Setting a Course to Protect Indigenous Cultures and Communities in our National Suicide Prevention Agenda

It is now more widely acknowledged within the current fields of clinical psychology and psychiatry that suicide in the US is more than a mental health problem (Barnhorst et al., 2021, p. 299), that social determinants of health are key drivers of increasing suicide death rates (Dev & Kim, 2021), and that for ethnoracially minoritized youth, structural racism constitutes a key social determinant (Alvarez et al., 2022). In response, the Surgeon General’s office has released a Call to Action (U. S. Department of Health and Human Services 2021) to fully implement the National Strategy on Suicide Prevention. Addressing upstream factors including social determinants of health is now one of six core National Strategy actions to prevent suicide. These developments represent a recent, and arguably long overdue shift in focus from individual psychopathology as primary driver of suicide behaviors towards recognition of multi-level influences in suicide, and in particular, recognition of the impact of societal level structures and systems on suicide outcomes. This shift follows decades of suicide prevention research in Indigenous communities that has specifically focused on socio-ecological models of risk and protective factors.

The systematic review by Wiglesworth et al. (this issue) reflects the current status of Indigenous suicide prevention science at a crossroads. An emerging consensus in the Indigenous suicide prevention literature now includes attention to protective factors as well as risk across multiple interacting ecological levels. Although the perspective expands on the narrow foci of mainstream suicide prevention beyond its typical tertiary or indicated prevention, individual-level risk-reduction efforts, a continuing emphasis on quantifying protective factors and their discrete associations without delving deeper into the complex dynamics that animate protective mechanisms is problematic. In short, considering protective factors in this way ignores the essential fact that these factors are inherently contextual. Protective factors function as mechanisms at the intersection of mutually reinforcing, interdependent levels rather than in isolation.

There has been increasing recognition in the Indigenous protective factors literature of this ongoing failure in distinguishing factors and their mechanisms (Allen et al. 2022). To understand the importance of this perspective in the research reviewed by Wigglesworth et al., we discuss risk and protection in Indigenous suicide from systemic perspectives, concluding that it may now be time to move beyond protective factors and expand the complexity in AIAN suicide research in ways that are guided by ecological models and systems theory. We offer examples taken from the studies reviewed by Wiglesworth et al. and discuss the implications of such transition for clinical practice, for multilevel theorizing that includes community and societal levels, and for advancing methods and models in suicide prevention research.

There is a large corpus of literature focusing on the development of risk for suicide in Indigenous communities (Wexler, et. al., 2015). This evidence-base has well established the causal pathways from colonialization and the systematic U.S. policy-driven disruption, dispossession and dismantling of our nation’s Indigenous peoples’ lands and socio-cultural structures to the rising rates of suicide in American Indian and Alaska Native (AIAN) communities, with particularly devastating consequences for AIAN youth. It is similarly well established that AIAN communities suffer the long-term impacts of intergenerational trauma, and while drawing from deep roots of resilience and strengths, this struggle continues to the current day as Indigenous people and communities seek to regain inherent rights.

One aspect of this broader resistance work includes AIAN Tribal efforts to regain control over health care resources and to more fully activate protective functions found in Indigenous practices, beliefs, and institutions for young people. That this effort to manifest protection and to foster protective environments for Indigenous children constitutes an ongoing struggle may in part be due to our general neglect of the societal level factors responsible for disrupting the existing Indigenous systems of care in the first place. Explicitly racist and genocidal national policies, spanning policy that includes the Indian Removal Act of 1830 to the criminalization of spirituality until the American Indian Religious Freedom Act of 1978, are responsible for the imperilment of US Indigenous peoples. Despite near universal acceptance that these societal factors of colonization and structural racism directly led to drastic and unabating suicide inequities for Indigenous peoples, solutions proposed for Indigenous suicide prevention largely continue to exclude the societal level as a target for intervention. While there have been some positive movements towards repatriation and aided restoration of Indigenous peoples’ possessions, lands, languages and cultures, we have not yet witnessed a similar tide of sweeping anti-racist policies and of national legislation to rebuild and re-center sources of power and equality in AIAN communities that were previously systematically removed.

In Indigenous suicide prevention, it may now be a time to move beyond protective factors, and to reimagine how to support the social and cultural systems that for many prior generations successfully supported Indigenous health. Resisting the systems of on-going racial and cultural marginalization by acknowledging and uplifting emic systems of care can promote contemporary health equity. In consideration of the complex ways structural violence impacts the lives of Indigenous people, a next step for AIAN suicide prevention can move beyond protection of individuals living in unjust environments, to instead challenge and recreate policies and practices that contribute to suicide as a systemic health inequity. Prioritizing health equity includes identifying and acknowledging protective factors and mechanisms at multiple levels, and must do so in cultural, economic, political and social context. Such a complex and wide scope necessarily includes careful consideration of the intersecting influences, local practices and meaning making, and power dynamics that contribute to protection (or risk).

To provide an example of the specific types of actions this next step can entail, a protective factors example cited in Wiglesworth et al. is illustrative. The authors discuss the Chandler and Lalonde (1998) social epidemiological finding of associations of community-level variables with community suicide rates, suggesting the influence of mechanisms of protection on societal level risk factors in suicide outcomes in Canadian Indigenous communities. The variables in this study that are associated negatively with community suicide rate (community control of health care, education, child protection, and fire/policing services; extent of community self-governance; community access to traditional lands; and community cultural facilities) meet the definition of community-level protective factors. However, Chandler and Lalonde never posited the variables they studied were causative in and of themselves. Rather, the variables under consideration were instead hypothesized markers of Indigenous community efforts to regain control over their cultural life in direct response to externally imposed disruption. It was instead the cumulative effects of this theory-driven, complex community-level variable the authors termed ‘cultural continuity’ underlying the presence of these markers that impacted suicide.

Complexity is a property of all systems; the theory of cultural continuity hypothesized this protective factor at the community-level crossed levels of analysis in influence at the individual level. The protective mechanism of cultural continuity was proposed to moderate impact of the societal risk factor of colonial social disruption. Its function as a moderator variable diminished cross-level influence of social disruption upon self-continuity at the individual level, which impacted individual level suicide risk among Indigenous youth. While many of the links proposed within cultural continuity theory continue to lack empirical support, cultural continuity provides one early model of a multilevel theory in clinical psychology and is suggestive of ways a protective factors framework can move beyond the study of protective factors in isolation to inform and deepen psychology research and practice.

The detailed theory the Chandler and Lalonde study proposed to test is often ignored in subsequent literature, thus offering an apt example of the limitations in much of the current protective factors research reviewed by Wiglesworth et al. In this literature, a critical distinction between protective factors and protective mechanisms is often ignored. Many of the protective factors identified in this review appear to cross levels in their impact, and some of the protective factors reviewed, such as hope and family connections can even function as either a risk or a protective factor in context dependent ways. When terms used to describe the same factor vary across studies, and when multidimensional variables with multilevel impacts are imprecisely defined as constructs, the predominate focus on a taxonomizing of protective factors and their discrete associations has led to contradictory findings and theoretical confusion. This confusion has impeded advancement of the field in development of effective Indigenous suicide prevention strategies. This narrow focus on the component parts of protective factors instead of the more difficult work to understand how the overall process of protection works to prevent Indigenous suicide, or the study of its mechanisms, neglects development of theory-driven understandings of the problem of Indigenous suicide that are critical to defining its potential solutions.

One important clinical practice implication of moving beyond protective factors as suggested by cultural continuity theory and by other recent work in Indigenous suicide prevention involves recognizing the importance of societal level factors, and centering Indigenous community and cultural strengths in efforts towards supporting community-centered strategies to address suicide risk. Moving beyond protective factors does not mean abandoning efforts to build protection. Practices should and must continue to include acknowledging sources of strength and connecting young people and communities to sources of care, opportunities, and protection. These efforts can certainly and must include critically needed clinical mental health care, but effective suicide prevention for many Indigenous people will depend on care grounded in and extended to family and community sources of support, culture and caring. Uplifting the value of locally-sustained and culturally-based systems of care is a way to counteract elements of the structural violence contributing to inequities in Indigenous youth suicide risk. Protection within Indigenous community-based suicide prevention, then, continues to build on cultural strengths, protective factors and reasons for life in ways that link one’s collective and personal past to present and future, thus encouraging continuity on multiple reinforcing levels. In contrast to individualistic approaches, supporting young people as they grow into adulthood involves collective and culturally-rooted resources, history, beliefs and practices. This shared cultural context supports young people’s sense of coherence, continuity and wellbeing over time in complex ways that cannot be separated from the dynamics within which they function.

What is critical in this strength-based focus on protection is that we center Indigenous communities as the drivers and resources to prevent suicide. The current orientation for suicide prevention has been to center on the individual who is at risk, and to direct resources to professionals, agencies and structures that focus on treating this individual. However, in low resource settings including the majority of Indigenous communities in the US, there are very few service providers or agencies to receive these resources to support an individual in place (Barnhorst, et. al, 2021), and fewer still with real depth and experience in culturally commensurate services provision. Very often currently, Indigenous people are sent out of their communities for stabilization following a suicide attempt, and receive very little follow-up upon their return. An Indigenous community-centered suicide prevention would re-orient the service model, targeting resources for the support of interconnected collectives of individuals and community structures that surround the individual. These resources aim strategically to protect Indigenous young people within their community by strengthening Indigenous social, cultural and institutional structures, including its own formal and informal services as well as community- and family-based systems of care. Such a re-orientation of the prevention spectrum for Indigenous suicide prevention will require a modest but not insignificant societal level of support, including policy-level change.

For researchers, this reorientation will involve shifting the current focus from merely identifying protective factors variables within AIAN communities and their associations with a particular health outcome (e.g., suicide attempt) to the study of the strategies by which they work as multi-level resources, including how they increase structural and racial equity, in ways that protect AIAN communities and their members. In other words: in order to function as maximally effective protective places for their young people, Indigenous communities require societal-level protection at the national level in the form of anti-racist policies and national legislation to sustainably rebuild and center sources of power and equality that were systemically removed. Protecting Indigenous communities protects the young and other vulnerable people within them.

Many of the salient protective factors identified in Wiglesworth et al. as strengthening individuals, such as being cared for, having hope, having safe settings and involvement in traditional cultural activities, are likewise protective for communities. For example, in this review one finding was that being cared for, particularly by parents, associated with lower suicide attempt among AIAN young adults. Other studies on protective factors with AIAN communities have supported this finding, while also expanding upon it to note the protective influence of not only being cared for but also of caring for others, and resultantly, of having a role and a purpose (Rasmus, et al., 2016). These factors are often identified as protective factors at the family-level, but as was noted earlier, these levels include complexity and potentially confounding dynamics in that certain family connections, lack of family connections, and family connections in certain contexts can instead contribute to risk.

Societal factors also complicate family-level protection in AIAN communities. A prominent example links to the disproportionately higher rates of state and federal child welfare involvement AIAN communities experience. Caring parents are protective and protective family connections provide young people with a purpose. Yet a robust literature details the dismantling of Indigenous family structures and systems in the US through the boarding school policies that instituted forced removal and isolation of Indigenous children in institutional settings. In a continuation of these policies, the current child welfare system is overburdened and unable to serve Indigenous families and children in ways that meaningfully consider the histories and the contemporary circumstances of racism and discrimination as they impact households and communities. Ignoring these structural influences and focusing only on the presence or absence of a family-level protective factor such as ‘being cared for by a parent’ ignores the source of the problem (structural violence). Instead, research, policy change and clinical practice might better focus on redirecting resources and efforts into strengthening Indigenous children’s home and community environments. This shift includes child welfare policy change and supporting Indigenous systems to care for children in homes that have been colonially disrupted and disenfranchised. Such efforts can provide communities with a deeper sense of purpose and with the power to care for their own people. Communities with purpose and with power are communities with hope; hopeful communities can inspire those living within them.

Importantly, Wiglesworth et al. note that hope can be a protective factor at the individual level. However, hope can also associate with higher suicide attempts (O’Keefe, 2012). There is clinical importance in connecting individual hope with societal level factors. Hope on its own can be viewed as feeling aspirational purpose. Should these aspirations not materialize and prove unrealistic, not possible or thwarted, hope can turn into a risk factor, and barring mitigating protective factors, even precipitate suicide attempt. What appears to be most protective, and of greatest challenge, is the fulfilling rather than the instilling of hope. Hopes do not need to be fulfilled all of the time, but consistent realization of goals and aspirations provides a sense of forward movement, of achievement and purpose. Societal level actions to protect and support Indigenous communities provide these communities with the opportunity for purpose through the power to care for the people living within them. Providing communities with the resources and supports to fulfill aspirational goals builds collective hope across multiple levels.

Indigenous suicide prevention at a crossroads requires a significant shift in its conceptualization. Focusing on the comprehensive identification of protective factors and their associations with a reduction in suicidal behaviors is inadequate and limiting. As a research approach, it has added to our knowledge base, but also contributed to conflicting findings and conceptual confusion. As an approach, it is unlikely to ultimately lead to reductions in Indigenous suicide disparities in its response to continued systemic inequities including the structural violence of racism and oppression that impact AIAN communities and populations. Protection from suicide for Indigenous youth includes strengthening the societal level processes producing structurally safe and supportive environments aligned to Indigenous priorities, values and practices. Additionally, protection from Indigenous suicide includes national policies and strategies that invest in Indigenous communities to redress past harms and contribute to rebuilding the protective infrastructure and systems of support that sustained wellbeing for millennia. One part of this effort involves broadening the scope of research and clinical practice to prevent suicide. Protective factors must be considered in context; they cannot be disentangled from the environments and meaning systems within which they intersect and function. This requires attention to the mechanisms of protection and their functions between people and within families and communities to understand how they mitigate or drive individual behavior that can be either prosocial or risk and self-harm inducing. This complex, systemic perspective includes moderating and mediating dynamics and other features, and can set the stage for clinical innovations. Such Innovation can shift the focus from providing services to individual youth to also offer support and resources to the Indigenous systems and structures that encircle young people in AIAN communities that have historically faced societal marginalization and dismantling, and that continue to experience structural violence. This reorientation invests in Indigenous communities as important resources for collective, culturally-based, effective strategies to prevent suicide and provides young people with hopeful futures and reasons for life.