J. Chu, P. Goldblum, R. Floyd, B. Bongar (2011) The cultural theory and model of suicide. Applied and Preventive Psychology.

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Please
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Chu,
J.
P.,
et
al.
The
cultural
theory
and
model
of
suicide.
Applied
and
Preventive
Psychology
(2011),
doi:10.1016/j.appsy.2011.11.001
ARTICLE IN PRESS
G
Model
APPSY-76;
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Applied
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Preventive
Psychology
xxx (2011) xxx–
xxx
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at
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Applied
and
Preventive
Psychology
jo
ur
nal
homepage:
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Review
The
cultural
theory
and
model
of
suicide
Joyce
P.
Chu∗,
Peter
Goldblum,
Rebecca
Floyd,
Bruce
Bongar
Palo
Alto
University,
1791
Arastradero
Road,
Palo
Alto,
CA
94304,
USA
a
r
t
i
c
l
e
i
n
f
o
Article
history:
Received
1
July
2011
Received
in
revised
form
23
November
2011
Accepted
23
November
2011
Keywords:
Culture
Suicide
Theory
Ethnicity
Sexual
orientation
Asian
American
Latino
African
American
LGBTQ
a
b
s
t
r
a
c
t
A
growing
body
of
research
has
demonstrated
important
variations
in
the
prevalence,
nature,
and
corre-
lates
of
suicide
across
ethnic
and
sexual
minority
groups.
Despite
these
developments,
existing
clinical
and
research
approaches
to
suicide
assessment
and
prevention
have
not
incorporated
cultural
variations
in
any
systematic
way.
In
addition,
theoretical
models
of
suicide
have
been
largely
devoid
of
cultural
influence.
The
current
report
presents
a
comprehensive
analysis
of
literature
describing
the
relationship
between
cultural
factors
and
suicide
in
three
major
ethnic
groups
(African
Americans,
Asian
Americans,
and
Latinos)
and
LGBTQ1sexual
minority
groups.
We
utilized
an
inductive
approach
to
synthesize
this
variegated
body
of
research
into
four
factors
that
account
for
95%
of
existing
culturally
specific
risk
data:
cultural
sanctions,
idioms
of
distress,
minority
stress,
and
social
discord.
These
four
cultural
factors
are
then
integrated
into
a
theoretical
framework:
the
Cultural
Model
of
Suicide.
Three
theoretical
principles
emerge:
(1)
culture
affects
the
types
of
stressors
that
lead
to
suicide;
(2)
cultural
meanings
associated
with
stressors
and
suicide
affect
the
development
of
suicidal
tendencies,
one’s
threshold
of
tolerance
for
psychological
pain,
and
subsequent
suicidal
acts;
and
(3)
culture
affects
how
suicidal
thoughts,
intent,
plans,
and
attempts
are
expressed.
The
Cultural
Model
of
Suicide
provides
an
empirically
guided
cohe-
sive
approach
that
can
inform
culturally
competent
suicide
assessment
and
prevention
efforts
in
future
research
and
clinical
practice.
Including
both
ethnic
and
sexual
minorities
in
our
investigations
ensures
advancement
along
a
multiple
identities
perspective.
© 2011 Elsevier Ltd. All rights reserved.
Contents
1.
Cultural
variations
in
suicide
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2.
Existing
theoretical
models
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3.
The
present
study
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4.
Methods
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5.
Results
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5.1.
Cultural
sanctions
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5.2.
Idioms
of
distress
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5.3.
Minority
stress.
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5.4.
Social
discord
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6.
The
Cultural
Model
of
Suicide.
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6.1.
Three
principles
of
the
Cultural
Model
of
Suicide
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7.
Conclusions
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implications
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References
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.00
1“LGBTQ”
populations
are
also
referred
to
as
“sexual
minorities.”
LGBTQ
is
an
abbreviation
for
lesbian,
gay,
bisexual,
and
transgender
or
transsexual
individuals,
and
people
questioning
their
sexual
orientation.
∗Corresponding
author.
Tel.:
+1
650
814
8376;
fax:
+1
650
433
3888.
E-mail
addresses:
jchu@paloaltou.edu
(J.P.
Chu),
pgoldblum@paloaltou.edu
(P.
Goldblum),
rfloyd@paloaltou.edu
(R.
Floyd),
bbongar@paloaltou.edu
(B.
Bongar).
1.
Cultural
variations
in
suicide
A
lack
of
uniformity
in
suicide
rates
and
risk
across
cultural
groups
points
to
the
public
health
importance
of
incorporating
cultural
factors
in
the
study
of
suicidology.
Though
overall
suicide
rates
are
higher
in
White
males
than
most
other
racial/ethnic
groups
(e.g.,
22.60
per
100,000
for
White
males
compared
to
5.78
for
Asian/Pacific
Islanders,
5.22
for
African
Americans,
and
5.17
for
Hispanics
during
2004
to
2008)
(CDC,
2009),
an
examination
of
0962-1849/$
–
see
front
matter ©
2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.appsy.2011.11.001

Please
cite
this
article
in
press
as:
Chu,
J.
P.,
et
al.
The
cultural
theory
and
model
of
suicide.
Applied
and
Preventive
Psychology
(2011),
doi:10.1016/j.appsy.2011.11.001
ARTICLE IN PRESS
G
Model
APPSY-76;
No.
of
Pages
17
2J.P.
Chu
et
al.
/
Applied
and
Preventive
Psychology
xxx (2011) xxx–
xxx
specific
ethnic
subgroups
and
trends
shows
particular
areas
of
elevated
risk.
For
example,
Latina
high
school
students
report
a
higher
percentage
of
suicide
attempts
than
their
White
or
African
American
peers
(14.0%,
7.7%,
and
9.9%,
respectively)
(CDC,
2008),
and
suicide
rates
are
growing
quickly
among
African
American
adolescent
males
(Day-Vines,
2007;
Heron,
2007;
Joe
&
Kaplan,
2001).
Additionally,
Asian
Americans
had
higher
suicide
rates
(6.41
per
100,000)
than
any
other
racial
or
ethnic
group
among
females
ages
65
and
older
during
2004
to
2008
(CDC,
2009).
Other
studies
have
also
showed
higher
rates
of
suicide
attempts
in
Asian
American
compared
to
White
students
(Leong,
Leach,
Yeh,
&
Chou,
2007)
and
elevated
rates
in
Asian
American
elderly
females
(Shiang
et
al.,
1997).
Among
sexual
minority
populations,
lesbian,
gay,
and
bisexual
(LGB)
people
are
at
greater
risk
for
suicidal
behaviors2than
heterosexual
people,
and
there
is
a
substantial
and
well-documented
increased
risk
for
attempts
among
young
gay
men
(King
et
al.,
2008;
McDaniel,
Purcell,
&
D’Augelli,
2001;
Meyer,
2003).
One
meta-analysis
showed
lifetime
attempt
rates
four
times
higher
in
gay/bisexual
males
compared
to
heterosexual
males
(King
et
al.,
2008).
Recent
data
also
suggest
that
transgender
people
carry
the
highest
suicide
risk
of
any
demographic
with
up
to
one
third
making
at
least
one
lifetime
suicide
attempt
(see
Haas
et
al.,
2011
for
review).
These
cultural
minority
group3variations
in
suicide
rates
are
complemented
by
research
finding
risk
factors
that
are
culturally
distinctive
and
risk
factors
with
different
strengths
of
associ-
ation
to
suicide.
Risk
factors
unique
to
LGBTQ
individuals,
for
example,
include
concealment
of
sexual
identity
or
internalized
homonegativity
(heterosexism)
(e.g.,
McDaniel
et
al.,
2001).
The
combination
of
low
acculturation
and
parent–child
conflict
predict
greater
risk
for
suicide
among
Asian
American
outpatient
youths
(Lau,
Jernewall,
Zane,
&
Myers,
2002),
whereas
acculturative
stress
predicts
suicidal
ideation
among
Latino
adolescents
(Hovey
&
King,
1996).
Low
family
cohesion
and
support
from
extended
commu-
nities
are
particularly
important
in
matters
of
suicide
for
African
Americans
(Compton,
Thompson,
&
Kaslow,
2005).
Without
question,
a
growing
body
of
literature
on
diversity
and
suicide
confirm
that
the
nature,
expression,
correlates,
and
behaviors
of
suicide
are
influenced
by
cultural
variation
and
ethnic
and
sexual
minority
group
status
(Lester,
2009).
This
literature,
however,
has
been
subject
to
four
major
problems.
First,
scientific
findings
represent
a
large
array
of
single
suicide
risk
correlates
spread
across
numerous
minority
groups.
Though
it
is
useful
to
know
that
older
age
for
Asian
Americans,
acculturative
stress
among
Latino
adolescents,
internalized
homonegativity
among
LGBTQ,
or
low
family
cohesion
among
African
Americans
partic-
ularly
predict
suicide
risk
in
these
respective
cultural
minority
groups,
it
can
be
difficult
for
clinicians
to
recall
these
complex
combinations
of
findings
in
the
minutes
or
hours
one
has
to
assess
and
manage
high
risk
situations.
Recent
advances
have
been
made
in
reviewing
cultural
group
differences
in
suicide
by
Leach
(2006),
Leong
and
Leach
(2008),
Goldston
et
al.
(2008),
and
Langhinrichsen-Rohling,
Friend,
and
Powell
(2009);
yet,
these
reviews
largely
reiterate
knowledge
about
each
separate
cultural
group
with
limited
efforts
at
comprehensive
synthesis.
Goldston
et
al.
(2008)
does
attempt
integration
by
identifying
cross-cutting
themes
for
ethnic
adolescent
groups
such
as
the
role
of
collectivism,
religion,
or
acculturative
stress,
and
Langhinrichsen-Rohling
et
al.
(2009)
advances
our
knowledge
about
gender
differences
in
ethnic
2The
terms
suicidal
behavior,
suicidality,
suicidal
tendencies,
and
suicide
are
uti-
lized
in
this
article
as
encompassing
the
complete
range
of
suicidal
ideation,
intent,
plan,
attempts,
and
completions.
3The
term
cultural
minority
in
this
article
is
an
inclusive
referring
to
both
ethnic
or
racial
minority
and
sexual
minority
(LGBTQ)
individuals.
adolescent
groups
along
several
levels
of
categorization.
How-
ever,
neither
of
these
recent
works
carry
these
cultural
themes
further
to
provide
a
overarching
framework
for
cultural
suicide
assessment
and
management.
Thus
far,
single
culturally
specific
risk
correlates
have
not
been
systematically
organized
around
underlying
principles
that
would
allow
for
ease
of
comprehension.
Second,
existing
reviews
and
discussions
of
suicide
among
cul-
tural
minority
groups
often
extrapolate
knowledge
about
suicide
from
data
on
related
constructs
such
as
depression
or
general
psy-
chological
distress.
Though
depression
is
strongly
predictive
of
suicide,
they
can
be
mutually
exclusive
with
one
recent
study
find-
ing
that
as
many
as
one-third
of
Asian
Americans
who
attempted
suicide
reported
no
history
of
depression
or
anxiety
(Cheng
et
al.,
2010).
It
is
important
for
future
syntheses
of
culture
and
suicide
knowledge
to
amass
empirical
data
directly
related
to
suicidal
behaviors.
Third,
there
has
been
a
lack
of
integration
between
ethnic
and
sexual
minority
literatures.
In
a
diversifying
world,
researchers
have
increasingly
recognized
the
importance
of
approaching
cul-
tural
work
from
a
multiple
identities
perspective
(e.g.,
D’Andrea
&
Daniels,
2001;
Jones
&
McEwen,
2000),
defining
“culture”
not
just
as
race
and
ethnicity,
but
more
broadly
in
terms
of
other
cultural
identities
such
as
sexual
orientation.
Sexual
minority
status
has
proven
to
be
particularly
important
in
matters
of
suicide
(McDaniel
et
al.,
2001;
Van
Heeringen
&
Vincke,
2000),
and
efforts
are
needed
to
integrate
sexual
and
ethnic
minority
research
into
a
broader
multiple
identities
model.
2.
Existing
theoretical
models
for
suicide
Fourth,
data
on
culture
and
suicide
have
not
been
grounded
in
guiding
theory
(Leenaars,
2009;
Lester,
2009).
Researchers
have
drawn
attention
to
this
problem
stating
that
“there
is
no
current
or
past
theory
development
with
regard
to
suicide
among
racial
ethnic
minority
groups
in
the
U.S.”
(Leach
&
Leong,
2008,
p.
314).
Within
the
mainstream
suicide
literature,
several
theoretical
per-
spectives
have
been
proposed
including
the
cognitive
theory
of
suicide
(Wenzel
&
Beck,
2008),
the
interpersonal
theory
of
suicide
(Joiner,
2005;
Van
Orden
et
al.,
2010),
cognitive-behavioral
theo-
ries
on
hopelessness
(Beck,
Brown,
Berchick,
Stewart,
&
Steer,
1990;
Beck,
Steer,
Kovacs,
&
Garrison,
1985),
and
psychodynamic
theories
of
desire
for
escape
from
psychological
pain
(Baumeister,
1990;
Shneidman,
1998).
Yet,
existing
theories
of
suicide
do
not
apply
well
across
cultures,
and
few
directly
or
comprehensively
explain
cultural
variations
in
suicide
(Lester,
2009).
Sociological
theories,
on
the
other
hand,
direct
some
attention
to
cultural
aspects
of
sui-
cide.
Durkheim
(1897),
for
example,
circles
the
question
of
cultural
context
in
his
theory
about
the
role
of
social
integration
and
social
regulation
in
suicide.
Durkheim’s
thesis
is
that
suicide
is
related
to
broken
or
excessive
integration
with
social
networks
and
too
much
or
too
little
regulation
of
emotions
by
cultural
standards
and
norms.
Socialization
theory
and
cultural
scripts
theory
also
provide
some
basis
for
conceptualizing
the
importance
of
culturally
signif-
icant
suicide
precipitants
(Canetto
&
Sakinofsky,
1998;
Mo´
scicki,
1994;
Stice
&
Canetto,
2008).
Cultural
scripts
are
beliefs
about
sui-
cide,
socialized
by
one’s
cultural
context,
that
determine
a
blueprint
for
action
and
influence
the
events
that
trigger
suicidal
behaviors.
Though
Durkheim’s
sociological
theories
and
the
cultural
scripts
and
socialization
theories
of
Canetto
or
Mo´
scicki
provide
impor-
tant
advances,
neither
comprehensively
account
for
the
ways
in
which
cultural
factors
or
context
influence
suicide.
Leach
and
Leong
(2008),
Leenaars
(2009),
and
Lester
(2009)
discuss
how
the
ecological
model
(e.g.,
Bronfenbrenner,
2005)
can
be
used
to
extend
cultural
understandings
of
suicide
beyond
the
individual
to
the
relationship,
community,
and
society.
Anthropo-
logical
theories
or
interpersonal
clusters
of
suicide
are
highlighted

Please
cite
this
article
in
press
as:
Chu,
J.
P.,
et
al.
The
cultural
theory
and
model
of
suicide.
Applied
and
Preventive
Psychology
(2011),
doi:10.1016/j.appsy.2011.11.001
ARTICLE IN PRESS
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Model
APPSY-76;
No.
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J.P.
Chu
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al.
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Applied
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Preventive
Psychology
xxx (2011) xxx–
xxx 3
as
examples
that
have
extended
suicide
beyond
the
individual.
All
of
these
authors
emphasize
the
need
for
theory
development,
supporting
the
need
for
a
specific
cultural
theory
for
suicide.
We
propose
that
a
model
specific
to
the
processes
of
suicide
risk
is
needed
to
encompass
the
full
spectrum
of
cultural
variations
in
suicide.
Without
theoretical
grounding
or
organization
around
variegated
research
findings,
the
suicidology
field
has
been
unable
to
provide
systematized
recommendations
to
advance
cultural
suicide
science
and
practice.
3.
The
present
study
In
their
seminal
text
on
suicide
among
ethnic
groups,
Leach
and
Leong
(2008)
highlighted
both
the
pervasive
underinclusion
of
ethnic
minorities
in
suicide
research,
and
the
absence
of
the-
ory
on
culture
and
suicide.
They
call
for
the
development
of
a
framework
that
can
be
utilized
to
guide
future
work
in
this
field;
such
is
the
aim
of
this
article.
We
utilized
an
inductive
approach,
synthesizing
existing
data
on
culture
and
suicide
to
generate
pat-
terns
and
commonalities
in
the
interplay
of
cultural
factors
with
suicidology.
Specifically,
we
conducted
a
comprehensive
suicide
literature
analysis
amongst
four
major
cultural
minority
groups:
African
American,
Asian
American,
Latinos,
and
sexual
minori-
ties
(LGBTQ).
It
was
necessary
to
include
minority
status
groups
with
sufficient
available
data
related
to
culture
and
suicide.
The
four
groups
chosen
represent
the
largest
minority
populations
in
America
and
also
are
the
most
commonly
studied
within
culture
and
suicide
research.
Patterns
induced
from
this
literature
were
then
used
to
inform
theory.
This
“bottom-up”
inductive
approach
assures
that
our
resulting
Cultural
Model
of
Suicide
is
empirically
based
and
able
to
guide
future
research
and
practice.
Our
literature
review
focused
only
on
empirical
data
directly
related
to
suicidal
behavior
rather
than
constructs
like
depression,
and
concentrated
on
culture-specific
findings
distinct
to
each
cul-
tural
group
(rather
than
culture
non-specific
findings)
to
further
this
article’s
goal
of
developing
a
model
that
addresses
the
unique
ways
in
which
culture
affects
the
developmental
suicide
process.
Including
both
ethnic
and
sexual
minorities
in
our
investigation
ensures
advancement
along
a
multiple
identities
perspective.
The
current
article
furthers
extant
reviews
of
the
cultural
suicide
liter-
ature
by
providing
an
empirical
synthesis
of
data
directly
related
to
suicidal
behavior
into
a
theoretical
model
inclusive
of
both
sexual
and
ethnic
minorities.
4.
Methods
Utilizing
PsycInfo,
PubMed,
the
Psychology
and
Behavioral
Sci-
ences
Collection,
and
the
Health
Source:
Nursing/Academic
Edition
databases,
a
literature
review
was
conducted
on
suicide
research
in
four
cultural
minority
groups
in
North
America.
In
order
to
pro-
vide
an
empirical
synthesis
of
culture
and
suicide
data
based
on
current
scientific
knowledge,
literature
was
limited
to
those
pub-
lished
in
the
last
twenty
years,
from
1991
to
2011.
Search
terms
related
to
suicidology
included
“suicide,”
“suicidal,”
and
“suicidol-
ogy.”
These
terms
were
paired
with
searches
for
each
respective
cultural
minority
group:
African
American,
Asian
American,
Latino,
and
LGBTQ.
Review
articles,
book
chapters,
or
conceptual
papers
were
excluded
from
our
final
literature
review
to
limit
the
search
to
empirical
works
only.
Studies
performed
outside
North
Amer-
ica,
and
those
that
measured
suicide-related
constructs
such
as
depression
or
schizophrenia
instead
of
direct
assessment
of
suicidal
behaviors
were
also
eliminated.
All
empirical
works
were
read
by
a
team
of
eight
graduate
research
assistants
and
one
clinical
psychologist
to
extract
variables
empirically
related
to
suicide.
Variables
that
showed
no
difference
between
a
minority
group
and
the
mainstream
(predominantly
White
heterosexual)
suicide
literature
were
excluded
from
the
final
extracted
list
of
culturally
specific
findings.
For
example,
if
past
sui-
cide
attempts
and
hopelessness
(two
common
risk
factors)
were
equally
related
to
suicide
for
both
a
cultural
minority
group
and
the
mainstream
literature,
they
were
not
included
in
the
literature
review
or
extracted
variable
list.
Additionally,
research
findings
that
reported
the
prevalence
or
incidence
of
suicidal
behaviors
among
cultural
minorities
were
excluded.
The
intention
of
this
selection
process
was
to
examine
culturally
specific
risk
factors
related
to
suicidal
behaviors
only.
Our
study
addressed
categories
separate
from
simple
minority
status
as
an
ethnic
or
sexual
minor-
ity
individual;
in
particular,
cultural
factors
are
defined
to
include
beliefs,
values,
norms,
practices,
or
customs
held
by
ethnic
and
sex-
ual
minority
groups
that
have
been
shown
to
influence
suicide.
Each
culturally
specific
research
finding
related
to
suicidal
behaviors
was
counted
separately;
thus,
it
was
possible
for
one
empirical
article
to
yield
more
than
one
qualifying
finding.
In
addition,
variables
within
the
same
study
that
were
similar
in
operational
definition
were
counted
as
one
research
finding.
For
example,
if
one
study
found
racial
differences
in
cocaine
and
alcohol
use
in
suicide
dece-
dents,
they
were
counted
as
one
culturally
specific
finding
under
the
category
of
substance
use.
Following
the
extraction
of
culturally
specific
factors
in
the
liter-
ature
for
African
Americans,
Asian
Americans,
Latinos,
and
LGBTQ
groups,
data
were
compared
by
two
lead
research
team
members
to
ascertain
commonalities
and
patterns
amongst
the
research
find-
ings.
Research
findings
were
grouped
based
on
related
themes,
and
factor
names
were
assigned
based
on
consensus
between
the
two
lead
raters.
Any
research
findings
that
were
unduplicated
or
unre-
lated
to
other
empirical
works
were
placed
in
an
“other”
category.
5.
Results
The
final
literature
search
and
exclusionary
criteria
process
yielded
144
empirical
articles
for
review.
From
these
144
articles,
240
individual
empirical
research
findings
were
identified
as
cul-
turally
specific
and
empirically
related
to
suicidal
behaviors
among
African
Americans,
Asian
Americans,
Latinos,
and
LGBTQ
groups.
Examination
of
commonalities
in
the
data
revealed
that
12
of
these
240
research
findings
were
classified
in
the
“other”
category
of
vari-
ables
unduplicated
and
thematically
unrelated
to
other
identified
findings.
The
remaining
228
research
findings
(listed
in
Tables
2–5)
were
encompassed
within
four
common
cultural
categories
of
sui-
cide
risk:
(1)
Cultural
sanctions,
(2)
Idioms
of
distress,
(3)
Minority
stress,
and
(4)
Social
discord.
In
essence,
it
is
possible
to
consider
the
vast
majority
(95%)
of
the
culture
and
suicide
literature
from
1991
to
2011
for
African
Americans,
Asian
Americans,
Latinos,
and
sexual
minorities
within
four
categories
of
cultural
factors
related
to
suicide.
The
following
sections
describe
the
culture
and
suicide
literature,
categorized
according
to
these
four
cultural
suicide
fac-
tors.
A
definition
of
the
four
cultural
factors
are
defined
in
Table
1,
and
literature
review
results
are
depicted
in
Tables
2–5.
5.1.
Cultural
sanctions
Our
culture
and
suicide
literature
review
found
that
cultural
context
influences
the
acceptability
of
two
constructs
that
bear
sig-
nificance
on
suicide
risk:
(1)
acceptability
of
suicide
as
an
option
and
(2)
unacceptability
and
shame
associated
with
life
events.
The
term
cultural
sanctions
–
defined
as
messages
of
approval
or
acceptability
supported
by
one’s
culture
–
encompasses
these
two
categories
(see
Table
2
for
a
summary
of
the
literature).
Cultural
sanctions
can
dictate
the
acceptability
of
suicide
as
a
solution
for
one’s
problems,
and
affect
whether
one
considers
sui-
cide
as
a
viable
solution.
Several
studies
have
shown
that
appraisal
of
suicide
as
unacceptable
or
amoral
predicts
a
lower
likelihood

Please
cite
this
article
in
press
as:
Chu,
J.
P.,
et
al.
The
cultural
theory
and
model
of
suicide.
Applied
and
Preventive
Psychology
(2011),
doi:10.1016/j.appsy.2011.11.001
ARTICLE IN PRESS
G
Model
APPSY-76;
No.
of
Pages
17
4J.P.
Chu
et
al.
/
Applied
and
Preventive
Psychology
xxx (2011) xxx–
xxx
Table
1
Description
of
four
major
categories
of
culturally
specific
risk.
Culturally
specific
risk
category
Description
Cultural
sanctions
Acceptability
of
suicide
as
an
option
Unacceptability
and
shame
associated
with
life
events
Idioms
of
distress
One’s
likelihood
to
express
suicidality
The
way
suicide
symptoms
are
expressed
Chosen
methods
or
means
of
attempting
suicide
Minority
stress Stresses
cultural
minorities
experience
because
of
social
identity
or
position
including:
•
Acculturation
as
moderated
by
ethnic
identity
and
density
•
Discrimination-related
strain
•
Social
disadvantages
Social
discord
Conflict,
lack
of
integration,
or
alienation
from
family,
community,
or
friends
for
suicidal
behavior
among
African
Americans
(Anglin,
Gabriel,
&
Kaslow,
2005;
Marion
&
Range,
2003)
and
Latinos
(Oquendo
et
al.,
2005;
Richardson-Vjlgaard,
Sher,
Oquendo,
Lizardi,
&
Stanley,
2009),
with
some
evidence
suggesting
that
this
protective
effect
applies
only
to
attempts
and
not
ideation
for
African
Ameri-
cans
(Richardson-Vjlgaard
et
al.,
2009).
Higher
scores
on
moral
objections
and
negative
attitudes
about
suicide
have
been
cited
as
possible
reasons
for
lower
overall
prevalence
rates
of
suicide
among
African
American
communities
(Bender,
2000;
Morrison
&
Downey,
2000;
Neeleman,
Wessely,
&
Lewis,
1998).
Molloy,
McLaren,
and
McLachlan
(2003)
additionally
found
that
the
suicide
of
a
homosexual
adolescent
is
seen
as
more
justified,
acceptable,
and
necessary
than
that
of
a
heterosexual
adolescent.
These
views
of
suicide
as
more
acceptable
for
homosexual
teens
were
the
strongest
among
homosexual
participants
themselves,
suggesting
that
greater
acceptance
of
suicide
as
a
viable
solution
may
pose
risk
for
suicide
in
some
LGBTQ
subgroups.
Religion,
a
cultural
identity
of
its
own,
is
a
common
pur-
veyor
of
cultural
sanctions
regarding
the
acceptability
of
suicide
with
variations
among
different
religions
(e.g.,
Buddhism
or
Tao-
ism
as
associated
with
more
accepting
appraisals
of
suicide
than
Catholicism
or
Judaism)
(Leach,
2006;
Lee,
Tsang,
Li,
Phillips,
&
Kleinman,
2007).
In
numerous
studies,
lower
levels
of
religios-
ity
have
been
associated
with
greater
suicidality
(Anglin
et
al.,
2005;
Burr,
Hartman,
&
Metteson,
1999;
Cohen,
Colemon,
Yaffee,
&
Casimir,
2008;
Greening
&
Stoppelbein,
2002;
Hovey,
2000a;
Kaslow
et
al.,
2004;
O’Donnell,
O’Donnell,
Wardlaw,
&
Stueve,
2004;
Walker,
Utsey,
Bolden,
&
Williams,
2005).
Yet,
several
other
stud-
ies
have
found
a
lack
of
systematic
association
of
religiosity
with
suicide
among
cultural
minority
groups
(Fortuna,
Perez,
Canino,
Sribnev,
&
Alegria,
2007;
Hovey,
2000b;
Olvera,
2001;
Spann,
Molock,
Barksdale,
Matlin,
&
Puri,
2006;
Watt
&
Sharp,
2002).
These
inconsistent
findings
may
be
explained
by
which
of
two
main
operative
components
of
religion
were
assessed
within
each
study:
the
extrinsic
social
support
function
of
attending
religious
services
versus
the
intrinsic
cultural
sanctions
imposed
by
reli-
gion
on
suicide.
Many
studies
neglect
to
measure
the
distinctions
between,
or
mix
together,
these
two
components
of
religion
in
their
statistical
analyses
(Burr
et
al.,
1999;
Cohen
et
al.,
2008;
Fitzpatrick,
Piko,
&
Miller,
2008;
Kaslow
et
al.,
2004;
Olvera,
2001).
Most
studies
that
directly
compare
the
relative
effects
of
the
cultural
sanc-
tion
versus
social
support
elements
of
religion
find
that
cultural
sanction
is
more
influential
for
suicide.
Neeleman
et
al.
(1998),
for
example,
found
that
orthodox
religious
beliefs
and
devotion
(elements
related
to
cultural
sanction
aspects
of
religion)
rather
Table
2
Cultural
sanctions:
summary
of
culturally
specific
suicide
literature.
African
Americans
•
Attempts
related
to
higher
suicide
acceptability
and
lower
religious
well-being
(Anglin
et
al.,
2005)
•
Greater
negative
attitudes
towards
suicide
and
intrinsic
religiosity
in
Blacks
than
Whites
(Bender,
2000)
•
Church
membership
related
to
decreased
probability
of
Black
male
suicide
(Burr
et
al.,
1999)
•
Religiosity
related
to
lower
suicidality
in
Black
and
White
elderly
(Cohen
et
al.,
2008)
•
Black
pastors
in
a
southern
U.S.
community
viewed
suicide
as
an
unacceptable
sin
and
a
“White
thing”
alien
to
Black
culture
(Early
&
Akers,
1993)
•
Black
teens
who
perceived
belonging
to
a
spiritual
community
had
lower
odds
of
ideation
(Fitzpatrick
et
al.,
2008)
•
Commitment
to
religious
beliefs
about
suicide
as
a
non-viable
solution
to
problems,
but
not
extrinsic
religiosity
or
church
attendance,
predicted
lower
perceived
risk
in
Black
and
White
teens
(Greening
&
Stoppelbein,
2002)
•
Black
male
but
not
female
suicide
decedents
less
likely
than
non-suicide
decedents
to
attend
church
(Joe,
2010)
•
Lower
religiosity
and
spiritual
well-being
predicted
attempts
in
Black
low-income
adults
(Kaslow
et
al.,
2004)
•
Views
of
suicide
as
unacceptable
predicted
lower
ideation
in
Black
female
college
students
(Marion
&
Range,
2003)
•
Church
attendance
and
level
of
activity
in
church
unrelated
to
ideation
or
attempts
in
Black
high
school
students
(Molock
et
al.,
2006)
•
Blacks
higher
than
Whites
on
moral
objections
to
suicide
and
survival/coping
beliefs
(Morrison
&
Downey,
2000)
•
Blacks
had
lower
acceptance
of
suicide
(an
indicator
of
orthodox
religious
beliefs
and
devotion
rather
than
practice
and
affiliation)
than
Whites
(Neeleman
et
al.,
1998)
•
In
contrast
to
Whites
and
Latinos,
Blacks
with
depression
did
not
report
a
negative
relationship
between
moral
objections
and
ideation
(Richardson-Vjlgaard
et
al.,
2009)
•
Religious
coping
style
unassociated
with
reduction
of
suicidal
risk
in
Black
teens
(Spann
et
al.,
2006)
•
Church
attendance
lowered
suicide
ideology
more
among
Whites
than
Blacks
(Stack
&
Wasserman,
1995)
•
Low
religious
or
spiritual
well-being
predictive
of
ideation
and
attempt
in
Black
adults
(Walker
et
al.,
2005)
•
Attendance
of
religious
services
was
unrelated
to
attempts
for
Black
and
White
teens
(Watt
&
Sharp,
2002)
Asian
Americans
•
Shame/disgrace
related
to
a
family
member
precipitated
suicide
in
two
Asian
American
decedents
(Blinn,
1997)
Latino/as
•
Frequency
of
church
attendance
unrelated
to
suicide
attempts
or
ideation
(Fortuna
et
al.,
2007)
•
How
religious
Central
American
immigrants
perceived
themselves
was
unrelated
with
ideation
(Hovey,
2000b)
•
Infrequent
church
attendance,
low
perception
of
religiosity,
and
low
perceived
influence
of
religion
related
with
increased
ideation
among
Mexican
immigrants
(Hovey,
2000a)
•
Use
of
religion
as
a
coping
mechanism
associated
with
ideation
in
Whites
and
Latinos
(Olvera,
2001)
•
Moral
objections
to
suicide
and
survival
and
coping
beliefs
negatively
related
to
suicidal
behavior
for
Latinos
and
non-Latinos
(Oquendo
et
al.,
2005)
Sexual
minorities
(LGBTQ)
•
Suicide
of
a
homosexual
teen
seen
as
more
justified,
acceptable,
and
necessary
than
of
a
heterosexual
teen,
particularly
among
homosexual
participants
(Molloy
et
al.,
2003)
•
Self-conscious
thoughts
about
others’
evaluation
of
one’s
body
predicted
attempts
in
transgendered
youth
(Grossman
&
D’Augelli,
2007)
•
White
heterosexual
participants
viewed
the
decision
to
engage
in
suicidal
behavior
following
coming
out
as
unacceptable,
unsound,
and
weak,
particularly
by
androgynous
participants
(Cato
&
Canetto,
2003)
Literature
with
more
than
one
cultural
minority
group
•
Greater
tolerance
towards
suicide
related
to
higher
ideation
among
Black,
Latino,
and
White
urban
low-income
high
school
students
(Marcenko,
Fishman,
&
Friedman,
1999)
•
Religiosity
marginally
related
to
ideation
among
Black
and
Latino
teens
(O’Donnell
et
al.,
2004)

Please
cite
this
article
in
press
as:
Chu,
J.
P.,
et
al.
The
cultural
theory
and
model
of
suicide.
Applied
and
Preventive
Psychology
(2011),
doi:10.1016/j.appsy.2011.11.001
ARTICLE IN PRESS
G
Model
APPSY-76;
No.
of
Pages
17
J.P.
Chu
et
al.
/
Applied
and
Preventive
Psychology
xxx (2011) xxx–
xxx 5
than
religious
practice
and
affiliation
indicated
lower
acceptance
of
suicide
in
African
Americans
compared
to
White
adults.
Greening
and
Stoppelbein
(2002)
discovered
that
among
a
community
sam-
ple
of
African
American
adolescents,
low
appraisal
of
suicide
as
a
viable
solution
to
problems,
but
not
church
attendance,
was
related
to
lower
perceived
suicide
risk.
Attending
religious
ser-
vices
was
also
found
to
be
unrelated
to
suicidal
behavior
among
African
Americans
(Molock,
Puri,
Matlin,
&
Barksdale,
2006;
Stack
&
Wasserman,
1995;
Watt
&
Sharp,
2002)
and
unrelated
to
ideation
and
attempts
among
Latinos
(Fortuna
et
al.,
2007).
One
contradic-
tory
study
of
Mexican
immigrants
found
that
church
attendance,
self-perception
of
religiosity,
and
influence
of
religion
on
one’s
life
all
predicted
lower
suicidal
ideation
(Hovey,
2000a).
Taken
together,
this
limited
evidence
suggests
that
cultural
sanctions
about
suicide
serve
a
prominent
function
in
determining
risk
for
suicidal
behaviors.
Cultural
sanctions
can
also
shape
which
life
events
or
expe-
riences
are
considered
shameful,
particularly
in
interdependent
cultural
minority
groups.
Such
shameful
life
events
can
precipitate
suicidal
ideation
or
behaviors.
Though
examinations
of
shame-
related
experiences
as
suicide
risk
factors
in
cultural
minority
populations
are
sparse,
one
study
examining
narrative
data
from
the
San
Francisco
Medical
Examiner’s
office
found
that
shame
or
disgrace
related
to
a
family
member
was
the
precipitating
event
for
suicide
completions
of
two
Asian
American
individuals
(Blinn,
1997).
Self-conscious
thoughts
that
may
be
related
to
internal
shame
about
others’
evaluation
of
bodily
appearance
were
shown
to
be
predictive
of
attempts
in
transgendered
youth
(Grossman
&
D’Augelli,
2007).
Interestingly,
suicidal
behavior
itself
can
be
a
life
event
that
is
viewed
as
unacceptable.
Cato
and
Canetto
(2003)
found
that
predominantly
White
heterosexual
individuals
viewed
sexual
minorities’
decisions
to
engage
in
suicidal
behavior
following
coming
out
and
being
rejected
by
family
as
unaccept-
able,
unsound,
and
weak.
These
disapproving
attitudes
may
create
additional
sources
of
stress
for
suicidal
LGBTQ
individuals.
Other
non-empirical
works
have
theorized
that
in
some
cultures
(e.g.,
hari-kari
in
Japanese
culture
or
suttee
in
Hindu
cultures),
suicide
can
be
a
culturally
acceptable
solution
to
alleviate
the
burden
of
shame
or
sin
levied
on
one’s
family
or
community
(Beautrais,
2006).
Additionally,
loss
of
face
common
in
Asian
American
cultures
–
the
shame
experienced
when
an
event
has
occurred
that
is
unaccept-
able
or
intolerable
to
social
relationships–has
been
discussed
as
an
influential
factor
in
mental
health-related
issues
(Zane
&
Yeh,
2002).
Clearly,
additional
research
is
needed
to
extend
and
clarify
these
preliminary
findings.
5.2.
Idioms
of
distress
It
is
well-recognized
that
there
are
cultural
variations
in
the
manifestation
or
expression
of
psychological
symptoms
–
a
phenomenon
coined
“idioms
of
distress”
(American
Psychiatric
Association,
2000).
Depression
symptoms,
for
example,
are
more
likely
to
be
expressed
in
psychological
terms
in
Western
cultures
compared
to
more
somatic
terms
in
other
cultures
(e.g.,
Eastern
cultures)
(Ryder,
Yang,
Zhu,
Yao,
&
Yi,
2008).
Cultural
variations
in
idioms
of
distress
also
apply
to
manifestations
of
suicide.
Culture
and
suicide
research
shows
differential
patterns
in
the
following
idioms
of
distress:
(1)
likelihood
to
express
suicidality,
(2)
the
way
suicide
symptoms
are
expressed,
and
(3)
the
chosen
methods
or
means
of
attempting
suicide
(see
Table
3
for
a
sum-
mary
of
the
literature).
Ethnic
minorities,
for
example,
are
less
likely
to
express
suicidal
ideation
than
Whites,
a
concept
called
“hidden
ideation.”
In
a
study
examining
outpatient
clients
at
a
university
counseling
center,
ethnic
minorities
(consisting
of
17
Asian
Americans,
24
African
American,
1
Latino)
were
less
likely
to
disclose
their
suicidal
thoughts
on
a
questionnaire
than
when
queried
in
an
in-person
intake
interview,
compared
to
their
White
counterparts
(Morrison
&
Downey,
2000).
Direct
assessment
of
suicidal
ideation
and
attempt
may
under-detect
suicide
risk
in
ethnic
minority
adolescent
males
in
particular
who
are
less
likely
than
ethnic
minority
females
(including
African
American,
Asian
American,
and
Latinos)
to
directly
report
suicidal
thoughts
or
attempts
(Langhinrichsen-Rohling
et
al.,
2009).
The
tendency
to
keep
suicidal
thoughts
private
has
been
hypoth-
esized
as
common
in
Asian
American
cultures
where
emphasis
on
minimization
of
shame
may
enhance
the
value
of
“suffering
in
silence”
when
feeling
suicidal
(e.g.,
Donnelly
&
Kim,
2008);
however,
such
ideas
have
remained
largely
non-empirically
tested
conjecture.
One
study
found
that
African
Americans
who
success-
fully
complete
suicide
exhibit
idioms
of
distress
opposite
to
that
of
hidden
ideation.
Specifically,
African
Americans
at
the
highest
risk
level
talked
about
suicidal
tendencies
more
often
in
the
time
preceding
their
suicidal
act
(Willis,
Coombs,
Drentea,
&
Cockerham,
2003).
Disclosure
of
suicide
was
more
strongly
predictive
of
a
sui-
cide
act
among
African
American
than
White
decedents,
suggesting
that
frequent
expressions
of
suicidal
symptoms
may
constitute
a
more
serious
indication
of
risk
among
African
American
individu-
als.
Yet,
more
frequent
expressions
of
suicide
may
not
extend
to
written
expression,
as
African
American
suicide
decedents
were
found
to
be
less
likely
than
Whites
to
leave
a
suicide
note
(Abe,
Mertz,
Powell,
&
Hanzlick,
2008).
It
is
notable
that
only
a
small
handful
of
studies
have
studied
the
phenomena
of
hidden
ideation
or
heightened
disclosure
of
suicidal
symptoms
preceding
a
suicidal
act.
The
literature
indicated
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.
Classic
signs
of
suicide
such
as
hopelessness,
withdrawal,
or
low
self-worth
may
be
less
predictive
of
suicide
for
African
Americans
compared
to
Whites
(Perkins
&
Hartless,
2002;
Walker,
Alabi,
Roberts,
&
Obasi,
2010;
Willis
et
al.,
2003).
Even
the
role
of
mental
illness
in
suicide
varies
according
to
cultural
group.
Latino
and
African
American
are
less
likely
than
White
suicide
decedents
to
have
a
diagnosed
mental
disorder
whereas
African
Americans
are
more
likely
to
have
schizophrenia
and
Whites
depression
or
bipolar
disorder
in
the
presence
of
death
by
suicide
(Abe
et
al.,
2008;
Karch,
Barker,
&
Strine,
2006;
Rockett,
Lian,
Stack,
Ducatman,
&
Wang,
2009).
Depression
and
anxiety
disorders
in
particular
may
be
less
strongly
related
to
suicide
among
African
Americans
than
Whites,
though
research
has
shown
inconsistent
results
(Greening
&
Stoppelbein,
2002;
Gutierrez,
Rodriguez,
&
Garcia,
2001;
Kung,
Pearson,
&
Wei,
2005;
Rockett
et
al.,
2009;
Vanderwerker
et
al.,
2007).
Violence,
aggression,
risk-taking
behavior,
anger,
or
irritability
may
be
alternate
expressions
of
suicidal
thoughts
or
intent
among
African
Americans,
Filipino
and
Hawaiian
youth,
or
Latino
adoles-
cents
(Else,
Goebert,
Bell,
Carloton,
&
Fukuda,
2009;
Hernandez,
Lodico,
&
DiClemente,
1993;
Juon
&
Ensminger,
1997;
Kaslow
et
al.,
2004;
Olshen,
2007).
One
study
found
that
completed
suicides
were
more
likely
to
involve
aggression
towards
others
in
African
Amer-
ican
than
White
suicide
decedents
(Abe
et
al.,
2008).
Among
Asian
Americans,
risk-taking
behavior
via
gambling
is
more
likely
to
be
associated
with
suicide
attempts
than
in
Whites
(Barry,
Steinberg,
Wu,
&
Potenza,
2009).
In
fact,
one
study
found
that
aggression
and
conduct-related
symptoms
identified
a
different
subset
of
suicidal
ethnic
minority
adolescents
than
depressive
symptoms
(Feldman
&
Wilson,
1997).
These
externalized
expressions
of
distress
would
not
typically
be
detected
as
a
flag
for
suicide
risk
by
clinicians
trained
in
traditional
suicide
query;
traditional
risk
assessment
would
instead
focus
directly
on
depressive
symptoms
or
suicidal
thoughts.
Especially
in
light
of
the
phenomenon
of
hidden
ideation
among
ethnic
minorities,
detecting
alternative
expressions
of
risk
will
be
especially
crucial
in
culturally
competent
suicide
assessment.

Please
cite
this
article
in
press
as:
Chu,
J.
P.,
et
al.
The
cultural
theory
and
model
of
suicide.
Applied
and
Preventive
Psychology
(2011),
doi:10.1016/j.appsy.2011.11.001
ARTICLE IN PRESS
G
Model
APPSY-76;
No.
of
Pages
17
6J.P.
Chu
et
al.
/
Applied
and
Preventive
Psychology
xxx (2011) xxx–
xxx
Table
3
Idioms
of
distress:
summary
of
culturally
specific
suicide
literature.
African
Americans
•
Black
more
likely
than
White
suicide
decedents
to
hurt
others
in
a
suicide
but
less
likely
to
report
depression
or
leave
a
suicide
note
(Abe
et
al.,
2008)
•
Methods
of
suicide
for
Blacks
included
staying
late
in
dangerous
neighborhoods
and
using
a
pillow
in
the
face
(Brown
&
Grumet,
2009)
•
Cocaine
use
more
frequent
in
Black
decedents;
alcohol
use
more
frequent
with
White
decedents
(Garlow,
2002)
•
Cocaine
use
more
frequent
for
White
than
Black
teenage
decedents,
but
more
frequent
for
Black
than
White
adult
decedents
(Garlow
et
al.,
2007).
•
Blacks
low
on
depression
reported
higher
risk
than
Whites
low
on
depression.
(Greening
&
Stoppelbein,
2002)
•
Depressive
symptoms
more
weakly
related
to
suicide
history
for
White
than
Black
undergraduates
(Gutierrez
et
al.,
2001)
•
Risk-taking
behaviors
more
likely
to
be
related
to
attempts
in
Black
than
White
teens
(Hernandez
et
al.,
1993)
•
Depression
related
to
risk
among
Black
female
but
not
male
suicide
decedents
(Joe,
2010)
•
Firearm
suicides
increased
at
a
greater
rate
from
1979-1997
among
Black
than
White
males
(Joe
&
Kaplan,
2002)
•
Black
men
twice
as
likely
as
White
men
to
use
firearms
to
complete
suicide
(Joe,
Marcus,
et
al.,
2007;
Joe,
Clarke,
et
al.,
2007)
•
Aggression
(high
assault
behavior)
and
drug
use
(cocaine)
related
to
suicidal
behaviors
in
Blacks
(Juon
&
Ensminger,
1997)
•
Attempts
in
Black
adults
related
with
more
aggression
and
substance
use
(Kaslow
et
al.,
2004)
•
Suicide
deaths
related
with
heavy
drinking
and
depression
in
Whites
but
not
Blacks
(Kung
et
al.,
2005)
•
Fewer
Black
than
White
college
students
use
alcohol
or
illicit
drugs
while
making
an
attempt
(Molock
et
al.,
1994)
•
Firearms
accounted
for
66–72%
of
suicides
in
Blacks
under
19
years
old,
followed
by
strangulation
(18–20%)
(MMWR,
1998)
•
Weaker
association
of
hopelessness
with
suicide
for
Black
than
White
adolescents
(Perkins
&
Hartless,
2002)
•
Blacks
had
the
highest
rates
of
misclassification
of
potential
suicide
deaths
(Phillips
&
Ruth,
1993)
•
Blacks
more
likely
than
other
races
to
suicide
by
firearm
(Price
et
al.,
2004)
•
No
difference
between
Black
and
White
substance
dependent
attempters
on
hostility
personality
(Roy,
2003)
•
80%
of
Russian
roulette
suicide
decedents
were
Black
compared
to
30.7%
of
a
control
suicide
decedent
group.
Blacks
were
three
times
more
likely
than
Whites
to
use
revolvers
in
suicides
(Stack
&
Wasserman,
2008)
•
Anxiety
disorders
predicted
suicidality
in
White
but
not
Black
elderly
patients
(Vanderwerker
et
al.,
2007)
•
Suicide
deaths
of
Black
police
officers
have
a
high
risk
of
being
misclassified
as
undetermined
(Violanti,
2010)
•
Hopelessness
linked
to
lower
reasons
for
living
in
Whites
but
not
Blacks,
other
than
Blacks
with
a
less
“African-centered”
world
view
(Walker
et
al.,
2010)
•
Greater
proportion
of
Black
than
White
decedents’
households
contained
firearms.
Completed
suicide
in
Blacks
was
related
to
hallucinating
and
violent
threats
but
unrelated
to
withdrawal,
verbalization
of
low
self-worth,
acting
suspicious,
and
property
destruction.
Antidepressants
and
stimulants
were
used
less
and
cocaine
used
more
among
Black
than
White
decedents.
Blacks
less
likely
to
use
substances
just
prior
to
suicide.
Talking
about
suicide
before
death
was
a
more
frequent
and
a
stronger
risk
factor
for
Blacks
(Willis
et
al.,
2003)
Asian
Americans
•
Asian
American
more
likely
than
White
gamblers
calling
a
gambler
helpline
to
report
attempts
(Barry,
Steinberg,
Wu,
&
Potenza,
2009)
•
Asian
Americans’
chosen
suicide
methods
were
hanging
(27.8%),
jumping
(20%),
gunshot
wound
(19.1%),
overdose
(13.9%).
(Blinn,
1997)
•
Suicidal
Filipino
and
Native
Hawaiian
youth
had
higher
rates
of
intimidating,
threatening,
isolating/excluding,
exerting
pressure
on
peers,
and
committing
physical
violence
(Else
et
al.,
2009)
•
Impulsive,
antisocial,
and
undercontrolled
behaviors
unrelated
to
risk
among
Asian
youth
(Lau
et
al.,
2002)
•
White
decedents
predominately
used
gunshot;
Asian
Americans
used
hanging.
Asian
decedents
used
drugs
only;
Whites
used
drugs,
alcohol,
and
comparatively
more
psychotropic
drugs
(Shiang
et
al.,
1997)
•
Asian
decedents
less
likely
than
Whites
to
use
a
firearm
(Sorenson
&
Berk,
1999)
Latino/as
•
Different
patterns
of
suicide
methods
evident
among
Hispanic
male
decedents
(48%
firearms,
35%
suffocation,
7%
poisoning)
compared
to
Hispanic
females
(29%
firearms,
29%
suffocation,
27%
poisoning)
(CDC,
2004)
•
Suicide
methods
different
between
Cuban-born
(42%
hanging
and
48%
gunshot)
versus
American-born
(74%
gunshot)
Cuban
elderly
male
decedents
(Llorente,
Eisdorder,
Zoewenstein,
&
Zarate,
1996)
•
Latino
patients
with
serious
mental
illness
made
less
lethal
attempts
than
non-Latinos
(Oquendo
et
al.,
2005)
•
Being
Latino
was
not
related
with
firearm
suicide
deaths
(Price
et
al.,
2004)
•
Non-fatal
self-harm
poisonings
in
the
emergency
room
included
71/100,000
for
Whites,
65
per
100,000
for
Blacks,
the
lowest
–
23/100,000
–
for
Latinos
(Prosser,
Perrone,
&
Pines,
2007)
•
Attempts
among
hospitalized
teen
girls
were
typically
impulsive,
non-lethal,
overdoses,
with
a
stated
wish
to
die
(Razin
et
al.,
1991)
•
Preferred
method
among
Mexican
female
students
was
pills
(41.8%)
and
wrist
cutting
(27.6%)
(Unikel
et
al.,
2006)
Sexual
minorities
(LGBTQ)
•
LGB
youth
attempters
worried
more
about
excessive
alcohol
use.
Attempt
methods
included:
70%
drug
overdose,
7%
knives,
6%
razor
blades,
7%
cars,
4%
alcohol
abuse,
and
2%
guns
(D’Augelli
&
Hershberger,
1993).
Literature
with
more
than
one
cultural
minority
group
•
Aggression
and
conduct-related
symptoms
identified
a
different
subset
of
ethnic
minority
teens
than
depressive
symptoms
(Feldman
&
Wilson,
1997).
•
White
suicide
decedents
more
likely
to
have
depression
or
bipolar
disorder;
Blacks
decedents
more
likely
to
have
schizophrenia.
Latino
more
likely
than
Black
and
White
decedents
to
have
substance
abuse
without
comorbid
mental
health
problems.
Black
decedents
lower
on
alcohol
use,
and
Whites
had
less
cocaine
but
more
antidepressants
and
opiates
(Karch
et
al.,
2006)
•
Black,
Asian
American,
and
Latino
teen
males
less
likely
than
females
to
utilize
direct
rather
than
indirect
reports
of
ideation
and
attempts
(Langhinrichsen-Rohling
et
al.,
2009)
•
Latina
female
teens
at
risk
for
suicide
who
used
drugs
had
higher
lifetime
cocaine,
methamphetamine,
and
ecstasy
usage
than
Blacks
and
Whites
(Luncheon,
Bae,
Sue,
&
Singh,
2008)
•
Latino
and
Black
suicide
decedents
3.3
and
1.9
times
more
likely
than
Whites
to
use
cocaine
immediately
before
committing
suicide
(Marzuk
et
al.,
1992).
•
Asian
Americans
and
Latinas
had
lower
percentages
of
alcohol-involved
suicide
poisoning
acts
at
a
hospital
than
White
females
(Miller
et
al.,
2010)
•
Percentage
of
decedents
with
alcohol
use/dependence
was
high
in
Latinos
and
low
in
Blacks
(MMWR,
2009)
•
Ethnic
minority
clients
at
a
college
clinic
disclosed
ideation
less
than
Whites
(Morrison
&
Downey,
2000)
•
Among
Black
and
Latino
high
school
students,
attempts
related
with
risky
behaviors
related
to
drugs,
disordered
eating,
violence,
and
safety
(Olshen,
2007)
•
Unprotected
receptive
anal
intercourse
associated
with
attempts
in
Asian
American
transgendered
women
(Operario
&
Nemoto,
2005).
•
Comorbid
psychopathology
more
than
twice
as
likely
to
be
documented
on
death
certificates
of
Whites
than
Black
and
Hispanic
males
(8%,
4%,
and
3%,
respectively).
Higher
underenumeration
of
comorbid
mood
disorders
and
higher
overenumeration
of
schizophrenia
evident
on
Black
and
Latino
than
White
suicide
death
certificates
(Rockett
et
al.,
2009)
•
Blacks
and
Hispanics
had
higher
suicide
misclassification
relative
to
Whites
(Rockett
et
al.,
2010)
•
Predominant
methods
used
in
completed
suicides
in
San
Francisco:
firearms
(30%
of
Blacks,
26%
of
Whites),
hanging
(31%
of
Latinos,
27%
of
Asians),
overdose
(28%
of
Whites)
(Shiang,
1998)
•
Deviancy-delinquency
more
strongly
predicted
attempts
for
White
than
Blacks
and
Latino
adolescents
(Vega,
Gil,
Zimmerman,
et
al.,
1993)

Please
cite
this
article
in
press
as:
Chu,
J.
P.,
et
al.
The
cultural
theory
and
model
of
suicide.
Applied
and
Preventive
Psychology
(2011),
doi:10.1016/j.appsy.2011.11.001
ARTICLE IN PRESS
G
Model
APPSY-76;
No.
of
Pages
17
J.P.
Chu
et
al.
/
Applied
and
Preventive
Psychology
xxx (2011) xxx–
xxx 7
Similar
to
the
externalization
of
suicide
expression
via
violence,
aggression,
or
anger,
suicidality
is
also
expressed
via
externalized
symptoms
of
substance
abuse.
Substance
abuse
as
an
omnibus
category
is
related
with
impulsivity
and
higher
risk
for
self-harm
among
mainstream
populations
(Rowan,
2001),
but
some
evidence
indicates
that
suicide
in
Latinos
may
be
more
likely
to
present
with
substance
use
problems
only
rather
than
with
comorbid
mental
health
and
substance
use
problems
(Karch
et
al.,
2006).
African
Americans,
on
the
other
hand,
are
less
likely
to
use
sub-
stances
just
prior
to
a
completed
suicidal
act
(Molock,
Kimbrough,
Lacy,
McClure,
&
Williams,
1994;
MMWR,
2009;
Willis
et
al.,
2003).
Distinct
cultural
variations
in
drug
of
choice
are
also
evi-
dent.
African
American
adults
and
Latinos
are
more
likely
than
Whites
to
have
cocaine
in
their
system
at
the
time
of
a
suicide-
precipitated
death,
whereas
alcohol,
stimulants,
antidepressants,
and
opiates
are
more
common
among
Whites
(Garlow,
2002;
Garlow,
Purselle,
&
Heninger,
2007;
Juon
&
Ensminger,
1997;
Karch
et
al.,
2006;
Marzuk
et
al.,
1992;
Willis
et
al.,
2003).
Asian
Ameri-
can
decedents
more
frequently
utilize
psychoactive
drugs
whereas
Whites
use
not
only
psychoactive
drugs
but
also
alcohol
(Miller,
Teti,
Lawrence,
&
Weiss,
2010;
Shiang
et
al.,
1997).
Additionally,
LGB
youth
attempters
have
worries
about
excessive
alcohol
use
(D’Augelli
&
Hershberger,
1993).
It
is
important
to
note
that
cul-
tural
subgroup
variation
exists
in
idioms
of
distress,
with
one
study
finding
that
non-Filipino
and
Hawaiian
Asian
American
youth
(including
Chinese,
Southeast
Asian,
Korean,
and
Japanese),
do
not
express
suicide
violently
or
impulsively
(Lau
et
al.,
2002).
Finally,
one’s
chosen
idiom
of
distress
for
methods
or
means
of
attempting
suicide
varies
according
to
cultural
minority
group.
Mainstream
suicide
assessment
and
management
literature
rec-
ommends
routine
assessment
of
access
to
means
of
suicide,
along
with
immediate
removal
of
means
in
the
presence
of
any
level
of
suicide
risk
(American
Psychiatric
Association,
2003).
The
major-
ity
of
this
research
has
focused
on
the
need
to
assess
for
the
most
common
method
of
suicide
in
Western
countries
–
firearms
–
as
the
gold
standard
of
care
and
the
most
common
suicide
method
chosen
among
Whites
(e.g.,
McNiel,
Weaver,
&
Hall,
2007;
Shiang
et
al.,
1997).
The
culture
and
suicide
literature,
however,
shows
that
focusing
assessment
on
firearms
would
not
capture
the
range
of
suicide
methods
utilized
by
some
ethnic
and
sexual
minority
subgroups.
In
African
American
groups,
firearms
are
actually
the
most
frequently
utilized
means
of
suicide,
with
some
studies
showing
higher
or
more
rapidly
growing
suicide
rates
by
firearms
in
African
American
compared
to
White
populations
(Joe
&
Kaplan,
2002;
Joe,
Marcus,
&
Kaplan,
2007;
MMWR,
1998;
Price,
Thompson,
&
Drake,
2004;
Stack
&
Wasserman,
2008;
Willis
et
al.,
2003).
In
contrast,
among
Latinos
and
Asian
Americans,
methods
such
as
hanging,
suf-
focation,
jumping,
or
poisoning
have
been
found
to
be
preferred
means
of
suicide
attempt
or
completion
over
firearms
(Blinn,
1997;
CDC,
2004;
Price
et
al.,
2004;
Shiang
et
al.,
1997;
Shiang,
1998;
Sorenson
&
Berk,
1999).
In
stark
opposition
to
African
American
and
White
groups,
one
study
found
that
only
2%
of
LGB
youth
who
made
attempts
utilized
a
gun,
compared
to
an
overwhelm-
ing
70%
majority
who
overdosed
on
drugs
(D’Augelli
&
Hershberger,
1993).
Other
studies
point
to
alternate
methods
of
suicide
attempts
that
would
not
be
captured
by
typical
suicide
assessment
such
as
staying
late
in
dangerous
neighborhoods
for
African
Americans
(Brown
&
Grumet,
2009),
or
engagement
in
unsafe
sexual
practices
among
Asian
American
transgendered
women
(Operario
&
Nemoto,
2005).
A
frequently
discussed
idea
of
African
Americans
enacting
“victim-precipitated
homicide”
or
“suicide
by
cop”
as
a
method
of
suicide
has
remained
non-empirically
verified
but
could
contribute
to
the
underdetection
and
misclassification
of
suicides
as
homicide
(Langhinrichsen-Rohling
et
al.,
2009).
In
an
examination
of
death
certificates,
Phillips
and
Ruth
(1993)
found
that
African
Americans
had
the
highest
rates
of
suicide
deaths
misclassified
as
other
causes
such
as
pedestrian
deaths
or
accidental
barbiturate
poisoning.
Sui-
cide
deaths
among
Black
police
officers
in
particular
have
a
high
risk
of
being
misclassified
as
undetermined
(Violanti,
2010).
Rockett
et
al.
(2010)
additionally
found
that
African
Americans
and
Lati-
nos
had
higher
suicide
misclassification
rates
than
Whites.
These
striking
differences
in
likelihood
to
disclose,
manner
of
expression,
and
preferred
method
for
suicide
point
to
the
importance
of
incor-
porating
variant
idioms
of
distress
into
routine
suicide
assessment
and
management
efforts.
5.3.
Minority
stress
Minority
stress
refers
to
the
stresses
cultural
minorities
expe-
rience
because
of
their
social
identity
or
position
(Meyer,
2003).
These
minority
positions
often
afford
disadvantages,
stigma,
or
stresses
that
can
contribute
to
vulnerability
for
suicide
(see
Table
4
for
a
summary
of
the
literature).
Minority
stresses
occur
at
two
lev-
els.
The
distal
level
refers
to
negative
events
such
as
discrimination
or
daily
hassles,
and
the
proximal
level
represents
the
internaliza-
tion
of
negative
events,
stereotypes,
and
beliefs
about
one’s
cultural
group.
For
ethnic
minorities,
acculturation
affords
unique
challenges
associated
with
adapting
and
balancing
cultures
of
origin
with
American
culture.
The
relationship
trends
of
acculturation
with
suicidality,
however,
are
inconsistent
within
the
literature.
Though
the
majority
of
the
culture
and
suicide
research
from
the
past
twenty
years
shows
that
greater
acculturation
(e.g.,
second
genera-
tion
individuals)
is
related
with
increased
suicidality
in
Latinos
and
Asian
Americans
(Baumann,
Kuhlberg,
&
Zayas,
2010;
Cheng
et
al.,
2010;
Duldulao,
Takeuchi,
&
Hong,
2009;
Fortuna
et
al.,
2007;
Pe˜
na
et
al.,
2008;
Sorenson
&
Shen,
1996;
Swanson,
Linskey,
Quintero-
Salinas,
Pumariega,
&
Holzer,
1992;
Ungemack
&
Guarnaccia,
1998;
Vega,
Gil,
Zimmerman,
&
Warheit,
1993),
a
handful
of
studies
show
the
opposite
effect
of
lower
acculturated
individuals
carrying
higher
suicide
risk
(Cho,
2003;
Kennedy,
Parhar,
Samra,
&
Gorzalka,
2005;
Razin
et
al.,
1991),
or
a
null
relationship
between
acculturation
and
suicide
(Lau
et
al.,
2002;
Marion
&
Range,
2003;
Sorenson
&
Shen,
1996;
Turner,
Kaplan,
Zayas,
&
Ross,
2002;
Zayas,
Bright,
Álvarez-Sánchez,
&
Cabassa,
2009).
Moder-
ating
variables
of
ethnic
density
or
ethnic
identity
explain
this
variability.
Wadsworth
and
Kubrin
(2007)
found
that
second
generation
Latinos
are
faced
with
increased
suicide
risk
only
when
compared
to
first
generation
immigrants
who
live
in
areas
of
high
ethnic
den-
sity
where
there
are
other
ethnically
similar
residents.
In
essence,
the
presence
of
other
ethnically
similar
individuals
may
help
to
preserve
ties
to
cultures
of
origin
or
provide
social
support
that
can
buffer
the
stresses
of
immigration.
Ethnic
or
racial
identity
may
also
moderate
the
relationship
between
acculturation
and
suicide,
espe-
cially
among
Latino
men
(Croyle,
2007)
or
African
Americans
where
pro-Black
attitudes
serve
a
protective
effect
against
suicide
(Bell,
2007;
Kaslow
et
al.,
2004;
Walker,
Wingate,
Obasi,
&
Joiner,
2008).
Given
that
acculturation
appears
to
confer
suicide
risk
among
sec-
ond
generation
(U.S.
born)
ethnic
minorities,
immigrants
who
are
isolated
from
other
ethnically
similar
individuals,
and
recent
immi-
grants,
some
investigators
have
conjectured
that
stresses
relayed
in
the
U.S.
cultural
environment
during
the
acculturative
process,
particularly
for
individuals
who
experience
weakened
ties
to
their
culture
of
origin,
constitute
the
primary
mechanism
of
heightened
suicide
risk
(Borges
et
al.,
2009).
These
environmental
stresses
have
been
called
acculturative
stresses,
and
encompass
discrimination-related
strains.
Mistreat-
ment,
harassment,
and
discrimination
show
the
most
consistent
relationship
with
increased
suicide
risk
for
sexual
minority
groups
(Clements-Nolle,
Marx,
&
Katz,
2006;
Díaz,
Ayala,
Bein,
Henne,
&

Please
cite
this
article
in
press
as:
Chu,
J.
P.,
et
al.
The
cultural
theory
and
model
of
suicide.
Applied
and
Preventive
Psychology
(2011),
doi:10.1016/j.appsy.2011.11.001
ARTICLE IN PRESS
G
Model
APPSY-76;
No.
of
Pages
17
8J.P.
Chu
et
al.
/
Applied
and
Preventive
Psychology
xxx (2011) xxx–
xxx
Table
4
Minority
stress:
summary
of
culturally
specific
suicide
literature.
African
Americans
•
Black
suicide
attempters
more
likely
to
be
homeless
than
nonattempters
(Anglin
et
al.,
2005;
Kaslow
et
al.,
2005)
•
A
trend
of
a
positive
relationship
between
pro-black
attitudes
and
suicidal
ideation
(Bell,
2007)
•
Higher
occupational
and
income
inequalities
between
Blacks
and
Whites
and
lower
socioeconomic
status
related
with
increased
suicide
risk
in
Black
males
(Burr
et
al.,
1999)
•
Blacks
at
higher
risk
for
attempts
were
more
likely
to
be
less
educated
(Joe,
2006)
•
Black
attempters
reported
lower
ethnic
identity
than
nonattempters
(Kaslow
et
al.,
2004)
•
Life
hassles
(social
cultural
difficulties,
work,
time
pressure
finances,
social
acceptability,
social
victimization)
was
a
risk
factor
for
attempts
in
Blacks
(Kaslow
et
al.,
2005)
•
Social
disadvantage
(poverty,
joblessness)
shaped
suicide
by
influencing
motivation
among
Whites
versus
gun
availability
among
Blacks
(Kubrin
&
Wadsworth,
2009)
•
Acculturation
uncorrelated
with
ideation
in
Black
female
college
students
(Marion
&
Range,
2003)
•
High
acculturative
stress
or
low
ethnic
identity
moderated
increased
ideation
among
Black
college
students
who
reported
depression
symptoms
(Walker
et
al.,
2008)
•
Low-status
occupations
related
to
higher
suicide
rates
for
Whites
but
not
Blacks
(Wasserman
&
Stack,
2000)
•
Status
strains
(not
going
to
college,
welfare
receipt,
low
social
acceptance,
poor
grades)
more
strongly
related
to
attempts
for
Whites
but
not
Blacks
(Watt
&
Sharp,
2002)
•
Black
less
likely
than
White
decedents
to
be
educated
beyond
high
school
(Willis
et
al.,
2003)
Asian
Americans
•
U.S.
born
reported
higher
rates
of
ideation
than
non-U.S.
born
Asian
Americans.
Ethnic
identity
associated
with
reduced
attempts.
Perceived
discrimination
associated
with
ideation
and
attempts
(Cheng
et
al.,
2010)
•
Korean
international
students
experienced
more
ideation
than
their
more
acculturated
counterparts
(Cho,
2003)
•
U.S.
born
Asian
American
women
at
greater
risk
for
ideation,
plans,
and
attempts
than
US
born
men,
immigrant
men,
and
immigrant
women.
Attempts
more
than
two
times
as
high
in
low-income
than
high-income
Asian
Americans
(Duldulao
et
al.,
2009)
•
Low
socioeconomic
status
related
to
2×
higher
attempts
in
Filipino
and
Native
Hawaiian
youth
(Else
et
al.,
2009)
•
Identification
with
heritage
culture
related
to
increase
risk
among
European,
Chinese,
and
South
Asian
immigrants
in
Canada
(Kennedy
et
al.,
2005)
•
No
differences
in
suicidality
based
on
acculturation
among
depressed
youths
(Lau
et
al.,
2002)
Latino/as
•
2nd
more
likely
than
1st
generation
Latina
teens
to
have
an
attempt
history
(Baumann
et
al.,
2010)
•
Risk
higher
among
early
immigrant
and
U.S.-born
Mexican
Americans
than
Mexicans
(Borges
et
al.,
2009)
•
Mexican
orientation
(not
acculturation)
related
to
lower
self-harm
for
men
but
not
women
(Croyle,
2007)
•
Acculturation
(U.S.
nativity,
language
proficiency)
correlated
with
attempts
(Fortuna
et
al.,
2007)
•
Acculturation
and
low
agreement
about
immigration
decisions
related
to
ideation
in
Latino
migrants
(Hovey,
1998a)
•
Acculturative
stress
related
to
elevated
ideation
in
Mexican
American
students
(Hovey,
1998b)
•
Acculturative
stress
related
with
ideation
in
Central
American
immigrants
(Hovey,
2000b)
•
Acculturative
stress
(as
measured
by
perceived
discrimination)
related
with
ideation
in
1st
and
2nd
generation
Latino
teens
(Hovey
&
King,
1996)
•
Acculturative
stress
related
to
ideation
among
Mexican
migrant
farm
workers
(Hovey
&
Maga˜
na,
2003)
•
Community
areas
with
greater
Latino
economic
disadvantage
(poverty,
high
school
dropouts,
female-headed
households,
nonprofessional
employment)
associated
with
more
suicides
(Nielsen
&
Martinez,
2009)
•
2nd
generation
were
2.87
times
and
3+
generation
were
3.57
times
more
likely
than
1st
generation
Latino
youth
to
have
an
attempt
history.
Repeated
drug
use
mediated
this
relationship
(Pe˜
na
et
al.,
2008)
•
Latina
teens
attempters
had
parents
born
outside
of
the
U.S.,
less
medically
healthy
mothers,
extended
families
on
public
assistance,
and
criminal
and
psychiatric
problems
(Razin
et
al.,
1991)
•
Mexican
American
more
likely
than
Mexican
secondary
students
to
report
elevated
ideation
(Swanson
et
al.,
1992)
•
Latina
adolescents
with
and
without
history
of
attempts
did
not
differ
in
acculturation
(Turner
et
al.,
2002)
•
In
Mexican
Americans,
acculturation
related
to
risk,
mediated
by
divorce/separation,
younger
age,
and
education.
Poverty
related
to
risk
for
Mexican,
Puerto
Rican,
and
Cuban
Americans.
Higher
education
related
to
ideation
in
Mexicans.
Low
income
related
to
ideation
and
attempts
for
Puerto
Ricans.
(Ungemack
&
Guarnaccia,
1998)
•
Acculturative
strains
(acculturative
conflicts,
perceived
discrimination,
perceived
poor
life
chances,
and
language
conflicts)
interacted
with
cocaine/crack
to
predict
attempts
in
7th/8th
grade
Latino
teens
(Vega,
Gil,
Warheit,
et
al.,
1993)
•
Acculturation
associated
with
attempts
among
Latino
adolescents
(Vega,
Gil,
Zimmerman,
et
al.,
1993)
•
Suicide
rates
higher
among
immigrant
than
U.S.
born
Latinos.
Immigrants
at
lower
risk
only
when
living
in
high
ethnic
density
areas.
Unemployment,
lower
income,
lower
education,
and
unequal
economic
resources
related
to
risk
(Wadsworth
&
Kubrin,
2007)
•
Latina
teen
attempters
and
non-attempters
were
similar
in
acculturation
(Zayas
et
al.,
2009)
Sexual
minorities
(LGBTQ)
•
At-school
victimization
was
more
strongly
related
to
suicidality
for
LGB
youth
than
heterosexual
youth
(Bontempo
&
D’Augelli,
2002)
•
Gender-based
discrimination
and
victimization
were
associated
with
attempted
suicide
among
transgender
individuals
(Clements-Nolle
et
al.,
2006)
•
Early
openness
about
sexual
orientation
was
associated
with
gay-related
suicide
attempts,
especially
for
males
(D’Augelli
et
al.,
2005).
•
LGB
youth
attempters
more
“out”
in
general,
knew
they
were
non-
heterosexual
younger,
were
handling
this
knowledge
for
longer,
felt
more
people
now
about
their
sexual
identity,
and
were
more
comfortable
disclosing
sexual
orientation
than
non-attempters
(D’Augelli
&
Hershberger,
1993)
•
Most
attempts
in
LGB
youths
followed
awareness
of
same-sex
feelings
and
preceded
disclosure
of
sexual
orientation
to
others
(Augelli,
Hershberger,
&
Pilkington,
2001).
•
School
safety
protective
against
ideation
and
attempts
in
9th–12th
graders;
LGB
youth
scored
lower
than
non-LGB
on
school
safety
(Eisenberg
&
Resnick,
2006)
•
Bullying
mediated
a
positive
relationship
between
gender-role
nonconformity
and
suicidality
among
gay
male
youth
(Friedman
et
al.,
2006)
•
Association
of
sexual
orientation
with
suicidality
mediated
by
violence/victimization
behaviors
for
female
high
school
students
(Garofalo
et
al.,
1999)
•
Reports
of
mistreatment
(including
anti-gay
verbal
harassment,
discrimination,
and
physical
violence)
associated
with
ideation
among
gay
and
bisexual
men
(Huebner
et
al.,
2004)
•
In
gay
and
bisexual
men,
being
a
sexual
minority
in
a
hostile
environment
was
a
suicide
risk
factor
(Paul
et
al.,
2002)
•
Gay-related
stressors
more
common
among
attempters
than
nonattempters
among
gay
and
bisexual
adolescent
males
(Rotheram-Borus
et
al.,
1994)
•
Suicide
attempts
related
to
higher
victimization
and
visible/behavioral
aspects
of
sexual
identity
among
sexual
minority
male
youth
(Savin-Williams
&
Ream,
2003)
•
Completed
suicide
among
3
homosexual
teens
did
not
directly
follow
episodes
of
stigmatization
(Shaffer
et
al.,
1995)
Literature
with
more
than
one
cultural
minority
group
•
Same-sex
attraction
predicted
attempts
in
Black,
Hispanic
and
White
boys
and
Black
and
White
girls
(Borowsky
et
al.,
2001)
•
Income
disparities
elevated
risk
more
for
Blacks,
and
Asians
than
Whites
(Clarke
et
al.,
2008)
•
Latino
and
Asian
gay/bisexual
more
likely
than
heterosexual
men
to
report
recent
attempts
(Cochran
et
al.,
2007)
•
Strong
relationship
between
social
discrimination
and
ideation
among
gay
and
bisexual
Latino
men,
mediated
by
social
isolation
and
low
self-esteem
(Díaz
et
al.,
2001)
•
LGB
Latinos
at
greater
risk
for
attempts
than
LGB
Whites
(Meyer
et
al.,
2008)
•
Outness
related
to
less
suicidality
via
lower
psychological
distress
for
Black
and
White
but
not
Asian
American
and
Latina
lesbian
and
bisexual
women
(Morris,
Waldon,
&
Rothblum,
2001)
•
Engaging
in
same-gender
sex
but
not
ethnic
identity
was
a
correlate
of
ideation
among
Black
and
Latino
low-income
youth
(O’Donnell
et
al.,
2004)
•
Attempts
related
to
homosexual,
bisexual,
or
unsure
sexual
orientation
in
Black
and
Latino
high
school
students
(Olshen,
2007)
•
Foreign-born
at
lower
suicide
risk
than
U.S.-born
Mexican
Americans;
this
effect
of
acculturation
not
applicable
for
Blacks
and
Asian
Americans
(Sorenson
&
Shen,
1996)
•
Unlike
heterosexual
youth,
Black
sexual
minority
youth
were
not
at
lower
suicide
risk
than
White
counterparts
(Walls
et
al.,
2008).

Please
cite
this
article
in
press
as:
Chu,
J.
P.,
et
al.
The
cultural
theory
and
model
of
suicide.
Applied
and
Preventive
Psychology
(2011),
doi:10.1016/j.appsy.2011.11.001
ARTICLE IN PRESS
G
Model
APPSY-76;
No.
of
Pages
17
J.P.
Chu
et
al.
/
Applied
and
Preventive
Psychology
xxx (2011) xxx–
xxx 9
Marin,
2001;
Huebner,
Rebchook,
&
Kegeles,
2004;
Garofalo,
Wolf,
Wissow,
Woods,
&
Goodman,
1999;
Paul
et
al.,
2002;
Rotheram-
Borus,
Hunter,
&
Rosario,
1994;
Savin-Williams
&
Ream,
2003),
with
bullying
and
at-school
victimization
as
particular
concerns
for
LGB
youth
(Bontempo
&
D’Augelli,
2002;
Friedman,
Koeske,
Silvestre,
Korr,
&
Sites,
2006;
Garofalo
et
al.,
1999).
One
case
study
of
three
homosexual
adolescent
decedents
provided
preliminary
evidence
that
suicide
did
not
directly
follow
a
life
event
involving
stigmati-
zation,
suggesting
that
suicide
risk
may
result
from
a
cumulative
effect
of
discrimination
experiences
(Shaffer,
Fisher,
Hicks,
Parides,
&
Gould,
1995).
In
fact,
D’Augelli,
Grossman,
and
Salter
(2005)
and
D’Augelli
and
Hershberger
(1993)
found
that
LGB
individuals
who
have
attempted
suicide
knew
they
were
LGB
at
a
younger
age,
were
handling
this
knowledge
and
were
open
about
sexual
orientation
for
a
longer
time,
and
felt
that
more
people
in
their
lives
were
aware
of
their
sexual
minority
status
than
LGB
people
who
have
not
attempted
suicide.
It
is
possible
that
these
suicidal
LGB
individ-
uals
who
were
more
“out”
to
the
people
in
their
lives
for
a
longer
period
of
time
experienced
more
long-standing
discrimination
or
harassment.
Acculturative
stress
or
life
hassles,
which
in
several
studies
include
discrimination
as
a
part
of
its
operational
definition,
has
been
found
as
associated
with
suicide
risk
among
Latinos
(Hovey,
1998b,
2000b;
Hovey
&
King,
1996;
Hovey
&
Maga˜
na,
2003;
Vega,
Gil,
Warheit,
Apospori,
&
Zimmerman,
1993)
and
two
studies
with
African
Americans
(Kaslow
et
al.,
2005;
Walker
et
al.,
2008).
In
addition,
Cheng
et
al.
(2010)
found
a
direct
and
independent
associ-
ation
between
high
levels
of
perceived
discrimination
with
suicidal
ideation
and
suicide
attempts
for
Asian
Americans.
Double
minority
status
may
confer
additional
minority
stresses
with
research
find-
ing
heightened
suicide
risk
among
individuals
who
identity
as
both
sexual
and
ethnic
minorities
(Borowsky,
Ireland,
&
Resnick,
2001;
Cochran,
Mays,
Alegria,
Ortega,
&
Takeuchi,
2007;
Meyer,
Dietrich,
Schwartz,
2008;
O’Donnell,
O’Donnell,
Wardlaw,
&
Stueve,
2004;
Walls,
Freedenthal,
Wisneski,
2008).
A
final
source
of
minority
stress
related
to
suicide
falls
under
the
category
of
social
disadvantages.
Asian
Americans
with
low
income
and
socioeconomic
status
are
over
two
times
as
likely
as
Asian
Americans
with
high
incomes
to
attempt
suicide
(Duldulao
et
al.,
2009;
Else
et
al.,
2009).
Inequalities
in
income,
unem-
ployment,
and
poverty
were
also
correlates
of
suicide
among
Latinos
(Nielsen
&
Martinez,
2009;
Razin
et
al.,
1991;
Ungemack
&
Guarnaccia,
1998;
Wadsworth
&
Kubrin,
2007).
Low
educational
attainment,
low
socioeconomic
status,
homelessness,
and
socioe-
conomic
inequalities
among
Blacks
were
related
with
higher
risk
for
suicide
attempts
(Anglin
et
al.,
2005;
Burr
et
al.,
1999;
Joe,
2006;
Kaslow
et
al.,
2005;
Willis
et
al.,
2003).
In
addition,
dispari-
ties
in
income
elevate
suicide
risk
more
for
Blacks,
Asians
and
South
Asians
compared
to
Whites
(Clarke,
Colantonio,
Rhodes,
&
Escobar,
2008).
However,
some
evidence
suggests
that
status-related
strains
such
as
not
going
to
college,
receiving
welfare,
or
having
a
low-status
occupation
are
less
predictive
of
suicide
for
African
Americans
than
Whites
(Wasserman
&
Stack,
2000;
Watt
&
Sharp,
2002).
Though
the
specific
reason
for
this
inoculated
response
to
status-related
strains
is
unknown,
one
idea
is
that
African
Americans
have
developed
a
hardiness
to
lower
status
stresses
due
to
endurance
of
years
of
inequality
(e.g.,
Burr
et
al.,
1999;
King,
1982).
Other
authors
have
suggested
that
social
disadvantage
shapes
suicide
for
African
Americans
at
more
severe
levels
of
dis-
advantage
via
increased
availability
of
guns;
this
mediation
effect
was
not
present
for
Whites
(Kubrin
&
Wadsworth,
2009).
Over-
all,
the
culture
and
suicide
literature
indicates
that
acculturation
as
moderated
by
ethnic
identity
and
ethnic
density,
discrimination
experiences,
and
social
disadvantages
all
serve
as
minority
stress
factors
that
increase
suicide
risk
among
ethnic
and
sexual
minority
individuals.
5.4.
Social
discord
Lack
of
social
support
is
a
general
source
of
suicide
risk
in
the
mainstream
literature;
however,
there
are
culturally
specific
varia-
tions
in
the
types
of
social
factors
that
play
a
role
in
suicide
risk
for
ethnic
and
sexual
minority
groups.
Social
network
categories
(e.g.,
family,
community)
in
intersection
with
several
types
of
discord
(e.g.,
conflict,
lack
of
integration,
alienation)
characterize
the
inter-
personal
troubles
that
place
ethnic
and
sexual
minorities
at
suicide
risk
(see
Table
5
for
a
summary
of
the
literature).
For
LGBTQ
individuals,
for
example,
conflict
in
the
form
of
family
rejection
or
alienation
from
friends
and
a
social
community
plays
an
important
role
in
suicidality
(e.g.,
D’Augelli
et
al.,
2005).
Particularly
among
LGBTQ
youth,
studies
have
shown
that
ejection
from
the
home
was
more
prevalent
among
suicidal
individuals
(Rotheram-
Borus
et
al.,
1994),
and
that
the
converse
construct
of
social
support
– family
connectedness
and
adult
caring
–
can
protect
against
suici-
dal
ideation
and
attempts
(Eisenberg
&
Resnick,
2006).
The
effects
of
family
rejection
on
suicide
appear
strong,
conferring
an
8.4
times
higher
likelihood
of
attempted
suicide
in
224
White
and
Latino
LGB
young
adults
with
high
levels
of
family
rejection
compared
to
similar
peers
with
low
or
no
family
rejection
(Ryan,
Huebner,
Diaz,
&
Sanchez,
2009).
Alienation
from
one’s
social
community
also
plays
an
important
role,
with
less
satisfying
homosexual
friend-
ships,
lower
social
acceptance,
and
loss
of
friends
due
to
one’s
sexual
orientation
placing
LGB
youth
at
greater
risk
for
suicide
(D’Augelli,
2002;
D’Augelli
&
Hershberger,
1993;
McBee-Strayer
&
Rogers,
2002;
Van
Heeringen
&
Vincke,
2000).
Having
a
socially
supportive
community
in
the
form
of
gay-straight
alliances
or
LGB
support
groups
in
schools
has
been
related
to
decreased
suicide
risk
for
sexual
minority
youth
(Goodenow,
Szalacha,
&
Westheimer,
2006;
Walls
et
al.,
2008).
Among
Asian
Americans,
suicide
is
related
with
social
discord
predominantly
in
the
form
of
family
conflict
(Cheng
et
al.,
2010).
Chung
(2003)
found
that
among
eight
Asian
American
females
with
a
history
of
suicidality,
family
discord
or
alienation
from
the
family
creates
the
hopelessness
and
helplessness
that
is
linked
with
suici-
dal
behaviors.
The
opposite
of
family
discord
–
perception
of
being
supported
by
one’s
parents
–
predicted
lower
suicidal
ideation
in
Korean
American
students
(Cho,
2003).
Narrative
analysis
of
death
records
for
Asian
Americans
who
completed
suicide
showed
that
themes
involving
family
discord
or
loss
such
as
burden
of
care
for
others,
family
shame
or
disgrace,
depression
over
the
death
of
a
family
member,
and
marital
dysfunction
were
common
in
the
presence
of
death
by
suicide
(Blinn,
1997).
Family
conflict
in
the
form
of
intergenerational
conflict
may
be
particularly
impactful
for
Asian
American
youth.
Lau
et
al.
(2002)
found
that
Asian
Ameri-
can
youth
with
high
levels
of
parent–child
conflict
had
a
30-fold
increase
in
risk
for
suicidal
behaviors.
Acculturation
was
a
moder-
ating
factor
with
lower
acculturated
more
vulnerable
than
higher
acculturated
Asian
American
youth
to
increased
suicide
risk
in
the
presence
of
parent–child
conflict.
In
addition
to
family
conflict
as
a
risk
factor
for
suicide,
one
study
found
that
weak
sense
of
commu-
nity
belonging
more
strongly
exacerbated
suicidality
among
Asians
than
Whites
in
Canada
(Clarke
et
al.,
2008).
Like
Asian
Americans,
social
discord
as
a
suicide
risk
factor
among
Latinos
is
also
embedded
in
family
conflict
or
lack
of
family
connectedness
(Borowsky
et
al.,
2001;
Fortuna
et
al.,
2007;
Guiao
&
Esparza,
1995;
Hovey
&
King,
1996;
Hovey
&
Maga˜
na,
2003;
Kuhlberg,
Pe˜
na,
&
Zayas,
2010;
Medina
&
Luna,
2006;
Olvera,
2001;
O’Donnell
et
al.,
2004;
Queralt,
1993;
Ungemack
&
Guarnaccia,
1998).
This
relationship
between
family
discord
and
suicide
may
be
mediated
by
the
low
self-esteem,
internalizing
behaviors,
lack
of
support,
or
increased
difficulties
one
may
experience
when
family
conflict
arises
via
an
increase
in
acculturative
stress
(Hovey
&
King,
1996;
Kuhlberg
et
al.,
2010).
Conflict
with
parents
appear

Please
cite
this
article
in
press
as:
Chu,
J.
P.,
et
al.
The
cultural
theory
and
model
of
suicide.
Applied
and
Preventive
Psychology
(2011),
doi:10.1016/j.appsy.2011.11.001
ARTICLE IN PRESS
G
Model
APPSY-76;
No.
of
Pages
17
10 J.P.
Chu
et
al.
/
Applied
and
Preventive
Psychology
xxx (2011) xxx–
xxx
Table
5
Social
discord:
summary
of
culturally
specific
suicide
literature.
African
Americans
•
Qualitative
interviews
indicated
that
community
solidarity
and
collectivism
decrease
(and
silence
increases)
in
situations
of
suicide
in
the
Black
community
(Barnes,
2006)
•
Family
disintegration
(marital
disruption,
female-headed
households)
increased
probability
of
Black
male
suicide
(Burr
et
al.,
1999)
•
Low
family
adaptability,
family
cohesion,
social
embeddedness,
and
social
support
predicted
higher
attempt
rates
in
low
income
Black
adults.
Depression
mediated
these
relationships
(Compton
et
al.,
2005)
•
Perceived
risk
related
to
lower
family
but
not
friend
support
in
Blacks
and
Whites
(Greening
&
Stoppelbein,
2002)
•
In
Black
but
not
White
suicidal
teens,
lower
perceived
family
support
associated
with
ideation
(Joe,
Marcus,
et
al.,
2007;
Joe,
Clarke,
et
al.,
2007)
•
Low
social
integration
and
frequent
mobility
were
risk
factors
in
Blacks.
Being
in
a
mother-alone
or
absent
family,
or
being
unmarried
were
risk
factors
for
Black
males
(Juon
&
Ensminger,
1997)
•
Social
support
a
protective
factor
for
attempts
for
Blacks
(Kaslow
et
al.,
2005)
•
Nonsupportive
family
and
friends
related
to
ideation
among
Black
college
students
(Kimbrough,
Molock,
&
Walton,
1996)
•
Among
Black
teens,
community
violence
associated
with
ideation
and
attempts
via
depressive
symptoms
and
aggressive
behavior
(Lambert
et
al.,
2008)
•
Perception
of
family
support
predicted
ideation
in
Black
female
college
students
(Marion
&
Range,
2003)
•
Seeking
support
from
friends/family
negatively
related
to
attempts
for
Black
and
White
adults
(Nisbet,
1996)
•
Perceived
social
support
(including
family,
friends,
and
significant
others)
predicted
lower
suicide
risk
and
differentiated
depressed
Blacks
with
and
without
history
of
suicide
attempts
(Palmer,
2001)
•
Black
substance
dependent
attempters
had
lower
childhood
emotional
neglect
scores
than
Whites
(Roy,
2003)
•
Low
marital
integration
(divorced,
widowed)
stronger
predictor
of
risk
for
Whites
than
Blacks
(Stack,
1996)
•
Black
adolescents
who
attempted
classified
their
families
as
disengaged
and
deficient
in
cohesion
and
adaptability
(Summerville
et
al.,
1994)
•
Relational
strain
(feeling
that
parents/adults
don’t
care
about
them)
predicted
attempts
more
in
Blacks
than
Whites
(Watt
&
Sharp,
2002)
•
Black
more
likely
than
White
decedents
to
have
their
community
complain
about
them,
talk
frequently
with
friends/relatives,
and
have
a
seriously
ill
family
member,
but
less
likely
to
have
recent
family
death
(Willis
et
al.,
2003)
Negative
relationship
between
social
support
and
suicidality
among
Black
men
(Wingate
et
al.,
2005)
Asian
Americans
•
Narrative
analysis
of
suicide
death
records
yielded
suicide
precipitant
themes
of
burden
of
care
for
others,
family
shame
or
disgrace,
depression
over
the
death
of
a
family
member,
and
marital
dysfunction
(Blinn,
1997)
•
Family
conflict
associated
with
ideation
and
attempts
(Cheng
et
al.,
2010)
•
Perception
of
being
supported
by
parents
predicted
lower
ideation
in
Korean
American
students
(Cho,
2003)
•
Family
discord,
alienation
from
family,
or
pain
and
frustrations
from
romantic
relationships
created
hopelessness
and
helplessness
among
8
Asian
females
with
suicidal
history
(Chung,
2003)
•
Asians
more
likely
than
Whites
to
report
weak
sense
of
community
belonging,
which
exacerbated
suicidality
(Clarke
et
al.,
2008)
•
Intergenerational
conflict
yielded
a
30-fold
increase
in
risk
for
Asian
American
youth.
Higher
parent–child
conflict
interacted
with
lower
acculturation
to
predict
risk
(Lau
et
al.,
2002)
Latino/as
•
Mother-daughter
reciprocal
empathy
and
engagement
negatively
related
to
internalizing
and
externalizing
behaviors
which,
in
turn,
predicted
attempts
in
Latina
teens
(Baumann
et
al.,
2010)
•
Family
conflict
related
with
attempts
among
Latinos
(Fortuna
et
al.,
2007)
•
Low
parental
availability
to
talk,
low
family
connectedness,
and
low
parental
caring
predictive
of
suicide
risk
in
Latino
teens
(Garcia
et
al.,
2008)
•
In
Mexican
teens,
family
cohesion
negatively
related
to
ideation
and
past
attempts
(Guiao
&
Esparza,
1995)
•
Ineffective
social
support
(not
low
family
functioning
or
unavailability
of
social
support)
correlated
with
ideation
in
Central
American
immigrants
(Hovey,
1998a,
2000b)
•
Less
effective
social
support
and
greater
family
dysfunction
related
to
ideation
in
Mexican
migrant
farm
workers
(Hovey
&
Maga˜
na,
2003)
•
Acculturative
stress
as
measured
by
presence
of
conflicts
in
social,
familial,
and
environmental
contexts
related
with
ideation
in
1st
and
2nd
generation
Latino
teens
(Hovey
&
King,
1996)
•
A
good
parental
relationship
was
a
suicide
protective
factor
in
Latino
teen
males
(Locke
&
Newcomb,
2005)
•
Social
and
interpersonal
conflict
and
family
distress
related
to
suicide
in
5
Mexican
special
education
students
(Medina
&
Luna,
2006)
•
Family
problems
related
to
ideation
for
Latino
and
White
youth
(Olvera,
2001)
•
Living
with
2
biological
parents
decreased
risk
for
attempts
in
Latino
adolescents
(Pe˜
na
et
al.,
2008)
•
Latino
teen
suicide
decedents
had
more
family-related
stressors
(e.g.,
parental
conflict,
living
separately
from
parents,
running
away,
or
having
separated
parents)
than
non-suicidal
counterparts
(Queralt,
1993)
•
In
Latina
teens,
attempts
precipitated
by
conflicts
with
their
mother
or
boyfriend.
Attempts
related
with
recent
loss
of
friends,
more
and
earlier
loss
(fathers
in
particular),
fewer
ongoing
paternal
relationships,
having
mistrustful
mothers
who
have
fewer
friends,
and
being
negatively
described
by
their
mothers
(Razin
et
al.,
1991)
•
Mutuality
(bi-directional
interpersonal
responsiveness)
between
adolescent
Latinas
and
their
mothers
negatively
related
to
attempts
(Turner
et
al.,
2002)
•
Absence
of
marital
ties
related
to
suicidality
in
Puerto
Ricans
and
Mexican
Americans.
In
Mexican
Americans,
a
positive
relationship
between
acculturation
and
suicide
risk
was
explained
by
support
networks
disrupted
by
divorce
or
separation
(Ungemack
&
Guarnaccia,
1998)
•
Maternal
affection
protected
against
suicidal
behavior
in
Mexican
female
students
(Unikel
et
al.,
2006)
•
Lower
mutuality
and
communication
between
mother/daughter
but
not
familism
more
common
in
Latina
adolescent
attempters
than
non-attempters
(Zayas
et
al.,
2009)
Sexual
minorities
(LGBTQ)
•
Loss
of
friends
because
of
sexual
orientation
was
related
to
attempts
in
LGB
youth
(D’Augelli,
2002)
•
Parental
efforts
to
discourage
gender
atypical
behavior
associated
with
gay-related
attempts,
especially
for
males
(D’Augelli
et
al.,
2005)
•
Among
LGB
youth,
suicide
risk
related
to
loss
of
friends
due
to
sexual
orientation,
problems
in
romantic
relationships,
less
parental
awareness
of
sexual
orientation,
having
more
LGB
friends
and
visiting
more
LGB
bars.
Involvement
in
LGB
organizations
unrelated
to
attempts
(D’Augelli
&
Hershberger,
1993)
•
LGB
youth
with
attempts
related
to
sexual
orientation
issues
had
more
close
friends
who
died
from
suicide
than
LGB
youth
with
attempts
unrelated
to
sexual
orientation
(D’Augelli
et
al.,
2001)
•
Family
connectedness
and
adult
caring
protective
against
ideation
and
attempts
in
9–12th
graders;
LGB
youth
scored
lower
than
non-LGB
on
both
protective
factors
(Eisenberg
&
Resnick,
2006)
•
Sexual
minority
teens
in
schools
with
LGB
support
groups
reported
lower
victimization
rates
and
attempts
than
those
in
other
schools
(Goodenow
et
al.,
2006)
•
Higher
parent–adolescent
conflict
in
Latina
teen
attempters
than
non-attempters.
Self-esteem
and
internalizing
behaviors
mediated
the
relationship
between
parent–teen
conflict
and
attempts
(Kuhlberg
et
al.,
2010)
•
Lower
social
acceptance
predicted
suicidality
in
LGB
individuals
(McBee-Strayer
&
Rogers,
2002)
•
In
gay
and
bisexual
adolescent
males,
attempts
associated
with
ejection
from
home
(Rotheram-Borus
et
al.,
1994)
•
Completed
suicide
among
3
homosexual
teens
did
not
directly
follow
lack
of
support
(Shaffer
et
al.,
1995)
•
Less
satisfying
homosexual
friendships
related
to
risk
for
homosexual
and
bisexual
youths
(Van
Heeringen
&
Vincke,
2000)
•
Presence
of
gay-straight
alliances
in
schools
associated
with
decreased
risk
for
sexual
minority
youth
(Walls
et
al.,
2008)
Literature
with
more
than
one
cultural
minority
group
•
Perceived
parent
and
family
connectedness
protective
against
attempts
for
Black,
Latino,
and
White
girls
and
boys.
Larger
household
was
a
unique
protective
factor
for
Black
males
(Borowsky
et
al.,
2001)
•
Family
closeness
but
not
peer
support,
was
a
resiliency
factor
for
ideation
and
attempts
in
Black
and
Latino
youth
(O’Donnell
et
al.,
2004)
•
LGB
young
adults
with
family
rejection
8.4
times
more
likely
to
attempt
than
those
without
family
rejection.
Latino
LGB
men
reported
the
highest
family
rejection
(Ryan
et
al.,
2009)

Please
cite
this
article
in
press
as:
Chu,
J.
P.,
et
al.
The
cultural
theory
and
model
of
suicide.
Applied
and
Preventive
Psychology
(2011),
doi:10.1016/j.appsy.2011.11.001
ARTICLE IN PRESS
G
Model
APPSY-76;
No.
of
Pages
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J.P.
Chu
et
al.
/
Applied
and
Preventive
Psychology
xxx (2011) xxx–
xxx 11
particularly
salient
for
Latino
youths,
with
several
studies
showing
that
low
parental
availability,
connectedness,
caring,
or
poor
parental
relationships
in
general,
are
associated
with
increased
suicide
risk
(Garcia,
Skay,
Sieving,
Naughton,
&
Bearinger,
2008;
Kuhlberg
et
al.,
2010;
Locke
&
Newcomb,
2005;
Razin
et
al.,
1991).
For
female
Latina
adolescents,
relationship
troubles
with
their
mothers
such
as
decreased
mother-daughter
reciprocal
empathy
and
engagement
or
low
maternal
affection
were
associated
with
suicidal
behaviors
(Baumann,
Kuhlberg,
&
Zayas,
2010;
Turner
et
al.,
2002;
Unikel,
Gómez-Peresmitré,
&
González-Forteza,
2006;
Zayas
et
al.,
2009).
Among
African
Americans,
lack
of
extended
social
networks
and
troubles
within
the
family
unit
such
as
conflict
or
feeling
unsupported
or
uncared
for
are
predictive
of
suicidal
behavior
(Borowsky
et
al.,
2001;
Greening
&
Stoppelbein,
2002;
Joe,
Clarke,
Ivey,
Kerr,
&
King,
2007;
Marion
&
Range,
2003;
O’Donnell
et
al.,
2004;
Summerville,
Kaslow,
Abbate,
&
Cronan,
1994;
Watt
&
Sharp,
2002).
Suicide
vulnerability
from
family
troubles
are
not
necessarily
focused
around
marital
discord,
as
Stack
(1996)
found
that
low
marital
integration
(e.g.,
being
divorced
or
widowed)
is
a
stronger
predictor
of
suicide
risk
for
Whites
than
African
Americans.
Instead,
one
characteristic
unique
to
social
discord
among
African
Americans
is
that
extended
social
networks
such
as
extended
family
or
informal
social
connections
play
an
important
role
in
buffering
suicide
risk.
In
fact,
some
scholars
have
con-
jectured
that
recent
increases
in
suicide
rates
(particular
among
African
American
male
youth)
are
indicative
of
social
and
economic
challenges
that
have
led
to
a
gradual
erosion
of
the
informal
social
supports,
educational
supports,
and
religious
communities
that
have
traditionally
protected
African
Americans
from
suicide.
Some
empirical
evidence
supports
this
notion;
constructs
such
as
low
social
integration,
low
social
embeddedness,
situations
of
frequent
mobility
(which
makes
the
establishment
of
extended
social
networks
difficult),
community
violence,
or
having
community
members
complain
about
an
individual
are
related
to
increase
sui-
cide
risk
(Compton
et
al.,
2005;
Juon
&
Ensminger,
1997;
Lambert,
Copeland-Linder,
&
Ialongo,
2008;
Willis
et
al.,
2003).
Additionally,
a
larger
household
(which
constitutes
a
larger
family
network)
is
a
unique
protective
factor
(Borowsky
et
al.,
2001)
whereas
being
in
a
family
with
a
single
mother
or
without
a
mother
were
suicide
risk
factors
for
African
American
males
(Burr
et
al.,
1999;
Juon
&
Ensminger,
1997).
Finally,
Barnes
(2006)
performed
qualitative
interviews
and
found
that
community
solidarity
and
collectivism
decrease,
and
silence
increases,
in
situations
of
suicide
within
the
African
American
community.
Overall,
discord
within
one’s
social
network
constitutes
an
important
source
of
suicide
risk
for
cultural
minority
groups.
Many
of
these
cultural
minority
groups
have
been
described
as
collectivis-
tic
or
interdependent,
where
self-concept
is
inclusive
of
important
family,
friend,
or
community
members
that
guide
decisions
and
behaviors
(e.g.,
Markus
&
Kitayama,
1991).
A
distinction
between
collectivistic
compared
to
individualistic
cultural
practices
of
West-
ern
cultures
may
explain
the
culturally
specific
areas
of
risk
within
social
discord.
Culturally
competent
suicide
risk
management
with
ethnic
and
sexual
minority
individuals
should
include
assessment
of
these
different
types
of
social
discord.
6.
The
Cultural
Model
of
Suicide
Fig.
1
presents
the
Cultural
Model
of
Suicide
which
represents
the
integration
of
our
inductively
derived
cultural
suicide
factors
(cultural
sanctions,
idioms
of
distress,
minority
stress,
and
social
discord)
into
a
developmental
theoretical
framework
of
suicidal
behavior.
The
reader
is
encouraged
to
refer
to
Fig.
1
as
each
step
of
the
Cultural
Model
is
described.
The
first
step
of
the
Cultural
Model
of
Suicide–life
stressors–is
defined
as
environmental
or
external
events
that
tax
one’s
ability
to
cope
and
therefore
increase
one’s
vulnerability
to
mental
illness
or
suicide
(Dohrenwend,
1998,
2000;
Pearlin,
1999).
Stressors
can
be
personal
(e.g.,
death
of
a
loved
one,
role
strain,
job
loss)
or
social
in
nature
(Allison,
1998;
Meyer,
2003;
Mirowsky
&
Ross,
1989).
Social
stresses
are
strains
that
stem
from
the
social
and
cultural
environment
such
as
poverty,
daily
hassles,
or
discrimination.
Three
culturally
specific
risk
factor
categories
from
our
literature
review
bear
weight
at
this
first
step
of
the
Cultural
Model
(box
a).
First,
research
has
found
social
stressors
to
be
more
prevalent
and
impactful
for
individuals
of
a
cultural
minority
status
(Meyer,
2003).
Social
stressors
specific
to
individuals
of
a
stigmatized
minority
identity–minority
stresses–impact
the
types
of
stressors
that
exacerbate
risk
for
suicide.
Second,
social
discord
such
as
lack
of
community
integration
or
support
for
LGBTQ
individuals
or
family
conflict
for
Asian
Americans
and
Latinos
present
as
culturally
relevant
stressors.
Third,
cultural
sanctions
in
the
form
of
shame-inducing
events
are
stressors
specific
to
certain
minority
groups
(i.e.,
Asian
Americans
and
African
Americans).
Continued
explication
of
the
Cultural
Model
of
Suicide
requires
explanation
of
an
expanded
theoretical
component–that
of
“cul-
tural
meaning.”
In
particular,
the
Cultural
Model
of
Suicide
incorporates
and
expands
on
existing
strengths
of
the
socializa-
tion,
cultural
scripts,
and
sociological
theories
of
suicide
discussed
in
section
2
of
this
article
(Canetto
&
Sakinofsky,
1998;
Durkheim,
1897;
Mo´
scicki,
1994;
Stice
&
Canetto,
2008).
These
theories
have
been
invaluable
in
establishing
that
suicidal
behavior
is
cultur-
ally
determined
and
regulated
(Canetto
&
Lester,
1998;
Marecek,
1998;
Rubinstein,
1987).
However,
Durkheim’s
theories
are
lim-
ited
in
application
to
the
role
of
social
networks
only,
and
do
not
encompass
the
array
of
cultural
factors
reviewed
in
this
paper.
In
addition,
research
supporting
the
cultural
scripts
theory
simply
identifies
culturally
significant
precipitating
stressors
like
physical
health
problems
for
elderly
(Stice
&
Canetto,
2008)
or
interper-
sonal
problems
for
females
(Canetto,
1992–1993,
1997).
Yet,
these
stressors
do
not
invariably
result
in
suicidal
behaviors
among
these
demographics
groups.
Instead,
a
seldomly
discussed
construct–the
cultural
meanings
ascribed
to
these
precipitants–mediates
the
development
of
suicidal
behavior
in
response
to
these
stressors.
For
example,
older
adults
who
ascribe
the
cultural
meanings
of
being
useless
in
the
world
or
a
burden
to
one’s
family
to
chronic
phys-
ical
illness
may
be
more
likely
to
consider
suicide
(Blinn,
1997).
Though
the
cultural
scripts
theory
is
ground-breaking
in
identi-
fying
the
importance
of
cultural
scripts
and
culturally
significant
precipitating
stressors,
it
only
briefly
mentions
and
neglects
to
fully
operationalize
the
cultural
meaning
of
suicide
(Canetto
&
Sakinofsky,
1998;
Stice
&
Canetto,
2008).
Thus,
incorporation
of
these
cultural
meanings
will
be
important
for
a
comprehensive
cultural
model.
Cultural
meaning
operates
at
two
critical
junctures
in
the
Cul-
tural
Model
of
Suicide.
First,
life
stressors
(box
a)
do
not
operate
in
isolation
of
one’s
interpretation
of
stressful
events
and
circum-
stances.
Instead,
a
person
ascribes
certain
meanings
(box
b)
to
stressors
that
influence
their
suicidal
consequences
of
ideation,
intent,
or
plan
(box
c);
this
meaning
is
influenced
by
one’s
cultural
context.
The
cultural
sanctions
factor
is
particularly
salient
in
the
mediating
mechanism
of
cultural
meaning.
For
example,
an
Asian
American
individual
who
attributes
the
meaning
of
unacceptabil-
ity,
shame
or
loss
of
face
to
her
job
loss
may
experience
suicidal
ideation,
intent,
or
plan
(pathway
b1).
In
contrast,
another
person
who
reacts
to
the
loss
of
a
job
merely
as
an
opportunity
to
explore
other
options
may
be
better
able
to
cope
and
tolerate
negative
affect
(pathway
b2).
Second,
cultural
meanings
of
suicide
can
determine
whether
one
chooses
to
perform
a
suicidal
act.
Cognitive
behavioral
theories
of

Please
cite
this
article
in
press
as:
Chu,
J.
P.,
et
al.
The
cultural
theory
and
model
of
suicide.
Applied
and
Preventive
Psychology
(2011),
doi:10.1016/j.appsy.2011.11.001
ARTICLE IN PRESS
G
Model
APPSY-76;
No.
of
Pages
17
12 J.P.
Chu
et
al.
/
Applied
and
Preventive
Psychology
xxx (2011) xxx–
xxx
N
ote: Italicized text indicates the current study’s inductively-derived culturally-specific factors.
Threshold
of
Toleranc
e
Suicidal Ideat
ion,
Intent
, Plan
Idioms of
distres
s
Cultu
ral Mean
ing of
Suicide
Cultural sanctions
(about suici
de)
Suicidal Attempt
or
Act
Idioms of
distres
s
(c)
(d)
(e)
(f)
(a) Life Stressors
Minority stress
Social disco
rd
Cultural sanctions
(b)
Cultural Meaning of
Event
Cultural sanctions
(about
event)
Tolerate affect
&
meaning
Acceptable event
or response
Unacceptable
event or
response
Unacce
p
table
Tolerate affect
&
meaning
Acce
p
table
(b1)
(b2)
(d1)
(d2)
Fig.
1.
The
Cultural
Model
of
Suicide.
suicide
discuss
that
a
suicide
attempt
or
gesture
(box
f)
occurs
when
one’s
tolerance
level
for
despair
(line
e)
is
surpassed
(e.g.,
Wenzel
&
Beck,
2008).
The
cultural
meaning
and
cultural
sanctions
(box
d)
that
exist
for
the
act
of
suicide
will
determine
whether
one’s
toler-
ance
threshold
for
distress
is
surpassed
and
ultimately
whether
a
person
acts
on
suicide
intention
or
impulse
(box
f).
For
example,
in
a
culture
where
suicide
is
viewed
as
an
acceptable
and
honorable
way
to
relieve
one’s
family
of
burden,
the
threshold
for
a
suicidal
act
may
be
more
easily
surpassed
(pathway
d1)
than
if
suicide
is
unacceptable
and
associated
with
bringing
shame
to
one’s
family
(pathway
d2).
6.1.
Three
principles
of
the
Cultural
Model
of
Suicide
Three
theoretical
principles
encompass
the
Cultural
Model
of
Suicide.
The
first
principle
states
that
culture
affects
how
suici-
dal
thoughts,
intent,
plans,
and
attempts
are
expressed
(boxes
c
and
f
in
Fig.
1).
Coined
“idioms
of
distress,”
this
cultural
factor
addresses
how
culture
dictates
the
language
or
method
one
chooses
to
express
one’s
suicidal
ideation
or
intents
(i.e.,
to
hide
or
disclose
thoughts,
box
c)
or
chosen
method
of
suicidal
gesture
or
attempt
(i.e.,
firearm,
household
poison,
or
hanging,
box
f).
The
second
principle
states
that
culture
affects
the
types
of
stressors
that
lead
to
suicidal
behavior.
Specifically,
minority
stress,
social
discord,
and
cultural
sanctions
(box
a)
play
a
role
in
the
types
of
factors
that
contribute
to
vulnerability
for
suicidal
ten-
dencies
like
ideation,
intent,
or
plan.
It
is
important
to
note
that
these
cultural
factors
interplay
with
other
risk
and
protective
fac-
tors
common
across
majority
and
cultural
minority
groups
(e.g.,
hopelessness,
past
suicide
attempts,
etc.)
to
determine
suicidal
behaviors;
it
is
well
recognized
that
suicide
is
determined
by
mul-
tiple
factors
rather
than
any
single
factor
in
isolation.
The
third
principle
states
that
cultural
meanings
associated
with
stressors
and
suicide
affect
the
development
of
suicidal
tendencies,
one’s
threshold
of
tolerance
for
psychological
pain,
and
a
subse-
quent
suicidal
act.
In
particular,
cultural
sanctions
and
messages
of
acceptability
associated
with
a
stressor
or
a
suicidal
act
(boxes
b
and
d)
play
a
part
in
the
determination
of
suicidal
behavior.
Notably,
the
literature
included
remarkably
few
examinations
of
cultural
mean-
ings
of
suicide;
future
research
should
be
aimed
at
expanding
our
understanding
of
the
range
of
possible
cultural
meanings
attributed
to
suicidal
tendencies.
7.
Conclusions
and
implications
This
paper
presents
the
Cultural
Model
of
Suicide
which
provides
a
framework
to
improve
the
“culturally
competent”
assessment
of
suicide
risk
among
cultural
minority
individuals.
We
comprehensively
reviewed
literature
on
cultural
variations
in
suicide
for
African
American,
Asian
American,
Latino/a,
and
sex-
ual
minority
groups
for
extraction
of
common
factors.
Results
showed
that
95%
of
the
culturally
specific
suicide
risk
literature
were
encompassed
by
four
factors:
cultural
sanctions,
idioms
of
distress,
minority
stress,
and
social
discord.
The
Cultural
Model
of
Suicide,
depicted
in
Fig.
1,
offers
an
integration
of
these
induc-
tively
derived
cultural
suicide
factors
into
a
theoretical
framework
of
suicidal
behavior.
Three
theoretical
principles
emerge
out
of
the
Cultural
Model
of
Suicide:
(1)
culture
affects
the
types
of
stressors
and
strengths
that
lead
to
suicidal
behavior;
(2)
cultural
mean-
ings
associated
with
stressors
and
suicide
affect
the
development
of
suicidal
tendencies,
one’s
threshold
of
tolerance
for
psychologi-
cal
pain,
and
subsequent
suicidal
acts;
and
(3)
culture
affects
how
suicidal
thoughts,
intent,
plans,
and
attempts
are
expressed.
Incorporating
the
categories
and
principles
of
the
Cultural
Model
of
Suicide
into
clinical
assessment
will
yield
a
broader
and
more
culturally
inclusive
approach
towards
risk
assessment.
For
example,
the
third
Cultural
Model
of
Suicide
principle,
“cul-
ture
affects
how
suicidal
thoughts,
intent,
plans,
and
attempts

Please
cite
this
article
in
press
as:
Chu,
J.
P.,
et
al.
The
cultural
theory
and
model
of
suicide.
Applied
and
Preventive
Psychology
(2011),
doi:10.1016/j.appsy.2011.11.001
ARTICLE IN PRESS
G
Model
APPSY-76;
No.
of
Pages
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J.P.
Chu
et
al.
/
Applied
and
Preventive
Psychology
xxx (2011) xxx–
xxx 13
are
expressed,”
may
lead
a
clinician
to
use
multiple
assessment
modalities
with
a
client
prone
to
hidden
ideation,
or
to
specifically
ask
about
means
of
suicide
other
than
a
firearm
(e.g.,
chemi-
cals
or
“victim-precipitated
suicide”).
Consideration
of
the
Cultural
Model’s
social
discord
category
may
prompt
a
clinician
to
include
friends
rather
than
family
members
as
social
supports
in
the
safety
plan
of
a
Latino
or
Asian
American
for
whom
family
conflict
is
a
precipitant
or
trigger
for
suicide.
It
is
important
to
note
that
a
culturally
attuned
approach
to
suicide
risk
assessment
and
management
is
justified
not
only
in
cultural
minority
groups
like
LGBTQ
youth
or
Asian
American
elderly
who
may
have
elevated
suicide
rates
relative
to
the
general
population.
Instead,
risk
management
should
incorporate
cultural
approaches
to
suicide
in
any
individual
regardless
of
their
group’s
overall
suicide
rate.
The
Cultural
Model
is
particularly
useful
for
idiographic
application
with
clients
from
ethnic
or
sexual
minority
backgrounds.
Clinicians
are
cautioned
to
practice
culturally
compe-
tent
skills
of
dynamic
sizing
(Sue,
2006)
and
a
flexible
rather
than
formulaic
approach
when
utilizing
the
Cultural
Model
to
assess
suicide
risk.
Several
limitations
must
be
considered
in
understanding
the
current
findings.
First,
though
existing
culture
and
suicide
research
has
amassed
a
substantial
literature
base,
investigations
remain
in
a
relatively
nascent
stage
and
may
represent
only
a
portion
of
the
ways
in
which
culture
interacts
with
suicide.
The
current
state
of
knowledge
also
does
not
allow
for
approximation
of
the
rela-
tive
strengths
of
contribution,
or
interaction
between,
the
cultural
factors
reviewed
in
this
article.
Further,
this
paper
only
reviews
literature
for
three
ethnic
minority
groups
and
one
overarching
LGBTQ
sexual
minority
group
without
addressing
the
effects
of
mixed
race
or
intersectional
identities.
In
an
diversifying
world
where
people
increasingly
hold
more
than
one
cultural
minority
identity,
future
research
will
need
to
address
the
important
issue
of
how
the
intersection
of
identities
affects
suicide
risk.
Additionally,
the
reader
should
be
cautioned
in
applying
the
current
model
to
other
minority
groups
or
cultural
groups
outside
of
North
America,
as
different
cultural
variations
may
be
evident
for
other
communi-
ties
(i.e.,
American
Indians,
Arab
Americans,
etc.).
In
order
to
develop
a
model
that
incorporates
cultural
suicide
factors
not
typically
assessed
and
managed
within
the
mainstream
literature,
it
was
necessary
to
compare
ethnic
and
sexual
minority
science
with
studies
performed
with
predominantly
White
hetero-
sexual
individuals.
As
such,
the
current
Cultural
Model
of
Suicide
may
not
apply
distinctively
to
White
heterosexual
individuals.
However,
the
multiple
identities
approach
states
that
each
indi-
vidual
possesses
several
cultural
identities
and
it
is
important
to
recognize
that
the
White
heterosexual
population
also
carries
a
set
of
distinct
cultural
values
and
practices.
For
similar
reasons
of
methodological
design
and
limited
available
research,
the
cur-
rent
study
was
unable
to
specify
cultural
factors
related
to
other
cultural
identities
such
as
age,
gender,
religion,
disability,
etc.
The
reader
should
be
aware
of
variations
in
the
Cultural
Model’s
cultural
factors
due
to
these
other
cultural
identities.
Despite
these
limita-
tions,
the
current
study
is
the
most
comprehensive
and
empirically
driven
synthesis
of
the
ethnic
and
sexual
minority
literature
to
date,
and
constitutes
an
important
advance
in
the
culture
and
suicide
literature.
An
additional
challenge
common
to
cultural
diversity
research
is
the
balance
between
cultural
specificity
and
generalizability.
Emic
investigations
of
individual
cultural
minority
groups
afford
richness
of
within-group
understanding
(high
cultural
specificity,
low
in
generalizability)
that
is
sacrificed
when
findings
are
col-
lapsed
across
omnibus
groups
(low
cultural
specificity,
high
in
generalizability).
The
existing
literature
contains
a
wide
array
of
individual
findings
that
are
difficult
to
synthesize
in
the
context
of
complex
clinical
risk
management
efforts
that
often
occur
within
limited
periods
of
time.
A
rubric
to
organize
this
within-group
level
knowledge
was
needed
to
provide
direction
for
future
research
and
clinical
efforts.
The
intention
of
the
current
Cultural
Model
of
Suicide
was
not
to
replace
detailed
within-group
knowledge,
but
rather
to
provide
an
organizing
framework
to
contextualize
and
understand
within-group
data
in
suicide
assessment
and
manage-
ment
efforts.
Finally,
the
Cultural
Model
of
Suicide
is
subject
to
several
inherent
limitations
in
the
measurement
of
suicide.
Reporting
biases
and
classification
errors
can
interfere
with
the
accuracy
and
comprehensive
nature
of
existing
cultural
suicide
studies.
For
example,
idioms
of
distress
like
hidden
ideation
among
ethnic
minorities,
externalized
self-destructive
reckless
behaviors,
or
mis-
classification
of
unintentional
injury
and
homicide
among
African
Americans,
for
example,
can
yield
underdetection
of
suicide
(Joe
&
Kaplan,
2001,
Morrison
&
Downey,
2000;
Rockett,
Samora,
&
Coben,
2006;
Willis
et
al.,
2003).
Numerous
methodological
limitations
of
psychology
autopsy
studies
(e.g.,
unreliable
information
about
sexual
orientation
from
informants
or
concealed
sexual
minority
identities,
especially
among
adolescents
who
have
not
come
out)
have
restricted
the
utility
of
autopsy
data
in
LGBTQ
populations
(Halpert,
2002;
King
et
al.,
2008).
As
a
result
of
these
measure-
ment
error
sources,
the
extant
literature
may
constitute
an
over-
or
under-representation
of
actual
cultural
variations
in
suicide.
The
Cultural
Model
of
Suicide
should
be
interpreted
with
these
cautions
in
mind.
The
Cultural
Model
of
Suicide
gives
a
common
language
to
understand
and
classify
cultural
variation
in
suicide
risk,
and
pro-
vides
the
foundation
needed
for
culturally
competent
research
and
clinical
management
of
suicide.
Including
both
ethnic
and
sexual
minorities
in
our
investigations
ensures
advancement
in
the
diver-
sity
and
suicide
field
along
a
multiple
identities
perspective.
Future
research
is
needed
to
further
test
the
utility
and
predictive
valid-
ity
of
this
model
for
different
cultural
minority
individuals.
Of
note
is
the
current
lack
of
assessment
tools
that
can
aid
clinicians
in
incorporating
cultural
factors
into
risk
management
efforts.
Subse-
quent
research
to
develop
a
questionnaire
or
guide
based
on
the
framework
of
the
Cultural
Model
of
Suicide
will
be
invaluable
in
accomplishing
next
steps
of
translating
the
model
for
direct
clin-
ical
application.
In
addition,
studies
should
explore
whether
the
Cultural
Model
of
Suicide’s
four
risk
categories
also
apply
to
other
cultural
minority
or
mixed
identity
groups
not
included
in
the
cur-
rent
investigation,
to
further
determine
the
scope
and
application
of
these
organizing
principles.
This
paper
represents
an
important
step
in
the
consolidation
and
advancement
of
the
cultural
and
sui-
cidology
literature.
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Please
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Chu,
J.
P.,
et
al.
The
cultural
theory
and
model
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suicide.
Applied
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ARTICLE IN PRESS
G
Model
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No.
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Pages
17
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Chu
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/
Applied
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