Who You Treat: Marginalized Populations

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.

Suicidality in Correctional Facilities: Challenges in Assessing and Treating

With suicide rates rising dramatically over the past few years in both state prisons and local jails, the need for effective assessment and treatment of suicidal behavior as well as other forms of mental illness for inmates also increases. However, the nature of the correctional system and local and state facilities present unique challenges to the effort.

Below are four of the major challenges our correctional facilities face in their efforts to serve inmates experiencing suicidal ideation or other suicidal behaviors.

Challenge #1: Rising Mental Illness and Suicide Rates

The alarming trend of rising mental illness and suicide rates in correctional facilities is a major concern in the United States. The chart below visualizes the increase in the number of suicides in local jails and federal state prisons in the United States from 2000-2019.

Suicide and Mental Health Statistics for Incarcerated Individuals

  • The Bureau of Justice Statistics (BJS) has reported a staggering 30% increase in suicide rates in state prisons from 2013 to 2014, highlighting the dire state of mental health care in these facilities.
  • Suicide was also found to be the leading cause of death in 2014 in local jails, with a 13% increase from the previous year.
  • The rate of mental health issues in jails and prisons is three times higher than that of the general population.
    44% of jail inmates and 37% of prisoners report having been diagnosed with a mental health disorder prior to their incarceration.
  • The most common mental health disorder among both prisoners and jail inmates was major depressive disorder, which is known to be highly associated with suicidal thoughts and behaviors.

Challenge #2: Difficulty in Assessing “Secondary Gain” Behaviors

Occasionally, savvy inmates and prisoners may recognize opportunity in feigning suicidal thoughts or behavior in order to manipulate “the system”. This is called “Malingering.” Reference Here:

 

Malingering is falsification or profound exaggeration of illness (physical or mental) to gain external benefits such as avoiding work or responsibility, seeking drugs, avoiding trial (law), seeking attention, avoiding military services, leave from school, paid leave from a job, among others.

 

In correctional facilities, presenting suicidal behavior can result in extra attention, trips to the hospital, special treatment, and more. It becomes difficult to discern between a genuine cry for help and those employing manipulative measures for their own gain or entertainment.

This presents a dilemma for administrators and health providers in correctional facilities, as they must balance the need to provide appropriate care with the risk of enabling manipulative or “secondary gain” behaviors. In some cases, the presence of these individuals can lead to a sense of suspicion or distrust, causing some administrators to become overly cautious in their approach to treatment. Unfortunately, this cautious approach can also result in underserving inmates who are genuinely struggling with mental health issues and suicidal ideation.

Challenge #3: Frequent Transfers and Short Terms

The issue of frequent transfers and short terms for inmates in correctional facilities poses a significant challenge for mental health professionals tasked with addressing suicidal behavior.

In some settings, clinicians and other mental health professionals may only have the opportunity to meet with a suicidal inmate for one or two sessions before the inmate is transferred or released.

This limited time frame makes it extremely difficult to accurately assess an inmate’s risk of suicide and to identify the underlying drivers of their suicidality. Without a comprehensive assessment and prevention program in place, mental health professionals may not have the tools or resources needed to quickly uncover an inmate’s true drivers of suicidal behavior.

As a result, accurate risk assessment and effective treatment become virtually impossible, and inmates may not receive the care and support they need to address their mental health issues. The root causes of their suicidal behavior may go unaddressed, leading to a continued risk of suicide even after their release.

Challenge #4: Most Correctional Policies Focus on Containment Instead of Treatment

The prevalence of mental illness in correctional facilities is a significant issue, and unfortunately, correctional officers are often more concerned with maintaining order and security within their facilities, and this can result in limited attention being given to caring for inmates with mental health disorders. Policies for addressing suicidality in particular tend to prioritize containment over treatment, especially when resources are scarce. In some facilities, the policies for managing a suicidal inmate may be inadvertently counterproductive and even punitive or demeaning, which can discourage inmates from seeking help and exacerbate their mental health issues.

Moreover, while some inmates may be screened for suicide, it can be challenging to provide follow-up screening and assessment or access the resources to provide treatment for suicidal inmates. This can result in inadequate care for inmates with mental health disorders, leaving them at risk of harming themselves or others.

A supporting example that offers insight into the containment vs treatment statement comes from a U.S. Department of Justice National Institute of Corrections training guide titled “Inmate Behavior Management: The Key to a Safe and Secure Jail”, (published in 2009):

The inmate behavior management plan consists of six essential elements:

  • Assessing the risks and needs of each inmate at various points during his or her detention.
  • Assigning inmates to housing.
  • Meeting inmates’ basic needs.
  • Defining and conveying expectations for inmate behavior.
  • Supervising inmates.
  • Keeping inmates occupied with productive activities.
For more information

For more information on this topic, read “The Challenges of Assessing and Treating Suicidalty in Correctional Facilities: A Possible Solution with CAMS-care” by Jennifer Crumlish, Ph.D.

About the Author

Jennifer Crumlish Ph.D.

Jennifer Crumlish Ph.D.
Dr. Jennifer Crumlish received her Ph.D. in clinical psychology at The Catholic University of America in 1996. She completed her pre-doctoral internship at St. Elizabeths in Washington, D.C., Her interest in research started while working in the Biological Psychiatry Branch in the NIMH at NIH during graduate school. She has taught courses in the graduate psychology program at Catholic University in psychopathology and diagnostic assessment and supervised students in the psychotherapy practicum. From 2006 until 2017, Dr. Crumlish was a consultant to the D.C. Department of Human Services Adult Protective Services division and conducted capacity evaluations of adults throughout the city. Dr. Crumlish is currently an examiner for the Superior Court of D.C. Probate Division and has presented at several conferences on elder abuse in Washington, D.C. Currently Dr. Crumlish is a partner in the Washington Psychological Center where she provides therapy to adolescents, adults and couples. In addition, she is the Assistant Director of the Suicide Prevention Lab at the Catholic University of America where she has been a consultant on several randomized controlled trials of CAMS. As a Senior Consultant with CAMS-care, LLC, Dr. Crumlish has provided training in CAMS to mental health providers at multiple military posts, a state correctional organization and local and state mental health suicide prevention organizations.

See More Articles by this Author

About Jennifer Crumlish Ph.D.

Jennifer Crumlish Ph.D.
Dr. Jennifer Crumlish received her Ph.D. in clinical psychology at The Catholic University of America in 1996. She completed her pre-doctoral internship at St. Elizabeths in Washington, D.C., Her interest in research started while working in the Biological Psychiatry Branch in the NIMH at NIH during graduate school. She has taught courses in the graduate psychology program at Catholic University in psychopathology and diagnostic assessment and supervised students in the psychotherapy practicum. From 2006 until 2017, Dr. Crumlish was a consultant to the D.C. Department of Human Services Adult Protective Services division and conducted capacity evaluations of adults throughout the city. Dr. Crumlish is currently an examiner for the Superior Court of D.C. Probate Division and has presented at several conferences on elder abuse in Washington, D.C. Currently Dr. Crumlish is a partner in the Washington Psychological Center where she provides therapy to adolescents, adults and couples. In addition, she is the Assistant Director of the Suicide Prevention Lab at the Catholic University of America where she has been a consultant on several randomized controlled trials of CAMS. As a Senior Consultant with CAMS-care, LLC, Dr. Crumlish has provided training in CAMS to mental health providers at multiple military posts, a state correctional organization and local and state mental health suicide prevention organizations.

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.

Reflections on Suicidal Ideation

Crisis – The Journal of Crisis Intervention and Suicide Prevention published an Editorial written by David A. Jobes and Thomas E. Joiner called, “Reflections on Suicidal Ideation”. The study focuses on the prevalence of suicidal ideation. In the United States, “10,600,000 people experience thoughts of ending their lives.”

Read the full editorial >

The Journal of Crisis Intervention and Suicide Prevention is an international periodical that publishes original articles on suicidology and crisis intervention.

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.

See More Articles by this 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.

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.