n = 12)1_5'7~9,12,14,17,19 focused on deficits or
risks, and only 30% (n = 6)47~51 described doing the research
in collaboration with AI/AN groups. Some of these trends, such
as focusing on individual-level processes and outcomes and
limited information about community involvement in project
development and implementation, were found in another recent
literature review focused on existing AI/AN alcohol, tobacco,

and other drug and suicide prevention intervention literature. In
addition, the recent review by Allen et al.49 noted a need for
increased focus on the process aspects of this work rather than
only on outcomes and for use of local knowledge and theory to
frame and guide intervention.
KEY CHALLENGES IN INDIGENOUS SUICIDE RESEARCH
Key challenges in developing an AI/AN suicide research agenda
are complex and include epistemological differences, an
emphasis on individual- versus community-level variables,
deficit- instead of strengths-based foci, and methodological and
ethical concerns. First, the assumptions, methods, and activities
that structure the production of knowledge within the behavioral
and health sciences are associated by Indigenous communities
with colonial European American processes of dispossession
and subjugation and may not align with community beliefs and
practices. Furthermore, decades of government intrusion,
regulation, and management have reinforced the perception
among many Indigenous peoples that bureaucratic guarantees
and assurances presented as rational, technological, and
scientifically grounded have often failed to respect and benefit
Indigenous people.41 Key challenges have emerged from this
history50 and from the sometimes divergent epistemologies and
priorities of Western and Indigenous inquiry into the nature of
suicide and the implications of prevention.
W estern vs Indigenous Epistem ologies The cautiousness or
skepticism about the value of research often seen in Indigenous
communities may result in part from divergent traditions related
to the creation, validation, and transmission of knowledge. For
instance,
Indigenous knowledge is often characterized by generational
perspectives that deliberately incorporate attention to the past,
present, and future and also by an experiential holism grounded
“in the context of living in a particular place in nature, in the
pursuit of wisdom, and in the context of multiple rela-
tionships.”51<p556) Western science emphasizes the observable
and reproducible, manipulating phenomena in the present with

the aim of future prediction and control. Science and
biomedicine aim to develop decontextualized understanding of
phenomena that can be decomposed into distinct parts,
functions, and interrelationships to obtain knowledge that can
be generalized across historical and societal contexts; the
NAASP’s prioritized research agenda5 reflects this orientation.
By contrast, Indigenous peoples tend to emphasize heritage and
respect for personal experience, which may conflict with the
scientific ideals of objectivity and generalizability.41 The
primary contrasts are between knowledge that is general versus
particular, reductionist versus holist, and abstracted versus
contextualized.51-52 Contributing to these epistemological
tensions is the tendency within Indigenous perspectives to view
experience in its historical, social and environmental contexts.
As a result, standard Western approaches that emphasize
individual-level variables associated with suicide may be
viewed within Indigenous communities as both counterintuitive
and dismissive of sociohistorical and cultural context.52,53
Indigenous and Western perspectives also have epistemological
differences regarding what is knowable and, more specifically,
how suicide should be studied. In some AI/AN knowledge
systems, words are seen as powerful interventions that express
and enact people’s intentions and alter reality.54,55 As a result,
processes such as talking about suicide, even in the context of
research, may be viewed as problematic because they may cause
the problems that they aim only to describe. This way of
thinking about the power of language is not often considered in
scientific inquiry or study design. Similarly, what can (and
should) be known about another person’s internal world reflects
culturally based values of identify and social personhood.53 A
dominant focus of suicide research involves
identifyingindividual-level risks and psychological processes
that contribute to suicidal behavior, yet this kind of inquiry can
seem disrespectful from the perspective just described. Some
Indigenous communities value autonomy to such a degree that
actively not knowing is considered the right way to respond in

cases of suicide.55 This sensibility runs counter to Western
scholarly assumptions about the nature of inquiry and social
personhood.
Individual vs Com m unity-Level Research Despite a century of
sociocultural work showing that suicide rates vary dramatically
from one society to another,56 the bulk of European American
suicide research has focused on individual-level factors.7,57
This emphasis is reflected in the NAASP prioritized suicide
agenda,5 on which 12 of the 15 key objectives focus on
individual-level concerns. A central tenet of this “Judeo-Greco-
Roman- Christian-Renaissance-Enlightenment-
Romanticist”58(p57) perspective is that suicidal thoughts and
behaviors (similar to pathologies) are best understood and
treated 1 individual at a time. Several drawbacks result from
thinking about suicide and its prevention in terms of individual
impacts and dynamics rather than considering systemic,
contextual, communal, and historical contexts and processes
that contribute to it.7,59 The dominant focus on individual-level
risk factors tends to eclipse what is known about sociocultural,
economic, historical, and political risk factors, which place
certain social actors or communities at greater relative
risk.60,61 Inquiry into communify-level and social determinants
of suicide could enhance understanding of why, for instance,
White men older than 85 years are at greatest risk in the overall
US population, whereas young men are at greatest risk among
AI/AN people.2 It is also important to note that although
Indigenous suicide rates aggregated across whole nations or
geographical regions are remarkably high, suicide rates actually
vary dramatically when examined at the level of Indigenous
tribes or communities. Collapsing this variability across AI/AN
groups to create an overall description of Indigenous suicide
prevalence (and risk factors) may obscure important clues to
prevention that could be revealed through careful
disaggregation and analysis of information about the origins and
causes of suicide in different groups. Little research is available
to explain why rates are extraordinarily high in some

communities and not in others, but a ground-breaking study
suggests that self-governance, intact social systems, community
control over resources, and collective efforts to rehabilitate
traditional culture are all associated with reductions in youth
suicide.62
Intervention vs C om m unity Developm ent Approaches to
suicide prevention driven by the technological and product
orientation of much health research have yielded limited
outcomes in Indigenous populations. Although there have been
some successes in more generic preventive programming for
children’s behavioral health,63 the independent, nonfed- eral
Task Force on Community Preventive Services assessed whether
a broad range of such interventions resulted in improved health
outcomes and concluded that half produced insufficient
evidence to support practice recommendations.64 A recent
review of dissemination and intervention research cautioned
that evidence-based practices are also generally not
disseminated spontaneously and that passive approaches to
dissemination are largely ineffective.65 Knowledge translation
in child and youth mental health has been similarly
unsuccessful,66 a fact that is of particular relevance to
Indigenous suicide research. Studies aimed at developing
replicable individually-focused interventions that are
generalizable across communities—reflected in the NAASP
research agenda5—have had limited utility in preventing youth
suicide in Indigenous communities. First, with the occasional
notable exception,6 '" 70 very few empirically validated
interventions and prevention initiatives are available, and few if
any of these evidence-based interventions have been sustained
even in the communities for which they were developed. Thus,
there is little evidence to suggest that developing, testing, and
disseminating AI/AN suicide prevention interventions will
spontaneously translate into practical and sustainable
programming for the many distinct AI/AN communities in the
United States. There is a great need to understand these
discouraging outcomes and to engage in innovative

implementation research
that includes explicit attention to problems of translation,
adaptation, and sustainability. Notably absent from the available
literature are attempts to consider how the research process
itself might also contribute to sustainable outcomes. This kind
of perspective is absent from the NAASP prioritized research
agenda.5 Many Indigenous communities seek collaborative
research relationships that provide tangible local benefit,
enhance local health and research infrastructure, provide a
vehicle to address disparities, and advance tribal self-
determination.71" 75 Collaborations between researchers and
Indigenous communities potentially allow for the research itself
to be an emancipatory process that enables community members
to identify and frame issues important to their community and
to develop solutions that reflect community priorities,
epistemologies, ontologies, and practices.76'77 Such
collaborative approaches to knowledge generation and
utilization hold out the promise that research results are more
readily applied and sustained in the communities from which
they developed.78 As such, mobilizing communities may
constitute potentially effective interventions in their own right.
D eficit- vs Strengths-Based Studies Indigenous communities
have voiced concern that most research has focused on risk
factors, psychopathology, and deficit models, which encourage
individual and group stigmatization and even self-
stigmatization.79,80 As a consequence, many Indigenous
communities are drawn to strengths-based models. Such
approaches tend to emphasize the protective role of culture,
cultural processes, and activities in prevention. Such
consideration of matters of well-being and positive health
outcomes can direct attention to local contextual factors,
families, and community networks81 that bolster the material,
institutional, cultural, political, and historical factors that may
protect against suicide.82" 84 Within such strengths-based
approaches, well-being is defined in cultural terms,85 given that
both what it means to be well and even what it means to be a

person are culturally determined. Such understandings reorder
the primary or proximate outcomes of suicide prevention
efforts. Despite the rich possibilities of well-being serving as a
culturally defined
theoretical construct and an outcome variable desired by many
tribal communities, the broader notion of well-being remains
both underdeveloped and poorly used in most suicide prevention
research.
Bottom -Up vs Top-Down Priorities for
Suicide Research Although the National Institutes of Health
mandates the equitable inclusion of ethnoracial minorities and
children in research,86 current funding priorities appear to limit
the accomplishment of this directive. To fully meet such
requirements, researchers and funders must focus on questions
of interest to both the scientific and the ethnoracial
communities that are directly involved. Instead, the dominant
priorities of the agencies that fund AI/AN suicide research are
frequently misaligned with the priorities of Indigenous
communities. The lack of shared priorities between the NAASP
research agenda5 and those we present in this article
underscores this point. The Canadian Institutes of Health
Research’s Institute of Aboriginal Peoples’ Health is a
promising way to create infrastructure to address this issue. The
commitments of funding agencies and mainstream scientists
emphasize research that is capable of demonstrating clear and
generalizable causal links between interventions and outcomes
though experimental or quasi-experimental designs. However,
such efforts to maximize internal validity commonly minimize
the role of context (including culture and heritage) that is so
often prioritized by Indigenous communities. The recent turn
toward investigating the neuro- biological mechanisms
(including the genomics and epigenetics) of mental disorders
exacerbates this problem by overshadowing equally important
cultural processes and social determinants of interest to
Indigenous groups. By contrast, studies that provide the deep
cultural and contextual descriptions that are possible with

qualitative methods are rarely funded. Recent reviews of
National Institutes of Health funding have revealed that most
health research uses only quantitative methods.87 Although
there have been recent calls for mixed-methods research to
study complex social phenomena such as suicide, the number of
such studies funded remains very low.88
The matters we have outlined are reflected in the ethical
conduct of research. Since the 1970s, oversight related to
ethical practice with individual research participants has
increased, but less attention has been paid to community
interests in the context of research.89 AI/AN communities, with
their unique status as domestic dependent nations, are
increasingly demanding that researchers actively engage them in
identifying potential benefits and harms of research at both
individual and community levels of analysis.90 To achieve this,
researchers must understand the ethical and political dimensions
of their research, and AI/AN community members must fully
understand the realities and conventions that drive both research
objectives and processes. This degree of involvement frequently
requires capacity building as well as prolonged relationship and
trust-building activities,72,91,92 which the current funding
climate does not typically support. In addition, current funding
mechanisms do not usually allow for the proportionately higher
costs associated with research with small populations (such as
many AI/AN groups), logistics for working in geographically
dispersed rural reservations and Alaska villages, and protracted
timelines for undertaking genuinely collaborative research
partnerships. These ethical, political, and logistical constraints
make it especially difficult to design studies that are acceptable
to both funders and Indigenous communities.
PROMISING DIRECTIONS FOR INDIGENOUS SUICIDE
RESEARCH
We have briefly summarized current knowledge about
Indigenous suicide and articulated key challenges in the
dominant approaches to Indigenous suicide research. Progress
toward reducing the devastating health disparity of AI/AN

suicide has been slow due to discrepant research priorities and
practices as described above. Mainstream research has yet to
focus on aspects of suicide prevention that are potentially most
relevant and meaningful for AI/AN people, precluding effective
and sustainable solutions for Indigenous communities. At the
risk of some oversimplification, we have framed these
challenges as simple dichotomies in an effort to highlight
alternative
FRAMING HEALTH MATTERS
perspectives that suggest future directions for Indigenous
suicide prevention research (see the box on the next page). The
epistemological divides, or different ways of knowing, that
often separate Indigenous and scientific communities provide
important contrasting perspectives.51,52 Addressing these
divergent worldviews requires attention to alternate
epistemologies and knowledge claims that may contribute to
building more accurate scientific models— models that include
key determinants of mental health and resilience at the level of
whole communities and environments, all situated within their
larger sociopolitical contexts.83 Such lines of research demand
consideration of the distinctive, defining experiences of
different cultures and different generations to better understand
how political, economic, and historical forces constrain and
create opportunities and shape priorities and subjectivities of
diverse peoples. For example, such approaches might consider
how cultural and generational changes affect child-rearing
practices and investigate how particular communities convey
meaning and provide scaffolding to help their children become
actively contributing and healthy adults. Puzzling through the
complex connections between individual and community health
shapes many of the most promising contributions to the
Indigenous suicide research agenda (as seen, e.g., in the
importance of culture as prevention83), yet relatively little
attention has been given to this aspect of the problem in
mainstream research. To date, the majority of suicide research
has focused on individual- level risk, and individuals’ thinking

and behaviors are the targets of most intervention efforts. To
the extent that Indigenous suicide arises from enduring
structural inequities, which are poorly addressed through the
provision of mental health services, it is important to expand
the focus of future research.52’60,93 The health disparities
made evident by cross- cultural variations in suicide rates may
be better understood as the culmination of cultural wounds
inflicted on whole communities and whole ways of life94 or as
a consequence of structural violence, in which processes of
disadvantage, marginalization, and exclusion are woven into
institutions and social practices.50
A crucial area of research concerns the social determinants of
mental health. Examining how societal-level factors contribute
to the clusters of Indigenous suicide in some communities (e.g.,
poverty, unemployment, discrimination, and historical trauma;
i.e., the cumulative effects of emotional and psychological
wounding across generations) is an important area of
research.46,62,95-98 For example, Chandler and Lalonde62,96
have reported that half of British Columbia’s 200-plus First
Nations communities have experienced absolutely no youth
suicides, whereas other studies have reported rates several
hundred times the national average. Similar findings have
recently been reported across Western Australia’s culturally
diverse Aboriginal communities.99 The variation between
Indigenous communities can provide important insights into the
community-level variables that reduce the risk for suicide. The
almost exclusive focus on universally measurable individual
variables tends to preclude attention to other social, historical,
and cultural realities that affect Indigenous people’s health. The
importance of these factors becomes clear when considering the
large community and ethnic variations in suicidal behavior.
Differences between Indigenous communities in suicide rates
can be used to develop hypotheses about the interaction of
community-level processes, family systems, and individual
psychology that affect young people’s well-being and
resilience.100-102 Although few studies have focused on

community-level protective factors, it appears that communities
with higher levels of political engagement (sovereignty rights),
functional community institutions, and cultural continuity62,9,3
have lower suicide rates. An empirical test of 1 multilevel
protective factors model identified community-level factors as
explaining the largest proportion of the variance in suicide
outcomes.70 Community-level support and opportunities;
family-level relational dimensions of emotional support,
cohesion, and conflict resolution; and communal mastery at the
individual level were interrelated and together provided
protection from suicide. Indeed, certain individual protective
factors for Indigenous suicide include school completion and
enculturation,24,45,103 and these factors can be understood in
terms of their links to
well-functioning community institutions (e.g., schools) and
intact cultural systems. The close-knit composition of rural
reservations and Alaska village communities means that rural
AI/AN youths are often exposed to suicide among friends and
family members, which may put them at higher risk for
contagion in these settings.103 Studying these settings can offer
unique insights into the community- level influences and
interpersonal dynamics of suicide clusters.104 This
understanding is particularly important in the context of
multiple suicides in small communities in which specific
strategies are needed to mobilize resilience— a need that has
been identified as a national priority for suicide research more
generally.5 Understanding the patterns within groups that
produce such dramatic community-level differences is an
important area of research that could identify locally developed,
evidence- based practices that would otherwise remain
unknown.105 Indigenous suicide research has much to gain,
therefore, by considering community-level information.
Expanding on this community-level perspective, it is imperative
to develop interventions capable of increasing community

health as well as individual well-being. To date, suicide
prevention intervention research focused on producing
standardized interventions has had disappointing results. To
some extent, this may reflect difficulties in implementation. We
argue, therefore, that focusing on the processes of change
through community engagement and participatory inquiry may
help identify and address the limitations of current
interventions. Such an approach to research ensures that there is
always knowledge gained, whatever the outcome.
Investigating locally derived, empowering approaches to
research will inform efforts to engage with Indigenous
communities to promote productive, endogenous, and
sustainable change. This kind of collaborative, community-
driven inquiry can promote the lateral transfer of Indigenous
knowledge and increase the likelihood that new strategies are
implemented and sustained in Indigenous communities. In this
line of research, it is important to evaluate the adaptation and
dissemination of off-the-shelf interventions in Indigenous
contexts,106 as well as the kinds of interactions and
conceptions that are promoted through such efforts. All such
community-focused research requires the development of
collaborative relationships. Indigenous communities may be
hesitant to engage in suicide research as a result of past studies
that showed little regard for then- needs, had limited local
oversight or direct benefit, and in some cases may have caused
harm,75 creating an ethical imperative for community-based
participatory research and community-driven approaches.
Important and significant AI/AN suicide research is thus
currently feasible in community settings when the research
question and associated research design align with the priorities
of both grant-funding organizations and AI/AN communities.
This kind of research is built on strong community partnerships
developed through trust. Such research requires adequate
timeframes, a commitment to collaborative inquiry, and shared
control, as well as mutual respect for differing experiences and
interpretations. In addition to understanding how multiple risks

combine to increase suicide vulnerability,
the research agenda must elucidate the ways in which multiple
protective factors can interact to create community-level
patterns of continuity, care, and support.5 Such knowledge
could reveal how available support systems can be mobilized to
prevent suicidal behavior. These kinds of studies will require an
elaboration of constructs related to wellbeing and resilience,
which is an essential counterbalance to suicide research in many
Indigenous communities.
CONCLUSIONS
Productive future directions include community-based
participatory suicide intervention research with an explicit
commitment to local capacity building and translation; social
network approaches to uncover constructive community-level
environments, situations, and contexts that reduce suicidal
behavior and promote resilience; and descriptive studies using
qualitative and mixed-methods approaches to facilitate
discovery-based research on the social determinants of
Indigenous suicide. Such studies hold the potential to elaborate
innovative new theories of suicide and strategies for prevention
and mental health promotion. Because of the high rates of
Indigenous suicide, especially among youths, and the unique
demands on researchers who work in this sensitive area, this
area epitomizes high-risk-high-reward research. Through the
innovative research pathways described here, and underscored
by aspects of the NAASP’s prioritized research agenda5 (in
particular, objectives 1A, 5B, and 5C, which are focused on
larger social and policy- oriented questions), we believe that
Indigenous suicide researchers can advance knowledge and
reduce suicide in partnership with AI/AN communities. ■
About the Authors Lisa Wexler is with the Department of
Health Promotion and Policy, Community Health Education,
School of Public Health and Health Sciences, University of
Massachusetts, Amherst. Michael Chandler is with the
Department of Psychology, University of British Columbia,
Vancouver. Joseph P. Gone is with the Departments of

Psychology and American Culture, University of Michigan, Ann
Arbor. Mary Cwik is with the Division of Social and Behavioral
Interventions, Department of International Health, Johns
Hopkins Bloomberg School of Public Health, Baltimore, MD.
Laurence J. Kirmayer is with the Division of Social and
Transcultural Psychiatry, Department of Psychiatry, McGill
University, Montreal, Quebec. Teresa LaFromboise is with the
Stanford Graduate School of Education, CA. Teresa Brockie is
with the National Institutes of Health Clinical Center, Nursing
Research and Translational Science, Bethesda, MD. Victoria
O'Keefe (Seminole/Cherokee), is a Doctoral Candidate in the
Department of Clinical Psychology, Oklahoma State University,
Stillwater. John Walkup is with the Department of Psychiatry,
Weill Cornell Medical College, New York, NY. James Allen is
with the Department of Biobehaviorcd Health and Population
Sciences, University of Minnesota Medical School, Duluth
Campus. Correspondence should be sent to Lisa Wexler, 715
North Pleasant Street, University of Massachusetts, Amherst,
MA 01003 (e-mail: [email protected] edu). Reprints can be
ordered at http://www.ajph.org by clicking the ‘Reprints" link.
This article was accepted December 7, 2014.
Contributors L. Wexler led the writing and conceptualization
process, coordinated the group writing, and synthesized
individual contributions to the article. L. Wexler, J. P. Gone
and T. LaFromboise organized the meeting on which the
findings of this article are based. M. Chandler added substantial
perspectives and intellectual insights in each round of draft
writing. J. P. Gone wrote a short section of the article, provided
extensive edits on an earlier draft, and added substantial
perspectives regarding main arguments in the article. M. Cwik
contributed to the article by adding specific examples and
references and editing language to reflect scholarly work done
in American Indian (AI) communities. L. J. Kirmayer added
specific examples and references from his previous work and
edited the language to reflect scholarly work done in Canada’s
Aboriginal communities. T. LaFromboise provided feedback

relating to future directions and evidence-based critiques. T.
Brockie shaped some of the arguments relating to community-
based interventions in AI communities. V. O’Keefe contributed
to the literature review. J. Walkup added important insights that
helped shape the main arguments of the article. J. Allen offered
substantive feedback on all drafts of the article and contributed
to the main arguments of the article.
Acknowledgments We thank the National Institutes of Health’s
National Institute of Mental Health, National Institute on Drug
Abuse, and Office of Behavioral and Social Sciences Research,
as well as the Aspen Institute, for supporting the meeting of the
National Action Alliance for Suicide
FRAMING HEALTH MATTERS
Prevention’s (NAASP’s) American Indian and Alaskan Natives
Task Force; August 19-20, 2013; Washington, DC. We are
grateful to NAASP’s American Indian and Alaska Natives
Taskforce and particularly appreciate the efforts of Jeff
Schulden and LaShawndra Price, who contributed diligently to
this effort from the beginning.
Human Participant Protection Institutional review board
approval was not needed for this work because it did not
involve human participant research.
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HUN 1201: Elements of Nutrition
Assignment 2.1: Food Journal
View example attachment to begin food journal. You can track a
friend or yourself to complete the food journal. Follow the steps
directions below.
Step 1: Track your food over the course of a minimum of 5-7
days
Keep a record of journal entry:
· Include ALL of your food - meals and snacks
· Include ALL of your beverages - alcoholic and non-
alcoholic
· Include a full weekend (Friday, Saturday, and Sunday)
· Include all exercise
Step 2: Take your food log and import into a Nutrition app of
your choice, (ex. MyFitnessPal) and track your food.
· Include the meals and the servings sizes for each day.
Two examples attached of what a day would like from
MyfitnessPal. Submit your food log and your MyFitnessPal
dietary journal. (See Examples)
View the attachments;

My 7 Day Diet Analysis
My diet analysis covers seven days of daily intake of food and
liquids. It also includes the activity level of all days. The
following paragraphs show a detailed snap shot of where I could
improve upon as well as what I need to consume to meet a
healthy diet according to MyPlate.
The first thing that I realized was the calorie consumption for
the days was well below what was required to maintain a
healthy weight. For my height, weight and activity level it is
required for me to intake at least 1,814 calories per day. This
calorie requirement is based upon MyPlate. I took in about
1,502 of my daily calories. There was only one day that I meet
the calorie requirement for the day. My eating habits do not

change much on a weekday compared to a weekend. I don’t eat
breakfast most days and usually don’t eat my first meal until
3:00pm. This is because I’m not usually hungry upon waking
and I leave for the day and return late afternoon. Then I will
eat all my meals after that time. For the seven days on average
I was only consuming 83% of calories to maintain my weight.
Some things that contribute to the low calories intake is not
eating breakfast and not snacking in-between meals enough.
Stress along with not making my health a priority has
contributed to a poor diet.
The protein intake for my analysis was exceeding what I should
be taking in. My lifestyle is sedimentary and with my weight of
129lbs, a woman according to the DRI should consume 46
grams per day. My actual intake was 59 grams per day. This is
due to eating meat in most of my meals and not having a
balance plate of fruit and vegetables. My diet consists of
Pakistani food where the dishes are mostly meat, rice and bread.
My husband does most of the cooking and I cook on occasion. I
was raised with a typical American diet so when I cook I will
make a meat dish with a carbohydrate side dish and a vegetable.
Due to busy schedule and truly a lack of interest in cooking the
meals are more tailored to my husband’s culture and taste.
The carbohydrates consumed were under the recommended 250
grams. My intake was 193 grams. Which kind of surprised me.
When I do eat Pakistani dishes, I tend to not eat a lot of rice or
I limit my bread to only one bread to eat curry dishes. I just eat
for nourishment. I don’t enjoy food as I use to. I could raise
my carbohydrate intake by eating a bigger portion of rice and
bread. Also, I could snack in between meals with yogurt or a
granola bar. The yogurt would be a good choice to help reach
the calcium per day of 1,000 mg. With my current eating
habits, I’m falling well behind in calcium with only consuming
44% of the recommend amount.
The fat intake according to the DRI should be 56 grams and I
consumed a little more then that at almost 58 grams. The fat
intake was a little over because of some fast food that I had for

the week. I can lower the fat intake by having a more balanced
diet with including smaller portions of meat and increase the
serving size of fruits and vegetables. The other area that I
exceeded was the sodium intake. I should consume no more
than 2,300mg and I took in 2,510 mg. To lower the fat and
sodium in my diet I can exclude any fast food and eat at home
where everything is home made.
Overall my diet is not horrible. I should add breakfast to
everyday of the week. An area for improvement is also not
waiting so long to eat lunch and snack in between meals with
fruit, vegetables or even a class of almond milk. I tend to not
be very hungry because I don’t eat at regular intervals. My
vitamins and minerals were also lacking considerably except for
B3. I buy fruit and vegetables all the time for my family but
rarely pick them up to eat except for an apple. Some good areas
of my diet were that the cholesterol and saturated fat were well
below the healthy limit. To increase my vitamins and minerals
darker leafy vegetables and more selection of fruit besides an
apple need to be included throughout the day. I need to add
more water as well. The water intake fell short daily and the
average for the week was only 38%. I can do this by drinking a
glass of water upon waking which will help kick start my
metabolism. Also, with every snack and meal drink water or a
sports drink which will provide me with some extra potassium
and carbohydrates. I need to increase my activity level passed
just walking passively on a treadmill. To help keep lean muscle
from wasting I need to include some weight and resistance
training. If exercise becomes more often then this in return will
help the eating habits be more conscious and more frequent.
My goal will be to keep tracking my food habits and review
them weekly and keep finding areas to improve upon.
Psychological Assessment
© 2013 American Psychological Association
2013, Vol. 25,
No. 2, 424–434 1040-3590/13/$12.00 DOI: 10.1037/a0031264

A Tool for the Culturally Competent Assessment of Suicide:
The Cultural Assessment of Risk for Suicide (CARS) Measure
Joyce Chu, Rebecca Floyd, and Hy Diep Palo Alto University
Seth Pardo Alliant International University
Peter Goldblum Palo Alto University
Bruce Bongar Palo Alto University and Stanford University
School of Medicine
PAGE 424
Despite important differences in suicide presentation and risk
among ethnic and sexual minority groups, cultural variations
have typically been left out of systematic risk assessment
paradigms. A new self-report instrument for the culturally
competent assessment of suicide, the Cultural Assessment of
Risk for Suicide (CARS) measure, was administered to a diverse
sample of 950 adults from the general population. Exploratory
factor analysis yielded a 39-item, 8-factor structure subsumed
under and consistent with the Cultural Theory and Model of
Suicide (Chu, Goldblum, Floyd, & Bongar, 2010), which
characterizes the vast majority of cultural variation in suicide
risk among ethnic and sexual minority groups. Psychometric
properties showed that the CARS total and subscale scores
demonstrated good internal consistency, convergent validity
with scores on other suicide-related measures (the Suicide
Ideation Scale, the Beck Depression Inventory suicide item, and
the Beck Hopelessness Scale), and an ability to discriminate
between participants with versus without history of suicide
attempts. Regression analyses indicated that the CARS measure
can be used with a general population, providing information
predictive of suicidal behavior beyond that of minority status
alone. Minorities, however, reported experiencing the CARS
cultural risk factors to a greater extent than nonminorities,
though effect sizes were small. Overall, results show that the
CARS items are reliable, and the instrument identifies cultural
suicide risk factors not previously attended to in suicide
assessment. The CARS is the first to operationalize a systematic
model that accounts for cultural competency across multiple

cultural identities in suicide risk assessment efforts.
Keywords: culture, diversity, suicide, assessment, measurement
Recently, investigators have illuminated a lack of systematic
incorporation of cultural variation into standard suicide risk
assessment practice (Chu, Goldblum, Floyd, & Bongar, 2010;
Leach, 2006; Leong & Leach, 2008). Even though cultural
literature has shown that suicide rates, expression, experience,
risk factors, and protective factors vary across gender, ethnic,
age, sexual orientation, and other cultural groups (see Chu et
al., 2010, for a review), standard risk assessment protocol does
not systematically account for these differences. Without
particular attention to cultural variation in suicide risk
expression, suicide risk may be underdetected and managed
improperly (e.g., Joe & Kaplan, 2001;
Langhinrichsen-Rohling, Friend, & Powell, 2009; Morrison &
Downey, 2000; Rockett, Samora, & Coben, 2006; Wendler &
Matthews, 2006; Willis, Coombs, Drentea, & Cockerham,
2003). Burr (2002), for example, interviewed mental health care
professionals and argued that stereotypes and knowledge based
on Western culture may result in misdirected assessment and
treatment of suicide and depression for South Asian
communities. Other research has shown greater
misclassification of suicides in African Americans and Latinos
compared with European Americans (Phillips & Ruth, 1993;
Rockett et al., 2010; Violanti, 2010). The current study provides
a critique of existing approaches to culturally competent suicide
risk assessment and presents a measure (CARS; the Cultural
Assessment of Risk for Suicide measure) designed to facilitate
systematic integration of cultural competency into suicide risk
assessment.
How Culture Affects Suicide Risk
Cultural literature has shown that suicide rates vary across
gender, ethnic, age, sexual orientation, and other cultural
groups. When aggregated across age, U.S. suicide rates have
been historically highest in White males and lowest in African
American women (Centers for Disease Control and Prevention,

2009). A more detailed examination, however, shows that
suicide rates are
This article was published Online First January 28, 2013. Joyce
Chu, Rebecca Floyd, and Hy Diep, Department of Psychology,
Palo Alto University; Seth Pardo, Rockway Institute, Alliant
International University; Peter Goldblum, Department of
Psychology, Palo Alto University; Bruce Bongar, Department of
Psychology, Palo Alto University, and Department of Psychiatry
and Behavioral Sciences, Stanford University School of
Medicine. Correspondence concerning this article should be
Pg 425
growing quickly among African American adolescent boys
(Heron, 2007; Joe & Kaplan, 2001) and among older adults are
highest in Asian Americans (Bartels et al., 2002; Centers for
Disease Control and Prevention, 2009; Shiang et al., 1997).
Additionally, research shows that suicidal behavior is elevated
among Latino adolescents (Centers for Disease Control and
Prevention, 2004; Choi, Meininger, & Roberts, 2006) and
LGBTQ1 adolescents (young gay men in particular; King et al.,
2008; McDaniel, Purcell, & D’Augelli, 2001; Meyer, 2003).
Minority group variations in suicide rates may reflect
underlying differences in other important aspects of suicide:
expression, experience, risk factors, or protective factors (see
Chu et al., 2010, for a detailed review). These cultural
differences in suicide among ethnic and sexual orientation
minorities affect the types of questions one must ask to
accurately capture and predict self-harm risk. For example,
within a clinical setting, ethnic minorities are referred to as
hidden ideators—clients who are less likely than Whites to self-
disclose feelings of suicide unless directly assessed by
clinicians (Morrison & Downey, 2000). Methods of query that
decrease the potential of stigma or embarrassment may elicit a
more accurate picture of risk for someone prone to hidden
suicidal ideation. Assessing for family conflict may be a
particularly important indicator of suicide risk for individuals
from interdependent cultures such as Asian Americans or

Latinos (Cheng et al., 2010; Fortuna, Perez, Canino, Sribney, &
Alegria, 2007; Garcia, Skay, Sieving, Naughton, & Bearinger,
2008; Lau, Jernewall, Zane, & Myers, 2002). Additionally,
research shows that LGBTQ individuals often turn to
community supports in the face of rejection from family
members, making high levels of family rejection and alienation
from one’s social community particularly important suicide risk
factors (D’Augelli, 2002; McBee-Strayer & Rogers, 2002; Ryan,
Huebner, Diaz, & Sanchez, 2009; Van Heeringen & Vincke,
2000). Assessing social isolation from a supportive LGBTQ
community may be a better indicator of suicide risk than social
isolation from friends for an LGBTQ client struggling with the
coming-out process. To understand how clinicians typically
account for such cultural variations in their risk assessment
efforts, we turn to an examination of current suicide risk
assessment tools and procedures.
How Is Cultural Variation Currently Incorporated Into Suicide
Risk Assessment?
Several researchers have provided guidelines for the
incorporation of cultural influence into current suicide risk
assessment practices. Westefeld, Range, Greenfeld, and
Kettmann (2008), for example, recommended that four aspects
of cultural sensitivity be included in the science and process of
risk assessment: (a) inclusion of ethnic minorities in the
standardization of suicide instruments, (b) awareness of
differences in likelihood to disclose suicide information, (c)
recognition and acknowledgment of various minority groups,
and (d) careful attention to cultural issues when assessing for
suicidal thoughts and behaviors. Worchel and Gearing (2010)
advised that culturally competent suicide assessment should
include careful and active consideration of culture-specific risk
and protective factors and attitudes regarding suicide
acceptability. In its seminal document providing practice
guidelines on the assessment of suicidal behaviors, the
American Psychiatric
Association Work Group on Suicidal Behaviors (2003) provided

general recommendations to explore common contributors to
suicide in different cultural groups and cultural differences in
beliefs about death and view of suicide as part of the suicide
assessment process. These assessment guidelines also advised
remembering that cultural beliefs influence one’s willingness to
talk about suicide. Other researchers have recommended the
inclusion of specific cultural factors into risk assessment for
certain minority groups. Kaslow et al. (2004), for example,
recommended assessing for aggression in flagging suicide risk
for African Americans, whereas Cheng et al. (2010) advised that
family conflict and perceived discrimination are instrumental in
identifying Asian Americans at risk for suicide. An abundance
of individual empirical studies delineate a multitude of cultural
risk and protective factors that should be integrated into the risk
assessment practices for specific cultural groups.
Weaknesses of Existing Cultural Risk Assessment
Taken together, existing efforts to integrate cultural factors
into risk assessment practices have been sparse and
unsystematic and carry several weaknesses. First, most
recommendations are general without specific or concrete
guidelines to direct the incorporation of cultural factors into
suicide assessment, leaving clinicians and researchers without a
course of action for an arguably complex task. Second,
individual recommendations to include specific cultural factors
into assessment efforts do not aid clinicians in synthesizing the
volume of findings identifying differences in suicide-related
factors for multiple ethnic and sexual minority groups. The
range of research on cultural suicide risk factors is difficult for
any one clinician or researcher to comprehensively grasp or
access quickly within the limited time often allowed in crisis
situations. Additionally, people typically identify not with one
cultural group but instead with multiple identities (e.g., an
African American woman who is bisexual carries multiple
identity categories), making prioritization or synthesis of
research findings for suicide in these multiple cultural groups
an involved effort. Third, specific to existing suicide

assessment tools, most suicide questionnaires are presumed to
have reliable and valid interpretations of suicide risk for
cultural minorities without empirical research to support such
assumptions (Molock & Douglas, 1999; Molock, Matlin, &
Prempeh, 2008). Furthering the problem, few suicide
questionnaires were specifically developed with minority
populations in mind (e.g., Brown, 2002; Dana, 2000; Wendler &
Matthews, 2006; Westefeld et al., 2008). Although some
validation samples may have included (usually limited numbers
of) minority group members, measure items do not assess for
the range of risk factors unique to cultural minority groups and
do not incorporate the variation in language or content of query
needed to account for important cultural minority differences in
how suicide develops, is expressed, or is experienced (Brown,
2002; Colucci, 2006; Leach & Leong, 2008; Westefeld et al.,
2008).
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.
ThisdocumentiscopyrightedbytheAmericanPsychologicalAssocia
tionoroneofitsalliedpublishers.
Thisarticleisintendedsolelyforthepersonaluseoftheindividualuser
andisnottobedisseminatedbroadly.
Pg 426
CULTURAL ASSESSMENT OF RISK FOR SUICIDE (CARS)
A New Approach for Culturally Competent Risk Assessment:
The Cultural Assessment of Risk for Suicide (CARS) Measure
The numerous challenges of recommendations that are too
general, limited measures validated on diverse samples, a
complex range of research findings, and multiple cultural
identities have presented barriers to the systematic
incorporation of cultural variations into risk assessment
practices. To address the need for parsimony in culturally
competent risk assessment, Chu et al. (2010) developed the
Cultural Theory and Model of Suicide that inductively

categorized cultural differences in suicide into major risk or
protective factors common across four major ethnic and sexual
minority groups (African American, Asian American, Latino/a
American, and LGBTQ). Chu et al. (2010) performed a
comprehensive literature review of studies in North America
from 1991 to 2011 that examined cultural factors related to
beliefs, norms, practices, or customs that have been shown to
influence suicidal behaviors. As such, findings on the effects of
simple minority status or on prevalence rates were excluded.
Results found that over 95% of empirical data showing unique
cultural factors in suicide risk for the four referenced ethnic and
sexual minority groups were encompassed within four major
categories: Cultural Sanctions, Idioms of Distress, Minority
Stress, and Social Discord. The first factor, Cultural Sanctions,
is defined by Chu et al. (2010) as cultural values or practices
conveying messages about the acceptability of suicide as an
option or the acceptability or shame associated with certain life
events that may precipitate suicide risk. The association of
moral objections and lower acceptance of suicide to decreased
suicidal behavior in African American communities is an
example of a Cultural Sanction risk factor (Neeleman, Wessley,
& Lewis, 1998). Idioms of Distress are defined as cultural
variations in one’s likelihood to express suicidality, the way
suicide symptoms are expressed, and chosen methods or means
of attempting suicide. The tendency to express suicidality as
risky behavior among Latinos exemplifies the Idioms of
Distress factor (Olshen, 2007). The third cultural factor,
Minority Stress, includes stresses cultural minorities experience
because of social identity or position (e.g., acculturation,
discrimination related strain, or social disadvantages).
Mistreatment, harassment, and discrimination as strong suicide
risk factors for sexual minority groups illustrates the Minority
Stress factor (Clements-Nolle, Marx, & Katz, 2006; Huebner,
Rebchook, & Kegeles, 2004). The final factor of Social Discord
includes the suicide risk factors of alienation, conflict, or lack
of integration with one’s family, community, or friends. The

association of family conflict with increased suicide risk among
Asian Americans is an example of Social Discord as a cultural
risk factor (Cheng et al., 2010; Lau et al., 2002). The categories
of the Cultural Model of Suicide integrate and streamline the
body of knowledge regarding cultural suicide factors and
identify a set of risk factors that have not been incorporated
into existing suicide assessment tools. Chu et al. (2010)
highlighted the need for development of an assessment tool
based on the Cultural Model of Suicide to operationalize its
framework in clinical, screening, and research application.
The Present Study
The purpose of the present study was to develop and examine
psychometric properties of scores on a measure of cultural
suicide risk based on the Cultural Model of Suicide (Chu et al.,
2010). The Cultural Assessment of Risk for Suicide (CARS)
measure assesses cultural factors not typically examined in
general suicide assessment research. We sought to administer
the CARS with a diverse community sample overly inclusive of
the racial/ethnic and sexual minority individuals often
overlooked in previous suicide assessment study samples. An
exploratory factor analysis (EFA) followed by internal
consistency calculation was performed to examine the
consistency of scores on the CARS with the major cultural
categories of risk from the Cultural Model of Suicide: Cultural
Sanctions, Idioms of Distress, Minority Stress, and Social
Discord. We expected the CARS to demonstrate good
convergent validity with other established measures of suicidal
ideation and risk and to show further evidence of construct
validity in terms of its ability to discriminate between
participants with high versus low suicide attempt history.
Wealso tested the CARS measure’s application in assessing risk
for cultural minority versus nonminority groups. Because the
cultural factors of the CARS encompass cultural context,
beliefs, values, norms, and practices separate from differences
in suicide risk due to simple minority status alone (Chu et al.,
2010), we hypothesized that the CARS would apply to a general

population, providing information predictive of suicidal
behavior beyond that of cultural minority versus nonminority
status. Yet, we expected that cultural minorities would report
experiencing the cultural constructs assessed by the CARS to a
greater extent than nonminorities.
Method
Participants The total sample included 950 participants who
were 18 years and older (M 25.26 years, SD 10.39) and diverse
in ethnicity and sexual orientation. The sample was composed
of mostly women (63.8%) but also included 31.1% men, 1.3%
transgender (four male-to-female and eight female-to-male), and
3.9% unspecified. The sample was diverse and overly inclusive
of ethnic and sexual minorities typically underrepresented in
suicide assessment study samples. For example, 22.4% of
participants identified as having a nonheterosexual orientation
(10.5% homosexual, 8.2% bisexual, 3.5% questioning, and 1%
unlabeled). More than half of the respondents identified as
ethnic minorities, including 34.1% Asian Americans, 19.1%
Latino/a American, and 5.8% African Americans. Suicide risk
was also adequately represented, with
roughly16.4%oftherespondentsreportedahistoryofoneormore
suicide attempts.
Procedures Participants were recruited from universities,
colleges, community fliers, social networking sites, and online
advertisements targeted at recruiting a sample diverse in
ethnicity and sexual orientation. Participants completed a set of
questionnaires either online via Survey Monkey (75.3%) or via
paper form completed in
Pg 427
CHU, FLOYD, DIEP, PARDO, GOLDBLUM, AND BONGAR
person (24.7%). The study was advertised to potential
participants as a study of culture and self-harm risk assessment.
Recruitment from colleges and universities was accomplished
through announcements made during class with the permission
of the instructor or through listings on university human subject
pools. Student respondents were offered extra credit or course

credit in exchange for their participation. University and college
recruitment involved both paper and online administration,
depending on the preference of the course instructor or subject
pool administrator. Recruitment through social networking sites
and online advertisements was accomplished via postings on
www .craigslist.org. In addition, investigators shared Survey
Monkey links accompanied by a brief description of the study as
a study of culture and self-harm risk assessment to their
network of online contacts. Snowball sampling continued as
contacts were free to forward the link to their own contacts.
Finally, fliers with the Survey Monkey link were posted in
coffee shops and grocery stores. After providing informed
consent, participants were prompted to fill out a demographic
questionnaire, the Cultural Assessment of Risk for Suicide
(CARS), one item assessing suicidal behaviors from the Beck
Depression Inventory (BDI; Beck & Steer, 1987), a question
about past suicide attempts, the Suicide Ideation Scale (SIS;
Rudd, 1989), and the Beck Hopelessness Scale (BHS; Beck &
Steer, 1988). The BDI suicide item, SIS, and BHS were used to
assess the convergent validity of the CARS. Participants were
provided debriefing information that included suicide crisis
telephone numbers and Web resources. Contact information for
the principle investigator (a licensed psychologist), and the
institutional review board chair were also provided to allow
participants opportunities to ask further questions or express
concerns. This study was approved by and operated in
accordance with a human subject’s review committee.
Measures
Demographic questionnaire. Participants were asked to
complete demographic questions regarding age, gender, race or
ethnicity, and sexual orientation identity.
The Cultural Assessment of Risk for Suicide (CARS).
The CARS included an initial set of 52 items developed to
assess for the four cultural risk categories of the Cultural Model
of Suicide (Cultural Sanctions, Idioms of Distress, Minority
Stress, and Social Discord) with the purpose of guiding the

researcher or clinician in incorporating cultural factors into risk
assessment efforts. The CARS was designed to be used in
adjunct to usual suicide assessment procedures. All initial
CARS items were based on the psychological literature on
cultural variations in suicidal behaviors and refined by a
research team of three licensed clinical psychologists and 11
clinical psychology doctoral students. Items are rated on a 6-
point Likert scale (1 =strongly disagree,2 = moderately
disagree,3= slightly disagree,4= slightly agree,5= moderately
agree, and 6 = strongly agree), and participants are instructed to
“Choose the response that best applies to you.” Higher scores
on the CARS indicate greater suicide risk.
Suicide item from the Beck Depression Inventory (BDI; Beck &
Steer, 1987). The BDI is a 21-item self-report questionnaire
assessing depression symptoms. Item 9 was administered to
participants to assess suicidal ideation on a 4-point scale (from
0 =
I don’t have any thoughts of harming myself and 1 = I have
thoughts of harming myself, but I would not carry them out to 3
= I would kill myself if I could). This BDI suicide item
demonstrates good stand-alone convergent validity with the
Beck Scale for Suicide Ideation in inpatient and outpatient
samples in terms of desire to attempt suicide (r = .56–.58; Beck
& Steer, 1991).
Past suicide attempts. Respondents reported lifetime history of
suicide attempts using Item 20 from the Beck Scale for Suicide
Ideation (BSI; Beck & Steer, 1991): 0 = I have never attempted
suicide;1= I have attempted suicide once; or 2= I have
attempted suicide two or more times. The latter two response
options were combined to create two participant groups: those
who never attempted suicide versus those who have attempted
suicide one or more times.
Suicide Ideation Scale (SIS; Rudd, 1989). The SIS is a 10-item
self-report measure of a continuum of suicidal thoughts from
covert ideation to overt ideation and attempts among nonclinical
and clinical samples. Items are scored on a 5-point Likert scale

(from 1 = never to 5 = always). The SIS items have shown high
internal consistency (coefficient a=.86). The measure’s ability
to determine suicide risk has moderate convergent validity via
correlations with the Beck Hopelessness Scale (r = .49) and the
Center for Epidemiologic Studies–Depression Scale (r = .55;
Rudd, 1989). The SIS also discriminates between individuals
who have attempted versus those who have not attempted
suicide (Rudd, 1989). In the present study, items of the SIS had
a Cronbach’s alpha value of .94.
Beck Hopelessness Scale (BHS; Beck & Steer, 1988). The
BHSisa20-itemtrue–false self-report measure of hopelessness,
or positive and negative beliefs about the future. The BHS has
shown highly consistent scores among clinical and nonclinical
populations with Kuder–Richardson reliabilities from .87 to .93
(Beck & Steer, 1988) and scores that correlate moderately well
with scores on the Suicide Intent Scale (e.g., Beck, Steer, &
McElroy, 1982; Dyer & Kreitman, 1984) and suicide ideation
items on the Scale for Suicidal Ideation (r = .46; Beck, Steer,
Beck, & Newman, 1993). The BHS has also shown excellent
predictive validity as a risk factor for suicide attempts and
completed suicide in numerous
studies(e.g.,Beck,Brown,Berchick,Stewart,&Steer,1990;Beck &
Steer, 1989; Brown, Beck, Steer, & Grisham, 2000). In the
present study, items of the BHS had a Cronbach’s alpha value of
.90.
Results
Factor Analysis
We conducted an EFA on the data to discern the underlying
factor structure of the CARS scale. The solution was produced
using an oblique rotation because some correlations between
factors were expected. Three criteria guided the exploratory
factor analysis to ensure a coherent solution: (a) a minimum of
three variables per factor, (b) factor loading size greater than
.40, and (c) inclusion of items in factors with the strongest
factor cross-loading (Costello & Osbourne, 2005; Guadagnoli &
Velicer, 1988; Kahn, 2006; Velicer & Fava, 1998). We

combined several approaches to determine the number of factors
to retain in the final solution, including parallel analysis
(Hayton, Allen, & Scarpello, 2004), examination of the scree
plot
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CULTURAL ASSESSMENT OF RISK FOR SUICIDE (CARS)
of eigenvalues, and interpretability of factors. The scree plot of
eigenvalues indicated the acceptability of either a seven- and
eight-factor solution, and the parallel analysis revealed that
seven factors achieved statistical significance. Results showed
that the primary difference between the seven- and eight-factor
solutions was the retention of a minority stress factor
nonspecific to sexual orientation or ethnic minorities in the
eight-factor solution. These nonspecific minority stress items
are important for inclusion because they broaden the range and
generalizability of minority stress in the CARS scale. In
particular, they capture minority stress applicable across
different minority individuals, whereas other factor items
(forming the sexual minority stress and the acculturative stress
factors) are more specifically tied to sexual minority or ethnic
minority issues. Further, examination of the internal consistency
and concurrent validity with other measures of suicidal behavior
showed that the nonspecific minority stress items stand alone as
a coherent factor. As such, preference was given to the eight-
factor solution, shown in Table 1. Bartlett’s test of sphericity
was significant for the full sample factor solution, X2(741) =
14,450.30, p < .001, indicating that the sample is adequate and
appropriate for factor analysis.
The final eight-factor solution included 39 items that accounted
for 57.39% of the total variance. CARS items are listed in the
factor solution shown in Table 1, and Cronbach’s alpha
coefficients for items of the total CARS scale and its eight
subscales are shown in Table 2. Individual factors were
interpreted and labeled based on the items that grouped together
and the strongest defining items of each factor; an overall
examination of all eight factors revealed that they distinguished

a structure similar to that expected by the four theoretical
constructs of the Cultural Model of Suicide. Two factors—
Family Discord and Social Support—accounted for 28.25% of
the total variance and are related to the Social Discord construct
of the Cultural Model of Suicide. The six items of the Family
Discord factor had a Cronbach’s alpha value of .82 and identify
the extent to which one experiences discord with family
members. The Social Support factor includes five items that
assess one’s access to a variety of social resources as protective
factors in situations of psychological distress. Items of the
Social Support factor had a Cronbach’s alpha value of .76.
Three factors—Sexual Minority Stress, Acculturative Stress,
and Nonspecific Minority Stress—accounted for 12.87% of the
total variance and measure the Minority Stress construct of the
Cultural Model of Suicide. The Sexual Minority Stress factor
includes five items that assess stresses related to sexual or
gender orientation and showed a Cronbach’s alpha value of .74.
The three items of the Acculturative Stress factor had a
Cronbach’s alpha value of .76 and encompass a subtype of
minority stress that cultural minorities experience in dealing
with the challenges of balancing one’s culture of origin with
American culture. Acculturative stress is most commonly
experienced by ethnic minority individuals. The Nonspecific
Minority Stress factor assesses issues related to many minority
groups and is composed off our items that assess the stresses
that cultural minorities experience because of their minority
status. Items of the Nonspecific Minority Stress factor had a
Cronbach’s alpha value of .73. Two factors—Idioms of Distress
(Emotional/Somatic) and Idioms of Distress (Suicidal
Actions)—accounted for 8.73% of the total variance and are
related to the Cultural Model of Suicide’s Idioms of Distress
construct. The seven items of the Idioms of
Distress (Emotional/Somatic) factor had a Cronbach’s alpha
value of .80 and encompass alternative expressions of distress
such as anger, somatization, risky behavior, or feelings of
shame. The five items of the Idioms of Distress (Suicidal

Actions) factor had a Cronbach’s alpha value of .83 and assess
cultural variations in one’s expression of suicidal intentions,
actions, and choice of self-harm method. One final factor—
Cultural Sanctions—accounted for 7.53% of the total variance
and includes four items that reflect familial or cultural messages
about the acceptability of suicide that can precipitate or protect
against suicidal behaviors. Items of the Cultural Sanctions
subscale had a Cronbach’s alpha value of .65. None of the items
seemed to improve the internal consistency of this subscale
score if dropped; thus, all four items were retained. With 39
total items, the total summed overall CARS score also
demonstrated excellent internal consistency, .90. When the
sample was split by minority (racial/ethnic or sexual minorities)
versus nonminority status, the internal consistencies of CARS
subscale and total scores were similar, suggesting that they are
similarly reliable across both minority and nonminority samples
(see Table 3).
External Validation of the CARS
Convergent validity of scores on the CARS scale with
established measures of suicidal behavior or hopelessness (a
construct highly predictive of suicide) was estimated by
correlating each of the total and subscale CARS scores with the
following measures: the SIS, the suicide item from the BDI, and
the BHS (see Table 4). We computed CARS subscale scores by
calculating the total sum of item scores within each subscale.
An examination of the distribution of the CARS scale scores
indicated skewed data with the amount of skew exceeding the
range of plus-or-minus twice the value of standard error. Given
the low base rate of suicide risk, skew is inevitable and reflects
reality (i.e., the population) rather than a problem with our
sample. Convergent validity was assessed with Spearman’s rho
nonparametric correlation coefficients to account for the skewed
data. As expected, all of the psychometric validation measures
were significantly correlated at the p .001 level in the expected
directions. Although the correlations were moderate to low in
magnitude, the CARS total and subscale scores were each

significantly and positively correlated with the SIS, suicide
item from the BDI, and BHS. The nonparametric Kruskal–
Wallis test was utilized to test the CARS measure’s ability to
discriminate between those with versus those without suicide
attempt history. Results provided additional evidence of
construct validity. Respondents who reported a history of
suicide attempts reported significantly higher scores on the
CARS total scale and subscales compared with those without a
history of suicide attempts (see Table 2). Effect sizes of group
differences ranged from small to large.
CARS as Applied to Cultural Minority Versus Nonminority
Groups
A hierarchical logistic regression analysis was performed to
test how well the total CARS scale predicted suicidal behavior
over and above the variance predicted by minority status. For
parsimony, regressions were performed with only the CARS
total scale
Page 429
Table 1
and history of past suicide attempts. Minority status
(racial/ethnic or sexual minority versus nonminority status) was
entered in Step 1. Alone, minority status predicted two thirds
greater risk of having at least one suicide attempt in the past
(odds ratio [OR = 1.67], df = 1, p = .02) with an explanatory
power of R2 = .01. After minority status was controlled, the
addition of the CARS
total scale score in Step 2 indicated greater explanation of
suicide attempt history, ^R2 = .27, X2(1) = 156.75, p <.001.
Minority status was no longer a significant predictor (OR =
1.13, df = 1, p > .05); instead, the CARS total scale was the
only significant predictor of past suicide attempts in the full
model (OR = 1.04, df = 1, p < .001), indicating that higher
Page 430
Table 2

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