Where You Work: Primary Care

A Guide to Contextualizing the Reality of Systemic Racism and Black Suicidology

These past months, I have been engulfed in a haze of 24/7 media coverage. It began with the COVID-19 pandemic, filling me with increasing anxiety. The mortality rate for COVID-19 has been disproportionately affecting the African American, Latinx, and Indigenous communities.1 I worried about my family members whose positionality reflects comorbidities, older age, and minority populations. The hospitalization/death of family members and family friends has left me physically exhausted—experiencing insomnia and feeling mentally drained. I was still glued to the television when the recorded murder of George Floyd literally ignited America.

We Black professionals have learned how to master navigating through the murky waters of microaggressions and institutionalized oppression. Over a duration, I thought the clout of respectability politics – the discourse that professional minorities can rise above racism due to their professional status – would shield me from this. I was wrong. I have awakened, this week, with a complete comprehension of my positionality as a mental health professional, and a clear understanding of the context of suicide among Black Americans.

This article, the first in a series, is written with the objective of examining the social-political context of Black suicidology. We will examine the historical catalyst that has created the “perfect storm” of racial civil unrest and trauma within the Black community. The main goal is to understand how this impacts the growing trend of suicide among Black youth.2

Psychological Theories on Black Suicide

Postulated by Dr. Joy Degruy, the theory of Post-traumatic Slave Syndrome asserts that chattel slavery (which allowed people — considered legal property — to be bought, sold, and owned forever) left a legacy of intergenerational, psychological trauma on the descendants of enslaved Africans.3 It is represented in the current mental health crisis and racial disparities that we observe today. Another theorist, psychiatrist Dr. Alvin Poussaint, elaborates that the stigmatization of depression/suicide within the Black community, compounded with the minimalization of the mental health crisis by mental health professionals, constructs the current rise in suicide among Black boys and men.4 These scholars argue that suicide is a symptom of a larger trauma that Black people endure.

To enhance our comprehension of these theories, let us visualize the traumatic stress of the Black community in comparison to a rubber band. A moderate amount of stress, which is a natural reaction to stimuli within our environment, is intrinsically linked to our survival. Similarly, a rubber band is engineered to be elastic and handle a moderate amount of stress and tension. However, when too much force is exerted, without any release, the rubber band will snap.

In recent years, suicidal behavior among Black youth has significantly increased.5 As experts across a multitude of specialties continue to work in understanding the methodology behind this trend, we can look to previous and current events to paint a snapshot of what in the world is happening. In my opinion, the vicarious trauma experienced by the Black collective – because of repeated exposure to stress – has cultivated the internal and external stress that is currently present.

This stress is not random nor coincidental; it is systemic. African Americans have been funneled through imperialism, the trans-Atlantic slave trade, chattel slavery, Jim Crow, the Civil Rights Movement, and a “post-racial” America. In between these defining moments, space has not been created to holistically heal and breathe.

The COVID-19 pandemic, which disproportionately impacts African Americans, has increased these tensions. African Americans mostly reside in densely populated cities. Their homes are often intergenerational and contain extended family. They are more likely to lack medical/mental health resources, preventive care, are overrepresented in the prison system, are essential/critical workers, have little to no sick time, and work under horrible working conditions. 6

These stresses are heightened by the political racial divide that has resurfaced as a result of the killings of Ahmaud Aubrey, Breonna Taylor, and George Floyd. The global protest we are witnessing in this historical era is directed at police brutality. Within their lifetimes, Black boys and men are at the highest risk of being killed by police than any other racial group.7

The Role of Social Media

I think it is important to also understand the role social media plays in all of this. On one hand, it serves as a platform to facilitate the quick distribution of information to a large mass of individuals. This helps to circulate instances of police brutality and other discriminations to the masses, which helps mobilize movements within activism.

On the other hand, the lack of filtering violence has repeatedly exposed adolescents to images of brutalized Black bodies. You can easily find, as you scroll through your social media feed, at least one if not several uncensored videos or images of Black traumatization. For Generation Z, where technology and social media are embedded in their daily lives, these images may have adverse effects.

How does the repeated exposure to these images influence the psyche of Black youth? Does it correlate with or contribute to the increased suicidal behavior among Black youth? The present pandemic and police brutality together cultivate the conditions for a global protest and increase mental health dysfunctions that are currently apparent. Comparable to the upward trend of Black youth suicide, the disproportionate mortality rate of COVID-19 and police brutality may be linked to the systemic overlap of marginalization.

Connecting Systemic Racism to Black Youth Suicide

What does this all have to do with Black youth suicide? Black suicidology does not exist within a vacuum. It is situational and framed by a multitude of factors. Therefore, it is important to contextualize the collective experience. And in a society with a history of racial division, we cannot separate the system from the context. The growing trend of suicide among Black youth is a symptom of systemic racism and the systematic marginalization of Black experiences.

For example, a recent study documented that several White doctors hold racial beliefs that “Black people have physically tougher skin” and “have a higher pain threshold than White patients”.7 Perceived racial biases such as these contribute to the systematic mistreatment of Black people by the medical field. Black women have a maternal mortality rate that is three times higher than White women. ADHD Black youth are often underdiagnosed or misdiagnosed with Oppositional Defiant Disorder (ODD).9

Although Black youth are the fastest growing group within adolescents for suicidal behavior, Black people are underrepresented in suicide-related research and treatment, and as mental health professionals. The patterns that we are observing are conditioned upon institutionalized racism. How do we address Black suicide without acknowledging the whole system?

It is like a hive of hornets have built a nest in your attic, and instead of removing the whole nest, you spend your days and nights shooing away the hornets around you. The underlying causes of the problem persist.

The Role of Mental Health Professionals

The Black mental health crisis is a residual effect of a system that needs reforming. This state of emergency has been afire for over four-hundred years. What steps can we in the mental health field take to increase the efficacy of treatment for Black suicidal behavior?

When we address Black suicidology, it is essential to address the impact of racism on our clients’ experiences. It is essential to evaluate institutionalized oppression holistically – meaning, examine how housing, financial, economic, environmental, and other social factors directly impact your client. As we address and acknowledge systemic oppression, we as mental health professionals must strive to understand the whole picture.

I think that as mental health professionals it is our responsibility to acknowledge and strive to understand and act upon the uniqueness of the Black life experience. I conclude that there are five main components in reforming the ways we deal with racial disparities within Black suicidology.

  1. Provide more inclusive research. As with research in general, the general body of suicide research currently focuses on Whiteness. We need to fund more research tailored to addressing the unique experiences of Black people. We cannot be under the assumption that research impacts people of color similarly to Whites. It is essential to acknowledge and address how cultural/social differences should effect specialized nuances in assessment and treatment methodology.
  2. Integrate the community. The survival of Black America is built on community, family structure, and the church. To address suicide, we must meet clients where they are. As CAMS and other effective treatments understand, the individual is the expert on their own experience. People know what they need, and it is our objective to provide them with the tools and terminology for their mental health. For example, many in the Black community may describe suicidal behavior as a manifestation of physical pain (ex., “I’m feeling pain in my stomach” or “my head hurts”) or as a symptom of “strange” behavior (i.e., “my child is being lazy” or “her behavior has been changed”). Mental health professionals not versed in these cultural differences may dismiss, overlook, and misdiagnose their clients.
  3. Introduce accessible mental health services. Accessibility refers to providing services in communities of color and services that are affordable. We have discussed the political and social disparities that make accessible mental health services difficult. Accessibility is crucial in the struggle to combat suicide in the Black community.
  4. Fund evidence-based treatments that support multicultural therapy. There is limited research on the efficacy of treatments/therapies directed specifically towards Black trauma and suicide. We are not fully adept at understanding what works; however, of the literature available, treatments that are multicultural in nature are most effective with this community. Multicultural treatments integrate a collaborative (client-led) and community-centered approach.
  5. Educate and hire more Black mental health providers. Due to a history of medical/mental health racism, there is distrust of the mental health field by Black people.11 Is it fair to expect marginalized people to freely interact with a system they perceive to be oppressive? Instead, it is more beneficial to validate and empathize with our clients, and Black mental health providers are most inherently suited for this. Therefore, we need more Black mental health professionals who more likely possess an acute understanding of the lived experiences of those they are treating.

Next Steps

We are experiencing a shift in the American conscious. As Black Americans continue to deal with stressors of racism, mental health services are a necessity.

What is our responsibility in providing preventive measures and intervention to this community during these extraordinary times? How do we continue to address the growing trend of suicidal behavior among Black youth? What is our responsibility as mental health providers in comprehending the pain of our clients, colleagues, and students?

These questions form the basis of conversations that need to happen in our field, but it starts with acknowledging the reality of systemic racism, the impact of institutionalized marginalization and racial disparities, and the psychological toll it takes to survive.

References:

  1. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/racial-ethnic-minorities.html
  2. Degruy, Joy. (2005). Post traumatic slave syndrome: America’s legacy of enduring injury and healing. Milwaukie, Oregon: Upton Press.
  3. https://www.npr.org/templates/story/story.php?storyId=5070636
  4. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/racial-ethnic-minorities.html
  5. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/racial-ethnic-minorities.html
  6. https://www.pnas.org/content/116/34/16793
  7. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4843483/

About the Author

Tanisha Esperanza Jarvis M.A.

Tanisha Esperanza Jarvis M.A.
Tanisha Esperanza Jarvis received her B.A. in anthropology and sociology at Spelman College in 2015, where she also minored in Comparative Women’s Studies. While at Spelman, her research focused on integrating academia and social justice. As a Bonner Scholar and Social Justice Fellow her research work included preventative and interventional treatment of sexual trauma and LGBTQ and racial/ethnic minority research. She finished her M.A. in psychological sciences from The Catholic University of America (CUA) in 2019. Her research within the Suicide Prevention Lab (SPL) focused on integrating an international approach to CAMS research and treatment of suicidality within marginalized communities.

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About Tanisha Esperanza Jarvis M.A.

Tanisha Esperanza Jarvis M.A.
Tanisha Esperanza Jarvis received her B.A. in anthropology and sociology at Spelman College in 2015, where she also minored in Comparative Women’s Studies. While at Spelman, her research focused on integrating academia and social justice. As a Bonner Scholar and Social Justice Fellow her research work included preventative and interventional treatment of sexual trauma and LGBTQ and racial/ethnic minority research. She finished her M.A. in psychological sciences from The Catholic University of America (CUA) in 2019. Her research within the Suicide Prevention Lab (SPL) focused on integrating an international approach to CAMS research and treatment of suicidality within marginalized communities.

Malpractice Liability Related to Suicidal Risk: How to Decrease the Risk

Few clinical concerns frighten mental health providers more than the fear of being sued for malpractice related to working with suicidal patients.

In my professional life, I routinely train clinicians across the spectrum of mental health care. Over the past thirty years, I have trained thousand of mental health providers who practice in virtually all disciplines and treatment settings. As an Associate Director of Clinical Training in an APA-accredited clinical psychology training program, I have had countless opportunities to discuss the topic of suicide risk assessment and treatment with aspiring mental health providers. In all my years of teaching, training, supervising, and consulting, I have been struck by the concern that seemingly affects all types of mental health providers: the fear of malpractice liability pertaining to clinical work with suicidal patients.

Mental Health Providers Want to Know “How Do I Not Get Sued?”

Recently, I presented at a psychiatric grand rounds at a prestigious medical center. As often is the case with such engagements, I had a series of meetings with young mental health providers at this facility – psychologists, clinical social workers, and psychiatrists. In one meeting, I was introduced to a group of young providers, and they were invited to ask me “anything under the sun” about clinical work and suicide risk. After going around the room, the single most pressing question, by far, was, “How do I not get sued if a patient of mine takes their life?” We had an hour to talk about any topic related to clinical suicide prevention, and yet we spent fifty minutes talking about how to avoid getting sued.

This example underscores perhaps the most problematic aspect of the fear of malpractice liability related to treating suicidal patients. Namely, that mental health clinicians can easily become preoccupied with the perceived threat of malpractice and thus resort to defensive practices. In adopting a defensive posture, one may come to see the suicidal patient as a threat to one’s professional livelihood. Within this dynamic, the patient (and potentially the patient’s family) may seem like the enemy—an adversary who is ready and eager to sue if treatment goes south.

Fatal Suicide Outcomes Are Often Viewed as Malpractice

Early survey data has shown that when there’s a fatal suicide outcome of someone engaged in mental health care, the majority of family members studied considered the death of their loved one as an obvious case of malpractice. Indeed, within this survey, 25% of family members of people who had died by suicide contacted an attorney to pursue litigation for malpractice.

Reflecting on the topic of mental health provider malpractice, it is interesting to note that, within our culture, there is not the same routine presumption of negligent liability with other fatal outcomes following health care treatment. Certainly, with egregious examples, malpractice litigation is considered (e.g. a surgical procedure in which a surgical tool is left in the body). But despite the fact that we live in a highly litigious society, malpractice lawsuits are not routinely considered across health care delivery as they are in cases of suicide. There is one notable exception: Fatalities in childbirth that occur during delivery also often prompt the assumption of negligent malpractice. As a society, apparently, there is little tolerance for care that fails to prevent a self-inflicted death or the loss of an infant during childbirth. Even if the care provided was competent or heroic, a lawsuit might well be considered and pursued.

Fear of Malpractice Can Change the Way You Practice

In describing the topic of malpractice liability, I do so in full recognition that any death is a personal and family tragedy. But the concern that I am presently raising is how the fear of malpractice litigation can potentially paralyze an otherwise conscientious provider – leading to the proverbial deer in headlights. Such paralysis can lead to defensive practices in mental health care that might decrease the apparent exposure to malpractice risk but may have little to do with what is actually in the patient’s best interest.

As I have written about elsewhere, defensive practices within mental health can often lead to the overuse of inpatient psychiatric hospitalizations. Because of fear of malpractice, this type of “better safe than sorry” rationale often comes into play for patients who do not necessarily need this level of intensive intervention. In addition, there is often an overreliance – even a kind of wishful thinking – related to prescribing psychotropic medications to treat underlying psychiatric disorders of suicidal people. Despite the fact that the literature supporting the use of medicine to treat suicidality is limited or mixed at best, malpractice-related concerns may compel pursuing options that are extreme or ineffective.

If defensive practice is not the best way to avoid a malpractice suit, what is?

Definition of Malpractice in Mental Health Care

The answer to this question lies in understanding what constitutes malpractice. Briefly, malpractice is a tort action wherein a plaintiff (typically a surviving family member of someone who has died by suicide) engages a lawyer to argue that the defendant (the mental health provider) insufficiently met the “standard of care” and that what the provider did or did not do was a direct or proximate cause of the fatal outcome.

The standard of care for mental health providers is defined on a case-by-case basis by expert witnesses who attest to what a similarly trained clinician (with a similar case and in a similar setting) would do. An expert witness is hired by the plaintiff’s attorney to argue that the defendant did not meet this standard of care. The burden of proof lies with the plaintiff. In turn, the defendant’s lawyer hires their expert witness who argues that the mental health provider actually did meet the standard of care.

What ensues is an unpleasant process of discovery of records and relevant documentation, interrogatories, and depositions of the major parties within the case. Many, if not most, malpractice cases do not make it to trial—they get dropped or settled—yet the process of litigation can be traumatic for the defendant.

How to Decrease Your Potential Exposure to Suicide-related Malpractice Liability

More than twenty-five years ago, I published a journal article about how mental health providers can decrease their exposure to malpractice liability related to suicide. The glib answer was, and is, to save every suicidal patient! In reality, tragically, this is not always possible.

What one can do, however, is provide the best possible care, which is both suicide-specific and well-documented. This can be readily accomplish in your routine clinical practice by developing and adhering to “usual and customary practices” that focus on four key pillars of competent clinical care for suicidal patients.

These key pillars are:
1) Routinely and thoroughly assess for suicidal risk, and document that risk within the ongoing medical record.
2) If your patient is suicidal, there should be a sufficient focus on suicidality within the treatment plan, the use of a stabilization plan, and ongoing discussions about lethal-means safety.
3) As a competent mental health provider, you cannot “drop the ball” on the topic of suicide within the ongoing course of care. This means that the issue of suicide should be routinely assessed, treated, and well-documented.
4) You need to seek consultation on cases of potential suicide and document the consultative input.

Fatal suicide outcomes in mental health care are difficult for everyone involved, including families, providers, and organizations. But such outcomes are not necessarily legitimate grounds for malpractice litigation. There is no guarantee that by following these relatively simple steps, you will not be sued in the event of a fatal suicide outcome. But such routine practices can reduce one’s risk of malpractice exposure to negligible levels. This is because plaintiff attorneys take malpractices cases on contingency, which means they do not make a great deal of money unless they win or settle the case.

Skip Simpson, one of the nation’s leading plaintiff attorneys, has noted that if mental health providers follow the steps listed above and diligently document their practices, there is little incentive for malpractice lawyers to pursue litigation. Why? Because if a provider does follow these steps, the central litigation question becomes: Where was the negligence? Mental health providers are not expected to be mind readers or miracle workers, with unlimited control over the behaviors of their patients. But they are expected to be competent and to meet or exceed the standard of care.

CAMS Integrates “Competent Care” into All Clinical Care

While mental health providers can readily follow the recommended steps described above, the use of CAMS ensures that these basic steps of competent care are “baked” into their clinical care practices. CAMS, which stands for “Collaborative Assessment and Management of Suicidality,” is an evidence-based approach for the assessment and treatment of suicidal risk.

While I have seen cases in which patients who received CAMS-guided care have died by suicide, I have never seen or heard of a successful case of malpractice against a provider who adherently used CAMS. I have in fact seen on a few occasions that the use of CAMS has directly discouraged the pursuit of malpractice litigation. More to the point, I have directly seen or heard about countless cases in which CAMS successfully helped suicidal patients walk back from the brink of self-destruction.

Within CAMS-care, all of the members of our team are dedicated to reliably providing the best possible mental health care for patients at risk of suicide. In most cases, that will result in saving a life and averting the hardship that befalls families—and providers—who lose someone to suicide.

About the Author

David A. Jobes Ph.D. ABPP

David A. Jobes Ph.D. ABPP
David Jobes, PhD, ABPP, is the founder of CAMS-care, LLC. He began his career in 1987 in the Counseling Center of the Catholic University of America, where he developed a suicide risk assessment tool for college students that evolved into CAMS. Dr. Jobes is now a Professor of Psychology and Associate Director of Clinical Training at Catholic; he has trained thousands of mental health professionals in the United States and abroad in evidence-based assessment and treatment of suicide risk and the use of CAMS.

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About David A. Jobes Ph.D. ABPP

David A. Jobes Ph.D. ABPP
David Jobes, PhD, ABPP, is the founder of CAMS-care, LLC. He began his career in 1987 in the Counseling Center of the Catholic University of America, where he developed a suicide risk assessment tool for college students that evolved into CAMS. Dr. Jobes is now a Professor of Psychology and Associate Director of Clinical Training at Catholic; he has trained thousands of mental health professionals in the United States and abroad in evidence-based assessment and treatment of suicide risk and the use of CAMS.

The Gender Paradox of Suicide: How Suicide Differs Between Men, Women, and Transgender/Gender Diverse Individuals

Over the last 60 years, research in field of suicidology (the science of why people die by suicide) has produced a large body of knowledge, including identifying hundreds of risk factors and dozens of theories on cause. Multiple suicide prevention initiatives have also been tested during this time.

And while we’ve learned a lot, perhaps one of the most important aspects of study consistently present across the decades of research on suicide is what is commonly referred to as the gender paradox, or why men account for more suicide deaths than women. More recently, the question of gender in suicidal behavior has expanded to include transgender and gender-diverse (TGD) individuals. Here’s a look at the role gender plays in suicide.

What is the Gender Paradox of Suicide?

The traditional gender paradox of suicide is simple: Men die by suicide more often than women, even though women report thoughts of suicide more often and make more non-fatal suicide attempts than men. In fact, the data from research on the subject is quite striking.

CDC data demonstrates that men account for over 76% of suicide deaths in the United States each year. The CDC also found that there are 3.3 male suicide deaths for every female suicide death. In contrast, in research studies, women are two to three times more likely to discuss thoughts of suicide than men, and there are approximately three female suicide attempts per every one male suicide attempt.

Although rates of suicide are different across age groups (e.g., middle-age and older adults die by suicide more than younger adults) and race/ethnicity (e.g., non-Hispanic White and Indigenous individuals die by suicide more than people of Hispanic ethnicity and/or Black racial identity), the gender paradox remains true across other demographics.

These data points demonstrate a simple truth: men die by suicide far more than women, but women experience thoughts of suicide and attempt suicide more than men. So why does this gender disparity persist when it comes to suicidal thoughts vs suicidal behavior?

Why Do More Men Die by Suicide Than Women?

Certainly, answering this question would provide meaningful information on the broad nature of suicide. However, the findings from this line of research are far more complicated than the paradox itself.

One potential reason that men die more by suicide than women is that men, compared to women, appear to be more fearless of death and able to tolerate more physical pain. As such, they may have a higher capability of a lethal suicide attempt if thoughts of suicide develop. This understanding is fairly intuitive. If people do not fear death and can feel confident they can tolerate the pain associated with suicide, they may be more likely to follow through on a plan to die by suicide. This concept is a central component of the Interpersonal Theory of Suicide, which provides clear hypotheses about how the desire and capability for suicide develops and has been researched for almost 20 years.

This fearlessness of death and tolerance of pain may also explain one key finding within the gender paradox of suicide. Compared to women, men generally use more violent methods for suicide, such as suicide by firearm. For example, approximately 60% of male suicides are by firearm, whereas just over 30% of female suicides include self-inflicted gun violence. This finding is important, since suicide attempts by firearm result in death in nearly 90% of cases. With other suicide methods such as overdose, suffocation/hanging, and self-piercing/burning, death is the result in less than 10% of these cases.

This means that for many men, their first attempt at suicide is fatal, whereas women are more likely to live through a first attempt. In fact, less than half of men who die by suicide have a documented history of one or more previous suicide attempts, whereas well over 50% of women who die by suicide have attempted before.

Why Do Women Attempt Suicide More Than Men?

According to the American Foundation for Suicide Prevention (AFSP) women are 1.5 times more likely to attempt suicide than men. But why are suicide attempts so much higher in women while the mortality rate of suicide is 3 to 4 times higher in men? One potential answer lies in the different rates of deliberate self-harm (DSH) between men and women.

According to a Cambridge study on gender differences in suicide behavior, researchers found that DSH is more common in women. The study goes on to suggests that:

“Acts of DSH by females are more often based on non-suicidal motivation.” In females, the appeal function of DSH, whereby DSH is used to communicate distress or to modify the behavior and reactions of other people, seems more common. In males, DSH is more often associated with greater suicidal intent. It is interesting that in community samples, suicidal ideation is reported far more often by females than males and when DSH is found in men it more strongly correlates with suicide.”

Another important suicidal driver for women is major Depression. According to a Danish study, major depression is approximately “twice as common in females, and is known to underlie more than half of all suicides” which can potentially account for the increased rate of suicidal behaviors in women.

What About Transgender and Gender Diverse (TGD) People?

Although some of the above ideas may explain why the gender paradox of suicide exists, there is potentially a need to revise our understanding of the paradox as we begin to learn more about suicide in transgender and gender diverse (TGD) individuals. For the sake of terminology, the term TGD refers to individuals whose sex assigned at birth (“natal sex”) does not match their own feelings about their gender, or “gender identity.” In this way, people who were deemed to be a man at birth (male natal sex) but feel as though their gender is not male (a gender identity of female or neither male/female, etc.), would fit under the umbrella term of TGD.

Our field’s understanding of the gender paradox of suicide was developed when most scholars viewed gender as a male/female binary. It has only been since the late 2000s that scholars have investigated suicide in those whose gender identity do not match their sex assigned at birth.

What Do We Know About Suicide in TGD Individuals?

As with the “why does the gender paradox exist” question, the answer is not simple. Some research suggests that TGD individuals whose sex assigned at birth was female may be at slightly higher risk for thoughts of suicide compared to those who were assigned male at birth, while other research has found the opposite relationship. More consistently, suicidal thoughts appear to be more prevalent in those TGD individuals who perceive their gender as neither male nor female (sometimes referred to as “non-binary”) compared to transgender men and transgender women (TGD individuals who view themselves as the male or female gender that is incongruent with their sex assigned at birth).

Like the relationship between suicidal thoughts and sex assigned at birth, the relationships between suicide attempt history and the TGD aspects of gender are murky at best. For example, as mentioned above, in relationship to suicide attempts, some research has found higher lifetime rates of attempts in TGD individuals with a female sex assigned at birth as compared to male sex assigned at birth. A roughly equal number of studies have found no relationship between sex assigned at birth and suicide attempt history.

A similar lack of consistent findings has been seen in studies comparing suicide attempt histories in those who identify within and outside of the gender binary. Simply put, there currently is no consistent research regarding the relationship between suicide attempt history and both natal sex and current gender identity in TGD individuals.

Suicide Attempts vs. Suicide Deaths

As you may notice, the paragraphs above note relationships with suicidal thoughts and attempts, not death by suicide. In fact, a very clear lack of research regarding death by suicide in TGD individuals can be seen in the research literature. Why is this? This answer is fairly simple: National rates of suicide are most often calculated using death certificates filed in each state.

These death certificates are most commonly completed by coroners and other medical certifiers, many of whom may not know a deceased individual identified as TGD. Also, early versions of these certificates only allowed for binary male/female gender identification. Thus, we do not know how the gender paradox “plays out” in TGD individuals as it relates to death by suicide.

So what do we know about death by suicide in TGD individuals? First and foremost, we know it is prevalent – and likely more prevalent than suicide in those who identify with their sex assigned at birth (“cisgender”). A study of all veterans who were given a gender-related diagnosis in the Veterans Affairs healthcare system between the years 2000-2009 indicated that TGD veterans died by suicide at over two times the rate of the national average of veteran suicide, and over six times the rate of the general population. This research corresponds with death records review in Denmark that demonstrates a higher suicide rate in their TGD versus cisgender population.

This study published in the American Journal of Public Health in 2013 unfortunately did not contain additional information about sex assigned at birth or gender identity and relied on healthcare providers having asked questions regarding a gender-related diagnosis in order to have a record of TGD status in patient charts. Scholars argue that, because of these limitations, the estimates for suicide in TGD veterans may be underestimated.

Gender and Suicide Conclusions

For years, the gender paradox was quite simple: women think about and attempt suicide more than men, but more men die by suicide. This has been and continues to be true in basically all age groups and races/ethnicities.

Complexity to the paradox has been added over the last decade or so for two reasons:

  1. Scholars wanted to identify why this paradox existed
  2. Work with TGD individuals became more prominent.

It is likely that we will learn more over the next decades of research regarding why this paradox exists and if it can be extended to the understanding of suicide in TGD individuals.

Although it is simple in theory, the gender paradox is a great example of the complexity of why people die by suicide. There may be trends, risk factors, and consistencies across stories, but for those who die, there is great individual complexity in why and how. Although hundreds of risk factors play a role in predicting suicide, including sex assigned at birth and gender identity, the prevention of suicide in clinical settings will likely rely on far more than knowing basic demographic factors.

One’s own suicide story, reasons for living, reasons for dying, and visualized method of suicide are likely important and may only slightly be influenced by one’s sex assigned at birth/gender.

How CAMS Can Help

Clinical tools such as the Suicide Status Form (SSF), a critical component of the Collaborative Assessment and Management of Suicide (CAMS), exist to help providers and patients collaboratively determine one’s drivers for suicide that can be mitigated through intervention to reduce suicide risk. Regardless of a patient’s sex assigned at birth, gender, or even mental health diagnosis, the collaborative assessment of these individual factors may help clinicians and patients alike understand more about one’s suicide risk and how a future suicide attempt could be prevented. Recommendations for the integration of affirmative care practices into the CAMS Framework® have been published and can help guide providing CAMS to TGD individuals.

Learn more about how you can become CAMS Trained™ and CAMS Certified™ to provide an evidence-based suicide treatment framework with all of your patients, no matter their gender.

References:

  1. Centers for Disease Control and Prevention, Suicide rising across the US.
  2. National Center for Biotechnology Information, The interpersonal theory of suicide: A systematic review and meta-analysis of a decade of cross-national research. https://www.ncbi.nlm.nih.gov/pubmed/29072480
  3. Joiner, Ph.D., Thomas E., “Why Do People Die By Suicide” Lecture Video. https://www.youtube.com/watch?v=DESRIZtUIT4
  4. National Center for Biotechnology Information, Prevalence of gender identity disorder and suicide risk amount transgender veterans utilizing veterans health administration care. https://www.ncbi.nlm.nih.gov/pubmed/23947310

About the Author

Raymond P. Tucker Ph.D.

Raymond P. Tucker Ph.D.
Raymond is an Assistant Professor of Psychology at Louisiana State University (LSU) where he founded the Mitigation of Suicidal Behavior (MOSB) Laboratory in 2017. He also is a Clinical Assistant Professor of Psychiatry at Louisiana State University Health Sciences Center /Our Lady of the Lake Medical Center. He finished his Ph.D. in clinical psychology from Oklahoma State University in 2017 following his clinical internship at VA Puget Sound. Raymond's research broadly focuses on the enhancement of theoretical models of suicide and suicide risk assessment tools, particularly in underserved populations (e.g., Veterans, Transgender and Gender Diverse adults). Raymond began his tenure as a CAMS consultant in 2019 after receiving a state-level grant to implement CAMS across the Our Lady of the Lake Regional Medical Center in Baton Rouge L.A. He is a former board member of the American Association of Suicidology and is a current faculty member at the National Suicidology Training Center.

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About Raymond P. Tucker Ph.D.

Raymond P. Tucker Ph.D.
Raymond is an Assistant Professor of Psychology at Louisiana State University (LSU) where he founded the Mitigation of Suicidal Behavior (MOSB) Laboratory in 2017. He also is a Clinical Assistant Professor of Psychiatry at Louisiana State University Health Sciences Center /Our Lady of the Lake Medical Center. He finished his Ph.D. in clinical psychology from Oklahoma State University in 2017 following his clinical internship at VA Puget Sound. Raymond's research broadly focuses on the enhancement of theoretical models of suicide and suicide risk assessment tools, particularly in underserved populations (e.g., Veterans, Transgender and Gender Diverse adults). Raymond began his tenure as a CAMS consultant in 2019 after receiving a state-level grant to implement CAMS across the Our Lady of the Lake Regional Medical Center in Baton Rouge L.A. He is a former board member of the American Association of Suicidology and is a current faculty member at the National Suicidology Training Center.

An Exploration of Future Research and Treatment to Combat the Crisis of Black Youth Suicide in America

While the American public was preparing for the Holiday season, on December 17, 2019 Rep. Bonnie Watson (D-NJ) introduced a bill to U.S. House of Representatives.1 H.R. 5469, or more commonly known as the “Pursing Equity in Mental Health Act of 2019”, proposes to allocate funding to organizations to address mental health problems among youth of color. This bill specifically pertains to addressing the epidemic of suicide among Black adolescents. In the early months of 2019, an emergency taskforce was formed by the Congressional Black Caucus (CBC), which included research findings that were based on the collective work of Black professionals within numerous fields of expertise.

The report states that suicide is the second leading cause of death among Black adolescents between the ages of 10-19.2 The report further states that Black youth disproportionately die by suicide at higher rates than other races/ethnicities. In the last decade, suicide rates for Black adolescents have increased by 73%.3 Contrary to the trends we observe with Black adolescents, current research finds that the suicide rates among Black adults are relatively low in comparison to White counterparts.4

Focus of the Pursuing Equity in Mental Health Act

The Pursuing Equity in Mental Health Act of 2019 aims to:

  • Increase research on the risk factors, preventative factors, and methodology of suicide within Black youth, and
  • Support organizations focused on providing holistic, mental health treatment.

The current literature of research tackling the suicidology of Black adolescents is minimal. An explanation for this conundrum may be explained by implicit bias within research. The congressional report mentions a study that found that Black researchers are denied funding 10x the rate of White researchers.11 There is a necessity for research and treatment concentrated on the alarming trend of suicide among Black youth.

Based on my research with CAMS (Collaborative Assessment and Management of Suicidality), my research interest aligns with examining suicidal behavior within marginalized individuals (i.e., racial/ethnic, gender, and sexual minorities). In this article, I provide suggestions for the allocation of future research, treatment, and interventions supported by the proposed bill.

But first, why do we observe this alarming trend among Black youth? There are a few risk factors that influence suicide and suicidal behavior among this demographic.

Risk Factors

Trauma & Social Media

The image of a dead or injured Black body flashes across the screen of a personal computer or smartphone.

While scrolling through any of multiple, popular social media sites, a teenager may view dozens of these images. In the age of technology, sharing information across platforms is instant, and unfiltered. Whether accurate or appropriate, the information is available.

This increased exposure to graphic images shared among social media has been shown to increase depression and suicide among adolescents.5,6 In addition, other psycho-social stressors such as SES, academic opportunities, and systematic marginalization may contribute to suicidal behaviors among black adolescents. 7

LGBTQ+ Identity

Individuals who identify as LGBTQ+ experience higher rates of suicidal behavior than other groups. 8 Association of this risk factor is often linked to bullying, lack of social acceptance, and heightened occurrence of homelessness. These trends are evident across race/ethnicity and age.

Implicit Bias and Stigma

There is a history of mistrust and bias that permeates the therapeutic relationship between the African American community and a “white” mental health field, stemming from the origins of racist pseudo-science and unethical experimentation.9 This is among several reasons Black people are often reluctant to seek mental health support. Another factor that may contribute to an increase in suicidal behavior among Black youth is perceived social stigma. Black adolescents with mental illness experience stigmatization from family, communities, and the larger society.10

Future Research and Treatment

It is appropriate for allocations of funding to go towards organizations/individuals who are already working with suicidal Black youth. These individuals would already have established rapport within the community and possess advance knowledge on implementing research and providing support. By focusing attention on the existing expertise within this area, we help to lessen the “learning curve” and improve training towards other professionals who have Black clientele.

There are a multitude of established literature on the effectiveness of treatments for suicidal individuals. When working with marginalized groups, it is important to incorporate what works. Why fix what is not broken? Just adapt.

Research has shown that Cognitive Behavioral Therapy (CBT) and Dialectic Behavioral Therapy (DBT) are effective in treating suicidal behaviors.12,13 Furthermore, research also highlights the effectiveness of CAMS as a therapeutic framework.14 What makes these treatments work? The use of client-focused therapy and incorporation of holistic methods (e.g., collaborative approach, community engagement, cultural inclusion, etc.) are the foundations that stabilize these interventions.

A CAMS Hypothetical Randomized Control Trial (RCT)

The efficacy of CAMS was initially measured using RCTs. Suicidal clients (whether recruited through outpatient centers, universities, etc.) were split into a treatment as usual (TAU) group in comparison to the CAMS administered group.15 The Suicide Status Form (SSF) was used as a guide to administer CAMS between the clinician and client. The TAU and CAMS groups were compared after the initial and consecutive sessions.

A similar design could be applied when using an RCT to compare TAU with CAMS in a sample of Black adolescents with a history of suicidal behavior. These participants possibly could be recruited from outpatient centers, counseling centers on college campuses, middle school and high school programs, and through other organizations. Of course, these individuals must meet the requirements of race/ethnicity and a history of suicidal behavior and/or mental health.

Based on previous CAMS RCT research, a hypothetical study is outlined in the flowchart below:


Figure. A flowchart depicting an RCT examining the efficacy of CAMS treatment within a sample of suicidal Black adolescents.

Conclusion

If the Pursuing Equity in Mental Health Act of 2019 is passed into legislation, it will be a milestone for research and treatment of suicidology within Black adolescents. The rising trend of suicide among this group rings warning signs, which call to action experts who provide an interdisciplinary lens to research and treatment.

More extensive and intense research into the risk and preventative factors of suicide among Black youth may begin to tackle a stressor of systematic marginalization. Implementing more efficient mental health treatment specifically designed for this demographic may provide holistic and cost-effective interventions.

As I continue my work as a Black researcher and clinician, I am discovering that integrating a client-focused, community-centered, and culturally inclusive approach into therapy/research is the difference between life and death for our clients.

  1. References World Health Organization. Suicide Rates (Per 100,000 Population); World Health Organization: Geneva, Switzerland, 2019.
  2. U.S. House of Representatives, Emergency Taskforce on Black Youth Suicide and Mental Health. (2019). Ring the Alarm: The Crisis of Black Youth Suicide in America. Retrieved from https://watsoncoleman.house.gov/uploadedfiles/full_taskforce_report.pdf
  3. Runcie, A. (2019, December 17). Proposed legislation attempts to address rising suicide rates among black children. CBS News. Retrieved from https://www.cbsnews.com/news/proposed-legislation-attempts-to-address-rising-suicide-rates-among-black-children-2019-12-17/
  4. Leong, F. T. L., Nagayama Hall, G. C., McLoyd, V. C., & Trimble, J. E. (Eds.). (2014). APA handbook of multicultural psychology (Vols 1 & 2). Washington, DC: American Psychological Association.
  5. Twenge, J.M., Joiner, T.E., Rogers, M.L., & Martin, G.N. (2017). Increases in depressive symptoms, suicide-related outcomes, and suicide rates among u.s. adolescents after 2010 and links to increased new media screen time. Clinical Psychology Science, 6, 3-17.
  6. Feuer, V., & Havens, J. (2017). Teen suicide: Fanning the flames of a public health crisis. Journal of the American Academy of Child & Adolescent Psychiatry, 56, 723-724.
  7. Hope, E.C., Hoggard, L.S., & Thomas, A. (2015). Emerging into adulthood in the face of racial discrimination: Physiological, psychological, and sociopolitical consequences for african american youth. Transitional Issues in Psychological Science, 1, 342-351.
  8. Pritchard, E.D. (2013). For colored kids who committed suicide, our outrage isn’t enough: Queer youth of color, bullying, and the discursive limits of identity and safety. Harvard Educational Review, 83, 320-345.
  9. Washington, H.A. (2006). Medical apartheid: The dark history of medical experimentation on black americans from colonial times to the present. New York, NY: Doubleday.
  10. Rose, T., Joe, S., & Lindsey, M. (2011). Perceived stigma and depression among black adolescents in outpatient treatment. Children and Youth Services Review, 33, 161-166.
  11. U.S. House of Representatives, Emergency Taskforce on Black Youth Suicide and Mental Health. (2019). Ring the Alarm: The Crisis of Black Youth Suicide in America. Retrieved from https://watsoncoleman.house.gov/uploadedfiles/full_taskforce_report.pdf
  12. Stanley, B., Brown, G., Brent, D.A., Wells, K., Poling, K., Curry, J., …Hughes, J. (2009). Cognitive-Behavioral therapy for suicide (cbt-sp): Treatment model, feasibility, and acceptability. Journal of the American Academy of Child & Adolescent Psychiatry, 48, 1005-1013.
  13. Ougrin, D., Tranah, T., Stahl, D., Moran, P., & Rosenbaum, A. (2014). Therapeutic interventions for suicide attempts and self-harm in adolescents: Systematic review and meta-analysis. Journal of the American Academy of Child & Adolescent Psychiatry, 54, 97-107.
  14. Jobes, D.A., Moore, M.M., & O’Connor, S.S. (2007). Working with suicidal clients using the collaborative assessment and management of suicidality (cams). Journal of Mental Health Counseling, 29, 283-300.
  15. Jobes, D.A., Au, J.S., & Siegelman, A. (2015). Psychological approaches to suicide treatment and prevention. Curr Treat Options Psychiatry, 2, 363-370.
For more information

To learn more about effective methods for working with suicidal minorities, read “5 Effective Approaches When Working with Minority Clients” by Tanisha Esperanza Jarvis, M.A.

About the Author

Tanisha Esperanza Jarvis M.A.

Tanisha Esperanza Jarvis M.A.
Tanisha Esperanza Jarvis received her B.A. in anthropology and sociology at Spelman College in 2015, where she also minored in Comparative Women’s Studies. While at Spelman, her research focused on integrating academia and social justice. As a Bonner Scholar and Social Justice Fellow her research work included preventative and interventional treatment of sexual trauma and LGBTQ and racial/ethnic minority research. She finished her M.A. in psychological sciences from The Catholic University of America (CUA) in 2019. Her research within the Suicide Prevention Lab (SPL) focused on integrating an international approach to CAMS research and treatment of suicidality within marginalized communities.

See More Articles by this Author

About Tanisha Esperanza Jarvis M.A.

Tanisha Esperanza Jarvis M.A.
Tanisha Esperanza Jarvis received her B.A. in anthropology and sociology at Spelman College in 2015, where she also minored in Comparative Women’s Studies. While at Spelman, her research focused on integrating academia and social justice. As a Bonner Scholar and Social Justice Fellow her research work included preventative and interventional treatment of sexual trauma and LGBTQ and racial/ethnic minority research. She finished her M.A. in psychological sciences from The Catholic University of America (CUA) in 2019. Her research within the Suicide Prevention Lab (SPL) focused on integrating an international approach to CAMS research and treatment of suicidality within marginalized communities.

4 Things that Can Go Wrong When Working with Suicidal Minorities

One thing that has become increasingly important in this contemporary age of diversity is the importance of tailoring programs to individual needs. Arguably, nowhere is this more important than in the field of suicide prevention and treatment.

Using a cookie-cutter approach to treatment with a suicidal person who is part of a minority community (such as racial and religious minorities, women, LGBTQ, etc.) further alienates the client, who most likely already feels marginalized by “the system”. It’s important for therapists and care providers to take the cultural and societal differences of minority groups into careful consideration when working with these individuals and in devising prevention and treatment plans for these valuable members of our society.

Here are four things that can go wrong when we fail to consider and understand cultural differences in suicidal minority clients.

#1: Misunderstandings Cause Confusion and Alienation

Since the dawn of time, different cultures have developed their own unique ways of life, including beliefs, values, behaviors, and methods of communication. Something as simple as unfamiliar terminology can cause the client and the provider to misunderstand each other.

Minority clients especially need to feel confident that their unique needs are understood to develop confidence in their care provider or therapist. We as providers should strive to understand where our clients are coming from and find common ground from which to work – especially when their societal norms differ from our own.

#2: Trust is Eroded

We all know that the bedrock of any therapy session is trust. Without it, our counsel can fall on deaf ears. Clients need to feel that they can rely on their therapist or care provider to have their best interests at heart.

But how can we really have a minority client’s best interests at heart if we don’t understand their heart?

Taking time to understand a client’s cultural background provides valuable insight into her needs and helps build a foundation of trust between you and your client.

#3: Suicidal Thoughts May Become Exacerbated Instead of Mitigated

Many minorities already feel alone in their thoughts and experiences – even mentally healthy ones.

When minority clients feel misunderstood and unsupported (especially by the very person that is charged with helping them), this can contribute to a feeling hopelessness and increased “otherness”. If a suicidal minority client feels further alienated as a result of their treatment, her thoughts of suicide may become even more prevalent.

#4: Treatment is Less Effective

We all want to feel like our efforts are succeeding, and that our work with those struggling with suicidal ideation or behavior is making a difference. However, when misunderstandings and a lack of trust exist between a client and his provider, even the most proven-effective prevention methods can fall flat.

Clients can sense when we simply don’t “get them.” As a result, they are less like to open up and share, which prevents us from providing the best care possible.

As professionals in the suicide prevention and treatment field, we need to become culturally aware of our more diverse communities’ specific needs in order to ensure that the work we do is effective and successful.

To avoid these pitfalls, it’s important to consider ways to “bridge the cultural divide” when working with minority clients who do not share our own experiences and identities.

For more information

To learn more about effective methods for working with suicidal minorities, read “5 Effective Approaches When Working with Minority Clients” by Tanisha Esperanza Jarvis, M.A.

About the Author

Tanisha Esperanza Jarvis M.A.

Tanisha Esperanza Jarvis M.A.
Tanisha Esperanza Jarvis received her B.A. in anthropology and sociology at Spelman College in 2015, where she also minored in Comparative Women’s Studies. While at Spelman, her research focused on integrating academia and social justice. As a Bonner Scholar and Social Justice Fellow her research work included preventative and interventional treatment of sexual trauma and LGBTQ and racial/ethnic minority research. She finished her M.A. in psychological sciences from The Catholic University of America (CUA) in 2019. Her research within the Suicide Prevention Lab (SPL) focused on integrating an international approach to CAMS research and treatment of suicidality within marginalized communities.

See More Articles by this Author

About Tanisha Esperanza Jarvis M.A.

Tanisha Esperanza Jarvis M.A.
Tanisha Esperanza Jarvis received her B.A. in anthropology and sociology at Spelman College in 2015, where she also minored in Comparative Women’s Studies. While at Spelman, her research focused on integrating academia and social justice. As a Bonner Scholar and Social Justice Fellow her research work included preventative and interventional treatment of sexual trauma and LGBTQ and racial/ethnic minority research. She finished her M.A. in psychological sciences from The Catholic University of America (CUA) in 2019. Her research within the Suicide Prevention Lab (SPL) focused on integrating an international approach to CAMS research and treatment of suicidality within marginalized communities.

5 Approaches When Working with Mental Health Minority Clients

Addressing Mental Health Disparities Among Minorities

24-year-old Violet Blue is a suicidal, transgender Mexican-American client at her initial appointment with Dr. Green to address her suicidal behavior. Dr. Green, a 54-year-old European-American, has been a practicing clinician for over 25 years and is considered an expert in his field. However, his clientele is predominately white males, and Violet is his first encounter working with anyone from the transgender and/or Mexican-American communities. To be honest, Dr. Green is feeling a little apprehensive and nervous about working with Violet. He doesn’t want to say anything that could be interpreted as offensive. Dr. Green tells himself to ignore these feelings and proceed as he would regularly do with his other clients – after all, we should be “colorblind” and treat everyone equally, right?

Let’s listen in on how this first visit goes:

Dr. Green: Violet, I am aware of your history of suicidal behavior and depression. I want to dive into the root causes of this. When did the suicide attempts and depression start?

Violet: I don’t know. I’m uncomfortable.

Dr. Green: Therapy can be uncomfortable, for everyone. It’s important that you immerse yourself in this experience so we can address your problems. When did the suicidal behavior and depression start?

Violet: Ok. I guess when I was seven and realized I was born in the wrong body. I told my family and they said something was wrong with me.

Dr. Green: You are referring to feeling transgender?

Violet: Yes, to being trans.

40 minutes later…

Dr. Green: OK, let’s move on to your treatment plan. I want to create a treatment plan to address your suicidal behavior. I have a homework assignment and next week we can discuss your progress.

In this brief fictional scenario, we encounter a clinician who is clearly uncomfortable working with his client, which causes him to unintentionally harm the therapeutic relationship. First, when Violet shares that she is uncomfortable, Dr. Green dismisses her discomfort by generalizing her experience and not addressing how she, specifically, feels. As Violet explains her history with suicidal behavior and depression, Dr. Green diminishes her identity (“feeling transgender”) and then quickly moves on from the topic. We start to see how Dr. Green’s discomfort is projected onto the session. He allows his nervousness and inexperience to drive the situation – which in his case means avoiding the subject of her identity. Lastly, Dr. Green informs Violet of a treatment plan, but throughout the process, Violet is delegated to backseat passenger rather than co-pilot. Her experiences are invalidated, and she is not allowed to play an active role in her recovery.

When treating suicidal clients, we often sculpt out our treatment plan within a larger framework of suicide research and practice, providing a universal treatment plan without considering the nuances of an individual’s identity that may influence their suicidal behavior. This creates an atmosphere in which the client becomes uncomfortable with the therapeutic process, lessening the bond between the client and therapist and rendering services less effective.

Working with clients belonging to marginalized and minority communities (e.g., LGBTQ, women, racial & religiousminorities, etc.) presents a challenge to the modern psychologist. While the psychology workforce is becoming increasingly diverse, racial/ethnic and LGBTQ psychologists are still a minority within research and practice.1

With the majority of both caregivers and patients in the white male category, anyone who does not fit into the majority becomes the ‘other’. The ‘other’ becomes the invisible, the marginalized, and the untreated (or ineffectively treated). When we ‘other’ clients, we invalidate their experience.

5 Effective Approaches when Treating Minority Mental Health

It is important to address the needs of all suicidal clients, including examining the different societal and cultural conditions that influence the identity of an individual. The following are five effective approaches to consider when treating minority clients:

1.  Acknowledge Differences.

When a client discusses experiences as a minority, it is detrimental for the therapist to avoid acknowledging the client’s positionality—the lens through which the world views an individual. Dismissing their individuality contributes to ‘othering’—and to practice a colorblind approach might create an environment where you have invalidated their experiences.

Another important note is that the minority client’s identity could be a contributing factor to their suicidal behavior. For example, a client who is Asian-American might feel isolated navigating their American and Asian identity or they could experience workplace/academic pressures that stem from cultural stressors. Addressing these caveats may improve and increase the effectiveness of treatment.

Equally important is the ability of the therapist to acknowledge their own positionality and examine how that impacts the therapeutic relationship. Minority clients may express difficulties when being treated by white therapists.2 They may feel isolated or disempowered by the heightened, unbalanced power dynamics created by systematic marginalization. To acknowledge and discuss these fears builds trust in the therapeutic relationship.

2.  Validate Experiences.

 As discussed in the first approach, minority clients might feel that their daily experiences are often overlooked, marginalized, and invalidated. As important as it is to acknowledge their experiences, it is equally important to validate them. For example, a suicidal gay client might confide to their therapist feelings of social alienation and rejection due to continued prejudices against gay people. These stressors may influence that client’s suicidality.

Affirming the validity of the client’s feelings and experiences is a crucial part of effective treatment. Validation does not simply mean that you understand or agree, it is the act of letting your client know that you acknowledge, recognize, and support their experiences.

3.  Accept Your Limitations.

Transparency as a therapist is an important skill to develop. Let’s be honest, working with minority clients can be intimidating without a background in or experience working with these communities. What if you say the wrong words and appear insensitive – or worse, prejudice?

Your trepidation is valid, and during the right circumstances, discussing these limitations with the client may ease anxiety on both sides. For example, during an initial session treating a black client, a white therapist might observe discomfort and hesitation from the client or experience their own hesitation. Openly addressing your own limitations and the client’s anxiety builds trust and honesty between the client and therapist.

4.  Use a Collaborative Approach.

The collaborative approach uses a model in which the client and therapist work together to create and implement a treatment plan. This plan is tailored to the client’s unique challenges and strengths. This process helps to create a more egalitarian relationship in which the client is respected as the expert on their experiences and the therapist as the expert on the treatment.

This approach is crucial to treating suicidal behavior because many suicidal clients express feelings of hopelessness and powerlessness. A collaborative approach provides them with the tools to begin to change the predicament and re-establish power to oneself.

Working through this therapeutic process, the client and therapist begin to build rapport and trust, and control is placed in the client’s hands. This is important, because suicidal minority clients especially may feel powerless and hopeless. Creating an environment for a safe space where the individual feels a part of something may help reduce some of the symptoms.

5.  Inquire about their Community Support System.

To many minority clients, the family and community unit is an essential part of their healing and stabilization processes. Having a support system can play a big role in the responsiveness of a client and the effectiveness of treatment. For instance, an African American client might be hesitant to disclose suicidal behavior due to community and cultural ideologies about suicide. A transgender client might be more open towards the therapeutic process if they have supportive family and friends that validate their expression of self.

Community support systems are complex aspects of a client’s life, and learning about these structural systems (or lack thereof) will help the therapist better address the client’s needs.

Clinician and Suicidal Minority Client Scenario

Now that we have become familiar with more healthy approaches to working with minority clients, let’s recreate the fictional scenario between Dr. Green and Violet Blue:

Dr. Green: Violet, I am aware of your history of suicidal behavior and depression. I want to dive into the root causes ofthis. When did the suicide attempts and depression first start?

Violet: I don’t know. I’m uncomfortable.

Dr. Green: Yes, I understand. Sometimes the therapeutic process can be uncomfortable, and that is valid. I want us to address this discomfort, so we can improve our working relationship and your treatment. Violet, would you mind sharing why you feel uncomfortable?

Violet: I guess. Sometimes it’s hard seeing therapists who don’t understand what it’s like to be a trans Chicana. My last therapist just didn’t get me. It was a waste of time.

Dr. Green: Violet, thank you for sharing with me. I am an old, white guy and to be honest, I have limited experience working with trans… Chicana? I’m not familiar with the term. Can you explain it to me?

Violet: It’s what us Mexican-American women call ourselves.

Dr. Green: Thanks for the clarification. I was not familiar with Chicana, but now it will become a part of my vocabulary. Thank you. I have limited experience working with trans Chicana women. However, I do understand suicide and I want to help you with your recovery. I hope to work with you to get a better understanding of your identity, culture and suicidal behavior. There are sometimes references that I might not understand, but it’s important for both of us to acknowledge these differences and work together. What do you think?

Violet: Yeah, we can do that. Thanks.

Dr. Green: Great. Thank you, Violet. Addressing your suicidal behavior and history with depression, can we go back towhen you first started feeling this way?

Violet: I guess it was when I was 7 and realized I was born in the wrong body. I told my family and they said something waswrong with me.

Dr. Green: I can imagine that experience was hard for you. I can assure you there is nothing wrong with your identity. Does your family still think the same way about you?

Violet: Thanks. Some of them don’t, but my mom is very supportive, and I have really great friends in the transcommunity.

Dr. Green: I’m glad that you have a good support system through your mom and friends. I think incorporating their supportinto the treatment plan will be very beneficial.

Violet: Yeah, I agree.

Dr. Green: Wonderful. I would like us to sit together and discuss a treatment plan that would be right for you. I am thinking about a range of approaches that might be best. We can discuss more about what is the options are and what treatment will looklike. Would you like us to do that?

Violet: Yes. That sounds good.

In this re-created scenario, Dr. Green provides a welcoming space that is conducive to building trust and improving the therapeutic process. First, when Violet shares her discomfort, he addresses her concerns and shares his limitations. Sharing his own discomfort shows Violet that Dr. Green is honest and truly cares about helping her. This time, he validates her experience when he individualizes her discomfort and re-assures her identity as a transgender Chicana woman. Even when he was confused about terminology related to her identity, he addressed those limitations.

As Violet discusses her background and support system, Dr. Green follows up with questions to assess how to include her support system within the treatment plan. Throughout the session, Dr. Green uses a collaborative approach by allowing Violet to be the expert in her experience. He provides her with an understanding of therapy, yet consults her opinion throughout their interaction.

This session is more productive, collaborative, and efficient than the previous one and is a good model of the therapeutic approach that is often used within CAMS – or Collaborative Assessment and Management of Suicidality.

Research suggests that CAMS is effective in treating minority communities.2 A major reason for this effectiveness is the use of the collaborative approach, which centers the client as an expert on navigating their suicidal behavior. The CAMS direct approach to handling suicide-related treatment also provides space for the therapist to practice a more multicultural and humanistic care, allowing for a therapeutic process that:

  • acknowledges the social/cultural differences of the client-therapist dynamic,
  • validates the experiences of the client,
  • allows space for the therapist to acknowledge their limitations,
  • provides a collaborative treatment plan, and
  • seeks to learn about and include the client’s community support system in

These tips can be used within a wide scope of clinical framework, not just CAMS. Throughout my continuous training as a psychology student, I have observed my mentors, supervisors, colleagues, and myself implement these techniques while working with minority clients. As a minority, receiving therapy from a therapist who incorporated these techniques has often alleviated my own apprehension towards the process. When treating mental health — especially suicidal behavior — it is essential to consider the impact of a client’s identity.

Footnotes:

1 American Psychological Association. (2015). Demographics of U.S. Psychological Workforce: Findings from the AmericanCommunity Workforce. [Online pdf]. Retrieved from https://www.apa.org/workforce/publications/13-demographics/report.pdf

2 Jeffrey A. Hayes, Andrew A. McAleavey, Louis G. Castonguay, and Benjamin D. Locke. Psychotherapists’ OutcomesWith White and Racial/Ethnic Minority Clients: First, the Good News. Journal of Counseling Psychology 2016, Vol 63, No 3, pp 261-268. https://www.apa.org/pubs/journals/features/cou-cou0000098.pdf

3 Jayong L. Choi, James R. Rogers, James L. Werth, Jr. Suicide Risk Assessment With Asian American College Students: A CulturallyInformed Perspective. Sage Journals, Vol 37, Issue 2, pp 186-218. https://journals.sagepub.com/doi/10.1177/0011000006292256

About the Author

Tanisha Esperanza Jarvis M.A.

Tanisha Esperanza Jarvis M.A.
Tanisha Esperanza Jarvis received her B.A. in anthropology and sociology at Spelman College in 2015, where she also minored in Comparative Women’s Studies. While at Spelman, her research focused on integrating academia and social justice. As a Bonner Scholar and Social Justice Fellow her research work included preventative and interventional treatment of sexual trauma and LGBTQ and racial/ethnic minority research. She finished her M.A. in psychological sciences from The Catholic University of America (CUA) in 2019. Her research within the Suicide Prevention Lab (SPL) focused on integrating an international approach to CAMS research and treatment of suicidality within marginalized communities.

See More Articles by this Author

About Tanisha Esperanza Jarvis M.A.

Tanisha Esperanza Jarvis M.A.
Tanisha Esperanza Jarvis received her B.A. in anthropology and sociology at Spelman College in 2015, where she also minored in Comparative Women’s Studies. While at Spelman, her research focused on integrating academia and social justice. As a Bonner Scholar and Social Justice Fellow her research work included preventative and interventional treatment of sexual trauma and LGBTQ and racial/ethnic minority research. She finished her M.A. in psychological sciences from The Catholic University of America (CUA) in 2019. Her research within the Suicide Prevention Lab (SPL) focused on integrating an international approach to CAMS research and treatment of suicidality within marginalized communities.

6 Risk Factors for Transgender & Gender Diverse Suicide

Our understanding of how gender affects suicidality was developed when most scholars viewed gender as a male/female binary. However, over the last decade, scholars have begun investigating suicide in those whose gender identity does not match their sex assigned at birth.

Recent studies have shown that transgender/gender-diverse (TGD) adults share many risk factors for suicide with the general population, such as mental health concerns, substance abuse, and life stressors. However, unique risk factors for TGD individuals are also becoming more apparent through recent research. This research attempts to understand the factors that relate differently to suicidal thoughts (such as symptoms of depression) and suicidal behaviors (such as access to a firearm). This way of understanding suicide is often referred to as the ideation-to-action framework. By understanding the unique risk factors for suicide in TGD individuals, we can develop more effective prevention strategies and interventions to support this vulnerable population.

Why do Transgender People Die by Suicide?

The following are six risk factors that providers should be aware of and assess in order to better understand suicide risk in their TGD patients.

Risk Factor #1:  External minority stress

Studies have identified various factors that contribute to suicide and suicidal ideation in transgender individuals. These factors include different forms of violence, discrimination, harassment, and rejection based on one’s minority gender identity. These factors are consistently associated with increased suicidal ideation but have a weaker link to suicidal behavior. The factors that are most highly related to suicidal ideation include harassment, discrimination, social stressors such as rejection, and non-affirmation in one’s identity. On the other hand, experiences of physical and sexual violence are related to both suicidal ideation and behavior. By understanding and addressing these risk factors, we can work towards developing effective prevention strategies and interventions to support the mental health and well-being of transgender individuals.

Risk Factor #2:  Internal minority stress

Transgender/gender-diverse (TGD) individuals face unique risk factors for suicide and suicidal ideation that are experienced more internally compared to external discrimination or violence. These risk factors include internalized stigma and transphobia, which can lead to shame about being transgender. Other factors include concealment of identity and nondisclosure, expectations of social rejection, an inability to express gender, negative self-concept, and an unclear gender identity. These internal factors are particularly associated with the vulnerability for suicidal ideation, but they have a weaker link to suicidal behavior once suicidal ideation has developed. By addressing these internal risk factors through therapy, support, and affirmation of identity, we can reduce the risk of suicidal ideation and improve the mental health and well-being of TGD individuals.

Risk Factor #3:  Psychiatric morbidity

As with the general population, mental health problems are linked to an increased risk of suicide and suicidal ideation among transgender individuals. Common mental health issues that contribute to suicidal thoughts and behaviors include depression, loneliness and isolation, emotional instability, anxiety, PTSD, alcohol and drug abuse, physical and mental disabilities, and learning disabilities. Some risk factors are more closely related to suicidal behavior than others, such as substance abuse and PTSD. However, internal factors like loneliness and social isolation can also contribute to suicidal ideation. By addressing mental health issues through therapy and support, we can help transgender individuals manage these risk factors and reduce the likelihood of suicide and suicidal ideation.

Risk Factor #4:  Transition and healthcare

Gender transition is a unique and personal experience for transgender individuals, and the steps involved in the process can vary widely. These steps can range from social transition, such as dressing in one’s gender, to medical interventions like hormone therapy or surgery. However, there are certain risk factors related to the transition process and healthcare that are associated with an increased risk of suicidal thoughts and behaviors in TGD adults. These factors include not completing hormone therapy, a lack of medical interventions such as breast or genital surgery, living as one’s birth gender, identity documents that do not align with one’s gender identity, limited healthcare coverage for gender-related interventions, a lack of psychotherapy for gender dysphoria, and visual nonconformity. By addressing these factors and providing access to appropriate healthcare and support, we can help reduce the risk of suicidal ideation and improve the overall well-being of transgender individuals.

Risk Factor #5:  Reasons for living

There are certain factors that can serve as protective measures against suicidal thoughts and behaviors among transgender individuals. These include reasons for living, such as religiosity, optimism, survival coping beliefs, concerns about how loved ones would react to their suicide, fear of suicide, fear of social disapproval if one attempts suicide, and moral objections to suicide. By focusing on and strengthening these protective factors, we can help reduce the risk of suicidal ideation and behavior in transgender individuals. Additionally, providing support and resources to individuals who may be struggling with suicidal thoughts can also be helpful in preventing suicide and improving overall mental health.

Risk Factor #6:  Demographics

Certain demographic and static risk factors have been identified in studies related to suicide and suicidal ideation among transgender individuals. These include assigned female sex at birth, gender self-identification as male, and childhood gender nonconformity. Additionally, factors such as younger age, racial or ethnic minority status, education, income, employment, socioeconomic status, and sexual orientation as gay, lesbian, bisexual, or unsure have also been linked to suicidal thoughts and behaviors in this population. By taking these risk factors into consideration during patient assessments and suicide prevention efforts, healthcare providers can work to improve outcomes for transgender individuals and decrease the risk of suicide.

References:

 

1https://www.apa.org/topics/lgbt/transgender.pdf

2https://www2.psych.ubc.ca/~klonsky/publications/ita.pdf

For more information

To learn more about how gender and gender identification affects suicidality, read “The Gender Paradox of Suicide: How Suicide Differs Between Men, Women, and Transgender/Gender Diverse Individuals” by Dr. Raymond P. Tucker, and “Correlates of suicide ideation and behaviors among transgender people: A systematic review guided by ideation-to-action theory” by Dr. Caitlin Wolford-Clevenger.

About the Authors

Alix Aboussouan

Alix Aboussouan
Alix Aboussouan is a second year PhD student in clinical psychology at Louisiana State University. As a member of the Mitigation of Suicidal Behavior (MOSB) research lab there, she studies risk and resilience factors for suicide in TGD adults. She is also a CAMS-trained therapist and delivers the intervention to at-risk adults at Our Lady of the Lake Regional Medical Center.

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Raymond P. Tucker Ph.D.

Raymond P. Tucker Ph.D.
Raymond is an Assistant Professor of Psychology at Louisiana State University (LSU) where he founded the Mitigation of Suicidal Behavior (MOSB) Laboratory in 2017. He also is a Clinical Assistant Professor of Psychiatry at Louisiana State University Health Sciences Center /Our Lady of the Lake Medical Center. He finished his Ph.D. in clinical psychology from Oklahoma State University in 2017 following his clinical internship at VA Puget Sound. Raymond's research broadly focuses on the enhancement of theoretical models of suicide and suicide risk assessment tools, particularly in underserved populations (e.g., Veterans, Transgender and Gender Diverse adults). Raymond began his tenure as a CAMS consultant in 2019 after receiving a state-level grant to implement CAMS across the Our Lady of the Lake Regional Medical Center in Baton Rouge L.A. He is a former board member of the American Association of Suicidology and is a current faculty member at the National Suicidology Training Center.

See More Articles by this Author

About Alix Aboussouan

Alix Aboussouan
Alix Aboussouan is a second year PhD student in clinical psychology at Louisiana State University. As a member of the Mitigation of Suicidal Behavior (MOSB) research lab there, she studies risk and resilience factors for suicide in TGD adults. She is also a CAMS-trained therapist and delivers the intervention to at-risk adults at Our Lady of the Lake Regional Medical Center.

About Raymond P. Tucker Ph.D.

Raymond P. Tucker Ph.D.
Raymond is an Assistant Professor of Psychology at Louisiana State University (LSU) where he founded the Mitigation of Suicidal Behavior (MOSB) Laboratory in 2017. He also is a Clinical Assistant Professor of Psychiatry at Louisiana State University Health Sciences Center /Our Lady of the Lake Medical Center. He finished his Ph.D. in clinical psychology from Oklahoma State University in 2017 following his clinical internship at VA Puget Sound. Raymond's research broadly focuses on the enhancement of theoretical models of suicide and suicide risk assessment tools, particularly in underserved populations (e.g., Veterans, Transgender and Gender Diverse adults). Raymond began his tenure as a CAMS consultant in 2019 after receiving a state-level grant to implement CAMS across the Our Lady of the Lake Regional Medical Center in Baton Rouge L.A. He is a former board member of the American Association of Suicidology and is a current faculty member at the National Suicidology Training Center.