Teen suicide in male Native American teens
Elizabeth Nather

Teen suicide in male Native American teens

Community can be interpreted and defined in a variety of ways depending on the group, it’s purpose, size, their interests, makeup, history, and bonds. Some communities have a history together while others form for just a short period of time. Because of these variables, a community can exist for different reasons, and have a unique make up with its own particular standards and goals. While one community may exist to counsel its members short term, another may have existed for many years with the goal of promoting future generations and preserving the history and traditions of their community. Webster defines community as, “a group of people with a common background or with shared interests within a society (Meriam Webster, 2010). The Native American Indians are an identified community. They share a common history and have shared interests within their society. Theirs is a unique culture with rich traditions and beliefs that have been passed on through many generations; a culture very different from many typical US ones. Historically, Native American communities have encouraged interdependence among Indian youth, families, and community connections (Long, et al.,2006). As these communities foster interdependence, many Native American youth are faced with a one sided knowledge of American society. The reservation is all they know so they cannot acclimate to anything outside of the reservation. Unfortunately, Native American reservations are not very conducive to providing healthy, productive environments for their youth. Many children are raised by single parents or by members of their extended families due to the high rate of unemployment and alcoholism (Williams, 2009). There are significant risk factors attached to Native American youths growing up on Indian reservations including; alcoholism, incarceration, death from injury, methamphetamine abuse, and mental health issues, specifically, suicide (Dorgan, 2010). Suicide among Native American teenage males is the health problem under study. Suicide is referred to as a single response to multiple problems. It is not only a clinical nor individual problem, but is one that affects and is affected by many communities (Grim, 2005). The statistics are staggering, and the fact that these numbers continue to grow is more chilling. The rate of suicide in this population is 70% higher than any other U.S. ethnic group (Dorgan, 2010). According to the CDC, from 1999 – 2001,the rate of suicide by male Native Americans was 45.9% per 100,000. From 2003 to 2005, this increased to 55.2% (CDC, 2010). When these numbers were compared to all races, suicide was 64% higher from 1999 – 2000. This number increased to 73%. The rate of suicide in Native American youths is 73% greater when compared with all races (CDC,2010). There are variances yet similarities on aspects of Native American suicide. Suicide rates vary among Native American youth across tribes in rural areas versus urban areas (Mullany, et al., 2009). Statistics showed the average rate of suicide for teen living in rural areas is 20.2 per 100,000. This is substantially higher than the rate of 11.7 for teen living in urban areas (Mullany, et al.,2009). Similarities include method, month, and day of incident. Suicide occurred more frequently on Saturdays during the month of August. Typical method was by hanging (Mullany, et al.,2009). Native American suicide has become a focal point for the Indian Health Service (IHS). This agency is within the Department of Health and Human Services and works exclusively with Native Americans. It is responsible for providing health services to American Indians facilitated by clinics across the United States. These services include child health, women’s health, physical rehabilitation, dental care, injury prevention programs, and behavioral health, though services vary by sites (IHS, 2011). An individual must be an enrolled member of a federally recognized tribe to be eligible for benefits. The individual has to be registered in the IHS database prior to receiving any services at clinics located in states including California, Arizona, New Mexico, Texas, North Dakota, and South Dakota. The IHS is staffed by professionals licensed to provide these services. Employees include, physicians, physician assistants, nurses, nurse practitioners, physical therapists, occupational therapists, dentists, social workers, and mental health counselors. Several education and prevention programs are offered at the facilities. These offer nutrition and diet counseling and injury prevention. The IHS also has a joint partnership with the National Institute of General Medical Science which conducts behavioral, biomedical, and health services research (IHS, 2011). The history of teen suicide on Native American reservations has been studied but more, recently, has become a focal point for the IHS because the numbers continue to grow. Currently, the agency is still working in partnerships with tribal communities, research centers, universities, and other agencies to study the problem and determine effective intervention strategies. The IHS has prepared a Behavioral Health Strategic Plan (2011 – 2015) to respond to the “growing evidence about how behavior and lifestyle affect health conditions (National Behavior Health Plan, 2011). The agency emphasizes using approaches that include cultural and traditional practices. They also include using prevention and treatment strategies (National Behavior Health Plan, 2011). The problem of Native American suicide is a deep rooted issue multi layered issue. Traditionally, Native Americans believe that if one takes his own life, his soul will wander and cause harm to living family members. That person’s soul will not go to heaven until the time that his death would have naturally occurred (LaFromboise & Lewis, 2008). This is also a source of stigma to the remaining family (ibid, 2008). There are several environmental factors related to teen suicide; lack of in tact families, high unemployment rates, limited mental health services, and alcoholism (Williams, 2009). Some blame it on the depressive lifestyle of the reservation, where there is no access to good education, no jobs, and basically no future for young people (Thackeray, 2011). Since the environment is a determinant factor in this issue it is appropriate to use this ecological model as the framework to use as a community needs assessment (Anderson & McFarland, 2011). The environment along with the culture, biological, socio-economical and physical factors all factor into the community needs. Perhaps the most influential factor here is the cultural and strong traditional beliefs these tribes have. Statistics would have to be obtained from individual tribes to determine the extent of the problem in each tribe. I would also be interested in seeing statistics for the number of attempted suicides as well. Statistics should be broken down according to sex, age group, and past mental health issues. These statistics may be difficult to obtain because some tribes are reluctant to keep these statistic or are leery of outsiders coming in and asking for these numbers (LaFromboise & Lewis, 2008). Tribes have the option of operating their own programs and have the choice to report data on suicides (Dorgan, 2010). Suicide rates and patterns were examined in a joint research effort conducted by the Apache tribe and the John Hopkins Center for American Indian Health. They conducted a community based participatory research project (CBPR) in 2004 to design and evaluate suicide prevention interventions (Mullany, et al, 2009). After a cluster of suicides in 2001, the Tribal Council enacted a resolution which mandated that all members and providers report suicidal behavior to a central registry. They determined that between 2001 and 2006, 61% of Apache suicides were by youths under 25 (Mullany, et al, 2009). There was a 5:1 ratio of male to female with hanging as the most common method (Ibid, 2009). A CBPR was used to ensure a culturally sensitive interpretation of these findings as there had been a volatile history in the tribal communities. This technique was also used because models for cause and treatment options are varied in tribal communities (Mullany, et al, 2009). This involved collecting data including name, age, gender, type of suicidal behavior, history, method, and possible precipitating factors. Because this technique was used, researchers were able to capture suicide traits unique to this tribe and develop appropriate intervention strategies. They determined that 35% of attempts presented to the local emergency department resulting in a evidenced based intervention to be used. This intervention educated the teen and his family about the severity of the attempt and provided culturally appropriate treatment options (Mullany, 2009). They also developed a family based intervention which included a home visiting plan to be instituted (Mullany, 2009). A study funded by the Bureau of Indian Affairs examined suicide attempts in Native American high school students (Shaughnessy, et al., 2004). The study aimed to correlate suicide attempts with risky behaviors. Students were asked to complete a Risk Behavior Survey which measured six categories of risky behaviors and asked about suicide attempts. Results showed 16% of surveyed high school students attempted suicide in the year preceding the survey (Shaughnessy, et al., 2004). Those that admitted to the attempts also engaged in some form of risky behavior; drugs, and alcohol. Several risk behaviors which correlated with suicide attempts were identified from the survey. The data suggested that there was a relationship between risk behaviors and suicide (Shaugnessy, et al, 2004). Suicide prevention programs were developed and implemented as a result of identifying this association between risk behaviors and suicide attempts. These programs were primarily school based interventions which alerted and educated school personnel to the responsibility of recognizing teens in need (Shaughnessy, et al., 2004). Alacantra and Gone (2007) studied teen suicide throughout Native American communities. They referred to the Standing Rock Sioux reservation initially. In 1997, there were 37 attempts and 5 successful suicides by male teens in this tribe. During this time there were an estimated 150 teens being monitored for as suicide risks. The authors’ goal in writing was to adopt a framework that would conceptualize and identify points of interventions which could be used by all Native American tribal members. They attempted to focus establishing interactions between teens and their environments in the hope of identifying conditions which would heighten suicide risk (Alacantra & Gone, 2007). The authors stressed the importance of identifying factors which lead to the suicide as this would formulate a deeper understanding of the problem. This would lead to the development of appropriate intervention programs. They felt that to combat the problem of teen suicide, interventions proposed would have to reinforce any protective factors (Alacantra & Gone, 2007). A life skills development program was developed as part of an initiative to address teen suicide among Zuni Tribe. This program was developed in 1987 after parents and leaders in the tribe became alarmed over the growing number of male teen suicides ((LaFromboise & Lewis, 2008). Researchers speculated that part of the reason for the increased rate was because the Zuni family structure was fragmented (Ibid, 2008). This was the result of increased single family housing which broke up extended families and disrupted the overall value of the family structure culturally, socially, and economically (Ibid, 2008). Since the family structure was disrupted, this impacted the Zuni culture as it was difficult for members to participate in tribe functions. This weakened the transfer of cultural knowledge and traditions to the youth causing a disconnect for the teens (LaFramboise & Lewis, 2008). Additional economic issues impacted the tribe causing further turmoil in families. Teens were interviewed and assessed for suicidal ideations. Risk factors identified included substance abuse, dislike for school, stress, limited social support, weak interpersonal communication, past suicide attempts, and mental health issues (LaFramboise & Lewis, 2008). After risk factors were identified, a community based high school suicide prevention program was designed. This program was different as it specifically addressed cultural values within the community structure. It was specific to the Zuni Tribe. The program was changed from a suicide prevention program to a life skills program. Initially suicide prevention was addressed but this was replaced with skills training in the beginning stage. Suicide and crisis management information was gradually phased in (LaFramboise & Lewis, 2008). The program offered extensive skills training through the use of small group work, role modeling exercises, and community gatekeeping (Ibid, 2008). The program was unique because it was specific to the Zuni culture. The culture revolved around communication, values, norms, and forms of recognition. The program was team taught with a Zuni and non Zuni teacher. Any personal issues were discussed in the Zuni language (LaFramboise & Lewis, 2008). Teens were told the most important possession they would ever have is the life they were given. Lessons focused on community cohesion and the strength of the family, while reinforcing the power of their culture (Ibid, 2008). Pettingell, et al., (2008) examined the likelihood of suicide and associated risk factors in Native American teens. They assessed risk and protective factors and concluded that both should be identified so that proper and successful intervention programs could be initiated. They surveyed 569 urban teen Native Americans who were asked to identify the strongest risk and protective factors that were relative to a past suicide attempt. They hypothesized that protective factors would offset the risk factors associated with a suicide attempt (Pettingell,et al., 2008).
Their analysis concluded that interventions had to respond to indications of vulnerability. Key risk factors also had to be addressed if interventions were to be successful and interventions should be designed to increase protective factors. The federal government has responded to the Native American crisis by offering suicide prevention programs through the IHS (Dorgan, 2010). In 2003, the IHS started a Suicide Prevention Initiative which resulted in a plan for implementing suicide response interventions. This mandates IHS mental health clinic to provide suicide assessment and prevention programs. The agency website also contains information providing resources and information on teen suicide (Dorgan, 2010). IHS and The Substance Abuse and Mental Health Services Administration (SAMHSA) have partnered to offer suicide prevention education. SAMHSA has funded various programs geared towards educating and preventing suicide in this at risk population (Dorgan, 2010). The U.S. Senate passed the Indian Health Care Improvement Act in 2001 which addresses Native American teen suicide. Though the issue has been recognized and addressed, programs are being cut todays and there are still not enough mental health services available to this population. Senator Dorgan has been an ardent supporter of American Indian rights and continues to push for these services and programs. Teen suicide has been addressed as part of the Healthy People 2020 initiative. The goal of the initiative is to improve the safety and well being of adolescents (HealthyPeople.gov, 2010). The initiative stems from the problems adolescents are facing today which prove to be destructive to their general health and well being. Teens are faced with injury, violence, substance abuse, mental health issues and other factors that can negatively impact their lives. These are all linked to family, school, neighborhoods, and media exposure (HealthyPeople.gov.,2010). Healthy People (2010) identified two issues concerning adolescent health. The racial makeup of adolescent health is changing. There is an increase in the numbers of Hispanics and Asian Americans. As such the health issues involving these populations have to be recognized and addressed. Healthy People (2010) has also research the effectiveness of intervention programs. It was determined that teens do respond to positive intervention programs so it is vital for their futures to continue to initiate these programs and educated them to these programs and resources. The Native American community has been identified as the community at risk. Many communities are riddled with criminal activity, inadequate health services, lack of job opportunities, and poor educational options which has impacted its residents, notably male teens. The most alarming concern is the number of suicides by Native American teen males. Nationally, suicide is the third leading cause of death among U.S. teens (CDC, 2006). The rate is even higher among Native American male teens. Suicide accounts for 1 in 5 deaths among Native Americans (CDC, 2006). This is 73% greater when compared with all races (CDC, 2006). A number of studies have been conducted which have identified risks factors that resulted in intervention screenings, and prevention programs. Researchers have incorporated cultural factors into these programs specific to the Native American tribe’s own culture and have devised wrap around programs to involve the individual community, school, and health center. The sad reality is that the problem of teen suicide is still a major concern in these communities. Stage II of this paper will continue to research this issue focusing on the tribal cultures, research findings, community diagnoses, and input from a Native American policy analyst at IHS .

Native American communities are individualized according to their cultural heritage yet they share significant problems. Many children witness abuse or are abused. There is a high rate of physical and emotional neglect (Thackeray, 2011). The reservations do not offer any kind of future for its youth. High unemployment rate is consistent and there are no job prospects of any kind (Thackeray, 2011). Thackeray (2011) also mentions how difficult it is for Native Americans to leave the reservation to work as they are usually in a foreign culture where there is no family

support. They feel very alienated and unwelcomed which adds to their stress. This additional stress impacts the home life and children.

The Zuni community speculated that one reason for the increase in teen suicide was because the Zuni family structure was becoming fragmented is because of dispersed housing developments (LaFramboise & Lewis, 2008). Extended families that once lived together in single family homes were now living separately in HUD constructed homes and subdivisions. This resulted in broken up families, which affected social, cultural, economic, and emotional ties (LaFramboise & Lewis, 2008). There was a huge impact on cultural traditions as this weakened the transference of culture to younger generations (Ibid, 2008). It is interesting to note that something that should have been beneficial to these people only caused additional hardship.

These determinations were found after reviewing numerous research studies which focused on teen suicide in the Native American culture. Statistics were found at online sites from the CDC and Indian Health Service. The IHS specifically addresses teen suicide and lists vital statistics along with intervention programs and resource agencies. The problem has been identified but it still seems to be understated and mismanaged by the public lending to its failures.

This writer had the opportunity to conduct a phone interview with Cheryl Peterson (personal communication, October 19, 2011), a senior public health analyst with the Indian Health Service in Maryland. Ms. Peterson is a Native American with a MSN concentration in psych nursing. She is well versed in Native American culture as she grew up on a reservation in Montana. She presented a more positive picture of the epidemic and looked at the issue using a different approach. According to Ms. Peterson, there are 560 Native American tribes in the United States today. Their cultures are very unique to their tribal heritage, which is an important consideration when planning programs.

Ms. Peterson (personal communication, October 19, 2011) feels these programs are making a difference as evidenced by the decline in numbers from the CDC. Statistics are only available up to 2008, but they do show a small decline. She feels the numbers will continue to show an increase in decline as the statistics become available for more recent years. Many of these prevention programs combine traditional ways with practices and strengths. They are seeing a new response to teens embracing their culture and are returning to incorporating cultural practices into educational programs. Ms. Peterson referred to this as returning to basic Native American beliefs and customs.

In the past, Native Americans were forced to hide their cultural practices as some were considered unlawful. Peterson’s (personal communication, October 19, 2011) own tribal customs were considered illegal so they were forced to go underground. As a result, many Native Americans were hesitant to admit to their heritage so many hide it or moved away from practicing the culture. She described Native Americans as a resilient and proud people who have suffered so much in the past, but she sees many strides being made. Native American youth is identifying with the culture and there is more cultural awareness as a whole. She feels educational opportunities have improved mostly because there are many tribal schools available for the children and teens, which incorporate heritage and customs in the learning environment. They are enthusiastic about practicing and learning their culture. It is more acceptable in the society.

Peterson (personal communication, October 19, 2011) also had many positive things to say about the programs available for teens; her favorites are Project Venture and the Zuni Life Skills. There are also new programs being initiated and research has continued, even grown in this area. These programs have moved to evidenced based so she is confident that they will continue to grow and be even more successful. She did stress that these strides have to continue and the communities have to be vigilant about maintaining their responses to the crisis.

There are many successful programs for Native American teens which promote life skills, social interaction, community service, alcohol awareness, substance abuse education, and spiritual awareness. These are evidenced based programs and are offered to preteen and teen age Native Americans. As Ms. Peterson (personal communication, October 19, 2011) said, they are making small but successful strides which will continue to grow. It takes a working relationship with health centers and the community to make these programs happen and work. The community has to accept the idea of outsiders coming in.

There are several community diagnoses which were identified for this problem but there are two that serve as focal points.

- Potential for destructive behaviors and associated consequences r/t lack of adequate social services available as manifested by exhibited substance abuse and violent behaviors.

- Potential for ineffective coping of male teens r/t lack of mental health services as evidenced by suicide rate.

These diagnoses reflect the importance of available programs which are proactive for this population. They also reflect the basis of the problem as this author sees it. These teens need access to services whether it is in a counseling situation, a school based wrap around, or an outreach program. They should have resources made available to them at young ages so they are aware of the negatives in their communities. They also have to be comfortable with asking for and receiving help. Maybe with this education and the available resources they will know how to get help should they need it.

A further examination of interventions for this issue should focus on this writer’s initial community diagnosis of; potential for destructive behaviors and associated consequences r/t lack of adequate social services available as manifested by exhibited substance abuse and violent behaviors. These behaviors are the product of these communities that cannot support their youth. Instead of offering them healthy productive futures tribal communities offer poor educational options, no job prospects, and bleak futures. This prospect pushes many teens into destructive behaviors as a coping mechanism. The intervention has to start within the community and should address successful life skills.

The literature suggests that a successful intervention program is one that incorporates tribal cultures into the plan. A hybrid approach was developed so it could be tailored according to a tribe’s specific customs (LaFromboise & Lewis, 2008). This is the perhaps the most important aspect of this intervention as Native Americans are reactive to their culture. We are the outsiders and unless their culture is recognized, the program will not be welcomed in the community. They have to identify with the program and this identity is through their specific cultural habits. Before an intervention plan can be initiated a thorough review of tribal customs should be completed.

Once tribal customs have been identified, an intervention plan has to include significant community players. This author promotes school based programs as school is considered to be a safe haven for a teen. The school has to work with community providers, stakeholders, attached clinics, and outside representatives depending on the community. The educational site has to support and be proactive for this program or it will fail. Everyone has to participate and promote this program.

One school based program initiated worked on changing the climate at the school (Thackeray, 2011). Schools have to address behavioral and bullying issues and get these in check in order to ensure that all students have school as their safe haven and as a support system. As the student recognizes that school is his support system, hopefully, this will encourage him to ask for and receive any support services he may need. For many Native Americans, school is the only place where there is stability and comfort so it is a natural place for him to be able to find and receive any support.

While schools should provide a safe and healthy environment for these teens, they must also provide a quality education to students. Naturally, this is a partnership, but these teens have to be taught that education is their way to success. They have to learn to embrace and appreciate education as it is one thing that can never be taken away from them. Many do not appreciate education because they are not taught the value of it and some schools just are not providing quality educations for these teens. These schools should be offering life skills and college prep programs.

A school based intervention program can also offer wrap around services for a student in need which ensures quality and consistent care for that student. A school based clinic is the ideal; however, an outside clinic is an alternative. This author prefers school based as it is readily available to the student and there is usually a higher level of comfort with the school based personnel. Students are free to go there and they offer consistent care.

This writer would also like to see activities that encourage teens to look toward their futures. This simple but powerful intervention can include identifying career interests, determining life after high school, arranging college trips, assisting with financial aid. Teens have to learn to advocate for themselves, but adults have to show them the way.

The schools should offer some kind of resources for parents in the way of support services, parenting classes, educational services, and parental involvement activities. There is always a cost issue, but some of these services can be offered free of charge from outside community providers. Some of the disruption in a teen’s life stems from family stress so if the family member can get these services through the school, it may help the teen. Healthy parental involvement and interest can be very beneficial to a teen.

This writer would use an intervention approach based on the American Indian Life Skills Development Curriculum as my project plan (LaFromboise & Lewis, 2008 ). This model is diverse but culturally informed designed to incorporate a specific tribe’s culture so that it acknowledges that tribe’s cultural beliefs and customs. A life skills approach was designed to encourage team building, peer relationships, support systems, and overall support (LaFromboise & Lewis, 2008). Family backgrounds were also addressed.

The life skills model would utilize nursing and mental health counselors. Nursing interventions should include screening teens for mental health issues, teaching mental health promotion, and referring for mental health services. Nursing would also try to incorporate outside providers as additional resources for teens in need. The nurse would work in tandem with these mental health counselors. This combined effort would hopefully be seen as a sign of support for teens in need.

An intervention program has to address the underlying cause of the problem. Here, there are several. Native American suicide is the result of ineffective coping skills related to destructive behaviors resulting in suicides. There are many layers to the problem but it starts with a depressed lifestyle which is reflective of an unstable home, abuse, and violent behaviors. These issues with cultural traditions must be identified and studied before a successful intervention can be put in place. The intervention must address the issue of hopelessness which many teens feel in these tribal communities.

Native American teen suicide is a multi - layered problem that must be remedied. The numbers continue to reflect teen suicide in this population is the highest in the country. These people are extremely proud and protective of their culture so interventions must be specific and respectful to this. Though CDC numbers reflect suicide rates up to 2008, some are confident that these numbers will decrease as new results are released (Peterson, personal communication, October 19, 2011). One can only hope she is right.

References
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