Racial Identity and Reasons for Living in African American Female Suicide Attempters

Abstract

The current study investigated the association between racial identity and reasons for living in African American women who have attempted suicide. Particular attention was paid to the relation between two elements of racial identity (private regard, racial centrality) and reasons for living, an alternative assessment of suicidal risk. While private regard refers to an individual’s beliefs about the African American race, racial centrality describes the importance an individual places on his or her racial identity. The sample included 82 low-income African American women, ages 18–64, who reported a suicide attempt in the past 12 months. Participants, recruited from a large, urban public hospital located in the Southeast, completed the Reasons for Living Inventory and the Multidimensional Inventory of Black Identity, which included the private regard and racial centrality subscales. Results indicated that, as predicted, higher private regard was associated with more reasons for living. Contrary to expectations, racial centrality was not correlated with reasons for living nor was there an interaction between private regard and racial centrality indicating that racial centrality did not function as a moderator in predicting participants’ reasons for living scores. Implications for culturally competent clinical interventions that target bolstering private regard are discussed.

Suicidal behavior exists along a continuum with risk elevating from a person having few reasons for living to engaging in a fatal suicide act, with suicidal thoughts with or without a plan, gestures, and nonfatal attempts being other key points on the continuum (Minino, Xu, & Kockanek, 2010; Walker, Alabi, Roberts, & Obasi, 2010). Suicide is the 11th leading cause of death among Americans: 34,598 suicides occurred in the United States during 2007 and of these, 5.5% were among African Americans (Centers for Disease Control & Prevention [CDC], 2011). However, suicide occurs at a lower rate among African Americans as compared with most other racial/ethnic groups, and there is considerable variation in the rate of suicide for African Americans depending on age (CDC, 2011). It should be noted that some investigators have questioned the findings of low suicide rates among African Americans, suggesting that African Americans tend to be more cautious with regard to self-disclosure, in part due to concerns about stigma (Morrison & Downey, 2000). While the rate of occurrence of suicide in different ethnic and racial groups continues to be of debate, research has revealed that suicide may be a growing problem in the African American community (Joe, 2006; Walker et al., 2010). Regardless of the rates of suicide in comparison to other groups, suicide attempts are a significant problem for African American women (Kaslow et al., 2010; Kaslow et al., 2002).

Reasons for living may be considered as a proxy for suicidal risk, as individuals with limited reasons for living are more vulnerable to consider suicide and act on these thoughts (Linehan, Goodstein, Nielsen, & Chiles, 1983; Malone et al., 2000; Wang, Lightsey, Pietruszka, Uruk, & Wells, 2007). Specifically, low levels of survival and coping beliefs, responsibility to family, child-related concerns, fear of social disapproval, moral objections, and fear of suicide are associated with elevated levels of suicidal ideation and with suicide attempts (Hirsch & Ellis, 1996; Linehan et al., 1983; Lizardi et al., 2007; Malone et al., 2000). The link between reasons for living and suicidal behavior has also been found to be true in African American samples (Westefeld, Badura, Kiel, & Scheel, 1996).

The fact that African Americans may have a lower rate of suicide than other racial/ethnic groups indicates there may be unique protective factors that buffer against their disproportionate exposure to risk factors (e.g., poverty, trauma). Studies have revealed key protective factors: hopefulness, self-efficacy, coping skills, high levels of social support, and effectiveness in obtaining resources (Kaslow et al., 2002; Meadows, Kaslow, Thompson, & Jurkovic, 2005). Similarly, because African Americans may be more likely than European Americans to report having reasons for living (Bender, 2000; Marion & Range, 2003; Morrison & Downey, 2000), unique protective factors for reasons for living might also be worth considering. There is some evidence that optimism, spiritual well-being and religiosity, and family social support are associated with increased reasons for living in African Americans (June, Segal, Coolidge, & Klebe, 2009; West, Davis, Thompson, & Kaslow, 2011).

One additional culturally relevant variable that may serve a protective role with regard to suicidal behavior and its correlate, reasons for living, is positive racial identity, particularly racial centrality, which has been linked to psychological well-being (Sellers, Rowley, Chavous, Shelton, & Smith, 1997). Racial identity is the role of race within the self-concept of African Americans or the “qualitative meanings they attribute to being members of that racial category” (Sellers, Smith, Shelton, Rowley, & Chavous, 1998, p. 18). There is variability in terms of how individuals define their racial identity and as such, researchers have analyzed the racial identity of African Americans as a complex social construct (Cross, 1991; Sellers et al., 1998). This complexity has been captured within four multidimensional constructs —racial regard, centrality, salience, and ideology (Sellers et al., 1998), two of which are the focus of this research (racial regard, racial centrality). Racial regard includes private regard, which refers to personally held beliefs about the African American race and what it means to be a member of that race, and public regard, which refers to feelings concerning how others view the African American race. Racial centrality describes the degree to which individuals formulate their social identity based on race and it is stable across various settings. Racial and ethnic identity have been explored by several cross-sectional and longitudinal research and models, notably Cross’s Nigrescence model of racial identity (Cross, 1991; Vandiver, Cross, Worrell, & Fhagen–Smith, 2002) and Phinney’s model of ethnic identity development (Phinney, 1992; Scottham, Cooke, Sellers, & Ford, 2010). Data highlight that although racial identity tends to be lower among low-income African Americans as compared to those in higher social classes (Paul, Boutain, Agnew, Thomas, & Hitti, 2008; Reese & Brown, 1995), it is a highly relevant construct for low-income, African Americans (Resnicow & Ross–Gaddy, 1997).

Although no research directly addresses the link between private regard and reasons for living or suicidal behavior, evidence suggests that private regard, as one aspect of racial identity, may be linked to reasons for living. Higher racial private regard is associated with lower levels of depressive symptoms, higher self-esteem, and higher levels of well-being in adolescent and adult community samples of African Americans (Rowley, Sellers, Chavous, & Smith, 1998; Sellers, Copeland–Linder, Martin, & Lewis, 2006; Settles, Navarrete, Pagano, Abdou, & Sidanius, 2010). Moreover, African Americans who have attempted suicide feel more disconnected from their own and other ethnic groups as compared with their nonsuicidal counterparts, suggesting that a low private regard may be a risk factor for suicidal behavior (Kaslow et al., 2004).

A few lines of research suggest that racial centrality may moderate the private regard–reasons for living relationship. One study found that private regard was directly associated with levels of depressive symptoms and racial centrality moderated the association, such that higher private regard was more strongly related to lower levels of depressive symptoms when African American women’s race was a central component of their self-concept (Settles et al., 2010). Moreover, in a study with African American college and high school students, racial centrality moderated the link between private regard and positive self-esteem (Rowley et al., 1998). There also is evidence that racial identity, including racial centrality, moderates the association between racial discrimination and depressive symptoms (Banks & Kohn–Wood, 2007). On a related note, holding an Afrocentric worldview appears to buffer the impact of stress on depressive symptoms (Neblett, Hammond, Seaton, & Townsend, 2010). An Afrocentric perspective was found to moderate the link between hopelessness and reasons for living (Walker et al., 2010). Similarly, multicultural identity attitudes have been found to moderate the link between race-related stress and psychological well-being (Jones, Cross, & DeFour, 2007). Further research is needed on the mechanisms by which various dimensions of racial identity and Afrocentric world-view protect individuals from the psychological effects of race-and non race-related stress and discrimination. One possible mechanism is racial identity, which may alter appraisals of circumstances such as stress, coping resources, or negative events, which in turn affects psychological well-being (Neblett et al., 2010; Smith, 1985).

The aim of this research was to examine the relation between racial identity and reasons for living in African American women with a suicide attempt in the prior year. The current study investigated whether racial centrality (one component of racial identity) acted as a protective factor in the private regard (another component of racial identity)–reasons for living (a correlate of suicidal behavior) link in African American women. It was predicted that women with higher private regard for African Americans would report more reasons for living. Further, it was expected that racial centrality would moderate the private regard–reasons for living link, such that for women who reported that racial identity was more central to their self-concept, higher private regard would serve as a protective factor and foster resiliency against suicidal intent. This study adds to the current literature by including an at-risk clinical sample, rather than a community-based sample, as well as by focusing on reasons for living, an extension of suicidal behavior, as the outcome variable.

Method

Participants

Participants were 82 women, ages 18–64, who self-identified as African American and who had attempted suicide in the prior year. Recruitment was conducted at a large public, university-affiliated hospital serving an inner city, at-risk population from September 2002 to September 2006. Potential participants were excluded if they demonstrated an inability to complete the pretreatment interview due to cognitive impairment, delirium, or acute psychosis. Possible participants who were actively psychotic were excluded by a psychotic-symptom screening questionnaire. The Rapid Estimate of Adult Literacy in Medicine (Williams et al., 1995) and the Mini Mental State Exam (MMSE, Folstein, Folstein, McHugh, & Fanjiang, 2001) were used to exclude women with cognitive limitations that could confound their ability to fully participate in the study protocol (MMSE ≤24 if literate or ≥22 if functionally illiterate).

Women were screened and recruited throughout the hospital by undergraduate and graduate volunteers to ascertain if they met inclusion criterion. Additionally, hospital staff referred African American women who presented with a suicide attempt.

Procedure

Data for the present report were collected as a part of a pre-intervention assessment for a treatment outcome study with low-income African American women who had attempted suicide. A comprehensive battery of measures including, but not limited to, the scales examined in the current study were given over two sessions. The full battery took 4 to 5 hours for participants to complete and was divided over two time points to prevent participant fatigue. There was considerable attrition between the first and second assessments. While 151 women completed the first part of the battery, which included the Reasons for Living Inventory (RFL), only 82 women completed the second half of the battery, which included the Multidimensional Inventory of Black Identity (MIBI). There were no significant demographic differences between those who completed one versus two pre-intervention assessment sessions. Verbal administration was utilized given the low level of functional literacy of many of the women in the project. Interviewers were of diverse racial backgrounds. Once participants completed the battery, they were debriefed, and provided with a $20 honorarium, two tokens for public transportation, and community referrals. The participants were then randomized to either a support group associated with the research project or a 10-week intervention group focused on meeting their psychiatric needs and decreasing their risk for suicide. The university and hospital institutional review boards approved the study, and all participants were treated in accordance with the guidelines set forth by the American Psychological Association Ethical Principles of Psychologists and Code of Conduct.

Measures

Demographic Data Questionnaire (DDQ)

The DDQ (Kaslow et al., 2010) invites the women to provide information about basic demographics (e.g., age, parental status), social class (e.g., income, employment status, homelessness status, educational history), and psychiatric status (mental health diagnoses and prior suicide attempts).

Reasons for Living Inventory (RFL)

(Linehan et al., 1983). The RFL is a 48-item inventory assessing a range of beliefs that differentiate suicidal from nonsuicidal persons. It measures an individual’s commitment to various reasons for not committing suicide, grounded in cognitive– behavioral theory, which assumes that cognitive patterns mediate suicidal behavior (Fischer & Corcoran, 2000). It taps suicidal and coping beliefs (e.g., “I believe I can learn to adjust or cope with my problems”), responsibility to family (“I have a responsibility and commitment to my family), child related concerns (e.g., “ I want to watch my children as they grow”), fear of suicide (“I am afraid of death), fear of social disapproval (“I am concerned about what others would think of me”), and moral objections (“I believe only God has a right to end a life”). Each reason within the inventory is rated from 1 (not at all important) to 6 (extremely important). Each subscale score is calculated by averaging item ratings, with higher scores indicating more reasons for living. The RFL total score has a good internal consistency (Osman et al., 1993), with α = .96 in the current sample, and has been shown to be a valid and reliable predictor of differentiating between suicidal and nonsuicidal persons (Connell & Meyer, 1991; Linehan et al., 1983; Osman et al., 1999). With African Americans, the measure has been found to have good construct validity (West et al., 2011).

Multidimensional Inventory of Black Identity (MIBI)

(Sellers et al., 1997). The 56-item MIBI is derived from the Multi-dimensional Model of Racial Identity. All items were measured on a 7-point Likert scale ranging from 1 (strongly disagree) to 7 (strongly agree). Scores for each of the subscales were totaled and averaged with higher scores indicating a higher level of agreement with each construct. Although the MIBI encompasses seven subscales, the current study only used the private regard and centrality subscales to investigate two of the three stable dimensions of racial identity. The private regard subscale (α = .78 in the current sample) includes six items that measure the extent to which individuals positively or negatively perceive African Americans and their membership in that group (e.g., “I am happy that I am Black”; “I feel good about Black people”). The centrality subscale (α = .74 in the current sample) consists of eight items assessing the degree to which participants normatively define themselves with regard to race (e.g., “Being Black is an important reflection of who I am”; “In general, being Black is an important part of my self-image”).

Results

Descriptive Statistics

Prior to conducting the analyses, descriptive statistics were obtained. Table 1 presents means and standard deviations for the background variables. As can be seen in Table 1, the women in the study were primarily 20–40 years old, low income and unemployed, homeless, high school educated or less, and mothers. The intercorrelations between the dependent variable (reasons for living) and background variables were examined to check for potential covariates. Only participants’ parental status (r = .36, p < .01) was significantly correlated with reasons for living. As a result, parental status was included as a covariate in the subsequent analyses.

Table 1.

Background Characteristics of the Sample

Characteristic	Value
Mean age (SD)	35.83 (11.07)
Monthly household income (%)
<$250	35.8
$250–$499	13.3
$500–$999	25.0
$1,000–$2,000	15.0
>$2,000	10.8
Unemployed (%)	87.5
Homeless (%)	52
Education (%)
Less than 12th grade	39.3
High school diploma or equivalent	37.2
Some college or technical school	15.2
Completed college or technical school	8.3
Mother (% yes)	80.7
Mental health diagnosis (%)
Schizophrenia	18.1
Depression	60.9
Bipolar disorder	38.4
Anxiety disorder	23.9
Personality disorder	6.5
Other	4.1
More than 1 previous suicide attempt(s) (%)	27.1

Note. SD = standard deviation.

Table 2 provides means and standard deviations, as well as a correlation matrix, for the key study variables. The mean for the RFL appeared somewhat lower than that reported for non-suicidal persons (Linehan et al., 1983) and the mean for the MIBI subscales appeared to be somewhat lower than those found in the sample of African American college students on whom the scale was developed (Sellers et al., 1997). As seen, there was a positive correlation between private regard and centrality, such that higher private regard was also associated with participants’ reporting that race was more central to their identity. Private regard and reasons for living also were correlated, indicating that as private regard increased, participants reported more reasons for living. However, contrary to expectations, there was no significant correlation between racial centrality and reasons for living. For the subsequent analyses, scale scores were centered to increase interpretability and reduce multicollinearity.

Table 2.

Descriptive Statistics and Pearson Correlations Between MIBI Private Regard, MIBI Racial Centrality, and Reasons for Living

		Correlations
Variables	M (SD)	Private regard	Centrality	Reasons for living
Private regard	5.72 (1.13)	—	.38**	.25*
Centrality	4.18 (1.14)		—	.09
Reasons for living	4.18 (1.19)			—

Note. M = mean; SD = standard deviation; MIBI = Multidimensional Inventory of Black Identity.

^*p < .05.

^**p < .01.

To test the first hypothesis that women with higher private regard for African Americans would report more reasons for living, hierarchical linear regression was used to analyze the main effects. The model included reasons for living as the outcome variable and private regard as the predictor variable, while controlling for participants’ parental status. As predicted, there was a significant main effect with private regard predicting reasons for living while controlling for parental status, with scores accounting for approximately 17% of the variance (R² = .17, F(1, 73) = 6.12, p < .05) [See Table 3].

Table 3.

Hierarchical Multiple Regression Analyses Predicting Reasons for Living (N = 82)

Predictor	ΔR2	Final β	p
Step 1
Parental status	.09**	.31**	.00**
Step 2
Private regard	.07*	.27*	.02*
Step 3
Racial centrality	.01	.08	.00
Step 4
Private regard × Racial centrality	.00	−.03	.00

Note. β@final = standardized beta value at step 4.

^*p < .05.

^**p < .01.

The second hypothesis stated that racial centrality would moderate the link between private regard and reasons for living, so that for women who reported that race was more central to their identity, private regard would have a greater impact in predicting reasons for living. A hierarchical linear regression that added parental status in Step 1, private regard in Step 2, centrality in Step 3, and the interaction of private regard and centrality in Step 4 was not significant. This indicates that counter to what was expected, the relationship between private regard and reasons for living did not change based on the centrality of racial identity.

Discussion

The current study examined the relations among private regard, racial centrality, and reasons for living (a correlate for suicidal behavior) among low-income African American women who recently attempted suicide. Attitudes toward one’s own ethnic/racial background have been a consistent theme in research literature on African Americans (Sellers et al., 1998). However, few researchers have examined racial identity in low-income or clinical samples. Consistent with our first hypothesis, our results suggest that positive beliefs about being a member of the African American community (i.e., private regard) are associated with having a sense of purpose and commitment to living. Second, it was hypothesized that racial centrality would moderate the link between participants’ private regard and reasons for living. However, findings indicated that racial centrality was not associated with reasons for living and there was no interaction between private regard and racial centrality. Thus, this hypothesis was not supported.

The findings contribute to our understanding of the importance of private regard and mental health outcomes. Although racial private regard has been linked to some mental health outcomes, such as depressive symptoms, self-esteem, and well-being in African Americans (Rowley et al., 1998; Sellers et al., 2006; Settles et al., 2010; Yip, Seaton, & Sellers, 2006) and individuals from other ethnic/racial backgrounds (Mossakowski, 2003), this is the first study to document its association with reasons for living, a proxy for suicidal behavior. It is possible that this link is related to the fact that private regard buffers against the negative impacts of race-related stress and discrimination (Sellers et al., 2006). In serving this protective role, it may allow African American women to feel more positively about living. In other words, private racial regard may be considered a coping resource that is important to capitalize upon in designing and implementing culturally informed interventions (Mossakowski, 2003).

The proposed moderation model was based on research that participants who had higher private regard and indicated that racial identity was more central to their self-concept, reported less depressive symptoms (Settles et al., 2010). Reasons for living and depressive symptoms are inversely correlated, as individuals who report having more reasons for living tend to score lower on measures assessing subjective depression (Malone et al., 2000). Given that depression and reasons for living are inversely correlated, it was predicted that the indicators of racial identity, (racial centrality and private regard) would be positively associated to reasons for living in the current study just as they were negatively correlated with depressive symptoms in the study by Settles and colleagues (Settles et al., 2010). Differences between the two constructs or differences in the samples may account for the discrepant findings. A key distinction between the two samples is that the women recruited for the current study came from a clinical population as compared with the participants in the study by Settles and coworkers who were drawn from a nonclinical population. It was likely that the women in the current sample had experienced higher levels of negative life events, depressive symptoms, and suicidal behavior compared with the respondents included in the study by Settles and colleagues. Consequently, it is possible that the women in the current sample, who have attempted suicide and therefore likely hold negative views toward self, may experience a discrepancy between their own personal low level of self-esteem and the potentially positive connotations associated with a social identity as an African American female. This may be especially true given that the items measuring racial centrality tended to focus on personal views of the self in relation to Black people (e.g., “My destiny is tied to the destiny of other Black people”), whereas items measuring private regard assessed participants’ beliefs about the Black community as a group (e.g., “I feel that the Black community has made valuable contributions to this society”). Thus, this sample of women, who have attempted suicide, may have had a greater propensity to hold negative views of themselves while maintaining the ability to view others in a positive light. Given the discrepancy in these findings, the moderation model requires further evaluation with different samples and with related outcome variable constructs.

Several study limitations should be considered when drawing conclusions about the findings. The first pertains to the sample and its generalizability. The sample was relatively small and there was a high rate of attrition. This limited the ability to more fully examine the relationships between variables of interest. For example, while parental status significantly predicted reasons for living, limited statistical power precluded the ability to further examine the interaction of this variable with others. The women were high risk given that they had acted on their suicidality in the past, low income, and either in crisis at the time the assessment was administered or had recently made an attempt. Thus, the generalizability of the findings to other samples needs to be examined.

Second, there was no control group included in the design. The absence of a control group precluded us from examining questions related to how the two groups would have compared on the two key constructs of interest as well as whether or not there were differences in the associations between racial identity and reasons for living in African American suicide attempters versus non-attempters.

Third, the fact that data were collected over two time points introduces additional room for error. Results may have differed if the participants’ reasons for living and racial identity were assessed on the same day. However, the MIBI and the RFL have demonstrated stability across time (Osman, Jones, & Osman, 1991; Sellers et al., 1997). In a related vein, only data from the baseline assessment interviews were used. For future research, it would be interesting to see if follow-up assessments would yield the same results, when the women were no longer in crisis, after the women attended intervention or support groups targeting suicide prevention and/or coping skills.

The fourth limitation is that our data were based exclusively on self-report measures, which may reduce the validity of findings. Due to the low literacy rate anticipated in our sample, the self-report measures were each read aloud to the respondents by interviewers. Given the sensitive nature of the items (e.g., suicidal ideation, depressive symptoms, racial attitudes), participants may have abstained from answering certain questions because it may have been too difficult to recount painful experiences, resulting in inaccurate or missing data. This could reflect feelings of shame, stigma, guilt, or the pull to give socially desirable answers. Reading the measures aloud and eliciting verbal responses may have increased the possible confounding effect of social desirability bias. Social desirability can affect the outcome of the interview and cause respondents to answer questions based on what they think is acceptable or desired by the interviewer rather than on what is accurate (Davis, Couper, Janz, Caldwell, & Resnicow, 2010; Krysan & Couper, 2003). These feelings also could have been reduced or enhanced depending on the demographic characteristics of the interviewer. Since the current study utilized both African American and non-African American interviewers, interviewer race could have changed participants’ responses as they may have felt more comfortable disclosing personal information to interviewers of the same race/ethnicity due to a belief that they have a shared sense of identity (Lowe, Lustig, & Marrow, 2011).

A fifth limitation of the study also related to measurement issues pertains to the fact that the sample endorsed fewer reasons for living and lower levels of racial identity than has been found in non-suicidal samples. While such a finding is consistent with other research that compares these measures in suicidal and non-suicidal persons (Linehan et al., 1983), it also is possible that these lower scores are a reflection of another psychological state, such as depression. Indeed, moderately high correlations have been found between depression and RFL scores (Strosahl, Chiles, & Linehan, 1992). Thus, future research would need to examine the role of other psychological factors as related to scores on the RFL and the MIBI. However, based on recent finding highlighting a complex relationship between racial identity and depression, it appears that the two constructs are related but not that racial identity is simply a manifestation of depression (Settles et al., 2010). Thus, future empirical examinations may want to consider the multifaceted nature of the associations between both reasons for living and racial identity and depression. In addition, such studies may want to conduct more fine grained analyses to ascertain whether lower scores among suicide attempters with regard to both reasons for living and racial identity reflect a negative response set as is commonly observed in depression persons (Teasdale, 1983) or are true phenomenon.

Finally, the anticipation of compensation for completing the assessment is another potential limitation. Half of the participants were homeless and 82% were unemployed and thus they may have depended on the money for basic necessities. Thus, participants may have altered information recorded during the assessment to ensure that compensation would be given, leading to inaccurate or skewed data.

Despite these limitations, the present study suggests a number of potential clinical interventions. Though racial centrality was not linked with reasons for living and there was no interaction with private regard, our findings reveal that bolstering private regard and positive views of African Americans can be a therapeutic strategy used for supporting African American women at risk for suicidal behavior and may foster resiliency against suicidal intent. Enhancing private regard may be associated with greater levels of self-actualization and more positive affective states, as well as lower levels of acculturative stress (Parham & Helms, 1985; Thompson, Anderson, & Bakeman, 2000).

It is important to employ interventions that draw upon historical references regarding the strength of African American women in the family and community setting, in a fashion that does not place an expectation on women to live up to the gender role requirements associated with the “Strong Black Woman” notion (Beauboeuf–Lafontant, 2009; Romero, 2000; Wyatt, 2008). That strategy may empower African American women who have lost sight of those positive images. Intervention efforts that provide African American women with positive messages about the value of the African American race as well as the resiliency and strength of African American women may catalyze the positive effect of more traditional forms of therapy for at-risk individuals. For example, incorporating exercises that encourage women to view themselves as powerful figures by having them draw images of themselves as goddesses may help provide women concrete, visual evidence of their strength (Davis et al., 2009; Kaslow et al., 2010). The aforementioned exercise could help to empower the women by allowing them to generate their own depiction of what a strong woman looks like. Other exercises may include having women act out scenes in which there is a strong, resourceful female lead. This would give women the opportunity to literally assume the strength of the character, which would hopefully promote the idea of developing similar qualities to the character in which they play. Finally, narrative approaches, in which women are helped to restory constraining narratives of racial identity into empowering racial identities are likely to be a useful therapeutic tool for increasing private regard (Hill & Thomas, 2000).