Taking a culturally responsive approach to suicide assessment

September 2023

Although the overall suicide rate in the United States has been decreasing in the past few years, death by suicide among people in marginalized groups has been increasing at an alarming rate. According to data by the Centers for Disease Control and Prevention (CDC), American Indian and Alaska Native people had the highest suicide rate increase from 2018 to 2021 at 26%. Although the second highest suicide rate was among non-Hispanic white people, this was the only group to show an overall decline by 4%. Other marginalized groups, particularly among youth and men, indicate areas of concern for mental health professionals. According to the CDC, suicide rates among Black youth age 10 to 24 increased 37% from 2018 to 2021, and the suicide rate among Hispanic men increased by 5.7% from 2019 to 2020, while the suicide rate among non-Hispanic white men decreased by 3.1%. Among Asian American and Pacific Islander communities, suicide was the leading cause of death for people ages 10 to 19 in 2020. Heather Dahl-Jacinto, an assistant professor and counseling program coordinator in the Department of Counselor Education, School Psychology and Human Services at the University of Nevada, Las Vegas, says while clinicians should not generalize about the experiences of marginalized groups, researchers have found that there is an association between historical and racialized trauma and suicide risk. “For those with marginalized intersectional identities (such as race/ethnicity, sexual orientation, social class, gender identity), there is an increased pattern of suicide risk in individuals,” she explains. “Understanding the intersectional identities of our clients and their own lived experience is vital to our work with clients.”

Socioeconomic factors associated with suicide

The COVID-19 pandemic and social injustices may have contributed to the rise in suicide rates in the past few years, especially among marginalized groups. Karlos Lyons, a licensed professional counselor (LPC) at Davis Counseling Center PLLC in Dallas, says during the pandemic the Black community struggled to come to terms with social isolation, loss of loved ones, ongoing health disparities and the racial unrest that spread worldwide in the wake of the murder of George Floyd. Ana Sierra, an LPC in Washington, D.C., says many of her Latinx immigrant clients, who work as essential workers, were among the first to get sick with COVID-19. She notes these clients suffered because they lacked access to health care and lost their jobs when they got sick, which forced many of them to lose stable housing. “Latinx men have a particularly hard time because in their gender role, seeking help or talking about their worries with others is a sign of weakness,” notes Sierra, founder and executive director at Ana Sierra Counseling/Consejeria PLLC, an all-Latinx, bilingual (English/Spanish) and bicultural group practice. When Latino men, who are viewed as the head of their household, cannot fulfill their responsibilities to their families they don’t feel validated and can be hit by intense feelings of uselessness, she explains. “In the Asian community, we have experienced an increased risk of suicide among Asian Americans due to systemic factors during the pandemic,” says Wales Khoo, a licensed mental health counselor in New York and the clinical director at the Chinese American Sunshine House, a nonprofit that provides mental health services for the Chinese community. “These factors include economic hardship, financial insecurity, racism, discrimination, hate crimes and limited access to health care.” In addition, immigrant youth may face significant pressure from their families and communities to excel academically, Khoo says, which can lead to mental health issues such as stress, anxiety and depression. This pressure is particularly intense for first-generation immigrants who “may feel their success or failure reflects on their family’s reputation,” he adds. “Many Asian American youths also experience acculturation stress as they navigate the challenges of living in a culture that is different from their parents’ or their family’s culture,” Khoo says. “Conflict between generations or between cultural values can contribute to feelings of isolation, depression and suicidal ideation.” Research shows systemic socioeconomic factors — specifically racism, discrimination and adverse childhood experiences — directly affect suicide rates among people of color, notes Dahl-Jacinto, whose research areas include suicide prevention and assessment and social justice issues in professional practice. In addition, these factors can prevent marginalized clients from seeking mental health services as they seek to thrive in a society that presents persistent obstacles. The counselors interviewed for this article recommend counselors be open to learn about a client’s lived experience, which will help people from marginalized communities feel safe enough to trust the therapeutic process and make it easier for counselors to thoroughly assess for suicide risk. Cultural responsiveness requires counselors of all backgrounds “to gain an understanding of the client’s worldview and experiences in concert with the client,” says Danica G. Hays, a professor of counselor education and educational psychology and the dean of the College of Education at the University of Nevada, Las Vegas. And this includes validating any experiences of oppression and disempowerment that clients may report. “Those experiences are real and can exacerbate any mental health issues a client may be facing,” she stresses.

Building rapport

Recent clinical research about suicide risk assessment and intervention shows that focusing on the counselor-client relationship and cultivating trust and rapport can go a long way when dealing with a difficult topic such as suicide, Dahl-Jacinto says. She stresses the importance of not making assumptions about a client’s personal identity; instead, she advises counselors to use the strategy of broaching in session to create a safe space that allows clients to feel comfortable sharing their story. “When working with communities that are traditionally marginalized, making sure that the counselor is intentionally acknowledging these concerns is essential to building rapport,” she explains. Suicide risks are multifaceted, notes Lyons, who specializes in treating Black adolescents age 12 to 18. Some young Black men, for example, may struggle with hypermasculine ideals that “dictate to them not to feel or process their emotions because they are boys,” he says, noting that these clients often report having trouble connecting with others and dealing with feelings of worthlessness. Lyons says it’s important to help these young men find others who can serve as healthy role models. “Once a young man has a positive, corrective, emotional experience with another male role model, whether it be a father, uncle, friend or even a peer, typically their mental health outcomes improve,” he explains. “They now have a safe place where they can go for validation and approval.” Counselors need to model unconditional positive regard for their clients to build rapport with them, Lyons adds. “When broaching the topic of suicidal ideation, look for the root cause of ideation, rather than the symptoms,” he advises. “I like to use Abraham Maslow’s hierarchy of needs to assess what needs are not being met that may have led to mental health distress.” Lyons says many adolescents have experiences in school such as poor school performance, bullying, a lack of friendships and isolation, which may lead to them becoming more suicidal. Lyons also uses age-appropriate games as a therapeutic tool to encourage dialogue with his clients. For example, he sometimes asks clients to play the Ungame, a noncompetitive board game that requires players to answer lighthearted or serious questions as they roll the dice and move around the board. “It fosters organic dialogue between the therapist and client, and it facilitates really healthy conversations that can lead to some extremely helpful therapeutic content,” he notes. Lyons, who is a Black man, says that simply “showing up as a Black man” can often help him gain his clients’ trust. For many Black youth, working with a clinician who looks like them and lets them know they are the expert on their own lives often helps them feel comfortable to “share their own truth,” he says. The majority of Sierra’s clients have immigrated to the United States, and she says they often do not understand how the country’s mental health system works. She uses psychoeducation to explain what therapy is, how it can help, the difference between having suicidal thoughts and a suicide plan, and the stigma of mental illness and suicide. She says the clinicians at her practice also discuss any fears clients may have about being treated for suicidal behavior and their immigration status. For example, immigrant clients are less likely to seek treatment because they fear it will affect their chances of becoming documented in the future or they fear being deported, she says. The therapists at Khoo’s clinic also adopt a culturally sensitive approach that acknowledges and respects clients’ cultural background and values. Because suicide is frequently regarded as a taboo subject in the Asian community, he and his colleagues, who treat primarily Asian American and immigrant clients, address the Asian community’s apprehension and worries about suicide by creating a safe and comfortable atmosphere, as well as encouraging family engagement, which are important elements that aid in healing. Demonstrating a genuine acceptance of a client’s struggles with oppression helps to build rapport and trust, says Hays, author of the recent ACA book Assessment in Counseling: Procedures and Practices (seventh edition). Counselors are then able to “define the broad spectrum of what suicidality is and note the relevant statistics based on the client’s cultural makeup.” It’s also important to help clients see that many other people face suicidality and that through treatment, clients have access to resources that can help them to heal, she adds.

Evidence-based assessment tools

Dahl-Jacinto and Hays acknowledge that while no suicide risk assessment tool is free from cultural bias or is completely culturally responsive, there are some evidence-based, standardized suicide risk assessment tools that can be used to evaluate a variety of clients. The counselors interviewed for this article recommend the following assessment tools:

• The Columbia-Suicide Severity Rating Scale helps physicians, mental health clinicians and other health care professionals assess suicide risk using a series of simple, plain-language questions. The Columbia Lighthouse Project, which distributes the scale, provides free training.
• The Collaborative Assessment and Management of Suicidality is an assessment and intervention framework where the client plays an active role in identifying and addressing the drivers of suicide risk.
• The Ask Suicide-Screening Questions assessment, produced by the National Institute of Mental Health, can be used for both adults and youth of all ages and provides four brief, direct questions to identify suicide risk. This assessment is also available in Spanish.
• The Patient Health Questionnaire-9 and Generalized Anxiety Disorder-7 are self-administered assessment tools that assess the severity of depression and anxiety, respectively. Sierra recommends clinicians use the Patient Health Questionnaire-9 to learn more about a client’s symptoms and any suicidal thoughts and feelings they may be experiencing.

Because of the link between trauma and suicidality, Hays also recommends counselors conduct a trauma assessment. She suggests clinicians use the Adverse Childhood Experience Questionnaire for Adults or the Clinical Ethnographic Narrative Interview. The counselors interviewed for this article advise clinicians to make suicide risk assessment a part of the intake process. Providing a comprehensive psychosocial evaluation allows practitioners to explore a client’s personal and family history, their social support network and other environmental factors, Khoo says, which helps clinicians gain a full picture of a client’s mental state and well-being, not just the symptoms they present in session. The evaluation can also give counselors insight into a client’s cultural traditions, spiritual beliefs and value systems, which can be useful in the assessment process and creating treatment and safety plans, he adds.

Protective cultural factors

A client’s cultural traditions and spiritual beliefs are important to consider when assessing suicide risk and are also an essential part of building a strong therapeutic alliance. Dahl-Jacinto says when counselors are working with clients who are experiencing suicidality, they want to make sure they have a good idea of potential protective factors in the client’s life, including ones from their cultural traditions or spiritual beliefs. “I like to use the building blocks metaphor that we use in suicide research — each protective factor we can identify acts as a building block that builds a wall around our client, protecting them from harm,” Dahl-Jacinto explains. Khoo says in some Asian communities, cultural traditions, religion and spiritual beliefs play a significant role in people’s lives. “Many Asian cultures have unique beliefs and practices around mental health and suicide, and incorporating these into the treatment process can help build rapport, enhance treatment engagement and increase the client’s sense of hope and resilience,” he notes. For example, therapists at Khoo’s practice might use storytelling, art or music to facilitate a dialogue and help clients connect with their cultural heritage, which can help them build a sense of pride and identity. Sierra says the clinicians at her practice normalize talking about suicide and make counseling a safe and welcoming space for clients — one that is similar to how clients might seek guidance from pastors, folk healers and others in their community. “A therapist,” she stresses, “is one more helper in their circle.”

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Suicide risk and prevention resources

• American Counseling Association’s suicide prevention resource page
• American Foundation for Suicide Prevention
• “The need for standardization in suicide risk assessment,” by Gregory K. Moffatt, Counseling Today, April 2020
• 988 Suicide and Crisis Lifeline
• Suicide Assessment and Treatment Planning: A Strengths-Based Approach by John Sommers-Flanagan and Rita Sommers-Flanagan, 2021
• Suicide Prevention Resource Center
• “Taking a strengths-based approach to suicide assessment and treatment,” by John Sommers-Flanagan and Rita Sommers-Flanagan, Counseling Today, July 2021

 

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Lisa R. Rhodes is a senior writer at Counseling Today. Contact her at lrhodes@counseling.org.

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