Table 1.

Applying the Structural Racism and Suicide Prevention Systems Framework to youth suicide prevention

Level	Definition	Example in Mental Health Services	Example in School Settings	Example in Crisis Care	Structural Intervention
Cultural racism	Negative attitudes and beliefs about racially and ethnically minoritized populations embedded in societal values and practices.	Living in a state with high levels of cultural racism impacts the efficacy of psychotherapy for Black youth.	Schools in states with higher cultural racism demonstrate greater racial disparities in school disciplinary actions that disadvantage Black youth.	There is an overreliance in the crisis response system on coercive, involuntary, or punitive responses to address the emotional and behavioral needs of youth of color.	Expand suicide prevention strategies to include macro-level policies promoting racial and economic justice and addressing cultural racism.
Institutional racism	Laws, policy, and regulations embedded in organizations or institutions that consolidate power among White people.	Mental health services are provided through coercive rather than voluntary pathways or via emergency services rather than ongoing sources of care.	Increased criminalization of disruptive behaviors in schools disproportionately impacts youth of color and reduces protective factors such as school connectedness.	Police presence in schools and crisis intervention may exacerbate psychological distress for youth of color or expose them to further harm.	Reduce overreliance on law enforcement to respond to mental health problems. Increase affordability of and remove structural barriers to quality preventive mental health services.
Interpersonal racism	Behavioral manifestation of racial or ethnic prejudices during interpersonal exchanges.	Emergency department personnel utilize disproportionate force (i.e., seclusion, restraints, and involuntary care) with Black youth, often due to fear of violence based in racist stereotypes.	School staff may not properly identify suicidality among youth of color and respond to disruptive behaviors with behavior management and control strategies instead of compassion and care.	Due to fear of interpersonal racism occurring within mental health settings, youth of color may avoid using preventive services, including calling 911 or crisis hotlines.	Diversify the field of suicide research and mental health providers. Train physicians and mental health professionals in structural competence and anti-racist clinical practice.
Intrapersonal racism	Internalization of negative attitudes and beliefs about oneself due to exposure to racism.	Mental health services and delivery lack cultural responsiveness to attend to the myriad ways that racism may be internalized and coalesce into suicidality for youth of color.	Youth of color may not feel empowered to voice their concerns about the harsh disciplinary actions they face and the subsequent feelings of unsafety at schools in the presence of SROs.	Youth of color may endure psychological suffering as their mental health needs continue to go unmet until emergency or crisis care is required.	Target race-based stress and trauma and promote racial socialization, raceaffirming, and race-validating strategies into clinical care.