Journal of Addictive Behaviors,Therapy & RehabilitationISSN: 2324-9005

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Review Article, J Addict Behav Ther Rehabil Vol: 2 Issue: 3

Incorporating Multicultural Factors Related To Prevention of Adolescent Suicide within Substance Abuse Treatment Settings

Valerie ED Russell1* and Ann M Melvin2
1Florida International University, USA
2University of Illinois Springfield, USA
Corresponding author : Valerie ED Russell, PhD
Assistant Professor, Counselor Education, Florida International University, College of Education, 11200 S.W. 8th Street, ZEB 238B, Miami, Fl. 33199, USA
Tel: 305-348-3865; Fax: 305-348-1515
E-mail: [email protected]
Received: May 04, 2013 Accepted: August 22, 2013 Published: August 24, 2013
Citation: Russell VED, Melvin AM (2013) Incorporating Multicultural Factors Related To Prevention of Adolescent Suicide within Substance Abuse Treatment Settings. J Addict Behav Ther Rehabil 2:3. doi:10.4172/2324-9005.1000109


Incorporating Multicultural Factors Related To Prevention of Adolescent Suicide within Substance Abuse Treatment Settings

According to the National Institute of Mental Health (NIMH), suicide is the 3rd leading cause of death among people age 15-24. In addition, adolescents in substance abuse treatment are at an even higher risk of suicidal behavior. Recent literature has also discussed the need to consider cultural differences when working with adolescents in substance abuse treatment who need suicide prevention and intervention because ethnic groups differ in rates of suicidal behaviors and context within which suicidal behavior occurs. Due to these alarming rates, developing a culturally competent suicide prevention program specifically for substance abuse treatment is essential. Therefore the purpose of this paper is to increase knowledge of factors related to ethnicity that can be incorporated into prevention of adolescent suicide within substance abuse treatment settings.

Keywords: Substance abuse treatment, Adolescents, suicidal behavior


Adolescent suicide; Vulnerability; Abuse treatment


According to the National Institute of Mental Health (NIMH) [1], suicide is the 3rd leading cause of death among people age 15- 24. Subsequently, the Center for Disease Control (CDC) conducted the most recent High School Youth Risk Behavior Survey (YRBSS) during October 2010-February 2012 with adolescents across the nation in grades 9-12. Results published in the 2012, indicated 15.8% of students had seriously considered attempting suicide during the 12 months before the survey and 7.8% of students had attempted suicide one or more times during the 12 months before the survey. In addition, adolescents in substance abuse treatment are at an even higher risk of suicidal behavior [2,3]. “Although suicide is often primarily considered a “mental health issue”, related to affective disorders in particular, studies consistently show that suicide and suicidal behavior are also highly related to addiction disorders,” [4]. Voss et al. report that in 2007, more than 200,000 people were treated in emergency rooms across the United States for drug related suicide attempts [5].
Conner et al. [6] research does not have supportive data about effective suicide prevention methods among substance abuse treatment agencies and there are no empirically supported suicide prevention training curricula tailored to traditional substance abuse treatment. Further, the American Association of Suicidology [7] purports there are risk factors and protective factors that should be considered in the prevention of suicide among adolescents. Moreover, there are differences among the adolescents in regards to risk factors as well as protective factors based on basic demographic information. The 2012 National Strategy for Suicide Prevention is a call to action from the Office of the U.S. Surgeon General and the National Action Alliance for Suicide Prevention. The NSSP Guide outlines 13 goals and 60 objectives that are meant to work together to reduce the significance of suicide among our nation. The effort was created based on new research and development within suicide prevention. One continued area of development is the link between certain demographics and suicidal thoughts and behaviors. The strategy suggests that community agencies work together to develop prevention techniques that address demographic differences. Of particular interest for this paper are the factors that stem from general demographic information such as gender and ethnicity, which highlights a need for culturally sensitive suicide prevention programs. According to the Center for Substance Abuse Treatment (CSAT), Race and ethnicity also can be factors that contribute to suicide risk. For example, suicide rates among American Indian/ Alaska Native adolescents and young adults, ages 15-24, are almost two times higher than the national average for that age group [4]. Young Indian women have rates of suicide that are two to three times higher than for females in the general population (Goldsmith et al., 2002) as cited in Substance Abuse and Suicide Prevention: Evidence and Implications—A White Paper [8].
Differences in demographics within the population are illustrated in the YRBSS, for example, of the students surveyed who reported seriously considered attempting suicide the rates were “higher among female (19.3%) than male (12.5%) students; higher among white female (18.4%), black female (17.4%), and Hispanic female (21.0%) than white male (12.8%), black male (9.0%), and Hispanic male (12.6%) students” [4]. Rates among adolescents reporting “having attempted suicide was higher among female (9.8%) than male (5.8%) students; higher among white female (7.9%) and Hispanic female (13.5%) than white male (4.6%) and Hispanic male (6.9%) students” [4].
In addition, Goldston et al. [3] discussed cultural considerations in adolescent suicide prevention and stated “ethnic groups differ in rates of suicidal behaviors among youths, the context within which suicidal ideations occur (e.g. different precipitants, vulnerability, protective factors,) and in patterns of help-seeking behavior”. Due to these alarming rates, developing a culturally competent suicide prevention program specifically for substance abuse treatment is essential. Therefore the purpose of this paper is to increase knowledge of factors related to ethnicity that can be incorporated into prevention of adolescent suicide within substance abuse treatment settings.

Substance Abuse Treatment

Research suggests that many types of suicide interventions have been developed, however none specific to substance treatment. Voss et al. purport people with substance use disorders are at 10 times more risk of suicide than those without substance use disorders. According to Werner and Kahn [9] purports the relationship between substance use disorders and suicidal behaviors are intertwined. Werner and Kahn also stress the need for suicide screening and interventions within substance abuse treatment. Further, Conner et al. [6] support the need for incorporation of suicide prevention training for substance abuse treatment centers. These authors state substance use disorders are a “potent risk factor for suicide” and that clients entering treatment are often at particularly higher risk. However, according to Conner et al. [6], research does not have supportive data about effective suicide prevention methods among substance abuse treatment agencies and there are no empirically supported suicide prevention training curricula tailored to traditional substance abuse treatment.
Due to the gap in literature, these authors used the Treatment Improvement Protocol (TIP 50), developed by the Center for Substance Abuse Treatment (CSAT) a division of the Substance Abuse and Mental Health Administration (SAMHSA), to develop a suicide prevention training curricula for their study. Their study showed a significant increase in the use of suicide prevention skills within traditional substance abuse treatment upon completion of the training. TIP 50 states that clients in substance abuse treatment should be screened on a regular basis for suicidal thoughts and behaviors. Cultural considerations are necessary within the screening and treatment of suicidal behaviors and are also addressed within TIP 50. Hence, there is a need to increase awareness on factors related to ethnicity that can be incorporated into adolescent suicide prevention and interventions within substance abuse treatment settings.

Multicultural Suicide Treatment Interventions and Considerations

Current literature recognizes the growing correlation of increased suicide rates and cultural minority groups [10-14]. In summation, these reports revealed that suicidal ideations or attempts and helpseeking behavior among cultural minority groups are correlated with different:” (a) precipitating factors, (b) protective factors, (c) vulnerabilities, (d) reactions to and interpretations of the behavior, and (e) resources and options for help-seeking” [3].
Conversely, literature reviews and discussions of suicide among cultural minority groups often deduce information about minority groups and suicide from data on associated constructs such as depression or general psychological distress. Though the construct depression is a resilient predictor of suicide, in a recent study, Cheng et al. [15] found that one-third of individuals in cultural minority groups who attempted suicide reported with no symptoms or history of depression or anxiety. Though some research has shown inconsistent results [16,17] mainstream culture and suicide literature supports the existence of cultural variation not only in the likelihood that suicide symptoms are expressed, but also in the manner in which they are expressed [18,19]. For example, depression symptoms are more likely to be expressed in psychological terms on Western cultures compared to more somatic terms in minority cultures. Moreover, classic signs of suicide such as low self-worth, hopelessness or withdrawal may also be less predictive of suicide for minority cultures. Alternate expressions of suicidal ideations or attempts among minority cultures may consist of acts of violence, aggression, risk-taking behavior, anger, or irritability [20]. In one study, Abe et al. [21] found that completed suicides were more likely to involve aggression towards others in African Americans than Caucasians. According to Barry et al. [22] risk-taking behavior via gambling is more likely to be associated with suicide attempts among Asian Americans. In addition, another study found that aggression and conduct-related symptoms identified a different subset of suicidal minority adolescents than depressive symptoms [23]. Rowan [24] purports that suicide ideations expressed through violence, aggression or anger may also manifest through symptoms of substance abuse. Typically, these expressions of distress would not be viewed as a red flag for suicidal ideation by counselors trained in typical suicide risk assessments. Hence, detecting alternative expressions of risk will be crucial in culturally competent suicide assessments at substance abuse treatment programs. Ignoring the impact of ethnicity, culture and race can jeopardize the well-being of the at-risk suicidal, minority culture adolescents and place them in a potentially fatal situation. Yet, in spite of the growing association of minority cultures and suicidal behaviors, there is sparse information on effective culturally sensitive substance abuse treatment interventions for minority groups with suicidal behaviors.
According to ACA [25], practitioners have an ethical responsibility to provide culturally specific services. Therefore, greater understanding of the minority cultural perspective of suicidal behavior may help substance abuse counselors, who work with atrisk suicidal individuals, (a) remove cultural barriers to treatment, (b) address culturally competent needs, (c) improve quality of care and (d) ultimately develop prevention and intervention strategies that are culturally relevant and focus on unique concerns of cultural minority groups. Heighten awareness of the significant interaction of culture and suicidal behaviors is critical in order to effectively development culturally sensitive interventions and increase the amount of culturally competent counseling professionals working to reduce suicidal behaviors in cultural minority groups. To increase substance abuse treatment practitioner’s knowledge of suggested culturally competent responses to suicidal behaviors in cultural minority groups. The following cultural treatment and considerations are examined in separate sections for each racial and ethnic minority group.
African americans
Recent research with African-American families suggests that authoritarian parenting practices may decrease African-American children suicidal behaviors. Authoritarian parents tend to place many restrictions and rules on their children, expecting maturity, obedience, and compliance [26]. The significant interaction effect for authoritarian parenting on African-American children is consistent with recent research linking features of the parenting style to fewer psychosocial adjustment problems with African-American youth [27]. More specifically, the clear communication, demands for obedience, and firm limit setting provides African-American children with boundaries against self-destructive behavior and might prove useful in reducing youth’s risk for suicidal behaviors. Other research suggests that the African American Christian churches, often referred to as the Black Church should be strongly considered as a resource to help aid in suicide prevention/intervention because of the longstanding significance of religion and spirituality in the African American community [28,29]. For example, the Black Church has restrained suicide by identifying the act as an “unpardonable” sin that goes against the values set by the African American Christian church and the African American community overall [28,30]. Additional cultural protective factors that serve as barriers against suicide within the African American community are the role of the elderly in the family unit and the extended family network, especially for African American women. Due to the increase in suicide rates among African Americans, professional counselors must be of aware these unique cultural protectors and be willing to utilize them as resources to help aid in responding to the suicidal behaviors with African American clients [28,30].
Hispanics/Latino americans
Hispanic/Latino adolescents experience disproportionate rates of emotional distress, including suicidal ideations. These disparities, in part, have been attributed to inadequate coping skills of the population [31]. To address this growing concern, the primary focus for suicide prevention and intervention treatment for Hispanics/ Latino Americans should be on the family. In a family-oriented treatment approach, therapeutic emphasis should be on treating at-risk youth and parents together, at-risk youth alone and parents alone, if necessary [31]. Equally prominent among suicide protecting features for Hispanic Americans is the importance of extended family and the Roman Catholic religion. In the Hispanic/ Latino culture, family oftentimes includes immediate relatives as well as uncles, aunts, father and mother-in law, entrusted religious leaders, and devoted friends of the family [3,30]. Historically, the extended family has served as a buffer for many negative life circumstances such as oppression and suicidal behaviors. Therefore, engagement of the extended family members of suicidal clients is particularly important for Hispanic/Latino Americans [3]. Additionally, another element of the Hispanic/ Latino culture that may impact suicidal behavior is fatalism. Fatalism is associated with the Catholic religion and it is interpreted as accepting life instead of attempting to change things that cannot be changed. Further, the Catholic doctrine is often a significant element in the Hispanic/Latino individuals’ lifestyle. This religious belief system which teaches that it is a sin to take your own life may be used as an intervention that will help to lower suicide rates in the Hispanic/Latino culture.
In recent literature, an interdisciplinary team of communitybased social work, nursing, education, and public health agencies developed a Hispanic/Latino adolescent specific stress management/ coping intervention called Project Wings. The program was based on existing evidence from interventions that had been successful with Latino youth with substance abuse issues. The intervention goals are to increase participant’s ability to identify stress and its physical, emotional and mental manifestations and provide practical tools to help cope with life stressors [32]. This school-based, semester long coping intervention has three components (a) sharing circles, (b) relaxation exercises and (c) life skills. Overall this multipronged in consistent with leading researchers beliefs on suicide preventive interventions for Hispanic/Latino youth population and it could compliment parent-focused outreach programs in the future.
Native americans
Although there is acknowledgement of huge diversity among the more than 562 identified Native American tribes in the United States and Canada, there are culturally appropriate suicide prevention programs which has been developed that incorporate culturally specific knowledge and traditions. More specifically, 4 out of the 9 programs that met Institute of Medicine criteria for evaluating preventive interventions, included suicide prevention as a component of their program [3]. The suicide preventions programs encompassed positive cultural heritage messages to increase self-esteem, focus on cultural protective factors and teachings on seeking social support as a coping method. These programs have been well received by the Native American communities and have had favorable results. Given the fact that historically Native Americans prefer traditional healing practices, these suicide prevention interventions will continue to be effective as long as they continue to incorporate cultural values of Native Americans, respect traditional practices, and reinforce cultural identity [3,30].
Asian american
Although slightly on the rise, suicidal ideation/attempt rates are lower than any other ethnic groups. Asian American adolescents experience emotional distress however these problems are often overlooked because of the model minority stereotype of having high achievement orientation and low rates of risky behavior. Even when Asian American seek treatment, they will focus on somatic symptoms of distress rather than disclose suicidal ideations. Hence, under recognition of suicidal risk in Asian Americans needs further exploration. As it relates to other treatment considerations, their religious culture may be a strong contributor to their low overall suicide rate. Asian Americans have three main religions (Confucianism, Buddhism, and Taoism). All three religious affiliations encourage interdependence and discourage individualism. Therefore an act of suicide could be viewed as harmful to everyone in the group and disrespectful [3,30]. In addition to religious beliefs, dignity and respect for the family name is another element of the Asian American culture that could affect their attitudes and behavior towards suicide. However, based on the Asian American cultures value of interdependence, including family members in treatment for suicide may help facilitate proper assessment and treatment. Furthermore, because family pride and “loss of face” play significant roles in the Asian American culture, attempts should be made to reduce the shame associated with suicidality and help-seeking behaviors [3].


When working with ethnic minorities, it’s critical that substance abuse treatment counselors become familiar with the unique ways a client’s cultural values and beliefs could interact with individual or societal forces to cause or become a barrier against suicidal behaviors. To work effectively with ethnic minorities with suicidal behaviors, substance abuse treatment counselors should develop culturally sensitive suicide interventions or programs for clients experiencing suicidal ideations or behaviors. These programs should provide interventions that (a) encourage and foster pride in heritage as an important aspect of personal development, (b) incorporate community outreach efforts that are sponsored by minority groups within the minority community (i.e., fraternal organizations, local businesses, and churches), (c) utilizes the strength of the family ties as an intervention resource, and (d) recognizes that religion provides a sense of purpose, social support, moral prohibitions and cognitive beliefs. When put together, all of these components can safeguard and often decrease the likelihood of suicide by adolescents of ethnic minority groups in substance abuse treatment [3,30].
Although we have concentrated on the general similarities and differences of minority cultural groups as it relates to influences that could affect suicidal behavior in substance abuse treatment settings, there are notable amounts of within-ethnic group differences. The diversity within-ethnic groups are apparent in the differing rates of suicidal behavior and cultural differences among individuals in substance abuse treatment settings within the same ethnic minority groups [31,32]. Therefore it is suggested that future research focus more on investigating (a) patterns of suicidal behaviors and withinethnic group differences and (b) cultural differences that could influence the probability of suicidal behavior among individuals within the same ethnic groups (i.e. socioeconomic status, educational background, levels of acculturation).


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