· U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Substance Abuse and Mental Health Services Administration

Center for Mental Health Services

www.samhsa.gov

To Live To See the

Great Day That Dawns:

Preventing Suicide by American Indian and

Alaska Native Youth and Young Adults

U.S. Department of Health and Human Services

Substance Abuse and Mental Health Services Administration

Center for Mental Health Services

Division of Prevention, Traumatic Stress, and Special Programs

Suicide Prevention Branch

To Live To See the

Great Day That Dawns:

Preventing Suicide by American Indian and

Alaska Native Youth and Young Adults
4

ACKNOWLEDGMENTS

The document was written by Gallup, Macro International Inc., and Kauffman & Associates, Inc. under 

contract number HHSS28320070231/HHSS28300001T, Ref. No. 283-07-2301, with the Substance 

Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and 

Human Services (HHS). Anne Mathews-Younes, Ed. D. and Cynthia K. Hansen, Ph.D., served as the 

Government Project Officers. 

DISCLAIMER

The views, opinions, and content of this publication are those of the author and do not necessarily 

reflect the views, opinions, or policies of SAMHSA or HHS. The listing of non-Federal resources in this 

document is not comprehensive and inclusion does not constitute an endorsement by SAMHSA or HHS.

PUBLIC DOMAIN NOTICE

All material appearing in this report is in the public domain and may be reproduced or copied without 

permission from SAMHSA or its Center for Mental Health Services (CMHS). Citation of the source is 

appreciated. However, this publication may not be reproduced or distributed for a fee without the specific, 

written authorization of the Office of Communications, SAMHSA, HHS.

ELECTRONIC ACCESS AND COPIES OF PUBLICATION

This publication may be downloaded or ordered at http://www.samhsa.gov/shin. Or, please call 

SAMHSA’s Health Information Network, toll free, at 1–877–SAMHSA–7 (1–877–726–4727) (English 

and Español).

RECOMMENDED CITATION

U.S. Department of Health and Human Services. To Live To See the Great Day That Dawns: Preventing 

Suicide by American Indian and Alaska Native Youth and Young Adults. DHHS Publication SMA (10)-4480, 

CMHS-NSPL-0196, Printed 2010. Rockville, MD: Center for Mental Health Services, Substance Abuse 

and Mental Health Services Administration, 2010.

ORIGINATING OFFICE

Suicide Prevention Branch, Division of Prevention, Traumatic Stress, and Special Programs, Center for 

Mental Health Services, Substance Abuse and Mental Health Services Administration, 1 Choke Cherry 

Road, Rockville, MD 20857. 

DHHS Publication SMA (10)-4480, CMHS-NSPL-0196, Printed 2010.

II
III5

Contents

Chapter 1: Introduction to the Guide 1

Introduction 1

Content and Structure 2

Themes 4

Conclusion 5

Chapter 2: Culture, Community, and Prevention 7

Introduction 7

The Concept of Culture 7

Risk and Protective Factors 8

Risk Factors 8

Factors Placing AI/AN Youth at Increased Risk 11

Historical Trauma as a Risk Factor 11

Other Cultural Considerations in Assessing Risk Factors 12

Protective Factors 14

Culture as a Protective Factor 14

Cultural Continuity as a Protective Factor 15

Acculturation, Assimilation, and Alternation 16

Urban Natives, Cultural Connectedness, and Suicide 17

Conclusion 18

Chapter 3: Breaking the Silence Around the Suicide Conversation 21

Introduction 21

Barriers to the Suicide Conversation 22

From Honorable to Forbidden Behavior 22

Historical Trauma 23

Guilt and Shame 23

Personal Pain 24

Collective Grief 24

Politeness and Respect 25

Stigma 26

Fear 27

Social Disapproval 27

Responding to Conversation Barriers 28

Myths About Suicide 28

Conclusion 32
IV6

Chapter 4: Responding to Suicide 35

Introduction 35

Responding to Suicide Survivors 35

Survivor Groups 37

Preventing Suicide Contagion 37

Identifying Individuals at Risk for Contagion 38

Developing a Postvention Plan 38

Role of the Media 40

Role of Emergency Health Care Providers 40

Role of Suicide Survivors and Suicide Attempt Survivors 42

IHS Emergency Response Model 42

Conclusion 43

Chapter 5: Community Readiness 45

Introduction 45

The “Readiness” Concept 45

Stages of Community Readiness 46

Community vs. Community Member Readiness 46

Historical Trauma and Community Readiness 49

Implications of Prevention for AI/AN Communities 50

Conclusion 51

Chapter 6: Community Action 53

Introduction 53

The Public Health Model 53

The Ecological Model 56

The Transactional-Ecological Framework 58

Action-Planning Tools 59

SAMHSA’s Strategic Prevention Framework 59

Guiding Principles of the SPF 59

The SPF Process 60

Applying the SPF Process 60

The SPF and Cultural Competence 62

The SPF and Sustainability 62

American Indian Community Suicide Prevention Assessment Tool 62

Engaging Community Stakeholders in Prevention 63

Building a Community’s Capacity for Prevention 63

Capacity Building and Gatekeeper Training 64

Conclusion 65
V7

Chapter 7: Promising Suicide Prevention Programs 67

Introduction 67

What Is Evidence? 67

Evidence-Based vs. Culturally Based Programs 68

Program Selection 69

Population of Focus 69

Culturally Based and Culturally Sensitive 71

Program Adaptation and Fidelity 71

Promising Program Databases and Descriptions 73

National Registry of Evidence-Based Programs and Practices 74

Suicide Prevention Resource Center Best Practices Registry 75

Promising Programs 76

Life Skills Development 76

Screening 77

Public Awareness/Gatekeeper Training 79

Counseling and Support Services 84

Attempt Response 87

Future Program Development 88

Chapter 8: Federal Suicide Prevention Resources 91

Introduction 91

Suicide Prevention Programs 91

State and Tribal Youth Suicide Prevention and Early Intervention Grant Program 92

Native Aspirations 93

Linking Adolescents at Risk to Mental Health Services Grant Program 94

Campus Suicide Prevention Grant Program 94

Suicide Prevention Resource Center 94

SPRC and State Resources 96

National Suicide Prevention Lifeline 96

National Suicide Prevention Lifeline Initiative for AI/AN Communities 97

Indian Health Service Resources 98

IHS National Suicide Prevention Initiative 98

IHS Community Suicide Prevention Web Site 99

IHS Regional Area Offices 99

Other Federal Resources 100

U.S. Federal/Canada Collaboration 101

Conclusion 101
VI 8

Chapter 9: Conclusion to the Guide 103

Appendix A: List of Contributors and Reviewers 105

Appendix B: Glossary of Terms 107

Appendix C: Statistics Related to Suicide by American Indian 

and Alaska Native Youth and Young Adults 113

Suicide and Self-Harm Among American Indians and 

Alaska Native Youth and Young Adults 113

Suicide and Self-Harm Among Alaska Native Youth 114

Background Statistics 116

General Demographics 116

Health Care, Employment, and Poverty 116

Other Factors Contributing to Suicide and Behavioral Health Disorders 118

Federal Sources for State and Local Statistical Data 120

Appendix D: Decisionaking Tools and Resources 121

State Prevention Planning Contact Information 143

Additional Tools for Assessment and Planning, School-Based 

Program Planning, and Coalition Building 152

Assessment and Planning Tools 152

School-Based Program Planning Tools 153

Coalition Building Tools 153

Partnership Self-Assessment Tool 154

National Suicide Prevention Lifeline Promotional Materials Order Form 155

Appendix E: Web Site Resources and Bibliography 157

Suicide Prevention Web Sites 157

U.S. and Canadian Government 157

Non-Federal 158

Suicide Prevention Crisis Lines 158

Native American Health Research Web Sites 159

Suicide Legislation 160
VII 9

Suggested Bibliography, by Chapter 160

Chapter 1: Introduction to the Guide 160

Chapter 2: Culture, Community, and Prevention 160

Chapter 3: Breaking the Silence Around the Suicide Conversation 161

Chapter 4: Responding to Suicide 161

Chapter 5: Community Readiness 162

Chapter 6: Community Action 163

Chapter 7: Promising Suicide Prevention Programs 163

References 165

National Suicide Prevention Lifeline Promotional Materials 

Order Form (Detachable) 171

1

Chapter 1: Introduction to the Guide

Introduction

Suicide and suicidal behavior are preventable. 

This fact has led communities across the Nation, 

including many American Indian and Alaska 

Native (AI/AN) communities, to implement 

programs that successfully reduce factors known 

to contribute to suicide by young people and 

strengthen factors known to help protect them 

against suicide. The approaches taken by these 

communities are based on the public health 

model, which means that they are proactive and 

holistic. Such approaches do more than help 

young people choose life. They also help young 

people choose to live their life well—full of hope 

in themselves and their ability to accept the 

challenges and gifts that life has to offer.

All of America’s young people deserve a life 

well-lived, which will have sound mental health 

as its foundation. To help achieve this goal, the 

Substance Abuse and Mental Health Services 

Administration (SAMHSA) has created this 

guide as a resource for community-based efforts to 

prevent suicide by AI/AN youth and young adults. 

The need is urgent, and the reasons are clear. More 

than 38 percent of AI/ANs are under age 19. 

Another 23 percent are between the ages of 20 

and 34. In total, AI/AN youth and young adults 

make up 61 percent of all Native populations. 

They are the center of hope for the survival of 

their people and their culture. They also are the 

living spirit of our country’s past and a vital part of 

its future. And yet AI/AN youth and young adults 

have the highest suicide rate of any cultural or 

ethnic group in the United States.1

The purpose of this guide is to support AI/AN 

communities and those who serve them in 

developing effective, culturally appropriate 

suicide prevention plans. Its intended users 

include Tribal and Village leaders, Elders, healers, 

and youth activists; State and county injury and 

suicide prevention program leaders; community 

organizers and program directors; school 

administrators; and other community members. 

In short, this guide is for everyone who has a 

stake in the health and well-being of AI/AN 

youth and young adults. 

This guide lays the groundwork for 

comprehensive prevention planning, with 

prevention broadly defined. Prevention is 

not limited to programs that just address the 

needs of individuals who may be at risk of 

suicide. Prevention also includes programs that 

a community can use to promote the mental 

health of its young. It also is the actions that 

“I think over again my small adventures

My fears, those small ones that seemed so big

For all the vital things I had to get and reach

And yet there is only one great thing, the only thing

To live to see the great day that dawns

And the light that fills the world.”

 — Anonymous Inuit

Indigenous People’s Literature Web site

http://www.indigenouspeople.net /inuit.htm
2

a community can take in response to a suicide 

that has occurred—or postvention—to help the 

community heal and thereby prevent related 

suicidal behaviors.

A comprehensive suicide prevention plan will 

involve community-based assessments of risk 

and protective factors, one or more programs or 

strategies that respond to those factors, and the 

building of coalitions to help fund, carry out, and 

sustain the plan. Therefore, this guide:

• Explores some of the cultural issues 

around prevention;

• Describes approaches that respectfully 

address these issues as part of prevention 

planning; and

• Provides practical tools and resources 

that a community can use for assessment, 

program selection, coalition-building, 

and implementation of the strategies it 

incorporates as part of a comprehensive plan.

This guide also reflects SAMHSA’s support of 

a public health approach to suicide prevention. 

The Institute of Medicine (IOM) defines public 

health as “what society does collectively to 

assure the conditions for people to be healthy.”2

The premise of a public health approach is that 

caring for the health of a community protects 

the individual, while caring for the health of 

an individual protects the community—with 

an overall benefit to society at large. The public 

health approach also assumes that it is inherently 

better to promote health and to prevent illness 

before an illness begins. By being proactive, the 

public health approach offers both a humane 

and cost-effective way for individuals, families, 

and communities to be spared the needless pain, 

suffering, and costly consequences of suicide. 

Content and Structure

The content of this guide represents a gathering 

of wisdom from many sources. Many Native 

individuals as well as many other caring 

individuals and organizations graciously shared 

their knowledge and experiences. A preliminary 

guide to suicide prevention prepared by the One 

Sky Center was the foundation on which this 

guide was built.

While much of the content may seem to apply 

most directly to AI/ANs living on reservations 

and villages, a great deal of it also is applicable 

to preventing suicide by urban Natives. Many 

urban areas have Indian health and community 

centers that can be the focal point for prevention 

efforts. Efforts undertaken by these centers also 

must be based on an understanding of how 

culture can profoundly affect health and healing. 

Respect for cultural appropriateness in health 

care has no boundaries. As Shankar Vedantam 

noted in Culture and Mind: Psychiatry’s Missing 

Diagnosis, “no matter how much science learns 

about the brain, culture and the environment 

will continue to play a huge role in why people 

develop emotional problems, what treatments 

they respond to, and whether they recover.”3

We have organized the guide in a way that is 

intended to help readers understand the complex, 

but necessary, process of developing suicide 

prevention plans within a cultural context.

The focus of each of the remaining chapters is 

summarized below.

• Chapter 2: Culture, Community, and 

Prevention explores risk and protective 

factors and the ways in which AI/AN 

cultures can help promote the mental 

health of a community’s young people.

• Chapter 3: Breaking the Silence Around 

the Suicide Conversation is intended to 

help break down the silence and the myths 

that too often surround suicide and are 

barriers to a community’s open discussion 

of potential solutions. 
3

• Chapter 4: Responding to Suicide deals 

specifically with actions that a community 

might take after a suicide occurs. Young 

people appear to be particularly susceptible 

to suicidal behavior when exposed to the 

suicide death of another person. As a result, 

a community’s effective response to one 

suicide may help to prevent others. 

• Chapter 5: Community Readiness discusses 

the stages of change that any community must 

go through before it can confront the possible 

causes and solutions to suicide. This chapter 

emphasizes that an AI/AN community may 

need to first heal from historical trauma as its 

foundation for change. 

• Chapter 6: Community Action describes 

the public health approach to prevention, 

with SAMHSA’s Strategic Prevention 

Framework as a model for action.

• Chapter 7: Promising Suicide Prevention 

Programs examines some of the issues 

around “evidence” of effectiveness and also 

describes programs that hold promise for 

preventing suicide among AI/AN youth 

and young adults. 

• Chapter 8: Federal Suicide Prevention 

Resources summarizes suicide prevention 

programs and resources offered by 

SAMHSA as well as resources, including 

possible funding opportunities, available 

from other Federal agencies.

• Chapter 9: Conclusion to the Guide

briefly states SAMHSA’s hopes for the 

conversations about culturally appropriate 

suicide prevention that this guide 

may inspire. 

Many of these chapters include text boxes entitled 

“Questions for Seeking the Wisdom of Elders.” 

The questions in each box are designed to explore 

a community’s traditional ways of maintaining 

“balance” or “harmony” among its members. This 

exploration will be beneficial to both AI/AN 

community members and those involved with them 

in laying the groundwork for a prevention plan. 

Not all cultures use the same language, concepts, or 

values in discussing or understanding the causes and 

prevention of suicide. “Mental illness,” for example, 

is not a universally accepted concept. Many cultures, 

including some AI/AN populations, understand 

health in holistic terms. Wellness, therefore, is a 

state of balance between a person’s mind, body, and 

spirit. Someone experiencing an emotional crisis 

would be considered as being out of balance or out 

of harmony with nature, including with possible 

spiritual forces. 

In this guide, we use the terms, mental health 

and balance or harmony, interchangeably. 

Developing a common language for 

understanding and discussing mental health 

will be essential to any effort to create culturally 

appropriate prevention plans and evaluate 

their effectiveness.

This guide also includes four appendixes that 

contain a wealth of information.a

• Appendix B: Glossary of Terms

contains definitions of mental health 

terminology used in the guide. These 

terms have been taken primarily from the 

National Strategy for Suicide Prevention: 

Goals and Objectives for Action.

• Appendix C: Statistics Related to Suicide 

by American Indian and Alaska Native 

Youth and Young Adults is a compilation 

of statistics that a community may find 

useful in completing a needs assessment 

for grant applications. A community also 

might use these statistics to direct media 

attention to the issue of suicide—without a 

precipitating tragedy.

Chapter 1: Introduction to the Guide

a

Appendix A, which was referenced in the front matter, contains a 

list of contributors and reviewers.
4

• Appendix D: Decisionmaking Tools 

and Resources contains a copy of the 

American Indian Community Suicide 

Prevention Assessment Tool. It also 

includes contact information for State 

suicide prevention planning team leaders, 

a list of other tools that may be helpful to 

prevention planning, and an order form 

for resources available from SAMHSA’s 

National Suicide Prevention Lifeline. 

• Appendix E: Web Site Resources and 

Bibliography categorizes numerous 

sources of online information about suicide 

prevention and Native American health as 

well as a bibliography for each chapter. 

Themes

If there are any primary “themes” within 

this guide, they are the overlapping 

themes of resilience, empowerment, 

and—ultimately—hope. 

First, this guide recognizes and pays honor 

to the resilience of AI/AN communities in 

resisting cultural suppression and overcoming 

a legacy of historical trauma. In many cases, it 

is by revitalizing their culture—and drawing 

upon their traditional values, beliefs, and 

practices—that AI/AN communities are 

successful in addressing the variety of social and 

economic challenges that confront them. 

This guide acknowledges historical trauma as 

an underlying and continuing threat to the 

balance and harmony of AI/AN communities. 

While some communities already have begun 

the courageous process of healing from historical 

trauma, other communities have yet to open up 

about this painful subject. Where healing circles 

have been held within small groups, the hope is 

that healing will move into the entire community, 

where all can benefit from the natural strengths 

and resources of its members. For many 

communities, healing from historical trauma is 

the first step in dealing with the causes of suicide.

Second, this guide recognizes the power of each 

community in developing the most appropriate 

responses to suicide and its related risk factors. 

This theme also demonstrates respect for the 

incredible diversity among AI/AN communities 

and the unique strengths of each individual 

culture. AI/AN communities have a wealth 

of traditions and stories to guide them in 

developing solutions that best meet the needs of 

their members. This guide provides guidelines 

on prevention planning. It is based, however, 

on the recognition that those most familiar 

with a community and its culture will know 

best which programs to choose, how they need 

to be implemented, and how such efforts can 

be sustained. 

The third theme is hope. This theme is based 

on an awareness of the power of hope in a 

future that is grounded in faith and derived 

from the AI/AN intimate understanding of 

the cycles of nature. It is the natural continuity 

of spring following winter and of a world that 

inevitably turns toward the dawn that becomes 

the foundation for a young person’s hope in 

the future. 

“It is time to speak your truth, create 

your community, and do not look 

outside yourself for the leader. We 

are the ones we’ve been waiting for.”

 — Hopi Elders

Community Works Web site

http://www.communityworksinfo/hopi.htm
5

Conclusion

This guide is a work in progress rather than a 

definitive guide to preventing suicide by AI/AN 

youth and young adults. There is a diversity 

of AI/AN cultures and limited—although 

growing—research into what strategies may 

work best within different cultures. Any 

current discussion of what works in AI/AN 

communities or what should be considered in 

prevention planning will be based largely on 

suicide prevention research within the American 

population in general, supplemented by the 

more extensive research that has been conducted 

among First Nations in Canada. Consequently, 

it is not possible or even wise for this guide to 

attempt to offer universal solutions to a problem 

as complex as suicide. In fact, we believe it is 

more important for this guide to raise questions 

about what we still need to learn from AI/AN 

communities about prevention than to offer any 

pat solutions. We trust that this guide—which is 

offered in the spirit of honoring and preserving 

the uniqueness of individual Tribes and 

Villages—will be an acceptable starting point 

for discovery.

Chapter 1: Introduction to the Guide

7

Chapter 2: Culture, Community, and Prevention

Introduction

Just as suicide rates vary greatly by country, 

State, and region, they also vary between and 

within racial and ethnic groups. While some 

American Indian and Alaska Native (AI/AN) 

communities have experienced suicide rates as 

much as 10 times the national rate, others have 

rates that are much lower than the national 

rate. The more extensive research that exists for 

suicide among Canadian Tribes indicates that 

some First Nations Tribes have not experienced 

a single suicide in 15 years.4 What explains 

these variations? 

The answer, in large part, is culture. Culture, as 

described in this chapter, plays a significant role 

in suicide prevention. Also, as discussed in the 

next chapter, culture can present some barriers to 

developing a comprehensive prevention plan. 

This chapter explores the relationship between a 

community, its culture, and prevention. As part 

of this discussion, it presents factors known to 

increase a person’s risk of suicide or to protect 

against it, with special attention given to those 

factors that place AI/AN youth and young 

adults at particular risk. The value of cultural 

connectedness as a protective factor also is 

examined. However, any attempt to describe 

suicide and suicidal behavior throughout 

AI/AN communities cannot fully take into 

account the vast cultural differences that exist 

within and between these communities. Caution 

should be used in any attempt to generalize 

cultural influences on suicidal behavior 

across Tribes.5

The Concept of Culture

Culture is difficult to define simply. This difficulty 

may result from the complexity of the many 

cultures that exist or because each person’s own 

unique culture defines his or her life and identity 

in many apparent and unseen ways. David 

Hoopes and Margaret Pusch, in their writing 

on multicultural education, made the following 

attempt to define culture comprehensively: 

Culture is the sum total of ways of living, 

including values, beliefs, aesthetic 

standards, linguistic expression, patterns of 

thinking, behavioral norms, and styles of 

communication which a group of people has 

developed to assure its survival in a particular 

physical and human environment. Culture, 

and the people who are part of it, interact, 

so that culture is not static. Culture is the 

response of a group of human beings to the 

valid and particular needs of its members. It, 

therefore, has an inherent logic and essential 

balance between positive and negative 

dimensions. [Emphasis added.]6

In practice, this definition implies that suicide 

prevention efforts need to acknowledge the 

cultural context of each individual community.

This would include each community’s unique risk 

and protective factors and how the community 

understands, discusses, and experiences suicide 

and suicidal behavior. 

The Institute of Medicine (IOM) similarly 

underscored the importance of culture in 

Reducing Suicide: A National Imperative. 

“Clearly, a society’s perception of suicide and its 

cultural traditions can influence the suicide rate.”

Reducing Suicide: A National Imperative

Institute of Medicine (2002)
8

According to the IOM: 

Society and culture play an enormous role 

in guiding how people respond to and view 

mental health and suicide. Culture influences 

the way in which mental health and mental 

illness is understood and defined, the ability 

of community members to access care, the 

nature of the care they seek, the quality of 

the interaction between provider and patient 

in the health care system, and the response to 

intervention and treatment.7

As these references to culture make clear, suicide 

does not happen within a vacuum. Rather, suicide 

reflects the many cultural forces that shape the 

lives of young people. Because culture, as defined 

by Hoopes and Pusch, has an “essential balance 

between positive and negative dimensions,” these 

forces are both good and bad—in other words, 

factors that protect against suicide and that 

increase a young person’s risk.

Research suggests that one of the strongest 

factors that protect Native youth and young 

adults against suicidal behavior is their sense 

of belonging to their culture and community.8

Similarly, the idea that a loss of culture or 

community can cause a loss of well-being is well 

understood by the many AI/ANs whose cultural 

identity gives purpose and meaning to their life. 

Risk and Protective Factors

Before we discuss the protective influences of 

culture and community, a general discussion of 

suicide risk and protective factors is in order. 

Briefly, risk factors are associated with a greater 

potential for suicide and suicidal behaviors. 

Protective factors are associated with reducing 

that potential. It may be helpful to think of these 

factors in terms of how they may hinder or help 

a person as he or she travels along life’s path. 

Protective factors, such as close family bonds, are 

like roadmaps that help a person stay safely on 

the correct path. Risk factors, such as substance 

abuse, are like detours and potholes that can 

cause a person to stumble off or along the path. 

Suicide occurs when a person becomes so lost 

and hopeless that he or she gives up hope of ever 

finding the way back or reaching a destination 

and ends his or her journey forever. It is often the 

role of Elders and adults, and sometimes the role 

of older peers, to guide the young along their life’s 

path and help them avoid, or at least cope with, 

some of the roadblocks that are bound to appear. 

Recognizing the extent to which risk and 

protective factors exist in a community is the 

beginning of an effective suicide prevention plan. 

Ideally, a community will not view the prevention 

of suicide alone as the sole reason for identifying 

these factors. As stated at the very beginning 

of this guide, sound mental health helps young 

people develop the resilience and skills they need 

to accept the challenges and gifts that life has 

to offer. Communities can and should identify 

factors that will promote the balance of its 

young people while also reducing or eliminating 

factors that increase their risk of suicide. Many 

programs, such as those described in Chapter 7: 

Promising Suicide Prevention Programs, enable a 

community to do both effectively. 

Risk Factors 

Suicide is complex, and there is no single reason, 

cause, or emotional state that directly leads to 

suicide. Substantial research has been conducted 

on suicidal behavior, risk factors, and trigger 

events in the general population, but research 

within AI/AN communities is comparatively 

limited. Exhibit 1 illustrates what current 

research into AI/AN suicide suggests are risk 

factors that place any individual at risk (e.g., 

mental illness and substance abuse) together 

with factors that are unique to AI/ANs (e.g., 

historical trauma). 
9

Risk factors can be divided into those that a 

community can change and those that it cannot 

change to reduce a person’s risk of suicide. Some 

changeable risk factors, such as substance abuse, 

are like a bear that crosses our path along life’s 

journey. If we are trained in the ways of bears, we 

know how to avoid them and the dangers they 

present. A community working together also 

can drive the bear away. Other changeable risk 

factors, such as exposure to bullying and violence, 

are like a tree that falls across the path. If we 

have the skills to cope with this challenge and 

remove it from the path, we can proceed with our 

journey. A community, for example, could help 

its children develop the resilience and problemsolving skills that enable them to cope with 

bullying, violence, or other challenges that may 

occur during their journey. 

Factors that cannot be changed, such as age, 

gender, and genetics, are different in that neither 

communities nor individuals can alter the risk 

of suicide they represent. For example, within 

AI/AN communities, the group at the highest 

risk for suicide attempts is females between 

the ages of 15 and 24. Those at highest risk of 

completed suicides are males in the same age 

group. The age and gender of the individuals 

cannot be changed, even though these 

characteristics place them in groups at higher 

Chapter 2: Culture, Community, and Prevention

Exhibit 1. Interrelated Risk Factors for Suicide Among 

American Indians and Alaska Natives*

*Adapted from Walker, D., Walker, P. S., & Bigelow, D. (2006). Native Adolescent Suicide Cofactors: 

Prevention and Treatment Best Practices. PowerPoint presentation available from One Sky Center, at 

http://www.oneskycenter.org/education/presentations.cfm.

Suicide

Family history

of mental illness/

substance abuse

Mental illness

and its stigma

Historical

trauma

Cultural

distress

Negative boarding

school experience

Psychological and

physical vulnerability

(e.g., chronic illness)

Poverty, unemployment,

geographic isolation, and 

other environmental factors

Substance use

and abuse

Feelings of

hopelessness or

isolation

Family disruption/

abuse

Suicidal behavior

of self or others

Impulsive

behavior
10

risk. This is similar to these youth having to travel 

down an unavoidable path known to be more 

dangerous. Unchangeable risk factors for suicide, 

however, do not predict anything, especially 

suicidal behavior. No matter how high the rates 

of suicide within any particular group, most of 

the individuals within the group do not plan, 

attempt, or complete suicide. In addition, while 

a community cannot change any of these factors, 

its members can be aware of the increased risk 

for suicide that these factors present. Mental 

health promotion and suicide prevention 

programs focused on youth and young adults in 

higher-risk groups can help them navigate their 

paths safely. 

Just as one example, consider how a community 

might offer programs to help its young 

males—the group at greatest risk of completed 

suicides—cope with life’s demands. The reasons 

why more males than females complete suicide 

are complex, but one possibility may be the 

social pressures and family demands placed on 

males at an early age. Males may feel burdened 

by the expectations that they will be strong 

protectors and providers, particularly during a 

time of high unemployment. In addition, the 

traditional role of males of any ethnic group is 

associated with greater risk-taking behaviors.9

Currently, these behaviors include substance 

abuse, aggression, violence, and others that might 

be considered antisocial.10

Young males also appear more reluctant than 

young females to seek help for a variety of 

health-related issues, including depression and 

stressful life events.11 Whether this lack of 

help-seeking behavior is the result of stigma, 

shame, conditioning, attitudes, or not wishing to 

appear weak, the outcome is the same—young 

males do not receive needed assistance. However, 

while males might not seek help, they may be 

willing to accept help when offered.12 If so, then 

programs that offer support and guidance, such 

as mentoring, can guide young males safely to 

adulthood and beyond.

Risk factors have a cumulative effect. That is, 

the larger the number of risk factors a person is 

exposed to, the greater the risk of suicide. Risk 

factors also are interrelated. This relationship 

appears to be very strong between mental 

illnesses and substance abuse and between these 

two factors and suicide. According to the IOM, 

an estimated 90 percent of individuals who die by 

suicide have a mental illness, a substance abuse 

disorder, or both.13 The next few paragraphs 

explore this relationship in more detail. 

Depression among youth in the general 

population is significant. Major Depressive 

Episodes Among Youths Aged 12 to 17 in the United 

States of America: 2006—a Substance Abuse 

and Mental Health Services Administration 

(SAMHSA) study released in 2008—concluded 

that 8.5 percent of adolescents, or the equivalent 

of 1 in every 12, had experienced a major 

depressive episode during the past year.14 This 

same report also revealed the often devastating 

effect these major depressive episodes can 

have on adolescents. Nearly half of adolescents 

experiencing major depression reported that it 

severely impaired their ability to function in at 

least one of four major areas of their everyday 

lives. These areas are home life, school/work, 

family relationships, and social life. 

In the general population, substance abuse 

disorders also are common among those who 

experience serious mental illnesses, which include 

chronic depression. Among individuals being 

treated in a mental health setting, 20 to 50 

percent also have a substance abuse disorder. The 

converse also is true: substance abuse is linked to 

risk factors for mental health problems. Underage 

drinking, for example, contributes to academic 

failure, violence, and risky sexual behavior.15

Among individuals receiving clinical treatment 

for substance abuse, 50 to 75 percent have a 

mental illness. 

On the positive side, the interrelationship of 

risk factors means that efforts to reduce one 
11

also can help to reduce others. Prevention of 

suicide thus becomes prevention of mental and 

substance abuse disorders and vice versa. The 

results of the U.S. Air Force suicide prevention 

program illustrate this connection. In 1996, in 

addition to specific training in suicide prevention, 

the U.S. Air Force introduced a broad-based 

program within its community to increase its 

general understanding of mental health and 

decrease the stigma of seeking help for a mental 

or behavioral problem. The outcome of the 

program was that while suicides were reduced by 

33 percent, homicides also were reduced by 52 

percent. Serious domestic violence rates dropped 

by 54 percent.16 Clearly, actions taken to reduce 

self-harm also help to reduce other forms of 

personal violence that threaten a community’s 

mental health. 

Factors Placing AI/AN Youth at 

Increased Risk 

Certain risk factors are more common among 

AI/AN youth and may contribute significantly 

to their higher suicide rate. These factors are 

not part of the AI/AN culture but, instead, 

may be symptoms of other factors such as 

poverty and depression that affect AI/AN 

communities disproportionately. 

AI/AN youth aged 12 to 17 have the highest 

rate of alcohol use of all racial/ethnic groups. 

In 2006, more than 20 percent, or one out of 

every five AI/AN youth, engaged in underage 

drinking.17 During the same time period, 15 

percent of AI/AN youth aged 12 to 17 had used 

marijuana within the past month. This rate is 

more than double that of any other racial group. 

AI/AN youth also were more likely than other 

groups to “perceive minimal risk of harm from 

substance use.” Research indicates that the 

lower the perceived risk, the less likely a person 

is to seek help for substance abuse. Other risk 

factors specific to AI/AN youth are the perceived 

discrimination felt by AI/AN adolescents,18 the 

racism they experience,19 and the related stress 

associated with these issues.

Historical Trauma as a Risk Factor

In the definition of culture given earlier, Hoopes 

and Pusch state that culture is what a group of 

people have developed “to assure its survival in 

a particular physical and human environment.” 

This statement raises serious questions about the 

way in which historical trauma may contribute 

to the suicide rates of AI/ANs. What happens 

to a group of people when they are torn away 

from their culture? What happens to their ability 

to survive? How do they adapt to trauma and 

what effect does this adaptation have on them 

personally and as part of a community? Because 

“culture, and the people who are part of it, 

interact,” these reactions to trauma become part 

of the culture. 

Historical trauma is a risk factor for suicide 

that affects multiple generations of AI/ANs. 

Historical trauma includes forced relocation, 

the removal of children who were sent to 

boarding schools, the prohibition of the practice 

of language and cultural traditions, and the 

outlawing of traditional religious practices. These 

past attempts to eliminate the AI/AN culture are 

well-documented, and the lasting influence of this 

legacy of victimization cannot be underestimated. 

Many parents and grandparents of young adults 

who currently are at risk of suicide may have 

experienced these traumas directly. They may 

have been removed from their parents and 

forced into boarding schools or been raised by 

parents who grew up in boarding schools. As 

described in The History of Victimization in Native 

Communities, “It is important to realize the 

historical content of victimization is not limited 

to individuals since all Native families have a 

collective history of trauma and abuse.”20

Elders who lived though the boarding school 

experience are “[N]ative children [who] suffered 

Chapter 2: Culture, Community, and Prevention
12

deprivations beyond description and those who 

did survive became the wounded guardians of 

the culture and tentative parents to the next 

generation of children.”21 As a result, many 

parents struggle every day to pass on to the next 

generation what they themselves may never 

have received in terms of nurturing or a sense 

of belonging. 

Historical trauma also may have an effect on 

the help-seeking behavior of AI/ANs, as does 

AI/AN culture in general. When seeking mental 

health care, some AI/ANs avoid professional 

services. They may believe these services 

represent the “white man’s” system and culture 

or that the professionals will not understand 

Native ways. They may have a lack of faith in 

mental health care in general.22 Some AI/ANs 

go to both specialized professional health 

services and to traditional healing rituals and 

services. However, not only do a majority of 

AI/ANs use traditional healing,23 they rate their 

healer’s advice 61.4 percent higher than their 

physician’s advice.24 In addition, they may not 

tell the physician everything. Only 14.8 percent 

of AI/AN patients who see healers tell their 

physician about their substance use.25 

Dolores Subia BigFoot, Ph.D., with the Indian 

Country Child Trauma Center at the University 

of Oklahoma Health Sciences Center, divides 

trauma into four interrelated categories: 

• Cultural trauma is an attack on the fabric 

of a society, affecting the essence of the 

community and its members. 

• Historical trauma is the cumulative 

exposure of traumatic events that affects 

an individual and continues to affect 

subsequent generations.

• Intergenerational trauma occurs when 

trauma is not resolved, subsequently 

internalized, and passed from one 

generation to the next.

• Present trauma is what vulnerable youth 

are experiencing on a daily basis.26

The lesson to be learned about trauma of any form

is that it never affects just one person, one family, 

one generation, or even one community. Like the 

rock thrown into the pond, the effects of trauma 

ripple out until its waves touch all shores.

Given the widespread and continuing impact 

of trauma, a community should ensure that its 

suicide prevention plan is “trauma-informed.”27

A trauma-informed plan will be one in which 

all of its components have been considered and 

evaluated “in the light of a basic understanding of 

the role that violence plays in the lives of people 

seeking mental health and addictions services.”28

While these words were written to describe direct 

service system planning, the same approach should 

apply to suicide prevention planning. 

Other Cultural Considerations 

in Assessing Risk Factors

Many risk factors for suicidal behavior are best 

understood and addressed within the context of 

culture and community. These risk factors explore 

the core questions that challenge youth and 

young adults, such as “Who am I?,” “What is the 

meaning of my life?,” and “Where am I going 

in life?” These factors also explore the broader 

question faced by all AI/ANs of “Who are we as 

a people?” 
13

Each of the factors listed below are followed by 

questions intended to stimulate discussion as to 

how they apply to youth and young adults within 

an individual community.

• Feeling disconnected from family and 

community. The need to belong to a 

valued group is powerful and deeply 

ingrained in all cultures. When this 

need is blocked or the individual feels 

disconnected, his or her physical and 

emotional health can be undermined.29

Given that suicide rates are highest among 

AI/AN adolescent males, how might 

community leaders and Elders help this 

vulnerable group feel connected? How 

might a community involve adolescents, 

especially males, in important decisions 

about their place within the community 

and their future? How can they have 

a meaningful role in community 

prevention efforts?

This factor may have particular significance 

for young AI/AN men and women returning 

from military service, some of whom feel 

isolated by their combat experiences.30 The 

New Mexico Veterans Affairs (VA) Health 

Care System in Albuquerque, NM, has 

created a Talking Circle Group for local 

American Indian veterans. The traditional 

Talking Circle brings people together in a 

quiet, respectful manner for the purposes 

of teaching, listening, learning, and sharing. 

The way in which this group is organized 

and the beliefs behind its slogan—Trauma 

for American Indian Veterans: The Warrior 

and the Soul Wound—is intended to 

help group members feel a part of a larger 

community and to bring some degree of 

healing to the mind, heart, body, and spirit. 

AI/AN communities should engage their 

military veterans, who may be at higher risk 

of suicide, in any suicide prevention planning 

so that their needs can be considered. 

• Feeling that one is a burden. A feeling that 

one is of little use to his or her community 

or a burden to others contributes strongly 

to the desire for suicide.31 What are some 

ways to help youth and young adults feel 

that they are an important part of the 

community, that they matter, and that they 

have a great deal to offer to everyone? How 

can their contributions be honored? These 

questions seem to be grounded in strong 

traditional beliefs, such as the need to honor 

one’s Elders and to consider how individual 

actions can affect generations to come. 

Perhaps the young person who feels the 

least valuable to a community is the same 

one that needs to be invited into exploring 

the solution. 

• Unwillingness to seek help because 

of stigma attached to mental and 

substance abuse disorders and/or suicidal 

thoughts. Stigma is not unique to AI/AN 

communities, but the cultural values and 

traditions of a community affect the way 

in which its young people perceive the risk 

of harm associated with certain behaviors 

and the likelihood that they will seek 

help for them. How does a community 

talk about mental illness, substance abuse, 

and suicide? What messages are the 

youth receiving? How is asking for help 

viewed within the community? How can a 

community let them know that asking for 

help is the brave thing to do?

• Suicide contagion or cluster suicide.

One or more suicides within a community 

can trigger additional suicides and suicide 

attempts, particularly among the family 

members and close friends of those 

who first took their lives. In what ways 

is a community prepared to respond to 

suicide? What grief-sharing or counseling 

opportunities are available? Chapter 4: 

Responding to Suicide discusses suicide 

response plans in greater detail.

Chapter 2: Culture, Community, and Prevention
14

Protective Factors

The reduction of risk factors is essential to any 

suicide prevention plan. However, a 1999 study 

of risk and strengthening protective factors 

among AI/AN youth showed that “adding 

protective factors was equally or more effective 

than decreasing risk factors in terms of reducing 

suicidal risk.”32 Thus, it may be more valuable 

for a community to expend limited resources 

on strengthening protective factors. Protective 

factors, similar to risk factors, are cumulative 

and interrelated. Enhancing the way in which 

young people feel connected to community and 

family and strengthening their ability to cope 

with life’s challenges will help them achieve 

their full potential as individuals as well as avoid 

suicidal behavior.

Common protective factors that have been found 

to prevent suicide include:

• Effective and appropriate clinical care 

for mental, physical, and substance 

abuse disorders; 

• Easy access to a variety of clinical 

interventions and support for seeking help; 

• Restricted access to highly lethal methods 

of suicide;

• Family and community support; 

• Support from ongoing medical and mental 

health care relationships;

• Learned skills in problem-solving, conflict 

resolution, and nonviolent handling of 

disputes; and 

• Cultural and religious beliefs that 

discourage suicide and support selfpreservation instincts.33

Culture as a Protective Factor

Nurturing of children is one of the most basic 

aspects of AI/AN cultures. Protection of children 

against harm is embedded in centuries-old 

spiritual beliefs, child-rearing methods, extended 

family roles, and systems of clans, bands, or 

societies. Although this cultural aspect has been 

threatened and undermined over time as a result 

of historical trauma, boarding schools, externally 

imposed social services, alcoholism, and poverty, 

traditional family values have survived. It is 

these very traditional family values that will lend 

strength to Native-led efforts to prevent suicide 

among their youth and young adults. 

“As Native Americans, we honor our 

families, cultures, and clan system 

and traditional values, but our 

greatest resource is our children.”

 — Carl Venne

Crow Tribal Chairman, Testimony Before

the U.S. Senate Finance Committee

September 12, 2006

“It is much more difficult to handle 

depression and suicidal ideation 

after the fact. If we can create a 

positive outlook for our youth, and 

programs that have daily contact 

with our young people, we will 

be much better prepared to stop 

this cycle of loss [to suicide].”

 — Julie Garreau

Executive Director,

Cheyenne River Youth Project

Testimony Before the U.S. Senate

Committee on Indian Affairs

June 15, 2005
15

According to a document jointly published by 

the Suicide Prevention Action Network USA 

and the Substance Abuse and Mental Health 

Services Administration (SAMHSA) Suicide 

Prevention Resource Center, the most significant 

protective factors against suicide attempts 

among AI/AN youth are the opportunity to 

discuss problems with family or friends, feeling 

connected to their family, and positive emotional 

health.34 When these factors are translated 

into action, culturally sensitive programs that 

strengthen family ties can help protect Native 

American adolescents against suicide.35

Various studies of the Native cultures suggest 

additional culturally based protective factors. 

One study of AIs living on reservations found 

that individuals with a strong Tribal spiritual 

orientation were half as likely to report a suicide 

attempt in their lifetimes.36 This is consistent 

with the role of religion as a protective factor 

in the general population. When a suicide has 

occurred, the possibility of suicide contagion (i.e., 

one suicide seeming to cause others) seems to 

be decreased by a healing process that involves 

the role of Elders and youth in decisionmaking, 

the presence of adult role models, and the use of 

traditional healing practices.37 

Cultural Continuity as a Protective Factor

Michael Chandler and Christopher Lalonde, 

researchers at the University of British Columbia, 

have found a distinct, positive relationship 

between some particular aspects of what they 

refer to as “cultural continuity” and reduced 

suicide and suicidal behavior among Native 

youth. Based on their studies, “First Nations 

communities that succeed in taking steps to 

preserve their heritage culture and work to 

control their own destinies are dramatically more 

successful in insulating their youth against the 

risks of suicide.”38 Their theory is that, when 

youth have a secure sense of the past, present, 

and future of their culture, it is easier for them to 

develop and maintain a sense of connectedness to 

their own future (i.e., self-continuity).b

Questions for Seeking the Wisdom of Elders

• What strengths do community members have that will help them cope with and overcome

their problems?

• How did the Elders help community members overcome past traumas and maintain their

cultural identity?

• In what traditional ways were the community’s children taught coping and problem-solving skills?

• How were community members helped to feel good about themselves?

• What are some of the old stories that help the youth deal with change?

• What can be said to young people to give them greater hope in themselves and their future?

Chapter 2: Culture, Community, and Prevention

b

 Chandler and Lalonde have written extensively about selfcontinuity and the need for a personal narrative in understanding 

one’s place in life, which they contend is closely tied to cultural 

continuity and suicide prevention among Native communities. 

According to the researchers, culture is the foundation of personal 

identity. If that culture is thrown into disarray, “the ground upon 

which a coherent sense of self is ordinarily made to rest is cut away, 

life is made cheap, and the prospect of one’s own death becomes 

a matter of indifference.” A detailed discussion of this theory and 

supporting evidence goes beyond the scope of this guide, but can be 

found in a series of articles by the researchers and available online at 

http://web.uvic.ca/~lalonde/manuscripts.
16

Although this research is based on First Nations 

Tribes and Inuit peoples in Canada and the 

Northern Territory, it has relevance for AI/AN 

communities. Furthermore, given common U.S. 

and Canadian concerns about the rising suicide 

rates within Native communities, cross-border 

research-sharing can help create solid culturally 

based prevention models. 

Cultural continuity is the extent to which the 

language, traditions, values, and practices of 

a culture have continued over time and are 

likely to continue into the future. In their 

study, the Canadian researchers found that 

cultural continuity could be promoted by a 

Tribe or Village’s control over such things as its 

educational services, police and fire protection 

services, and health delivery services by local 

institutions.39 Other results of their research 

demonstrate that indigenous language use, as 

a marker of cultural persistence, is a strong 

predictor of health and well-being in Canada’s 

Aboriginal communities.40 Furthermore, Tribes 

and Villages that had “established within their 

communities certain officially recognized ‘cultural 

facilities’ to help preserve and enrich their 

cultural lives” had lower youth suicide rates.41

These results should not be surprising. Just 

as with individuals, a community’s sense of 

having some control over its daily life can be 

empowering and contribute to the community’s 

general well-being. Youth who feel included in 

this community also share in this well-being, 

with positive results. Feelings of empowerment 

and hopelessness do not travel down the same 

path together. 

Another key aspect of cultural continuity is 

spiritual continuity. Western medicine recently 

has discovered what many AI/AN Elders 

always have known: Strong spiritual beliefs and 

practices are protective and promote survival. 

Furthermore, issues connected to illness and 

healing are best understood within the wider 

domain of a religious or spiritual worldview.42

This relationship is too seldom addressed in 

Western-based suicide prevention planning, 

even though “cultural and religious beliefs that 

discourage suicide and support self-preservation 

instincts” are described as a protective factor in 

the National Strategy for Suicide Prevention.43

To bridge the spirituality gap, any discussion of 

cultural considerations in suicide prevention also 

must include the spiritual.

Acculturation, Assimilation, 

and Alternation

As Chandler and LaLonde demonstrate in 

their studies of First Nations youth, cultural 

continuity appears to be a strong protective factor 

against suicide. This finding also implies that 

cultural disruption would be a risk factor. Several 

studies support this implication with research 

that concludes that social disruption caused 

by dramatic and rapid cultural changes may 

account for the increased suicide rates among 

indigenous groups in Alaska and Canada.44,45

This conclusion, however, does not fully address 

the sometimes conflicting outcomes of the long 

multigenerational acculturation and assimilation 

processes of many Tribal communities or the 

urban Indian experience. 

Acculturation is the process whereby the 

attitudes and behaviors of people from one 

culture are modified as a result of contact with 

a different culture. Acculturation implies a 

mutual influence in which elements of two 

cultures mingle and merge. For AIs and ANs, 

acculturation has affected their Tribal structure, 

religious practices, and community identity, 

among other cultural aspects. 

People undergoing acculturation essentially 

live in the juncture of two cultures. An AI who 

lives and works in the city, for example, might 

receive health care from the city-based Indian 

Health Service (IHS) services but go home to 
17

the reservation for a traditional healing ceremony 

when needed. An AN might practice a Christian 

religion while his or her parents or grandparents 

are grounded in traditional spiritualism. 

Depending on the degree to which a person is 

able to balance elements of the two cultures, an 

individual undergoing acculturation can feel part 

of two worlds, one world, or none. Furthermore, 

when a “clash of cultures” results, traditional 

values may be lost and not replaced by acceptable 

values from the new culture. Cultural voids 

created by acculturation can result in alienation, 

identity confusion, depression, alcohol abuse, 

and suicide.46

Assimilation occurs when a member of one 

culture gives up his or her original cultural 

identity as he or she acquires a new identity in a 

second culture. Assimilation may be voluntary or 

it may be involuntary, as occurred in the AI/AN 

experience with boarding schools. Some studies 

suggest that less assimilation into the dominant 

culture increases an individual’s risk of suicide.47

The speculation is that these less assimilated 

individuals are less prepared to handle the stress 

that may be imposed by their new lifestyle.48

Conversely, other studies suggest that too 

much assimilation may strip the individual of 

the protection that culture provides.49,50 This 

situation, for example, especially appears to be 

the case for immigrant families who bring their 

cultural protective factors to their new country, 

only to see those protective factors disappear in 

subsequent, assimilating generations. 

How, then, can these contradictory views of 

acculturation and assimilation be resolved? It 

may be that an important protective factor for 

many AI/AN youth and young adults is to have 

a solid foot in both worlds and to feel that this 

dual identity is acceptable to their peers and 

community. Without this grounding, they may 

develop feelings of isolation and alienation 

that cut them off from the protective factors of 

either world.51

Urban Natives, Cultural 

Connectedness, and Suicide

As mentioned previously, approximately 

2.8 million AI/ANs make up the “invisible 

Tribe” that does not live on reservations and may 

lack a strong connection to their culture and 

community. Currently, more than 65 percent of 

AI/AN youth live in urban areas. 

Because there is no formal public health 

surveillance system for urban Natives, little is 

known about suicide rates within this population. 

Some of what is known comes from a 2004 

study published in the American Journal of Public 

Health, which found that when urban Natives 

were compared to the general population: 

• Their death rate due to unintentional 

injuries was 38 percent higher;

• Their death rate due to chronic liver disease 

and cirrhosis was 126 percent higher; and 

• Their rate of alcohol-related deaths was 

178 percent higher.52

Unintentional injuries, substance abuse, and 

suicide are closely related. Consequently, these 

figures suggest that the suicide rate of urban 

Natives also may exceed the national rate.

Researchers are beginning to study protective 

and risk factors associated with suicide among 

AI/AN youth living in urban areas as well as 

those living on reservations and in villages. 

One such study revealed that while a Native 

who was raised in an urban setting had a lower 

rate of suicide ideation than a reservationreared youth, the suicide attempt rate was 

generally the same.53 This study goes on to state 

that there are some distinctive differences in 

psychological risk factors between these two 

groups. A history of physical abuse, a friend 

attempting or completing suicide, and family 

history of suicidality were positively associated 

with a history of attempted suicide by AI/AN 

Chapter 2: Culture, Community, and Prevention
18

youth raised in an urban setting. By comparison, 

depression, conduct disorder, cigarette smoking, 

a family history of substance abuse, and 

perceived discrimination were correlated with 

a history of attempted suicide only within the 

reservation-reared sample.54

The hope is that separate studies of these groups 

will lead to better prevention and intervention 

programs that account for each group’s strengths 

and challenges. Mounting evidence suggests 

that efforts to reestablish or strengthen the 

connection between urban Natives and their 

culture and community may have a significant 

effect on their mental well-being and their 

overall quality of life and health. 

Conclusion

In developing suicide prevention plans, 

communities will need to assess the presence of 

risk and protective factors that affect the balance, 

or overall well-being, of their members. While 

attention should be given to reducing risk factors, 

equal and perhaps greater attention should 

be given to increasing protective factors that 

promote overall mental health and well-being. 

This does not imply that communities should 

ignore risk factors. Examination of these factors 

can raise community awareness of the problems 

that people, especially youth, are facing and draw 

attention to their need for help and supporting 

programs and services. 

As part of this process, AI/AN communities may 

wish to identify and incorporate aspects of their 

culture that promote balance among their young 

people and also reduce their risk of suicide. These 

aspects include such things as spiritual beliefs, 

traditional values and healing methods, spiritual 

and cultural continuity, and ensuring that their 

young people have a valued role in preserving 

their heritage. In addition, communities might 

wish to encourage and support life skills and 

coping skills that help prepare youth to live 

successfully in a bicultural world.
19

21

Chapter 3: Breaking the Silence Around the 

Suicide Conversation

Introduction

The words of a First Nations Elder quoted 

above speak a powerful truth, particularly when 

applied to the silence surrounding the subject 

of suicide. Suicide, shrouded as it is in guilt, 

grief, anger, and the wrongful stigma of mental 

and substance abuse disorders, is one of the last 

great taboo conversations. The silence that may 

surround suicide, however, is not only dangerous 

but deadly. It affects the conversation that a 

community can have to address this issue, the 

conversation with an individual that can save a 

life, and the conversation with suicide survivors 

that can soothe their pain and prevent additional 

suicides. Only by having this conversation can a 

community begin to understand why some of its 

youth and young adults have chosen death. Only 

by having this conversation can a community 

then determine how it can help its children 

develop and maintain their hopes in themselves 

and their lives. 

Many of the barriers to having an open 

conversation about suicide are not unique to 

American Indian and Alaska Native (AI/AN) 

communities. Various cultures around the world 

share in the difficulty of having this conversation 

and for many of the same reasons. Many people 

believe that initiating a conversation about 

suicide is too painful or is too intrusive and 

inappropriate. Some might consider this to be 

disrespectful of the dead. Even general grieving 

and mourning processes incorporate various 

culturally based practices and formalities. How 

does someone who has lost a loved one to suicide 

speak of it with others? How do the members 

of a community that have lost numerous young 

people to suicide speak of it openly in public 

meetings and with people outside of their own 

community? What do you say to a parent who 

has lost a child to suicide? 

Although extremely difficult, such conversations 

are necessary in any community. Having said this, 

it is also important to acknowledge that some 

members of AI/AN communities may feel that 

there are religious or spiritual beliefs governing 

the appropriateness of the suicide conversation. 

Many belief systems contain rules that guide how 

and with whom this conversation can take place. 

These are traditions to respect as part of creating 

a culturally appropriate suicide prevention plan.

This chapter focuses on breaking the silence 

surrounding suicide. It describes some of the 

barriers and myths surrounding a suicide 

conversation, including those that may be specific 

to AI/AN communities. This chapter also discusses 

why it is important for a community to overcome 

these barriers in its own way and within its own 

specific cultural context. 

“Silence is dangerous when we pretend the problem is not there...

communication is a healer to break the silence.”

 — Canadian First Nations Elder

Lifting the Silence on Suicide: Together We Can Make a Difference

Conference Repor t from the Aboriginal Suicide Prevention Conference,

Alber ta, Canada (February 6-7, 2002)
22

Some of these barriers and myths apply to 

conversations with individuals who may be 

considering suicide, with family and friends 

of someone who has completed suicide, and 

with communities that hope to prevent or are 

responding to suicides. How does a father ask his 

son if he is thinking about suicide? How might 

someone who is contemplating suicide express 

those feelings to a friend, parent, grandparent, or 

other adult? These, too, are difficult conversations, 

but ones that can save lives.

Barriers to the Suicide 

Conversation

In the following discussion, honor, historical 

trauma, and respect are labeled as barriers to a 

suicide conversation. This labeling is not intended 

to minimize their importance within AI/AN 

communities but rather to explain and help us 

understand why having a suicide conversation is 

so complex. 

Underlying all of the barriers to the suicide 

conversation is language. As stated earlier, not 

all cultures use the same language, concepts, or 

values in discussing or understanding suicide. 

Consequently, the act of suicide, as well as its 

causes and prevention, may be spoken of in words 

and with a meaning not well understood within 

Native cultures. As a participant at the 2006 joint 

U.S.–Canada conference on indigenous suicide 

stated, “We find ourselves forced to speak about 

our health with language and concepts that are 

not our own.” Finding ways in which everyone 

can understand and discuss suicide is critical to 

holding the suicide discussion and developing a 

prevention plan. 

From Honorable to Forbidden Behavior 

Suicide is viewed differently by various cultures, 

depending on the circumstances and the 

period of time. For some individuals, suicide is 

“forbidden in their traditional culture” and “to 

take one’s own life will cause the soul to remain 

in a state of distress.”55 Other cultures have 

accepted—and some may still accept—suicide as 

honorable behavior when a person’s death is:

• An atonement for shame they have 

brought onto themselves and their family;

• A protest against injustice;

• A form of martyrdom or a show of 

devotion for a great cause or religion;

• An exercise of a person’s right to choose 

how and when he or she will die;

• A show of bravery when one charges an 

enemy who has superior weapons; and

• A demonstration of selflessness, as when 

a person has gone far out into the snow 

to die so that others may share what little 

food is available and live. 

Among AI/ANs, many of the stories, 

perspectives, and understanding of what has 

been labeled as suicidal behavior are deeply 

“One of the problems is that the 

definitions we are using here are 

too narrow. We need to remember 

the balance of the fire and the 

water, the male and female, the 

light and the dark, to be able 

to see this in a holistic way.”

 — Speaker, conference on “Indigenous

Suicide Prevention Research and

Programs in Canada and the United

States,” Albuquerque, NM (2006)
23

rooted in cultural history. Some deaths may be 

associated as easily with honor, sacrifice, and 

selflessness as with shame, grief, and depression. 

These contradictory and conflicting beliefs and 

emotions complicate the suicide conversation. 

The concept of suicide as “honorable” needs to be 

acknowledged within its historical context and 

then reassessed and confronted as it applies to 

the lives of today’s youth and young adults. 

Historical Trauma

As noted in the previous chapter, historical 

trauma is a risk factor for suicide that affects 

multiple generations. Many older members in 

the community may be reluctant to talk about 

this part of their past for a variety of reasons such 

as shame or not wanting to burden the young 

with their pain. Their silence might result from a 

reason as simple and basic as their not wanting to 

reexperience that terrible pain. 

As a result, it may be necessary for a community 

to address the impact of historical trauma 

prior to initiating or discussing any suicide 

prevention efforts. This conversation should 

only be undertaken with a full understanding 

of how an open and direct conversation about 

current suicides may force some older AI/ANs 

to reexperience and reveal painful events of 

years past. One personal experience shared at 

the 2008 Tree of Healing Conference, presented 

by Camas Path of the Kalispel Tribe of Indians 

in Washington State, can provide some insight. 

An Elder who grew up in boarding schools told 

how young Native males frequently were found 

hanged to death in the school basement. These 

suicides always were reported by the school’s 

administrators as “accidents” and never were 

discussed with the students. In this way, a whole 

generation may have been taught to respond 

to suicide with silence. Individual AI/AN 

communities will know best how to address the 

suicide conversation within the context of their 

own collective experience. 

Guilt and Shame

Native Americans view children as gifts from 

the Creator. Their parents, grandparents, aunts, 

uncles, Elders, and other members of the whole 

extended family and others are responsible for 

caring for and protecting that gift within the 

Sacred Circle of the community. What does 

it mean to all of these people to lose that gift 

to suicide? 

As much as we try to understand the continuing 

negative impact of historical trauma on AI/AN 

communities and families, this single factor 

seems like an inadequate explanation as to why 

a young person dies by suicide. Despite the best 

efforts of their community and family, youth and 

young adults sometimes take their own lives. 

Those most closely related to the person may find 

it hardest to explore the reasons why.

For parents, this tragedy is often compounded 

by guilt, shame, and the haunting questions of 

“What did I do wrong?,” “Why didn’t I see this 

coming?,” and “Why didn’t my child come to 

me?” Any direct discussion about their child’s 

death may cause them to experience these 

painful feelings again. Many will feel additional 

reluctance to engage in a suicide conversation 

if their child’s suicide is linked to alcohol and 

substance abuse, particularly if they or their 

parents also struggle with the same disorder. 

It also is common for parents who have lost a 

child to suicide to wonder what others in the 

community must be thinking. If they are asking 

themselves the “why” questions, then surely 

everyone else in the community must be doing 

the same. Again, parents may not want to talk 

with others within the community because of 

their feelings of guilt and shame. Some may not 

Chapter 3: Breaking the Silence Around the Suicide Conversation
24

want to bring up the topic of suicide for fear of 

causing others to feel these emotions. Either way, 

the end result for the suffering family member is 

the same: isolation. 

Having a suicide conversation can help a family 

member—or even a community—begin to heal 

from the tragedy of suicide. Even if someone does 

not know the proper words to say, he or she can 

take part in a conversation by listening. As one 

suicide survivor observed about her healing process, 

“Sometimes, I just needed someone to listen.” 

Personal Pain

The pain experienced by those who have lost 

loved ones to suicide is another barrier to having 

an open and public conversation about suicide. 

Some communities have many people who have 

lost a loved one to suicide, making a conversation 

about suicide even more difficult to start. Talking 

about suicide can be distressing both for the 

person who is talking and the person who is 

listening. Not talking about suicide is one way to 

try and avoid this pain.

With this barrier in mind, it is appropriate that 

the person wishing to hold a suicide conversation 

within an AI/AN community should first ask 

permission to bring up the topic. Permission can 

come in many forms, such as from the Elders 

within the community or the leadership of the 

community as well as from all those who attend 

the gathering and have lost a loved one. It also 

may be appropriate for the person who started 

the conversation to ask for forgiveness for 

causing painful feelings when the conversation 

is over. Time also must be available for those 

who wish to speak about loved ones who died 

by suicide, as it may be the first time anyone has 

asked them to share their stories. 

One example of sharing occurred as a result of a 

Talking Circle conversation about suicide, which 

was facilitated by a community coordinator 

with Native Aspirations, a Substance Abuse 

and Mental Health Services Administration 

(SAMHSA) program to reduce violence, 

bullying, and suicide among AI/AN youth. An 

Alaska Native woman spoke of her isolation, 

saying that “after my son killed himself, no one 

talked with me about it, no one came to my 

house to comfort me. I am still hurt and angry 

about that.” Her son had been dead for 20 years. 

As painful as the memory must have been for 

her, she came to the gathering and spoke publicly 

of her pain. Her ability to finally share her story 

with the community let the healing within 

herself begin.

During the same Talking Circle mentioned 

above, an elderly man spoke of his good friend 

who had completed suicide when they were 

just out of high school. With tears in his eyes, 

he spoke as if he were sharing the pain and 

experience for the first time. Having been 

invited to speak of this experience, he felt he had 

received permission to share his pain. 

Not every culture, however, relies on words to 

deal with grief and loss. For some, grieving 

involves participation in a specific traditional 

ceremony. Sharing a family’s loss may be 

expressed in an act as simple as offering 

condolences through a gift such as a pound 

of coffee. In attempting to open up a suicide 

conversation with a family who has lost someone 

to suicide, it is polite to inquire first as to what 

would be helpful or if they would like to talk 

about their loved one or about their grief. In any 

event, ask permission before beginning.

Collective Grief 

Given what has been discussed about barriers 

thus far, it is not unusual to find a great deal of 

unspoken grief surrounding the topic of suicide 

within the community as a whole. Perhaps the 

specific ceremony was not performed, or the time 

period for talking about the loved one has passed. 
25

Initial suicide prevention efforts either may 

be blocked by this silent grief or may provide 

community members with permission to release 

their grief in a flood of emotions. Either way, 

AI/AN community prevention plans may need 

to include community-based ceremonies and 

traditions to begin the healing of this collective 

grief. This may be accomplished through 

ceremonies such as the Wiping of the Tears or a 

Gathering of Native Americans (GONA).c

The release of pent-up emotions is more likely to 

happen over time rather than at once. Questions 

arise as to how the community can have the 

suicide conversation in a way that respects and 

protects people experiencing grief. A primary 

question is: How can suicide prevention planning 

meetings and training sessions be conducted in 

a way that provides enough time so that once 

the wounds have been opened they are not left 

open when everyone goes home? To ensure that 

everyone who attends these gatherings are given 

support during the conversation, counselors or 

traditional healers may need to be present and 

willing to stay after the meeting to help the 

community begin to heal its collective grief. 

Politeness and Respect

Politeness and respect may seem like strange 

barriers to a conversation about protecting the 

youth of a community. In any community, these 

qualities are valued as a necessity for community 

living. As Erving Goffman described in his 

early study of what has become known as 

“politeness theory:”

Politeness Theory and Suicidal Warning Signs

Someone who is contemplating suicide often will send warning signs to those around him or her, but these

signs may be unclear and difficult to recognize as a call for help. This raises the question of why people

considering suicide are not more direct in making their personal pain known. Politeness theory offers some

answer. This theory helps to explain why many of us use a unique conversational logic and language that:

• Is designed to very carefully avoid what could be interpreted as rude or disrespectful speech;

• Is intended to avoid an unpleasant confrontation that might lead to the receiver losing face or being

embarrassed; and

• Is meant to avoid placing a burden on the person hearing the call for help that they may not desire or

feel able to fulfill.

As for individuals experiencing a suicidal crisis, vague or indirect calls for help helps protect them from their

own embarrassment if others fail to respond. Potentially suicidal individuals also can deny the intent of their

warning signs if it leads to a conversation that makes them feel uncomfortable. Vagueness of warning signs

allows everyone concerned a way out of a potentially difficult and embarrassing situation.

No matter how strong the politeness convention of a culture is, the value of life should be stronger. Politeness

should not prevent a caring person from asking someone directly if he or she is thinking about suicide when

having this conversation may save a life.

Chapter 3: Breaking the Silence Around the Suicide Conversation

c

A GONA is a 4-day gathering for Native Americans who want 

to become change agents, community developers, and leaders. The 

GONA is based on several ideas: community healing is necessary 

for substance abuse prevention; healthy traditions in the Native 

American community are key to effective prevention; the holistic 

approach to wellness is a traditional part of Native American belief 

systems; every community member is of value in empowering 

the community; and the GONA is a safe place for communities 

to share, heal, and plan for action. A GONA manual can be 

downloaded from SAMHSA at http://preventiontraining.samhsa.

gov/CTI05/Cti05ttl.htm.
26

In any society, whenever the physical 

possibility of spoken interactions arises, it 

seems that a system of practices, conventions, 

and procedural rules comes into play 

which functions as a means of guiding 

and organizing the flow of messages. An 

understanding will prevail as to when and 

where it will be permissible to initiate talk 

among whom, and by means of what topics 

of conversations.56

In many ways, these conventions help define 

“culture” and establish the rules for how 

community members will interact. These 

conventions evolve over time and, while rarely 

written down, are passed from generation to 

generation. Although many members of a 

community and culture may not be able to list 

all of these conventions, they know it when they 

violate one. 

Holding a suicide conversation challenges these 

conventions. It is a difficult conversation to have 

on both the personal level and on the community 

level. For example, we might be able to ask a 

sister or brother if they are having thoughts of 

suicide but not a parent or Elder. We might be 

able to talk with a close friend about thoughts 

of suicide or of a suicide in the family but not at 

a public meeting or with strangers. In addition, 

it may be considered rude and disrespectful to 

make others uncomfortable or embarrassed in a 

public setting or to speak publicly about suicide 

within the community without first having 

permission from an Elder. As important as these 

conventions are to social interaction, they can 

prevent the community from coming together 

and talking about the causes and prevention 

of suicide. 

It falls on the community to resolve the issues 

presented by politeness and respect. Just as 

cultural differences occur between each Tribal 

community, different values are placed on 

politeness and respect. For prevention efforts to 

be successful, however, each community must 

find its way to have a respectful conversation 

about suicide. 

Stigma

The act of suicide is surrounded by stigma. Many 

religious denominations consider suicide a sin, 

and some previously did not allow a consecrated 

funeral for the “sinner.” Historically, suicide was 

reported as a crime—a practice that did not end 

in all States until the 1990s. We see this stigma 

in the language used to describe suicide: someone 

who takes his or her own life “commits suicide.” 

This wording carries the same social disapproval 

as when a person “commits” a sin or “commits” a 

crime. Consequently, those who have attempted 

suicide or survived the death of a loved one 

prefer the wording “completed suicide” or “died 

by suicide,” as is used in this document. 

The stigma of suicide also affects the suicidal 

person and his or her family.57 This stigma can 

cause many families to suffer in silence and 

isolation58 and prevent them from receiving the 

support they need, particularly when another 

family member responds to the first suicide with 

his or her own suicide. 

Some of the stigma that surrounds suicide can 

be positive. The idea that suicide is a sin or a 

crime against life prevents some people from 

attempting suicide. At the same time, this stigma 

can prevent a person experiencing a suicidal 

crisis from seeking the help he or she desperately 

needs. One 2007 survey of AI/AN adolescents 

who had thought about or attempted suicide 

identified “stigma” and “embarrassment” as 

common reasons for not seeking help.59 After 

a suicide completion or attempt, the stigma 

of suicide becomes a barrier to discussing 

why someone ended or tried to end his or her 

own life.

The stigma of suicide is compounded by 

the stigma associated with mental illness 
27

and substance abuse—the risk factors most 

commonly associated with suicide. It may be 

difficult for a community to have an open, 

comprehensive discussion about the causes 

and prevention of suicide before it first deals 

openly with the need to prevent and treat these 

two disorders. 

Paul Quinnett, author of Suicide: The Forever 

Decision,d often proposes that clinics, schools, 

hospitals, and other public places post signs 

that say “Suicide Spoken Here.” While such an 

action may seem extreme, it may be the kind of 

action needed to remove some of the stigma that 

surrounds a suicide conversation. Individuals 

should be able to speak without fear or shame 

about their suicidal thoughts and what may be 

causing these thoughts. When this is possible, 

they will find the care and support they need to 

honor themselves and their lives. 

Fear

A major barrier is fear—fear that talking to 

someone who appears at risk of suicide might 

push that person over the edge, fear that such a 

conversation might actually plant the seed for 

suicidal actions. If this fear of raising the topic of 

suicide with an individual exists, then how great 

is the fear of engaging an entire community in a 

discussion of suicide? This particular barrier will 

be addressed in greater detail later in this section, 

under Myths About Suicide. 

Social Disapproval

The stigma attached to suicide sometimes 

extends to those in the community who have 

broken the code of silence around suicide 

and are in the forefront of prevention efforts. 

Although these individuals have overcome their 

own reluctance, grief, and fear to speak openly 

about this sensitive topic, others in the same 

community may not have reached this level of 

openness or healing. As a result, they may feel 

Questions for Seeking the Wisdom of Elders

• What traditional values does the community associate with death and conversations about the dead?

• Does the community’s language have a word or phrase to describe suicide?

• How has suicide been understood, discussed, or dealt with?

• Are there any taboos around talking about suicide?

• If so, how might the community address these taboos so they may consider a

suicide prevention plan?

• Are there specific healing ceremonies for the family and community after a tragedy?

d

 This book is available free online from the QPR (Question, 

Persuade, Refer) Institute at http://www.qprinstitute.com.

Chapter 3: Breaking the Silence Around the Suicide Conversation

“Some people think curbing alcohol 

and substance abuse and the 

related problems is too sensitive an 

issue. It isn’t. I believe Villagers are 

ready to begin the healing process. 

We are a tough, strong people.”

 — Anonymous Alaska Native

Alaska Natives Combating Substance 

Abuse and Related Violence Through 

Self-Healing: A Report for the People

Center for Alcohol and

Addiction Studies (1999)
28

anger towards the person who is making them 

feel uncomfortable. They may resent the attention 

that a suicide conversation draws to risk factors 

within their community. In addition—out of 

fear or discomfort—they may avoid someone 

who seems unafraid of speaking to others about 

suicide and death. 

Elders, healers, and others in the community can 

reach out to those who are engaged in suicide 

prevention by supporting and blessing their 

work. Suicide prevention is difficult but vital 

work, and those who engage in it need to be 

assured that they and their work are valued by 

their community. With leadership, engagement 

in suicide prevention can be a community-wide 

priority. For example, in January 2001, the White 

Mountain Apache Tribe became the first group 

in the United States to mandate communitywide reporting of suicide completions, attempts, 

and ideation.60

Responding to Conversation Barriers

Many of the barriers to holding a suicide 

conversation overlap and compound each other. 

There is no easy or single solution to breaking the 

silence around suicide. Many Tribes and Villages, 

however, have faced this challenge successfully 

and are helping their children experience the 

joys of life. Some of the prevention activities 

being used by these communities are described 

later in Chapter 7: Promising Suicide 

Prevention Programs. 

As difficult as it is to have the suicide 

conversation, it seems that not having it is 

no longer an option. The question is not 

if a community should have conversation 

about suicide but how and when. It is the 

responsibility of each community to find the 

ways to overcome the barriers to the suicide 

conversation. Communities may want to invite 

a gathering of Elders to explore how suicide 

can be spoken of within the community. The 

results of this conversation may need to be 

shared with community members before any 

major prevention program is developed. The 

more people feel they have permission to talk, 

and the invitation, opportunity, and support to 

talk—with people who will listen—the more an 

open and productive conversation will flow. 

Myths About Suicide 

Several widely held myths about suicide interfere 

with a suicide conversation. Many people worry 

about what might happen if they talk about 

suicide. This concern is different from the worry 

about causing someone to feel guilt, shame, or 

pain, or being rude and disrespectful. Instead, 

this concern is grounded in the power of the 

spoken word. Within different AI/AN cultures, 

words have the power to call forth or create and 

to name or define. The person through which the 

words flow is the teller of history. Words are also 

about honor and the importance of giving one’s 

word to another. 

The power of the spoken word raises many 

questions about a suicide conversation. Will 

speaking about suicide cause it to happen? Will 

“I am firmly convinced that the 

‘secret’ to suicide prevention is 

family and community involvement 

and commitment in trying as many 

strategies as is necessary to save 

the lives of our youth. It can happen, 

and we will be the ones to do it.”

 — Dr. Rod McCormick

Mohawk Nation

Aboriginal Youth: A Manual of Promising 

Suicide Prevention Strategies

Canadian Mental Health

Association (2004)
29

it plant the idea in the mind of a young person 

who may have not otherwise thought about it? 

If suicide were never spoken of again, would 

suicides stop? These questions can create genuine 

concern about how, when, and under what 

circumstances a person can speak about suicide.

As important as it is to honor the belief in the 

power of words, it is equally important to be 

able to discuss suicide openly in order to develop 

a viable suicide prevention program. As noted 

in the National Strategy for Suicide Prevention, 

confronting the myths about suicide and suicide 

prevention is essential to creating an informed 

public and the kinds of social and policy changes 

that lead to greater investments in prevention 

efforts. Furthermore, “if the general public 

understands that suicide and suicidal behaviors 

can be prevented, and people are made aware 

of the roles individuals and groups can play in 

prevention, many lives can be saved.”61

Everyone needs to become involved in dispelling 

the following myths so that a conversation 

around suicide can take place. This may include 

recognizing the importance of involving Tribal 

Elders, leaders, and healers in any suicide 

prevention effort. This may mean an opening 

and closing ceremony around the suicide 

conversation, gaining permission from Elders 

to speak of suicide, or both. Each community 

may find specific ways of addressing the 

belief in the power of words in order to begin 

the conversation. 

Finally, while the following myths refer more to 

having a direct conversation with a potentially 

suicidal person than they have with communitywide prevention efforts, it is still important to 

address them in this section. If not addressed, 

these myths might interfere with the involvement 

of many AI/AN community members in the 

prevention effort. These stakeholders might even 

be afraid that any suicide prevention effort might 

cause more harm than good. 

Myth 1: Talking about suicide, especially 

with adolescents, will “plant” the idea.

Many adults find it difficult to believe that a 

young person, with a full life ahead, could be 

thinking about suicide. They fear that asking the 

person about suicide will only introduce it as a 

possibility. They wonder, “What does a question 

about suicide say to young people about our trust 

and belief in them and their future?,” “Isn’t it 

important to stay positive?,” and “What can or 

should I do if an adolescent admits to thinking 

about suicide?” It might be even more frightening 

to have our concerns and suspicions about their 

thoughts of suicide confirmed.

Truth: Talking with youth and young adults 

about suicide will not plant the idea in 

their heads. 

This truth bears repeating because the “seedplanting” myth is so powerful and pervasive that 

even some mental health professionals seem to 

accept it. First, AI/AN youth and young adults 

already are well aware of suicide from their 

experience and conversations with suicidal peers 

and from the media.62 In fact, they are more 

likely to feel relief that someone cares enough to 

ask. Starting the conversation about suicide may 

help them to feel less alone and isolated.63

Second, the research rejecting this myth is 

overwhelming. According to the U.S. Centers 

for Disease Control and Prevention (CDC), 

there is no evidence that youth who participated 

in general suicide education programs had 

any increase in suicidal thoughts or behavior.64

Instead, some studies indicate that these youth 

have decreased feelings of hopelessness and were 

less likely to believe that social withdrawal was 

an effective way to solve problems.65

Third, numerous research and intervention efforts 

have been completed without any reports of 

harm.66 Finally, several evaluations of schoolbased suicide prevention programs show that 

Chapter 3: Breaking the Silence Around the Suicide Conversation
30

adolescents are more likely to tell an adult about 

a friend who is suicidal or have reduced suicidal 

thoughts after being given information about 

suicide.67, 68, 69, 70, 71, 72

The most important reason for shattering this 

myth is that when suicide prevention programs 

are established in schools, they reduce the rates 

of suicide. Two long-term follow-up studies have 

demonstrated this fact. In various counties where 

suicide prevention programs were provided in 

nearly all of its schools over a period of years, 

youth suicide rates declined, while State rates 

remained unchanged or increased for the same 

period of time.73, 74

It is important to note that school-based 

suicide prevention programs are not designed 

nor intended to focus exclusively on suicidal 

feeling, but instead are focused on help-seeking 

behaviors, knowing the warning signs, addressing 

the myths about suicide, becoming aware of 

school resources, and resolving to take action. 

Of equal importance is the need to ensure that 

all of the adults in the school have received 

training prior to introducing such training to the 

students. In this way, the adults can develop the 

necessary policies, procedures, and resources to 

respond to any increase in requests for help from 

the students. 

Myth 2: No one can prevent suicide—

it is inevitable.

This fatalistic view of suicide is reflected in a 

belief that suicide has become so commonplace 

that it is to be expected. No one can do anything 

to prevent it. This false belief may be one of 

many responses to the high rates of suicide in 

a particular community. High suicide rates can 

numb the community and cause many people 

to want to shut down in grief. Community 

members can be so overwhelmed by loss that 

they feel helpless in finding opportunities to 

prevent more deaths. Accepting suicide as 

preventable also may create profound guilt. The 

question becomes, “Why couldn’t I prevent my 

loved one from killing himself/herself?” 

Others see suicide as too complicated and 

mysterious to understand. Why would anyone 

reject life? This view becomes a barrier to 

prevention because it may seem futile to try to 

prevent what cannot be understood. Still others 

may see suicide as one individual’s response to his 

or her own unique personal problems. What can 

a community as a whole do to prevent suicide 

among diverse individuals? 

Truth: Suicide is preventable.

According to former U.S. Surgeon General 

David Satcher, suicide is our most preventable 

form of death.75 And, as devastating as even one 

death by suicide in a community can be, most 

people, including AI/AN adolescents and young 

adults, do not die by suicide. 

To help dispel the idea that suicide is inevitable, 

suicide prevention actions frequently focus on 

the positive aspects of living: strengthening 

families, developing in youth the skills that help 

them cope with life’s challenges, and building 

up a youth’s sense of self-worth. A focus solely 

on risk factors could simply perpetuate a feeling 

of helplessness in a community. In suicide 

prevention, the message must be one of hope for 

everyone in a community. Prevention is as much 

about strengthening what is good and working 

within a community as it is about correcting 

what may be threatening the health and wellbeing of its members. 

The power of hope in preventing suicide cannot 

be over-estimated. An example of its power can 

be seen in clinical trials to test new medications. 

In some study designs, half of the group is given 

sugar pills while the other half is given the new 

drug. Up to 20 percent of the people taking 

the sugar pills may show improvement—

because they believe that they will. This result 

is called the placebo effect. Suicide prevention 
31

is as much about instilling hope in life as it is 

about knowing what programs are effective and 

implementing them.

Myth 3: Only the experts can prevent suicide.

This myth is based on the belief that suicide 

prevention is the work of therapists, physicians, 

psychologists, or other trained specialists rather 

than that of a community at large.

Truth: Prevention is the task of the 

whole community.

It seems logical that people who are considering 

suicide be seen by a professional. It is important, 

however, to distinguish between the treatment 

of a suicidal person and preventing suicide 

by engaging a person at risk in a suicide 

conversation. Everyone in the community needs 

to be involved in suicide prevention, from Tribal 

and Village leadership, to Elders, to the extended 

family, to teachers, and to youth and young adults 

themselves. Everyone can help to promote the 

mental health of youth as well as decrease factors 

that place them at risk of suicide. Everyone can 

be alert for signs that a young person may feel 

troubled. The idea that an entire community must 

come together to prevent suicide and how they 

can do so is discussed in more detail in Chapter 

6: Community Action. According to Native 

American culture, children are the gift of the 

Creator and it is the responsibility of the entire 

community to care for and protect that gift.

Myth 4: Individuals who are considering 

suicide keep their plans to themselves, and 

this secrecy makes prevention impossible.

This myth assumes that most people considering 

suicide do not want to be stopped.

Truth: Individuals considering suicide 

frequently give verbal, behavioral, 

and situational “clues” or “warning 

signs” before they engage in suicidal 

behavior.76, 77, 78, 79

Commonly accepted warning signs are shown in 

Exhibit 2. However, further research is needed to 

identify any signs that may be unique to AI/AN 

youth and young adults. 

Chapter 3: Breaking the Silence Around the Suicide Conversation

Exhibit 2. Suicide 

Warning Signs

Seek help as soon as possible by contacting

a mental health professional or by calling the

National Suicide Prevention Lifeline at 1–800–

273–TALK (8255) if you or someone you know

exhibits any of the following signs:

• Threatening to hurt or kill oneself or talking

about wanting to hurt or kill oneself;

• Looking for ways to kill oneself by

seeking access to firearms, pills, or

other means;

• Talking or writing about death, dying, or

suicide when these actions are out of

the ordinary for the person;

• Feeling hopeless;

• Feeling rage or uncontrolled anger or

seeking revenge;

• Acting reckless or engaging in risky

activities—seemingly without thinking;

• Feeling trapped—like there’s no way out;

• Increasing alcohol or drug use;

• Withdrawing from friends, family,

and society;

• Feeling anxious, agitated, or unable to

sleep or sleeping all the time;

• Experiencing dramatic mood

changes; and

• Seeing no reason for living or having no

sense of purpose in life.
32

As was discussed earlier in this chapter, many 

reasons exist as to why a suicidal person might 

“code” or disguise a warning that he or she 

intends to die. The reality is that most suicidal 

people tell someone about their intent during 

the week prior to their suicide attempt. This 

fact is the foundation for community awareness 

campaigns and general gatekeeper or peer 

training activities, which focus on identifying and 

referring at-risk individuals for treatment and 

supporting services. Gatekeeper training will be 

covered in greater detail in Chapter 7: Promising 

Suicide Prevention Programs.

Myth 5: Those who talk about suicide don’t 

actually go on to attempt it.

This myth is related to Myth 4, with many 

people believing that those who intend to 

complete suicide don’t tell anyone about it, while 

those who talk about it don’t intend to take their 

own life. 

Truth: The opposite of this myth is actually true. 

As described under Myth 4, verbal, behavioral, 

and situational clues and warning signs 

frequently precede suicidal behavior.

Myth 6: Once a person decides to die by 

suicide, there is nothing anyone can do to 

prevent it. 

This myth is a variation of Myth 2, which is that 

no one can stop suicide or a person intent on 

suicide. The mistaken belief appears to be that, 

even if we could watch over a suicidal person 

every day, all day, he or she eventually would find 

a way to end his or her life. 

Truth: Much can be done to prevent suicide.

It starts with asking someone who is showing 

suicidal clues and warning signs a simple 

question: “Are you thinking about suicide?” This 

question opens a conversation that can reduce a 

person’s feelings of isolation, anxiety, and distress 

and may lead them to seek help. Just asking 

the suicide question can reduce a person’s risk 

of suicide.

Also, as discussed under Myth 2, there are 

various reasons why someone would want to 

believe this myth. If a family has lost a loved one 

to suicide, and they are later told that suicide 

is preventable, what does that say about them? 

What could or should they have done to stop 

their loved one from dying? The idea that suicide 

is preventable can be very difficult to accept 

without experiencing guilt, shame, and anger if a 

suicide has occured. In any prevention program, 

it is important to stress that people should not 

feel guilty about the past because of what they 

are learning just now in the present. 

Conclusion

Talking about suicide is a difficult conversation 

that is complicated by barriers, myths, taboos, 

fears, and legitimate cultural considerations. 

As individuals, we might feel that suicide is 

beyond our abilities to prevent, yet we each have 

the power to speak and to act. Collectively, a 

community has incredible power when everyone 

comes together to talk, listen, plan, and act to 

help its children thrive.

It seems fitting to end this chapter as it 

began, with the words of the Canadian First 

Nations Elder:

Silence is dangerous when we pretend the 

problem is not there . . . communication is a 

healer to break the silence.
33

35

Chapter 4: Responding to Suicide

Introduction

The loss of a loved one by suicide is shocking, 

painful, and unexpected. Survivors, including 

whole communities, may experience a broad 

range of emotions including denial, anger, 

blame, guilt, helplessness, and confusion. One 

of the dangers of a suicide is that others in the 

community may be so overwhelmed by these 

emotions that they too try to take their own life. 

This situation is referred to as suicide contagion 

and, when it occurs, can be just as deadly to a 

community’s well-being as the spread of other 

deadly viruses. 

This chapter focuses on how a community might 

respond when tragedy does occur—when one 

of its youth or young adults takes his or her own 

life. It also describes actions that an American 

Indian and Alaska Native (AI/AN) community 

might take to reduce the risk of additional 

suicides or suicide attempts. Directions on how 

to request an emergency response team through 

the Indian Health Service (IHS) are given. 

Because a community is the sum of its individual 

members, this chapter begins with a discussion 

of how a community might comfort suicide 

survivors, who are those most affected by another 

person’s suicide or suicide attempt. 

Next, the chapter describes how a community 

might develop a planned response to suicide 

contagion, to which youth and young adults 

appear most susceptible. The roles of the media, 

emergency health care providers, and suicide 

survivors and suicide attempt survivors in 

reducing the possibility of suicide contagion 

also are presented.e The final section of the 

chapter describes Federal emergency response 

resources available to Tribes and Villages affected 

by suicide.

Responding to Suicide Survivors

For every suicide there are at least six survivors, 

which may be a conservative estimate.80

This most probably is the case for AI/AN 

communities because the number of suicide 

survivors usually refers just to blood relatives, 

significant others (e.g., spouse), or close 

friends. It does not take into account the 

interconnectedness of relationships within 

Tribes and Villages or the complex and extensive 

relational network of a culture that sees others 

as all my relations. When considered within the 

e

“Suicide survivor” is the term used to describe a family member or 

close friend of someone who dies by suicide, while “suicide attempt 

survivor” is the term used to describe someone who has made a 

suicide attempt and lived. 

“We can stop others from committing suicide if we talk 

openly in our communities and if we provide safe and 

supportive places for people to go when they need help 

for themselves or their family members. We need to share 

the message [of my sister’s suicide]—‘tell the ones trying 

to end their lives this way that it is not the way to go.’”

 — Dana (age 16), Spirit Lake Lakotah Nation

Testimony Before the U.S. Senate Committee on Indian Affairs,

February 26, 2009
36

AI/AN worldview, the number of survivors to 

a suicide might be closer to a range of 25 to 

everyone in the community and beyond. In a 

small Alaska Village of 500 to 800, all members 

conceivably could be considered survivors. 

Another way to understand the full impact of 

suicide on AI/AN communities is to expand the 

concept of survivors to include those affected by 

a loved one’s suicide attempt. Although estimates 

for Native Americans, in general, are not 

available, one survey of Bureau of Indian Affairs 

schools suggests that 16 percent of AI/AN youth 

had attempted suicide in the preceding year.81

While experiencing relief that their loved one is 

still alive, these individuals may experience many 

of the same feelings of pain, guilt, shame, and 

fear as those whose loved one did not survive. 

They also may be troubled by many of the same 

questions, such as “How could this happen?,” 

“Why didn’t he or she come to me?,” or “Why 

didn’t I see this coming?” When you include 

suicide attempt survivors with the numbers of 

suicide survivors, it is not difficult to imagine 

that the majority of AI/ANs have been directly 

and personally affected by suicide and suicidal 

behavior within their communities. 

The emotional turmoil felt by those affected 

by a suicide or suicide attempt can be intense, 

complex, and long-term. These feelings may be 

compounded by the preexistence of historical 

trauma. Feelings of isolation also may complicate 

the grieving process and impede healing. 

Survivors of suicide often feel abandoned at a 

time when they desperately need unconditional 

support and understanding. 

There is no timeline for grieving. Those around 

the survivor may help most when they: 

• Accept the intensity of the survivor’s grief;

• Listen with their hearts;

• Avoid simplistic explanations and clichés;

• Show compassion;

• Respect the survivor’s need to grieve;

• Understand the uniqueness of suicide grief;

• Are aware of holidays and anniversaries;

• Are aware of support groups;

• Respect the person’s faith and 

spirituality; and

• Work together as a helper for the survivor.82

Grief work is a culturally specific process that 

each person experiences in his or her own way 

and at his or her own pace.83 The way in which 

each community and its members respond 

to suicide survivors will depend on a variety 

of individual, family, and community cultural 

values and beliefs. In order for a community to 

develop the most appropriate and effective way 

of address survivor grief, community members 

Questions for Seeking the Wisdom of Elders

• What are traditional ways in which the community responded to a suicide, sudden death, or other

great loss?

• How did community members help the families most affected, what words were spoken, or what

actions were taken to help them heal?

• Were there rituals or ceremonies that helped the family and community deal with its loss?

• If someone became trapped in their grief, how did the community help them?

• What are some stories that could help families and communities deal with grief?
37

are encouraged to discuss how they might 

respond as part of their suicide prevention plan 

development. Possible sources of support for 

survivors include talking with Tribal leaders, 

Elders, church and traditional healers, other 

survivors, and other community members. 

The extended effect of suicides among AI/AN 

communities adds urgency to the need for 

communities to determine culturally appropriate 

ways to reach out and support those who have 

lost someone to suicide.

Survivor Groups

The Arctic Sounder, a newspaper serving 

Northwest Arctic and the North Slope, featured 

an article about a Tlingit woman originally from 

Hoonah who survived the death of her son to 

suicide. It was not long after her son died that 

people started telling her that she needed to “get 

over it.” The woman would respond by saying, 

“You don’t get over it. . . .You need help to get 

through it.” In a closing comment, she added 

that, “I want to let suicide survivors know that 

they’re not alone and they have someone to 

talk to.”84

Many Tribal and Village communities have 

established survivor support groups and Talking 

Circles to help survivors deal with their grief. 

A support group facilitator’s guide written by 

survivor Linda Flatt is available from the Suicide 

Prevention Action Network (SPAN) USA. The 

guide is titled The Basics: Facilitating a Suicide 

Survivors Support Group. While a community 

prevention specialist and leaders, Elders, and 

healers may need to first review the guide to 

ensure that it addresses culturally relevant beliefs 

and ceremonies, it does make a contribution 

to efforts to help survivors know that they are 

not alone. 

Preventing Suicide Contagion 

Suicide contagion is a process by which exposure 

to the suicide or suicidal behavior of one or 

more individuals influences other individuals 

to complete or attempt suicide. This term 

sometimes is used interchangeably with the 

term “suicide clusters,” which is more specifically 

defined as when a group of suicides or suicide 

attempts occur closer together in time and 

space than would normally be expected in a 

given community.

Suicide contagion is real, and research suggests 

that even a single suicide within a community 

can increase the risk of additional suicides.85, 86, 87

Suicide contagion is not a new phenomenon, nor 

is it confined to AI/AN communities. Contagion 

has been reported within high schools, colleges, 

Marine troops, prisons, and religious sects, to 

name a few. However, teenagers and young adults 

appear most at risk.88, 89 This is not surprising 

given the characteristics of impulsiveness, 

difficulty with delayed gratification, and 

susceptibility to peer and media pressure that 

are typically assigned to younger people. The 

addition of early experimentation with drugs and 

alcohol can further increase their susceptibility. 

Deaths that trigger suicidal behavior, however, 

do not have to be as a result of a suicide. 

According to the Centers for Disease Control 

and Prevention (CDC), several clusters of 

suicides or suicide attempts were preceded by 

one or more traumatic deaths—intentional 

or unintentional—among the youth of the 

community.90 In one case study, two close friends 

of a young person who died as a result of an 

unintentional fall went on to complete suicide.91

This research suggests a heightened potential for 

suicide contagion among AI/AN adolescents and 

young adults, given the rate of sudden deaths due 

to unintentional injuries. Unintentional injuries 

are the leading cause of death for AI/ANs ages 1 

to 44. Most of these deaths are caused by traffic 

crashes and poisoning.92

Chapter 4: Responding to Suicide
38

While there are no easy answers to the threat of 

suicide contagion, there are proactive steps that 

communities can take. “Postvention” is a term 

used to describe prevention measures that are 

taken after a crisis or traumatic event to reduce 

the risk to those who have witnessed or been 

affected by the tragedy. Postvention can involve 

both actions to help survivors through their grief 

process and to identify and respond to individuals 

who may be at risk of suicide contagion.

Identifying Individuals at Risk 

for Contagion

Exhibit 3 is a list of questions that community or 

school leaders can use to help identify individuals 

who may be at risk of suicide following the death 

of another. If someone appears to be vulnerable, 

a suicide conversation should follow and those at 

risk should be encouraged to seek help. 

Developing a Postvention Plan

A community’s efforts to develop a postvention 

plan will be similar to its efforts to develop a 

broader suicide prevention plan. The community 

will need to understand the risk and protective 

factors associated with suicide contagion and 

develop strategies to reduce risks and enhance 

protective factors. Some of the risk factors, such 

as preexisting trauma and assuming blame for the 

person’s death, are suggested in Exhibit 3.

A community should consider postvention as 

part of their overall suicide prevention planning 

rather than try to develop a response immediately 

after a suicide. At this time, a community may 

be in shock and mourning, which can prevent 

its members from coming together to deal 

effectively with the issue. 

The CDC has put together a number of 

recommendations for postvention planning (see 

Exhibit 4). Each community will need to consider 

its particular needs and cultural strengths as it 

incorporates various recommendations into its 

own plan. 

The CDC also offers general guidelines for 

preventing suicide contagion, which are to: 

Exhibit 3. Sample Questions for 

Identifying Individuals at Risk of 

Suicide Contagion*

• Which other adolescents or community

members might identify with the person

who died by suicide?

• Was the deceased person part of a

formal/informal group, organization,

team, etc.?

• What risk factors associated with the

deceased may be shared by peers or

others in the community?

• Are any peers/family members

currently demonstrating suicide–related

warning signs?

• Which peers/family members who may

have previously been identified as a

suicide risk need to be contacted for

follow up?

• What, if any, school/community

memorial services and/or gravesite vigils

occurred or have been planned?

• Are there any peers/family members

being blamed for or seen as a reason for

the suicide?

• Does a survivor blame himself/herself

for the suicide?

• Has the survivor experienced previous

trauma that was never addressed?

*Adapted from Community response: Effective action 

after a suicide, a presentation by Frank J. Zenere, Ed.S, 

National Association of School Psychologists, National 

Emergency Assistance Team. Available online at http://

www.sprc.org/featured_resources. trainingandevents/

conferences/no/pdf/commresponse.pdf.
39

Chapter 4: Responding to Suicide

• Avoid glorifying suicides;

• Offer support to families and friends 

of victims;

• Identify vulnerable relatives and friends 

and offer counseling; and

• Enlist the support of the media.

Some of these guidelines warrant further 

discussion as they apply to AI/AN communities. 

The first guideline is to avoid glorifying 

suicides. The concern is that too much “positive 

attention given to someone who has died (or 

attempted to die) by suicide can lead vulnerable 

individuals who desire such attention to take 

their own lives.”93 This is obviously a delicate 

balance without clear guidelines or rules. Many 

survivors become upset if told how they should 

grieve or what is an appropriate response. The 

need to avoid traumatizing suicide survivors 

any further is another reason to incorporate 

Exhibit 4. CDC Recommendations for a Community Plan for 

the Prevention and Containment of Suicide Clusters*

1. A community should review these recommendations and develop its own response before

the onset of a suicide cluster.

2. The response to the crisis should involve all concerned sectors of the community and should

be coordinated by:

a. A coordinating committee, which manages the day-to-day response to the crisis; and

b. A host agency, whose responsibilities would include “housing” the plan, monitoring the

incidence of suicide, and calling meetings of the coordinating committee when necessary.

3. The relevant community resources should be identified.

4. The response plan should be implemented under either of the following two conditions:

a. When a suicide cluster occurs in the community; or

b. When one or more deaths from trauma occur in the community, especially among

adolescents or young adults, which may potentially influence others to attempt or

complete suicide.

5. If the response plan is to be implemented, the first step should be to contact and prepare

those groups who will play key roles in the first days of the response.

6. The response should be conducted in a manner that avoids glorification of the suicide

victims and minimizes sensationalism.

7. Persons who may be at high risk of suicide should be identified and have at least one

screening interview with a trained counselor; these persons should be referred for further

counseling or other services as needed.

8. A timely flow of accurate, appropriate information should be provided to the media.

9. Elements in the environment that might increase the likelihood of further suicides or suicide

attempts should be identified and changed.

10. Long-term issues suggested by the nature of the suicide cluster should be addressed.

* From MMWR Supplements, August 19, 1988, 37(5-6), 1-12. Available online at 

http://www.cdc.gov/mmwr/preview/mmwrhtml/00001755.htm.
40

postvention planning into overall suicide 

prevention planning rather than as a reaction 

to suicide. As always, it is important to include 

a strong cultural foundation and to include the 

voices of survivors. In addition, this guideline 

should not be interpreted as a prohibition against 

the performance of Pipe or Wiping of the 

Tears ceremony. 

Role of the Media 

Another of the CDC guidelines for preventing 

suicide contagion is to enlist the support of the 

media. On the surface, this seems to contradict 

the recommendation to avoid glorifying suicides. 

Media stories can dramatize or romanticize 

suicides, with tragic results. For example, between 

1984 and 1987, journalists in Vienna, Austria, 

covered the deaths of individuals who jumped in 

front of subway trains. The media coverage was 

extensive and dramatic. In 1987, an educational 

campaign was launched that alerted reporters to 

the possible negative effects of such reporting 

and suggested alternative strategies for coverage. 

Within 6 months after the campaign began, 

subway suicides and nonfatal attempts dropped 

by more than 80 percent. The total number of 

suicides in Vienna declined as well.94, 95

While it is the media’s job to report on 

newsworthy events—whether local, Tribal, 

State, national, or international—it also is 

their responsibility to satisfy the “public’s 

right to know” in a way that does not exploit 

a community’s grief or cause further harm. 

The media, however, can have a powerful role 

in suicide prevention through responsible 

reporting. Stories about suicide can inform 

readers about the likely causes of suicide, its 

warning signs, trends in suicide rates, and recent 

treatment advances. The media also can highlight 

opportunities for individuals and organizations 

to help prevent suicide and inform community 

members about local resources.

The media also can be asked to participate in 

suicide prevention efforts before a suicide occurs. 

Local media can play an important and positive 

role in any community’s prevention plans and 

initiatives, especially when it comes to getting 

the message out about prevention events and 

activities. Individuals within the media make 

valuable partners in prevention planning efforts, 

and they should be recruited early in the process. 

Exhibit 5 summarizes guidelines for responsible 

reporting that were developed in collaboration by 

the CDC, National Institute of Mental Health, 

Office of the Surgeon General, Substance Abuse 

and Mental Health Services Administration 

(SAMHSA), American Foundation for Suicide 

Prevention, American Association of Suicidology, 

and the Annenberg Public Policy Center. At 

the very least, State and local media outlets 

should be provided with these guidelines before 

a community shares any detailed information 

about a suicide with reporters. Appendix E: Web 

Site Resources and Bibliography lists additional 

publications that provide guidance for enlisting 

the media in prevention efforts and for reporting 

on suicide. 

Role of Emergency Health 

Care Providers 

Whether in urban cities or in small towns 

in and around a reservation or village, the 

emergency department (ED) and after-hours 

health clinic play a unique role in health care 

delivery for AI/AN people in need of services. 

This need sometimes extends to those who have 

attempted suicide. The ED is their typical entry 

point into services and the place where many 

will have their first opportunity to have their 

suicidal behavior assessed. Such services can 

place a burden on a health care system already 

stretched. They also may be highly demanding 

of staff who may not be trained in suicide risk 

assessment and management. These statistics 
41

give some idea of the possible impact: There were 

33,300 completed suicides in the United States 

in 2006, the lastest data available at the time of 

this printing.96 In 2008, 1.1 million adults—0.5 

percent of all adult Americans—reported having 

attempted suicide in the past year, according to 

the first national scientific survey of its size on 

this public health problem. About 6 in 10 of 

those adults received medical attention for their 

suicide attempt.97

Attempt survivors are an extremely highrisk group for suicide. Consequently, ED and 

after-hours clinic personnel have a critical 

and necessary role in suicide prevention 

by encouraging attempt survivors to seek 

help. The training of emergency health care 

providers should be considered in developing 

any community-wide prevention initiative. 

General guidelines for ED care is available in 

the SAMHSA document, After an Attempt: A 

Guide for Medical Providers in the Emergency 

Department Taking Care of Suicide Attempt 

Exhibit 5. Media Guidelines for Safe Reporting on Suicide*

What To Avoid

• Avoid detailed descriptions of the suicide, including specifics.

• Avoid romanticizing someone who has died by suicide.

• Avoid featuring tributes by friends or relatives.

• Avoid first-person accounts from adolescents about their suicide attempts.

• Avoid glamorizing the suicide of a celebrity.

• Avoid oversimplifying the causes of suicides, murder-suicides, or suicide pacts, and avoid presenting

them as inexplicable or unavoidable.

• Avoid overstating the frequency of suicide.

• Avoid using the words “committed suicide,” or a “failed” or “successful” suicide attempt.

What To Do

• Always include a referral phone number and information about local crisis

intervention services.

• Emphasize recent treatment advances for depression and other mental illnesses.

• Include stories of people whose treatment was life-saving or who overcame despair without

attempting suicide.

• Interview a mental health professional who is knowledgeable about suicide and the role of treatment or

screening for mental disorders as a preventive strategy.

• Emphasize decreasing trends in national suicide rates over the past decade.

• Emphasize actions that communities can take to prevent suicides.

• Report on activities coordinated by a local or State suicide prevention coalition.

* From At-a-Glance: Safe Reporting on Suicide, available from the Suicide Prevention Resource Center at http://www.sprc.

org/library/at_a_glance.pdf.

Chapter 4: Responding to Suicide
42

Survivors. This document can be downloaded 

or ordered at http://www.samhsa.gov/shin. Or, 

please call SAMHSA’s Health Information 

Network at 1-877-SAMHSA-7 (1-877-726-

4727) (English and Español). (An order form 

is included in Appendix D: Decisionmaking 

Tools and Resources and on the last page of 

this document.) 

Role of Suicide Survivors and 

Suicide Attempt Survivors

Those who are most affected by suicide—including 

those who have attempted suicide—also have 

a role in preventing additional suicides. No one 

knows better the darkness that surrounds suicide 

than those who have walked in its shadow—or 

the light that comes from knowing that they 

might be able to help others avoid similar grief. 

The following are just a few examples of how 

suicide survivors are helping others to avoid the 

pain of a similar loss of a loved one.

Former Senator Gordon Smith of Oregon 

led the enactment of the Garrett Lee Smith 

Memorial Act in memory of his college-aged son 

who died by suicide. This Act provides significant 

funding for SAMHSA’s suicide prevention 

programs, and is a powerful example of how 

survivors have used their experiences to motivate 

others to action. 

SPAN USA, a division of the American 

Foundation for Suicide Prevention (AFSP), is 

dedicated to preventing suicide through public 

education and awareness, community action, 

and Federal, State, and local grassroots advocacy. 

SPAN USA was born out of a family’s grief 

over the suicide of their daughter and the need 

to “transform their grief into positive action to 

prevent future tragedies.”98 SPAN USA/AFSP 

also demonstrates the resiliency, power, and 

strength of families affected by suicide. 

In some communities, survivors have banded 

together to take turns going with the police when 

they inform a family of the death of a loved one 

by suicide so that they are available immediately 

to provide support. 

Suicide attempt survivors increasingly are asking 

that they be involved in suicide prevention 

efforts. No one can speak with greater 

understanding about outreach to and services 

most needed by vulnerable individuals than 

attempt survivors. Suicide attempt survivors also 

can be invaluable as mentors for those at risk. 

According to one participant at a SAMHSAsponsored meeting of suicide attempt survivors: 

There is a lot of fear and stigma 

associated with attempters, and people 

are uncomfortable dealing with us....That 

is the main reason for attempters to get 

involved and to get our stories out there to 

destigmatize the whole issue of people who 

have survived attempts, and to make the 

point that attempters are human beings who 

can be productive and can help others.99

IHS Emergency Response Model 

The IHS has designed an emergency response 

model for helping AI/AN communities when 

tragedy strikes. Under this model, communities 

work through the IHS to access support from 

the U.S. Public Health Service (USPHS). This 

support consists of teams of two or more USPHS 

mental health providers who offer emergency 

mental health and community outreach services. 

The teams work in 2-week rotations for up 

to 90 days of emergency response. The goal 

is to help the community lessen the impact 

of the immediate crisis and to stabilize its 

members so that they can begin to develop 

long-term solutions (i.e., planning, prevention, 

and implementation plans). The process for 

requesting and accessing such help follows.
43

1. The AI/AN community makes a request 

for help to the IHS area office through the 

IHS service unit, Tribal health program, or 

urban Indian clinic.

2. The IHS Area Director submits the request 

to IHS Headquarters (HQ) Division of 

Behavioral Health (DBH) director, who 

notifies the appropriate IHS HQ staff.

3. The IHS DBH and Emergency Services 

(ES) staff members respond to the affected 

community and conduct a rapid needs 

assessment. While on site, HQ staff 

members meet with the IHS area office, 

Tribal health program, urban Indian 

clinic, IHS Chief Executive Officer, the 

Tribal Council, and other Tribal programs 

as requested.

4. Depending on the rapid needs assessment 

and the expressed needs of the community, 

the IHS ES Director can forward the 

request for emergency assistance to the 

USPHS Office of Force Readiness and 

Deployment for action. 

Conclusion

A suicide within a community—whether that 

community is a school, a reservation or village, or 

a group of individuals in an urban area who share 

common bonds—can have a profound impact on 

the lives of those who are touched by the death. 

These individuals need the support, comfort, and 

understanding of others as they work through 

their grief. 

One danger of suicide is suicide contagion, 

for which suicide survivors and particularly 

adolescents and young adults appear at risk. 

Consequently, each community should strive 

to develop its postvention, or suicide response, 

plan before tragedy strikes. Such a plan is an 

essential part of any community’s efforts to 

prevent suicide by its youth and young adults. As 

with any suicide prevention effort, the broader 

the involvement of community members in 

helping to prevent suicide contagion, the more 

effective prevention will be. If suicides do occur, 

communities may want to request emergency 

support through IHS.

Chapter 4: Responding to Suicide

45

“To build something worthwhile that is lasting, 

whether as an individual or a community, one 

must have a working philosophy that allows one 

to dream and envision a better future.”

The Renaissance of American Indian Education: Capturing the Dream

Maenette Ah Nee-Benham and Wayne Stein (Eds.) (2003)

Chapter 5: Community Readiness

Introduction

Suicide prevention efforts often get their start 

as a response to a tragedy and from survivors of 

one or more suicides within their own family. 

The desire in their hearts is strong, their passions 

run deep, and their drive for action and results 

is understandable. However, as clear as the need 

for action may be to some, it doesn’t mean that 

everyone within a community agrees. Suicide 

prevention, by its very nature, implies changes 

in the status quo. And change, no matter 

how necessary, can be as uncomfortable and 

threatening to some as it is welcomed by others. 

Some community members may even oppose the 

degree of change involved, bringing community 

action to a halt.

Communities, just like their members, will 

differ in their ability to deal with all of the 

issues surrounding suicide and its prevention. 

The challenge in successful prevention planning 

is to understand a community’s readiness to 

take action and design prevention strategies 

accordingly. Strategies that are too ambitious are 

likely to fail because community members may 

not be ready or able to respond. Alternatively, 

efforts that are not ambitious enough will fail 

to take advantage of community commitment, 

resources, and momentum. 

This chapter focuses on a community’s readiness 

for change as it relates to suicide prevention. It 

describes readiness as a concept, the stages of 

readiness, and the potential impact of historical 

trauma on readiness. Implications of change for 

American Indian and Alaska Native (AI/AN) 

communities also are presented.

The “Readiness” Concept

Readiness is the degree to which a community 

is prepared to take action against an issue.100

The concept of “community readiness” evolved 

from research about individual readiness and the 

stages of change.101 According to this research, 

community readiness for change is related to 

the degree that its members become dissatisfied 

with the difference between the status quo and 

the desired goal or between what is happening in 

the present and what they value for the future.102

It is this discrepancy between what is and what 

is desired that becomes a community’s necessary 

motivational source for change. 

Beliefs and values play a large role in a 

community’s awareness of such discrepancies 

and their dissatisfaction with them. Many of 

the stories told by the Elders hold the values of 

what once was and the vision of what ought to 

be and can be for a Tribe or Village. Thus, when 

an AI/AN community views the behavior of 

its young and finds it at odds with the values of 

these stories, the seeds of change are germinated. 

When the discrepancy becomes large enough and 
46

change seems important enough, the community 

will begin to search for possible methods for 

change.103 The kind and degree of change possible 

depends on the community’s stage of readiness. 

Stages of Community Readinessf

The Tri-Ethnic Center for Prevention Research 

conducts research into community dynamics 

and the social, psychological, and cultural factors 

that contribute to substance use, violence, 

suicide, and other social problems. As part of 

its work, the center has helped a variety of rural 

AI communities develop prevention plans that 

address these problems within their communities. 

Center professionals soon realized that “initiating 

or improving prevention programs required 

learning first how to change a community’s 

readiness for prevention.”104

The Tri-Ethnic Center has identified nine 

developmental stages of community readiness 

(see Exhibit 6). The emphasis is on following 

a step-by-step process to move communities 

through the developmental stages of change and 

toward the implementation of comprehensive 

and effective prevention programs. Each stage 

of readiness is accompanied by an appropriate 

prevention goal and one or two examples of 

possible strategies.

Community vs. Community 

Member Readiness

Just as communities need to grow in readiness, 

so do their members. Not all members of a 

community will reach the same stage of readiness 

at the same time. Different community members 

may have different levels of motivation or be 

motivated by different issues. They also may 

demonstrate different levels of readiness to 

become involved at different points in time in 

the process. 

Some members have already started and have 

been waiting for the rest of the community to 

catch up. They may see themselves as the rightful 

“We now know that truly successful 

prevention efforts must be 

conceived from models that are 

community specific, culturally 

relevant, and consistent with the 

level of readiness of the community 

to implement an intervention.”

Community Readiness: A Promising 

Model for Community Healing

Pamela Jumper Thurman (2002)

f Much of what is reviewed in this section comes from the work 

of Pamela Jumper Thurman, Ph.D., Barbara Plested, Ph.D., and 

the staff of the Tri-Ethnic Center for Prevention and Research 

at Colorado State University. For additional information, readers 

are encouraged to visit http://www.triethniccenter.colostate.edu/

about.shtml, where they can review numerous articles, download 

the center’s Handbook for Successful Change, or contact the center for 

additional information or assistance.

Questions for Seeking the Wisdom of Elders

• How have community members traditionally come together to address important issues?

• What are the stories that can motivate members to address an issue as important as suicide prevention

and guide them in their efforts to join together in action?

• What are some examples of how the people have overcome difficult barriers in the past?
47

Chapter 5: Community Readiness

1. No awareness. Community members or

leaders do not generally recognize the issue

as a problem — “It’s just the way things

are.” Community climate may unknowingly

encourage the behavior although the

behavior may be expected of one group and

not of another (e.g., by gender, race, or age).

Prevention goal: Raise awareness of

suicide as an issue.

Possible strategy: Make one-on-one

visits with community leaders/members or

community groups to discuss suicide.

2. Denial or resistance. Some members

of the community recognize the issue

as a problem, but don’t see it as their

community’s problem or see any need for

community action — “It’s not our problem,”

“It’s just those people who do that,” or “We

can’t do anything about it.” Community

climate tends to be passive or guarded.

Prevention goal: Raise awareness that

suicide or the potential for suicide exist in

the community.

Possible strategies: Continue discussions

with community leaders/members;

write letters to the editor in local/Tribal

newspapers, develop informational flyers to

bring to community groups or to hand out at

places people gather.

3. Vague awareness. There is a general

feeling among some in the community that

there is a local problem and that something

ought to be done about it, but there is no

immediate motivation to do anything. There

may be stories or anecdotes about the

problem, but ideas about why the problem

occurs and who has the problem tend to be

stereotyped, vague, or both. No identifiable

leadership exists or leadership lacks energy

or motivation for dealing with this problem.

Community climate does not serve to

motivate leaders.

Prevention goal: Raise awareness that

the community can do something about

suicide prevention.

Possible strategies: Hold a suicide Talking

Circle to discuss who is most vulnerable and

why, conduct informal surveys, post/hand

out flyers at local events or Pow Wows.

4. Preplanning. There is clear recognition

on the part of at least some that there is a

local problem and that something should be

done about it. There are identifiable leaders,

and there may even be a committee, but

efforts are not focused or detailed. There is

discussion but no real planning of actions to

address the problem. Community climate is

beginning to acknowledge the necessity of

dealing with the problem.

Prevention goal: Continue to raise

awareness by presenting concrete ideas

about prevention opportunities.

Possible strategy: Hold a community

meeting to explore possible solutions

or have a GONA (Gathering of Native

Americans) to bring the community together

and lay the foundation for establishing an

action plan.

(A GONA manual can be downloaded from

the Substance Abuse and Mental Health

Services Administration (SAMHSA) at

http://preventiontraining.samhsa.gov/Cti05/

Cti05ttl.htm.)

5. Preparation. Prevention planning is

underway and is focused on practical

details. There is general information about

local problems and about the pros and

cons of prevention activities, actions, or

policies, but it may not be based on formally

collected data. Leadership is active and

Exhibit 6. Tri-Ethnic Center for Prevention Research’s

Stages of Community Readiness*
48

energetic. Decisions are being made

about what will be done and who will do it.

Resources (e.g., people, money, time, and

space) are being actively sought or have

been committed. Community climate offers

at least modest support of efforts.

Prevention goal: Gather existing

information with which to plan strategies.

Possible strategies: Conduct communityor school-based surveys or interviews about

risk and protective factors; ask community

leaders or Elders to become involved and

speak on behalf of these efforts.

6. Initiation. Enough information is available

to justify efforts (i.e., activities, actions, or

policies). There may be great enthusiasm

among the leaders because limitations

and problems have not been experienced

yet. Community climate can vary, but there

usually is no active resistance, (except,

possibly, from a small group of extremists),

and there is often a modest involvement of

community members in the efforts.

Prevention goal: Provide information that

is specific to the target audience.

Possible strategy: Begin basic evaluation

of prevention strategies.

7. Stabilization. One or two programs

or activities are running, supported by

community leaders or administrators.

Programs, activities, or policies are viewed

as stable. Staff are usually trained and

experienced. There is little perceived need

for change or expansion. Limitations may be

known, but there is no in-depth evaluation

of effectiveness, nor is there a sense that

any recognized limitations suggest an

immediate need for change. There may or

may not be some form of routine tracking

of prevalence. Community climate generally

supports what is occurring.

Prevention goal: Stabilize efforts

and programs.

Possible strategies: Conduct training

for community members; hold events to

recognize local supporters and maintain

community support for prevention.

8. Confirmation/expansion. There are

standard efforts in place and community

members feel comfortable in using the

services provided. Community leaders and

other decisionmakers support expanding or

improving prevention efforts to reach more

people at risk or different demographic

groups. Resources for new efforts are being

sought or committed. Data are regularly

obtained on the extent of local problems and

efforts are made to assess risk factors and

causes of the problems. Due to increased

knowledge and desire for improved programs,

community climate may challenge specific

efforts, but is fundamentally supportive.

Prevention goal: Expand and

enhance services.

Possible strategy: Use evaluation data to

support renewed and reinvigorated efforts.

9. High level of community ownership.

Community members have a detailed and

sophisticated knowledge of prevalence, risk

factors, and causes of the problem. Some

efforts may be aimed at general populations,

while others are targeted at specific risk

factors and/or high-risk groups. Highly trained

staff are running programs or activities,

leaders are supportive, and community

involvement is high. Effective evaluation is

used to test and modify programs, policies,

or activities. Although community climate

is fundamentally supportive, community

members ideally should continue to hold

programs accountable.

Prevention goal: Maintain momentum and

continue growth.

Possible strategies: Continue progress

reports for the benefit of community leaders

and program funders; diversify funding

sources to ensure sustainability.

* From Edwards, R. W., Jumper-Thurman, P., Plested, B. A., Oetting, E. R., & Swanson, L. (2000). Community readiness: 

Research to practice. Journal of Community Psychology, 28(3), 291–307.

(Continued)
49

Chapter 5: Community Readiness

leaders of any new program. They may believe 

that they should receive any grant funding 

coming into the community in recognition of 

their past efforts and involvement or so they can 

continue their good work. Some may still be in 

pain from a recent suicide and find it too difficult 

to talk about it, while others who have lost a 

loved one may feel driven to take immediate 

action. Others may never fully embrace 

community efforts.

Why someone might want to become involved in 

suicide prevention efforts and to what level and 

in what capacity will vary greatly. Regardless of 

their readiness stage as individuals, each person 

within a community may need to be honored and 

validated for the degree to which they feel ready to 

participate. The goal of prevention efforts should 

be to engage as many people as possible and as 

early as possible so that all who wish to speak can 

do so and all potential solutions can be considered. 

Historical Trauma and 

Community Readiness

Eduardo Duran, director of health and wellness 

for the United Auburn Indian Community 

of Northern California, provides community 

interventions and consultations around the issue 

of historical trauma. He contends that an AI/AN 

community’s seeming inability to address current 

issues of violence, including suicide, sometimes 

can be traced to the internalization of the violence 

perpetrated on Native people for generations.

In his book, Healing the Soul Wound: Counseling 

with American Indians and Other Native Peoples, 

Duran describes how important it is for a 

community to engage in a healing process that 

reflects its own history of trauma rather than 

generic Native American trauma. He writes, 

Preparation for community healing is critical. 

It is important that the community’s specific 

traumas be delineated first in order for the 

intervention to be relevant. It is useful to 

speak in general of the historical trauma and 

no one would fault the attempt at healing 

with this approach. However, I have found 

that communities, like individuals, have their 

own set of traumas that result in particular 

symptoms that need to be dealt with 

very specifically.105

It is through this process of healing that Duran 

feels community members begin to release the 

burden of shame and guilt and to recognize the 

historical path that has led them to the present 

day. The emphasis is on the process of healing 

and restoring balance. Identification of historical 

trauma is viewed as the beginning rather than the 

end of a journey. 

The Aboriginal Healing Foundation (AHF) has 

identified four phases to community healing that 

provide some insight into this journey. AHF is 

a Canadian initiative developed to address the 

impact of residential schools on First Nations 

communities. Its principle focus is on achieving 

community well-being by addressing personal 

and intergenerational trauma, which it believes 

will help end cycles of abuse and violence and 

“We have already paid the price. 

It’s time to accept the many 

blessings that the Creator has in 

store for us. We must honor our 

people who sacrificed everything 

through honoring ourselves and 

healing ourselves. By healing 

ourselves, we will also heal the 

wounds of our ancestors and 

the unborn generations.”

 — Healing the American Indian Soul 

Wound: International Handbook of 

Multigenerational Legacies of Trauma.

Eduardo Duran, et al. (1998)
50

build strength and resiliency within the survivors 

and the community. As shown in Exhibit 7, 

the healing process moves a community from 

personal healing to systems transformation and 

from problems to solutions.

Implications of Prevention for 

AI/AN Communities

The preceding sections of this chapter have 

dealt with a community’s readiness to change 

and how it may prepare itself for the changes 

that prevention implies. This section briefly 

addresses some additional implications as to 

how change relates to suicide prevention by 

AI/AN communities. 

Native peoples have a long history of being told 

that they should change. Such direction often 

has been unwelcome because the assumption 

has been that others outside of the Tribe or 

Village know what is best for its members. 

As a consequence, a call for “change” stirs up 

differing emotions and reactions. Although some 

community members may welcome programs 

to reduce suicide or its risks, others may resent 

the implication that their current efforts are not 

good enough or even wrong. Even those who 

may be advocating for change may not agree on 

what changes need to happen, how soon, and 

who needs to be involved in the change. Talking 

about change and the change process early in any 

prevention effort, and ensuring that all voices are 

heard, can be essential in moving the planning 

process along. People are far less resistant to 

change when they help initiate the change.

Another potential implication of suicide 

prevention is that the Tribe or Village may feel 

under attack. Historically, AI/ANs have tended 

to be described in terms of weakness, pathology, 

and mortality rather than as being adaptive, 

innovative, resilient, and strong. Native people 

also have been romanticized, creating an equally 

unrealistic picture of them and their culture. 

Exhibit 7. The Aboriginal Healing Foundation’s Four Phases 

of Community Healing* 

The four phases of Community Healing include the following.

Phase 1: The Journey Begins

Gathering of a core group of people, who begin to address their own healing needs

Phase 2: Gathering Momentum

Increasing of healing activity, with recognition of root causes of addiction, abuse, and violence though

community–wide awareness workshops

Phase 3: Hitting the Wall

Building healing capacity by providing training and employment, with a focus on community development

Phase 4: From Healing to Transformation

Shifting from fixing problems to transforming systems

* From Lane, P., Bopp, M., Bopp, J., & Norris, J. (2002). Mapping the Healing Journey: The Final Report of a National Research 

Project on Healing in Canadian Aboriginal Communities. (Four Directions International, unpublished research commissioned 

by the Aboriginal Healing Foundation and the Aboriginal Corrections Policy Unit. Ottawa: Solicitor General)
51

Chapter 5: Community Readiness

To some extent, these characterizations persist 

today and extend to the issue of suicide. If the 

suicide rate is so high in AI/AN communities, 

then what does that say about being a Native? 

Does this rate imply that just being AI/AN is 

an independent risk factor for suicidal behavior? 

Elders involved in their community’s healing 

process have described this negative way of 

thinking as a “spiritual injury, soul sickness, soul 

wounding, and ancestral hurt.”106 

Finally, there is the issue of change itself. Some 

Tribal and Village members might believe that 

the biggest challenge facing their community 

is the rapid changes taking place in the larger 

society that make it increasingly difficult for 

AI/AN youth to maintain their Native cultural 

identity. Some researchers argue that this rapid 

change is a primary reason for the high suicide 

rates in some Native communities.107, 108

Successful prevention within a community 

may mean a return to traditional ways or the 

integration of traditional ways into science-based 

prevention programs. As an example, mental 

health promotion programs work to strengthen 

a child’s resilience, which is the child’s ability to 

cope with the challenges that life can present. 

The concept of resilience is not new to AI/AN 

people. Native youth have long been taught to 

stand tall and strong, to try their best, and to 

never give up. Combining science and tradition 

in one prevention program may draw upon the 

best of both approaches.

Conclusion

Some communities may be ready for prevention 

planning, while others may be ready to expand 

successful efforts that are underway. Still other 

communities may need to go through a healing 

process that first restores their sense of balance, 

worth, and empowerment before they can 

confront an issue as traumatic as suicide. Which 

prevention strategies a community is willing or 

able to implement will be based on its stage of 

readiness for change. Furthermore, the process 

used to develop a community’s readiness will be 

important in developing its long-term capacity to 

carry out a comprehensive and sustainable suicide 

prevention plan. Consensus building among all 

members of a community may take longer up 

front, but the result can be stronger, more effective 

prevention efforts. 

53

Chapter 6: Community Action

Introduction

Although suicide is an individual act, we 

cannot understand or prevent such acts simply 

by considering the behavior of the individual. 

Just as with another living, interdependent 

community, there can be no true understanding 

of the behavior of a bee without considering its 

relationship to the hive. Similarly, there can be no 

true understanding of suicide and its prevention 

without considering how individuals fit within 

their communities. 

This chapter looks at the role of a community in 

prevention, both in theory and in practice. It first 

describes two general ways that a community 

can think about prevention: the public health 

model and the ecological model. Although 

presented separately, these models are related. 

The ecological model is simply an interpretation 

of the public health model that best fits the way 

Native communities historically have thought 

about their relationship to their members and 

their environment. 

As described, both the public health and the 

ecological models reflect the same key principles 

of prevention. First, prevention goes beyond a 

focus on the individual to include all members 

of a community. Second, prevention is proactive, 

with health promotion as an essential element 

of prevention. Third, prevention is collaborative. 

The broader the base of community involvement, 

the greater the chances that prevention efforts 

will succeed. And, finally, everyone within a 

community has a stake in and responsibility for 

the health of its individual members. 

The second half of this chapter describes 

tools that a community might use to develop 

a comprehensive suicide prevention plan. 

The Substance Abuse and Mental Health 

Services Administration (SAMHSA) Strategic 

Prevention Framework (SPF), which is based on 

the public health model, provides a set of steps 

that communities can use to assess their need 

for action, develop strategies and resources for 

responding to identified needs, and evaluate the 

effectiveness of their response. The American 

Indian Community Suicide Prevention 

Assessment Tool (see Appendix D) also may 

help communities assess suicide risks and 

possible responses. This chapter ends with a few 

suggestions about how communities can increase 

the effectiveness of their efforts by engaging all 

stakeholders in prevention.

The Public Health Model

The U.S. Surgeon General’s Call To Action To 

Prevent Suicide calls for a public health approach 

“. . . [W]hile we recognize the debilitating impacts of 

historical trauma and other environmental causes that 

represent limitations and promote dependency among 

our people, we must go well beyond this discussion and 

critically think about ways to demonstrate leadership 

as well as our individual and collective responsibility to 

create safe, life-enhancing Tribal communities.”

 — Hayes A. Lewis, Zuni

Testimony Before the U.S. Senate Committee on Indian Affairs,

February 26, 2009
54

to suicide. As suicide is considered a public 

health problem, with many complex contributing 

factors, this approach is very appropriate. In 

addition, the model’s emphasis on promoting 

mental health as a way to prevent mental illness 

holds great promise for American Indian and 

Alaska Native (AI/AN) communities and lends 

itself to cultural adaptation. 

The easiest way to understand the public health 

approach is to compare the public health model 

with the traditional medical model. The medical 

model focuses primarily on reducing illnesses 

by treating individuals who already have been 

diagnosed with a specific disorder. The public 

health model, on the other hand, is concerned 

with the health of an entire population. It 

goes beyond the diagnosis and treatment of 

individuals to include health promotion and 

disease prevention. It also includes evaluations 

of the health of the population at large, the 

effectiveness of available services, access to 

services, and how well these services reduce 

illnesses. Thus, while the medical model is 

concerned with restoring the health of an 

individual, the public health model is concerned 

with establishing and maintaining the health 

of a community. The most basic premise of the 

public health model is that caring for the health 

of the community protects the individual while 

caring for the health of an individual protects 

the community, with an overall benefit to society 

at large. Mandatory childhood immunizations, 

which have all but wiped out several oncecommon and deadly diseases, are examples of a 

successful public health approach.

The medical model also emphasizes the physical 

or biological causes of an illness, such as a virus 

or a person’s genetic vulnerability to disease. 

The public health model views health within 

a larger context. Health also is affected by the 

physical, psychological, cultural, and social 

environments in which people live, work, and 

go to school. This is a very holistic approach 

to health that considers many of the factors 

within a community that contribute to or 

reduce its health risks. When applied to suicide, 

the medical model considers the history and 

health conditions that could lead to suicidal 

behavior in a single individual. The public health 

model focuses, instead, on identifying and 

understanding patterns of suicide and suicidal 

behavior throughout a community. 

Similar to the medical model, there is a protocol, 

or process, to follow in applying the public health 

model. The public health model is based on an 

organized set of steps for identifying threats to 

a community’s overall health and in developing 

a comprehensive and effective response. Steps in 

the public health model are listed below: 

1. Define the problem (i.e., identify a 

community’s needs, resources, and 

readiness to address the problem);

2. Assess risk and protective factors;

3. Develop and test prevention strategies 

(i.e., which strategies works best for a 

community, given its culture and other 

specific circumstances);

4. Implement effective prevention 

strategies; and

5. Monitor and evaluate.

A later section on SAMHSA’s SPF will provide 

more details on how a community can apply 

these steps to suicide prevention efforts.

According to the public health model, all 

members of a community should be involved 

in promoting the mental health of individual 

members and preventing mental illnesses. 

This model represents a dramatically different 

approach to suicide prevention than many 

communities first consider taking. A common 

misperception about suicide prevention is that it 

is the sole or primary responsibility of the formal 

mental health system, which focuses on treating 

individuals who are experiencing a mental or 

substance abuse crisis. The public health model 

moves the prevention focus from the clinic into 

the community. This model recognizes that 
55

all members of a community share risk and 

protective factors and also accepts that an entire 

community can be affected by the problems 

experienced by any one individual. Consider, for 

example, a young man with untreated depression. 

If his condition causes him to drop out of 

school, miss work, or drink alcohol or use drugs, 

then his family, friends, school or workplace, 

and community also may suffer consequences. 

Perhaps most important, the public health model 

encourages a community to pursue the numerous 

opportunities it has to prevent mental health 

problems in young people before they begin. 

Under the public health model, all organizations 

within a community would collaborate in 

suicide prevention efforts that range from 

mental health promotion to risk reduction. For 

example, young people who are the victims or 

the perpetrators of violence are more prone than 

others to mental health problems. Families, 

schools, recreation centers, and the child welfare 

and juvenile justice systems all might work to 

teach and reinforce anger management skills in 

adolescents (promotion) and to identify and refer 

to counseling those young people who may have 

experienced violence (prevention). 

Similarly, under the public health model, all 

organizations within a community would help 

provide services and supports to anyone who 

experienced a mental health problem, including 

substance abuse. It would not be enough for a 

young person simply to be referred to counseling 

for suicidal behavior. Under this model, a 

community also would ensure that the person 

had transportation to counseling services and 

would not be stigmatized at school or in the 

workplace for seeking help. Family members also 

might receive guidance in how to support their 

child through a difficult time. 

A very powerful example of such a 

comprehensive and community-based public 

health approach to prevention can be found 

in the Western Athabaskan Tribal Nation (a 

pseudonym used to protect the identity of this 

Tribe) suicide prevention initiative. In the late 

1980s, this Tribe’s rate of suicide and suicidal 

attempts was 15 times the national average. 

This rate prompted the Tribal council, the 

community, and the Indian Health Service 

(IHS) to work together to establish and expand 

a comprehensive suicide prevention program. 

As part of this effort, the Tribe realized that it 

needed to address the community’s underlying 

issues of alcoholism, domestic violence, child 

abuse, and unemployment. Prevention programs 

aimed at the entire community as well as 

individuals at various levels of risk were selected. 

All key constituents—Tribal leadership, health 

care providers, parents, Elders, and youth—were 

involved in planning and implementing the 

overall suicide prevention plan.

According to the evaluation of this program 

published in the American Journal of Public Health, 

the Tribe experienced a steady reduction in suicidal 

gestures and attempts throughout the course of 

the program.109 Self-destructive acts, including 

suicide completions, among all age groups declined 

from 36 per year for 1988–1989 to 10 per year 

for 2000–2001. Among youth ages 11 to 18, the 

number of suicide attempts dropped from 14.5 per 

year for 1988–1989 to 1.5 per year for 2000–2001. 

Public health lessons learned by the community 

in reducing suicidal behavior follow. 

• Suicide prevention programs should not 

focus on a limited range of self-destructive 

behaviors; rather, programs must 

emphasize the root conditions and an array 

of social, psychological, and developmental 

issues. Community involvement from 

the beginning is critical in developing 

strategies with which to address issues 

identified in a culturally, environmentally, 

and clinically appropriate manner.

• Flexibility in program development and 

implementation is essential. Program 

development should be based on 

continuous evaluation and feedback from 

community and program staff.110

Chapter 6: Community Action
56

The White Mountain Apache Tribe, working 

together with the Johns Hopkins University 

Center for American Indian Health, has 

developed an important community-based 

suicide prevention effort. The White Mountain 

Apache Tribal Council enacted a resolution 

to mandate tribal members and community 

providers to report all suicidal behavior (ideation, 

attempts, and deaths) to a central data registry. 

For those who have made suicide attempts or 

were reported to be thinking about suicide, 

a community outreach visit by Apache paraprofessionals supervised by a clinical team from 

the Johns Hopkins Center for American Indian 

Health is attempted. SAMHSA is currently 

supporting an evaluation of the effectiveness 

of a specialized Emergency Departmentlinked intervention and in home coping skills 

curriculum for youth who have attempted 

suicide, as identified by the White Mountain 

Apache Tribe surveillance and community 

outreach system.

Clearly, a public health approach can prevent 

suicidal behaviors. But, as demonstrated by these 

examples, effective prevention requires the whole 

community coming together to address and 

overcome barriers and to follow through with a 

sustained effort.

The Ecological Model

As noted in the introduction to this chapter, 

the ecological model is one way to interpret 

the public health model. The ecological model 

has its origins in the observations of nature 

and the interrelationships among all living 

things and their environments. It acknowledges 

the cyclical nature of life and the necessity 

for interdependent relationships in creating a 

community. This relational worldview is a vital 

aspect to community-wide prevention efforts 

by AI/ANs. The ecological model is not new 

to AI/AN communities. It might even be said 

that AI/ANs and other aboriginal peoples were 

the first to truly live within and by this model, 

making it not so much an abstract theory as a 

way of life and of being in the universe. 

In the ecological model, community members 

are seen not as separate individuals but as parts 

of a whole (see Exhibit 8). This model places the 

individual inside the family, which resides within 

the community and its culture, which, in turn, 

is part of society at large. Each level influences 

and is influenced by the other levels. Ideally, 

each level strengthens and nurtures the others. 

As in the public health model, the health of the 

individual is seen as a reflection of the physical, 

social, cultural, spiritual, and environmental status 

of the surrounding levels. All of these factors 

are interrelated in how they affect the health of 

the family, community, and society as well as the 

health of the individual. 

The focus of the ecological model is on the 

interwoven relationships between individuals 

and their communities. While individuals are 

responsible for the choices they make that 

reduce their risk of illnesses and promote health, 

their choices largely are determined by their 

social environment, such as their community’s 

existing norms, values, and practices. As an 

example, alcohol and substance use—both of 

which are risk factors for suicide—are lower 

among youth who believe that their parents (i.e., 

Exhibit 8. The Ecological Model
57

the family as “community”) are more likely to 

disapprove of such behavior.111 Thus, mentally 

healthy individuals are created through families, 

communities, and a society that encourages 

mentally healthy behaviors. 

As this model implies, prevention involves a 

systemic, holistic approach to addressing risk and 

protective factors for mental and other illnesses 

at all of these levels. In addition, successful 

prevention efforts become part of each level and 

gain from everyone’s energy and involvement. To 

illustrate, consider the experience of the Shuswap 

Tribe of Alkali Lake, in British Columbia, 

Canada, in reducing and preventing alcoholism. 

A very simplified case history and illustrations 

demonstrate how the ecological model applies 

both to the increasing and decreasing use of 

alcohol and its consequences.g

In the 1940s, the Shuswap Tribe was introduced 

to alcohol by non-Natives. At the same time, the 

Chapter 6: Community Action

g For more information on the Tribal-led transformation of the 

Sushwap Indian Reserve at Alkali Lake and other real-life examples 

of community self-help and healing, visit the Squamish Nation, 

Four Worlds International, and the Chief Dan George Memorial 

Foundation Web site at http://www.4worlds.org/4w/ssr/Partiv.htm. 

We are grateful that we can share this story with others who may 

learn from it, and we thank the Shuswap Tribe for its courage in 

making this story known.

Society—Government mandates practices that 

undermine traditional Tribal culture and values.

Community—Alkali Lake Shuswap Tribe 

becomes increasingly vulnerable to the 

culture of alcohol. Excessive use of alcohol 

becomes more accepted and widespread.

Family/Peers—Poverty, illness, violence, and 

abuse among Tribal members becomes common.

Individuals—Alcoholism, 

hopelessness, and suicide result.

Community Decline

government was removing a whole generation of 

Tribal children from their families and sending 

them to boarding schools. While the schools 

provided a general education, school-based efforts 

to erase Tribal language and practices created a 

form of racial/cultural self-hatred in the children. 

The children also were exposed to widespread 

physical and sexual abuse. They returned to their 

communities damaged in mind and spirit. 

These children had not been parented themselves; 

nor had they been able to internalize traditional 

values and practices of healthy family and 

community life. Because of these losses, this 

generation of Alkali Lake people was much 

more vulnerable to the culture of alcohol. Under 

the combined weight of growing alcoholism 

Community Recovery

Society—Coalitions form to support Tribal 

wellness (e.g. Tribe and RCMP); society shares

in the benefits of improved Tribal status.

Community—Alkali Lake Shuswap Tribe 

reinstates sobriety as a traditional social 

norm and adopts a holistic approach to 

improving overall health and well-being.

Family/Peers—Prevention advocates/

role models emerge. Excessive use of 

alcohol becomes less accepted while the 

stigma of seeking treatment is removed.

Individuals—Sobriety and hopefulness 

become motivation to lead community change.
58

and a legacy of historical trauma, a once 

hardworking Tribe found itself and its children 

being destroyed by the poverty, hunger, sickness, 

violence, sexual abuse, and suicide that had 

become common on the reservation. By the early 

1970s, an estimated 100 percent of all adults and 

many young people drank excessively. 

Change came in the form of community healing 

and community action, led by the first few Tribal 

members to refuse alcohol. In 1972, one of these 

individuals was elected chief. Together, he and a 

core group of supporters banned alcohol on the 

reservation. They joined with the Royal Canadian 

Mounted Police (RCMP) to identify bootleggers. 

Tribal members who committed alcohol-related 

crimes were given a choice: treatment or jail. 

Non-native community members, including 

clergy, who opposed these reforms were asked to 

leave. As the use of alcohol became less accepted 

within the Tribe, more Tribal members who 

experienced alcoholism began to seek treatment.

Tribal leaders recognized that their growing 

success in reducing alcoholism would be 

strengthened by linking the community’s 

continuing healing process to social and 

economic progress. They achieved this critical 

linkage through these strategies: 

• Making a deliberate effort to revive 

traditional Native forms of spirituality 

and healing; 

• Creating a variety of economic enterprises 

to provide employment for the growing 

numbers of individuals who did not drink 

alcohol (By 1985, Alkali Lake had achieved 

full employment—everyone who wanted a 

job had a job.); 

• Introducing a wide variety of training 

opportunities that were connected to 

personal and community wellness and the 

continued pursuit of social and economic 

improvements; and

• Building community unity. Whenever 

Tribal members left the community for 

treatment, their children were taken care 

of, their house was cleaned up and repaired, 

and there was a job waiting for them when 

they got back.

In short, the approach taken by the Shuswap 

Tribe to reduce and prevent alcoholism and 

its consequences demonstrates the ecological/

public health model in action. Prevention efforts 

were both systemic and holistic. They went 

beyond a focus on the individual to include 

families, the Tribal community, and the larger 

surrounding society—which also had a stake in 

the outcome. The Tribal government, the justice 

system, businesses, and other local organizations 

all collaborated in both reducing risk factors 

for alcoholism and in promoting personal and 

community wellness. The success of this approach 

to prevention is apparent. By 1979—just a 

few years after prevention efforts began—only 

2 percent of Alkali Lake Tribal members were 

still drinking alcohol.

The Transactional-Ecological 

Framework 

The transactional-ecological framework is 

another way of looking at how a public health 

approach can be applied to suicide prevention. 

While similar to the ecological model, this 

framework places greater emphasis on two 

key elements within a community. Within 

this structure: 

• Disorders (e.g., suicidal behavior and/or 

substance abuse) result from deviations 

from normal developmental pathways and 

processes; and 

• The roots of an individual’s disorder can be 

and often are outside of the individual.
59

From the perspective of this framework, the 

central objective of prevention programs is to 

create a community environment that helps 

young people avoid situations and behaviors 

that will start them along a pathway leading 

to negative outcomes. Prevention efforts will 

not focus on individuals or groups at risk or 

on a single behavioral disorder because such 

efforts can be seen as “victim blaming,” in 

which the individual alone is responsible for 

his or her difficulties. Instead, a community 

would focus its efforts on the elimination of 

broad-based environmental conditions that can 

lead its members to engage in any number of 

undesirable, interrelated outcomes (e.g., school 

failure and substance abuse) and not just on one 

specific outcome (e.g., suicide).112 The preceding 

example of the Western Athabaskan Tribal 

Nation demonstrates the success of this approach 

for Native communities. 

The points of intervention—or the opportunities 

to return individuals to normal pathways—can 

involve the reduction of risk factors, the 

improvement of protective factors, or both. 

However, as noted earlier, increasing the number 

of protective factors has proved more effective 

in reducing suicide attempts than reducing the 

quantity of risk factors.113

Action-Planning Tools

The public health model is an evidence-based 

theory for picturing prevention. The following 

sections describe two tools that are available 

to communities in translating this theory 

into action. 

SAMHSA’s Strategic Prevention 

Framework 

The SPF has been shown to promote youth 

development, reduce risk-taking behaviors, 

build assets and resilience, and prevent problem 

behaviors across the lifespan. It is based on six 

key principles that are grounded in the public 

health approach. Because these principles are the 

foundation of the SPF process, they are described 

briefly first. 

Guiding Principles of the SPF

1. Prevention is an ordered set of steps along 

a continuum to promote individual, family, 

and community health, prevent mental and 

behavioral disorders, support resilience and 

recovery, and prevent relapse. 

Prevention activities range from deterring 

diseases and behaviors that contribute to them 

to delaying the onset of disease and reducing the 

severity of their symptoms and consequences. 

This principle acknowledges the importance of 

a spectrum of interventions that extend along 

the mental health continuum and involve all of 

the individuals and environments that affect a 

person’s mental health and well-being. 

2. Prevention is prevention is prevention. 

It does not matter if the focus of prevention is 

on reducing the effects of cancer, cardiovascular 

disease, diabetes, substance abuse, or mental 

illness—the common components of effective 

prevention are the same. In addition, prevention 

of any one disorder frequently helps to reduce 

another. As noted in an earlier discussion of 

the U.S. Air Force suicide prevention program, 

prevention of suicide also helped to prevent 

homicide and domestic violence.

3. Common risks and protective factors exist 

for many substance abuse and mental health 

problems. Good prevention focuses on the 

common risk factors that can be altered. 

Family conflict, low school readiness, and poor 

social skills all increase the risk for conduct 

disorders and depression in young people. These 

disorders, in turn, increase a young person’s risk 

Chapter 6: Community Action
60

for substance abuse, delinquency, violence, and 

other factors that may contribute to suicide. 

Alternatively, protective factors such as strong 

family bonds, coping skills, opportunities for 

school success, and involvement in community 

activities can foster resilience and lessen 

the influence of these risk factors. Effective 

prevention works to reduce common risk factors 

and enhance common protective factors. 

4. Resilience is built by developing assets 

in individuals, families, and communities 

through evidence-based health promotion and 

prevention strategies. 

Resilience is a person’s ability to cope with the 

frequent challenges that life presents. Youth who 

have positive relationships with caring adults, 

good schools, and safe communities develop 

optimism, good problem-solving skills, and other 

assets that help them deal with adversity and go 

through life with a sense of mastery, competence, 

and hope. 

5. Systems of prevention services work better 

than service silos. 

Working together, researchers and communities 

have produced a number of highly effective 

prevention strategies and programs. Implementing 

these strategies within a broader system of services 

increases the likelihood of successful, sustained 

prevention activities. Collaborative partnerships 

enable communities to leverage scarce resources, 

build greater capacity, and make prevention 

everybody’s business. 

6. Baseline data, common assessment tools, 

and outcomes shared across service systems 

can promote accountability and effectiveness of 

prevention efforts. 

A data-driven strategic approach that is adopted 

across service systems at the Federal, State, 

Tribal, community, and service delivery levels 

increases opportunities for collaboration and 

positive outcomes.

The SPF Process 

The SPF, just like the public health model, 

uses a five-step process to organize prevention 

efforts. As shown in Exhibit 9, the SPF process 

is circular rather than linear. It is designed to be a 

process of discovery rather than simply a process. 

Communities will experience a certain amount 

of back-and-forth between steps as new ideas 

or new threats to health emerge, goals are met, 

and priorities change. At the heart of the entire 

process are cultural competence and sustainability 

of prevention activities. 

Applying the SPF Process

The following section describes steps in the SPF 

process as they apply to suicide prevention by 

AI/AN communities. Additional information 

about the SPF is available at http://prevention.

samhsa.gov/about/spf.aspx.

1. Assess the problem.

In this step, a Tribal community will develop a 

profile of the problem, its readiness to address 

the problem, and its resource needs. Common 

actions are to:

Exhibit 9. SAMHSA’s SPF Process
61

• Collect epidemiological data; 

• Assess risk and protective factors, such 

as the magnitude of a substance abuse 

problem in or near the Native community;

• Assess Tribal/Village community assets 

and resources;

• Identify gaps in Federal and Tribal/Village 

services and capacity;

• Assess community readiness;

• Identify priorities; and

• Specify baseline data for the Tribe/Village 

against which process and outcomes can 

be measured.

2. Build the capacity to address these needs.

In this step, an AI/AN community will mobilize 

and build its capacity to address identified 

problems and gaps in service delivery. Capacity 

building activities may include:

• Convening Tribal/Village leaders and other 

community stakeholders;

• Building coalitions of Federal, State, local 

and Tribal/Village service providers; and

• Engaging Tribal/Village leaders and other 

community stakeholders to help sustain 

the activities.

3. Develop a strategic plan for addressing needs.

In this step, a community will develop a plan that 

will guide it in organizing and implementing 

the strategies that it believes will help it achieve 

its prevention goals. This plan also will help a 

community focus its resources on the group 

at greatest risk (e.g., adolescent males) and on 

issues of highest priority (e.g., mental health 

care services). The community can adjust its plan 

as new information becomes available or as it 

achieves its goals and objectives. 

4. Implement evidence-based strategies 

with fidelity.

In this step, the community will select and 

implement programs that have proven effective 

in achieving the desired results. “Fidelity” 

in carrying out a strategy will be essential if 

a community is to achieve the same results. 

Fidelity refers to the degree to which a program 

or strategy is implemented as designed. For 

example, there is a loss of fidelity if a counseling 

program is supposed to have 10 sessions but 

funding only is provided for 7 sessions. Loss of 

fidelity can result in a loss of effectiveness. To 

maintain fidelity and outcomes, key elements of 

a strategy should remain intact even when minor 

adaptations are made to meet cultural needs. 

Communities should consult with the program 

developer in adapting programs, if possible. 

Often, a program developer will help a 

community identify the key elements of the 

program that are necessary to achieve the desired 

outcomes and to adapt other elements to ensure 

cultural effectiveness. 

5. Monitor and evaluate.

This step involves monitoring and evaluating the 

effectiveness of the prevention activities. In this 

way, a community can sustain those activities that 

are working or modify or replace those that are 

Questions for Seeking the Wisdom of Elders

• How can the community use traditional ways to become closer and work for the benefit of all?

• How can people who have not dealt well with each other for a while come together again?

• What are some ways that the community can strengthen its balance and harmony?

Chapter 6: Community Action
62

not. Although evaluation is presented here as the 

last step, it actually is a continuous process that 

should begin with the first step. Evaluation lets a 

community and funding agencies (if any) know 

how effectively the community has defined, and 

is responding to, suicide. 

The SPF and Cultural Competence

Cultural competence is at the heart of the 

SPF process. A culturally competent program 

demonstrates sensitivity to and understanding 

of cultural differences in program design, 

implementation, and evaluation. Such programs:

• Acknowledge culture as a predominant 

force in shaping behaviors, values, 

and institutions;

• Acknowledge and accept that cultural 

differences exist and have an impact on 

service delivery;

• Believe that diversity within cultures is as 

important as diversity between cultures;

• Respect the unique, culturally defined 

needs of various populations;

• Recognize that concepts such as 

family and community are different for 

various cultures and even for subgroups 

within cultures;

• Understand that people from different 

racial and ethnic groups and other cultural 

subgroups are usually best served by 

persons who are a part of or in tune with 

their culture; and 

• Recognize that taking the best of both 

worlds enhances the capacity of all.

The SPF and Sustainability

Like cultural competence, sustainability is 

an essential element of each step of the SPF. 

Sustainability refers to the process through which 

a prevention system becomes a community norm. 

Sustainability is vital to ensuring that prevention 

values and processes are firmly established, that 

partnerships are strengthened, and that financial 

and other resources are secured over the long 

term. Sustainability also encourages the use of 

evaluation to determine which elements of a 

prevention program, policy, or service need to 

be continued and supported to maintain and 

improve outcomes. Because sustainability has a 

major effect on outcomes, communities need to 

make it an important part of each component 

in the whole planning process. If, for example, 

a community has a goal of reducing underage 

drinking by 20 percent, the community needs to 

plan how it will continue programs that produce 

the desired outcome. Such planning should begin 

as early in the assessment process as possible. 

American Indian Community Suicide 

Prevention Assessment Tool

The American Indian Community Suicide 

Prevention Assessment Tool was developed by 

the One Sky Center, a national resource center 

for American Indians and Alaska Natives. It 

is dedicated to improving the prevention and 

treatment of substance abuse and mental health 

disorders across Indian Country. 

This tool is designed as a template for 

assessing risk and protective factors within 

a Native community. It also is helpful in 

identifying available and needed prevention 

resources. Aspects of community health, 

such as the economic status of the Tribe, 

community readiness, and community selfhelp are integrated into a holistic evaluation 

of prevention opportunities. Some of the 

suggested uses of this tool include internal 

program assessment and planning. Information 

collected during the assessment also can be 

used to prepare grant applications, or the entire 

tool can be an appendix to an application. A 
63

copy of the template is included in Appendix 

D: Decisionmaking Tools and Resources. 

Communities can download the tool free from 

the One Sky Center Web site at http://www.

oneskycenter.org/education/publications.cfm.

Engaging Community 

Stakeholders in Prevention

Successful prevention means that an entire 

community is involved in planning, carrying out, 

and evaluating a comprehensive plan. Consequently, 

it is vital that all of a community’s stakeholders be 

engaged in identifying both problems and solutions. 

Stakeholders usually are individuals within the 

community with the most “at stake” around a 

particular issue. 

Stakeholders will vary from community to 

community. In suicide prevention, major 

stakeholders might include those who have 

been most affected by suicide, are in leadership 

positions, have direct access to youth and young 

adults, and have time and resources to invest in 

addressing the issue. Young people clearly should 

be involved in developing prevention efforts. 

Not only will they have an increased sense of 

their worth and belonging in the community, but 

they can also provide valuable insights into the 

challenges that their generation is facing. 

Engagement takes leadership. Tribal or Village 

leaders can encourage participation by making 

suicide prevention a priority for the community. 

Another approach is for a concerned and 

committed group of stakeholders to appeal to 

their leaders for support. 

Building a Community’s 

Capacity for Prevention

Although community capacity building was 

covered briefly in the section about the SPF 

process, this aspect of prevention deserves 

further discussion. When people think about 

capacity building, they frequently think in terms 

of treatment programs, counseling, and other 

support services. Community capacity building, 

however, goes beyond formal services. It also 

means building people’s commitment and skills 

to address problems and identify and respond to 

opportunities to promote mental health. It means 

recognizing the strengths that already exist 

within a community and making these strengths 

part of the solution. The emphasis of community 

capacity building should be on what is good and 

what already is working within the community. 

This approach has the added benefit of increasing 

a community’s sense of empowerment in 

charting a more promising future for itself and 

its children. 

 “Long ago it was the cottonwood 

tree who taught us how to make our 

tipis, for the leaf is an exact pattern 

of the tipi, and this we learned 

when some of our old people were 

watching little children making play 

houses from these leaves. This, 

too, is a good example of how 

much grown men and women 

may learn from very little children, 

for the hearts of little children are 

pure, and, therefore, the Great 

Spirit may show to them many 

things which older people miss.”

 — Black Elk, Lakota Sioux

The Sacred Pipe: Black Elk’s Account 

of the Seven Rites of the Oglala Sioux

Joseph E. Brown (Ed.) (1988)

Chapter 6: Community Action
64

On the other hand, community capacity 

building should not occur in isolation. As 

recognized in the National Strategy for Suicide 

Prevention, a comprehensive approach “requires 

a variety of organizations and individuals to 

become involved in suicide prevention and 

emphasizes coordination of resources and 

culturally appropriate services at all levels 

of government—Federal, State, Tribal, and 

community.”114 Prevention efforts need to be 

as broad and continuous as the threats to a 

community’s mental health and the opportunities 

to combat them are. The best way to build, 

maintain, and sustain such efforts is to engage as 

many participants as possible in prevention. 

Other ways in which community capacity 

building can increase the success of prevention 

plans are to:

• Use a variety of methods and a 

systematic approach;

• Emphasize collaboration and cooperation 

among community agencies; 

• Recognize that any particular suicide 

prevention effort will be more successful 

if it is part of a broader community health 

and wellness vision;

• Understand that efforts by local people 

are likely to have the greatest and most 

sustainable impact in solving local 

problems and in setting local norms; and

• Remember that when community 

resources are tapped, efforts are more likely 

to be based on concepts and ideas that are 

ethnically and culturally appropriate for 

that unique community.115

Capacity Building and Gatekeeper 

Training

Many communities are adopting gatekeeper 

training as part of their youth suicide prevention 

plan. Through gatekeeper training, teachers, 

natural peer helpers, and others who come in 

regular contact with young people are taught the 

warning signs of suicide and how to encourage 

someone at risk to seek help. Several gatekeeper 

training programs are described in Chapter 7: 

Promising Suicide Prevention Programs.

As effective as gatekeeper training may be in 

identifying young people at risk,116 it raises 

the issue of a community’s capacity to handle 

the increase in referrals for services that can 

result. For Tribal communities with limited 

access to behavioral health services, the 

question becomes “refer where?” Without some 

thought to this question, gatekeeper training 

may result in increased pressure on an already 

overwhelmed medical and behavioral services 

system. Whenever possible, a community needs 

to coordinate prevention efforts with local 

behavioral health and primary care systems to 

ensure that they are aware of these efforts and 

can plan for increased service demands. It may 

be possible for these systems to apply for funding 

for additional staff to meet demand. 

As community awareness increases, so do 

referrals. One answer to this increase in demand 

for services may be found in a particular type 

of community capacity building. As part of 

the community’s overall prevention plan, first 

responders, nurses, outreach personnel, and 

various paraprofessionals could receive training 

that goes beyond the gatekeeper level. This could 

include triage, intervention, and supportive 

counseling. Again, triage training programs 

are described in Chapter 7: Promising Suicide 

Prevention Programs. 

While there are costs associated with this 

additional level of training, it not only increases 

community capacity but also long-term 

sustainability. Where possible, Tribal and Village 

communities might seek partnerships and 

additional grants to address this need.
65

Appendix D: Decisionmaking Tools and 

Resources lists several guides for coalition 

building as well as tools for assessment, planning, 

and school-based program planning. 

Conclusion

Decades ago, Lone Man (Isna-la-wica) of the 

Teton Sioux said, “I have seen that in any great 

undertaking it is not enough for a man to depend 

simply upon himself.” As illustrated by the public 

health model, an entire community must come 

together in protecting its children from suicide. 

Prevention success cannot be achieved by leaving 

this greatest of undertakings to one family, one 

institution, one level of government, or even one 

Tribe or Village. Furthermore, what is learned 

about prevention must be shared among all of 

those who would benefit from this knowledge. 

Communities can strengthen their suicide 

prevention efforts by making use of tools that 

are based on the public health model. Such 

efforts provide a systematic way for communities 

to define the problem and develop an effective 

response. In carrying out prevention efforts, a 

community may find that it is more effective, as 

well as more cost-effective, to focus on promoting 

mental health as a way to reduce risk factors for 

suicide and prevent mental health problems from 

occurring in the first place. 

The most important part of this process, 

however, is the involvement of all individuals and 

institutions with a stake in the mental health 

and well-being of the community. Just as the 

causes of the problem of suicide can be found 

within a community, so can the solutions. The 

broader the base of community involvement, the 

more opportunities for prevention. The more 

a community builds its capacity for action, the 

greater the potential for success. This is the true 

measure of community’s action—people talking, 

sharing, and working together for the good of all. 

Chapter 6: Community Action

67

Chapter 7: Promising Suicide Prevention Programs

Introduction

Suicide prevention programs that show promise 

for American Indian and Alaska Native (AI/AN) 

communities are those that have proven effective 

in reducing suicides and suicidal behaviors 

by enhancing protective factors, reducing risk 

factors, or both. While this definition seems 

simple enough, it raises questions about how 

the effectiveness of the program was measured 

and for whom it was effective. These questions 

have particular relevance in determining which 

prevention programs will work best within 

AI/AN communities, where research has been 

limited and the evidence supporting traditional 

or culturally based approaches may be anecdotal. 

This chapter explores the issue of how evidence is 

defined and summarizes the difference between 

evidence-based and culturally based programs. 

The emphasis is on the need for all stakeholders 

to appreciate both of these approaches and to 

collaborate on building bridges between them. 

The issue is not which approach is best, but 

rather how we can learn from both in identifying, 

strengthening, and implementing AI/AN suicide 

prevention programs that work.

This chapter also identifies databases of evidencebased programs, such as the Substance Abuse 

and Mental Health Services Administration 

(SAMHSA) National Registry of Evidencebased Programs and Practices (NREPP) and its 

Suicide Prevention Resource Center’s (SPRC’s) 

Best Practices Registry. The chapter concludes 

with a discussion of two primary factors that 

a community should consider in selecting 

programs and descriptions of programs that hold 

promise for preventing suicides among AI/AN 

youth and young adults. 

What Is Evidence?

Federal and State governments and other 

funding sources are placing increasing emphasis 

on the need for communities to implement 

evidence-based practices; that is, programs that 

have been shown through documented scientific 

evidence to achieve the desired outcome for the 

population of focus. As a result, it is becoming 

increasingly difficult for communities and 

organizations to receive funding for programs 

that have not met this standard. The rationale 

is easy to understand. Given limited prevention 

dollars and the urgency of preventing suicides 

by AI/AN youth and young adults, it makes 

the most sense to invest in programs that have 

proven effective. 

“The goal of most prevention programs is to assist an individual in 

fulfilling their normative and developmentally appropriate potential, 

including a positive sense of self-esteem, mastery, well-being, and social 

inclusion and to strengthen their ability to cope with adversity.”

Preventing Mental, Emotional, and Behavioral Disorders 

Among Young People: Progress and Possibilities

National Research Council and Institute of Medicine (2009)
68

But how do we determine what is evidence? The 

move toward more evidence-based practices in 

recent years has elevated the standards within 

the field of suicide prevention, but it also has 

raised concerns among AI/AN researchers and 

community members as to whether traditional 

AI/AN community values and practices are 

being adequately addressed. Some researchers 

have argued that the emphasis placed on the 

use of evidence-based practices in AI/AN 

communities might lead to an abandonment of 

more traditional holistic approaches.117 These 

concerns are summarized in a report that was 

developed as a result of the National Alliance of 

Multi-Ethnic Behavioral Health Associations’ 

Consensus Meeting on Evidence-Based Practices 

and Communities of Color, which states: 

The introduction of evidence-based practices 

(EBPs) would appear to be a solution 

to the misdiagnoses and poor outcomes 

that so many in diverse populations have 

encountered in the mental health system. 

However, it is equally as likely that EBPs 

could exacerbate and deepen existing 

inequities if they are implemented without 

sufficient attention to cultural competence 

and/or if policymakers fail to take into 

account the many practices within diverse 

communities that are respected and highly 

valued by these groups. Such practices 

may not be considered ‘evidence-based’ 

as they often lack access to research and 

evaluation funds that are critical for studying 

the efficacy and effectiveness of mental 

health interventions.118

At the heart of these concerns is the perceived 

divide between evidence-based and culturally 

based programs.

Evidence-Based vs. Culturally 

Based Programs

SAMHSA’s National Registry of EvidenceBased Programs and Practices (NREPP) defines 

evidence-based programs (EBPs) as:

Approaches to prevention or treatment that 

are based in theory and have undergone 

scientific evaluation. ‘Evidence-based’ 

stands in contrast to approaches that are 

based on tradition, convention, belief, or 

anecdotal evidence.

Culturally based programs, on the other hand, are 

those that are grounded in tradition and supported 

by “anecdotal evidence.” For example, AI/AN 

prevention specialists or other Tribal members 

may contend that a traditional approach to suicide 

prevention will work, citing as evidence the rarity 

of suicide within their long cultural history before 

they came in contact with Western cultures. Such 

evidence, which is grounded in the stories passed 

down within the Native oral tradition, has value 

but is difficult to substantiate. It also may be 

that the culturally based program has yet to be 

evaluated in a meaningful way. 

These two approaches, however, are not mutually 

exclusive. One example of successful integration of 

evidence-based and culturally based practices can 

be found in the work of Terry Cross, an enrolled 

member of the Seneca Nation of Indians and the 

Executive Director of the National Indian Child 

Welfare Association. He describes a system-ofcare model for AI communities in which: 

Kinship networks and clan systems are 

being used as resources to provide respite 

care. Service providers and families are 

learning how traditional wellness concepts 

can facilitate a strengths-based approach to 

family harmony. Tools such as storytelling, 

the use of ritual and ceremony, rites of 

passage, and kinship support are being 

applied to a modern system of care.119
69

Although this example refers to a treatment 

delivery system, similar opportunities exist to 

integrate evidence-based and culturally based 

approaches to prevention efforts.

As stated earlier, the issue is not which approach 

is best. Instead, it is how we can use both 

approaches to develop and implement suicide 

prevention programs that work best in AI/AN 

communities. SAMHSA recognizes that EBPs 

have not been developed for all populations, 

service settings, or both. For example, certain 

programs for AI/AN populations, rural or 

isolated communities, or recent immigrant 

communities that appear effective may not have 

been formally evaluated. Thus, they will have a 

limited or nonexistent evidence base. In addition, 

other programs that have an established evidence 

base for certain populations or in certain settings 

may not have been formally evaluated with other 

subpopulations or within other settings.

SAMHSA has responded to this challenge by 

encouraging grant applicants who propose a 

program that has not been formally evaluated 

to provide other forms of evidence that the 

practice is appropriate for the population of 

focus. Evidence for these practices may include 

unpublished studies, preliminary evaluation 

results, clinical (or other professional association) 

guidelines, findings from focus groups held with 

community members, and other sources. 

In learning from culturally based programs, the 

focus may need to shift from why an AI/AN 

community believes a traditional approach will 

work to what its members can do to demonstrate 

its effectiveness. With this shift, the discussion 

can move to essential considerations such as 

how AI/AN communities can have a voice in 

determining how their traditional ways will be 

measured, who will be doing the measuring, and 

how the knowledge gained will be shared with 

others and for what purpose. 

Program Selection

A community needs to consider at least two 

factors in determining which strategy, or 

program, it will implement as part of its suicide 

prevention plan. The first is the population 

of focus. The second is the degree to which a 

program reflects or will need to be adapted to a 

community’s unique culture.

Population of Focus

All of the programs described in this document 

are intended to prevent suicide by AI/AN youth 

and young adults. The decision to be made is 

which program is most appropriate for the 

subgroup that is the focus of a suicide prevention 

plan. This is a multilayered decision. If the plan 

is to focus on school-aged youth, should the 

program involve all students within a school, just 

those who have been identified as at risk, or just 

adolescent males who are at high risk? Should a 

program focus all of its resources on school-based 

activities or should it direct resources towards 

families and the general community where the 

youth live? 

The Institute of Medicine (IOM) classification 

system is a useful tool in determining which 

program may best meet a community’s 

prevention goals. The IOM model views 

mental health promotion as the foundation for 

preventing mental, emotional, and behavioral 

disorders (see Exhibit 10). It classifies prevention 

strategies as universal, selective, or indicated. 

Each level of prevention targets a different 

population—from everyone in the population, 

to specific at-risk groups, to specific high-risk 

individuals—according to the population’s 

increasing degree of risk for or vulnerability to a 

mental health or substance abuse problem. 

Chapter 7: Promising Suicide Prevention Programs
70

Exhibit 10. IOM Classification System

From the National Research Council and Institute of 

Medicine (2009). Preventing Mental, Emotional, and 

Behavioral Disorders Among Young People: Progress and 

Possibilities.

Universal strategies involve an entire population, 

which could be all members of a Tribe or Village 

or all youth within a school. As the term implies, 

universal strategies are broad-brush efforts 

that are intended to affect everyone who may 

be at risk. A universal strategy, for example, 

might be to increase the population’s access to 

counseling or to improve general social supports 

in the community, such as through after-school 

programs and youth centers. Other examples of 

universal strategies are:

• Public education campaigns;

• School-based suicide awareness and risk 

reduction programs, such as anti-drug use 

or anti-bullying programs;

• School-based programs that support 

the social and emotional development 

of youth;

• Means restriction, such as building barriers 

on bridges or reducing access to guns, 

poisons, ropes and items used for hanging, 

and other lethal means of self-harm; and

• Education programs for the media on 

reporting practices related to suicide.

Selective strategies address smaller groups 

within the total population who have a higher 

probability of suicide, and are meant to prevent 

group members from developing suicidal 

behaviors. This level of prevention includes:

• Screening programs to identify and assess 

at-risk groups;

• Gatekeeper training for adults or natural 

peer helpers so that they can identify 

individuals at risk of suicide and refer 

them to appropriate treatment or 

supporting services; 

• Support and skill-building training for atrisk groups; and

• Crisis response and referral resources.

Indicated strategies address specific highrisk individuals within the population whose 

behavior shows early warning signs of suicide 

potential. Individuals who have some symptoms 

of a mental health problem, such as depression 

or hopelessness, or who are engaging in risky 

behaviors, such as alcohol and substance abuse, fit 

into this category. At this level, programs include:

• Skill-building support groups in high 

schools and colleges;

• Parent support training programs;

• Case management for individual high-risk 

youth at school; and

• Referrals to crisis intervention and 

treatment services.

Note that programs at all levels are designed to 

enhance protective factors and reduce risk factors. 

Ultimately, any comprehensive, community-based 

suicide prevention plan will need to address all 

levels of the IOM classification system. 
71

Culturally Based and 

Culturally Sensitive

A second consideration in program selection is 

the degree to which existing programs reflect 

or may need to be adapted to a particular 

community’s culture. Some programs are 

culturally based, meaning that they were 

specifically developed by and for AI/ANs. Some 

of these programs may not, as yet, have the 

support of rigorous evaluation and thus may 

not be considered to be evidence based. Other 

programs are culturally sensitive. Such programs 

were developed for the general population, 

achieved some level of evidence, and then were 

adapted for AI/AN populations. 

Both culturally based and culturally sensitive 

programs have potential strengths and limitations 

in their application to AI/AN communities at 

large. Culturally based programs were created 

around a specific culture. The more narrow 

the original cultural focus, the more difficult it 

may be for another community to achieve the 

same outcomes if its culture differs significantly. 

Programs that have been developed by and 

for AI communities in the lower 48 States, for 

example, may have limited applicability in AN 

Villages. Similarly, programs developed for one 

Tribe may not transfer well to another Tribe if 

the basis of the program is a tradition or practice 

unique to the original Tribe. However, if a 

particular culturally based program has reduced 

suicidal behavior in one community, then further 

investigation is called for. A careful evaluation 

of the program might identify a protective 

cultural aspect that may be transferable to 

another community. 

On the other hand, culturally sensitive programs 

should not take so general a view of Native 

culture as to lack relevance for any Tribe or 

Village. Cultural sensitivity means more than 

adding a generic Native American face to 

program materials. Appropriate programs should 

be flexible enough to integrate the values, beliefs, 

language, and practices of a particular community 

without a loss of effectiveness.

The need to honor and respect Native culture 

in programs to prevent suicide by AI/AN youth 

and young adults cannot be overemphasized. 

Research indicates that strong cultural 

identification makes adolescents less vulnerable 

to risk factors for drug use and more able to 

benefit from protective factors than adolescents 

who lack this identification.120 In addition, having 

a purpose in life appears to help young people 

feel positively about their life and their ability to 

handle its challenges. In the worldview of Native 

culture, everything has a purpose, including trees, 

animals, and rocks. One of the most important 

developmental tasks for Native youth is to 

discover their own purpose, and AI/ANs have 

many culturally sanctioned practices (e.g., vision 

quest) for accomplishing this.

Exhibit 11 is a list of cultural practices that Native 

communities have been integrating into their 

approaches to preventing substance abuse, which 

is frequently present in suicide attempts. Ways in 

which programs might become more culturally 

sensitive is to make them home- or family-based 

and deliverable by paraprofessionals. 

Program Adaptation and Fidelity

Differences by Tribal group, culture, degree 

of Native ancestry, and reservation or urban 

location make it difficult to develop a general 

prevention approach for all Native youth and 

young adults. Thus, it may be necessary to adapt 

an existing program—whether culture centered, 

culturally sensitive, or not yet tried in AI/AN 

communities—to the language, beliefs, values, 

and practices of an individual community. 

SAMHSA’s principles of cultural competence for 

its Strategic Prevention Framework (see Chapter 

6) can help guide this process.

Chapter 7: Promising Suicide Prevention Programs
72

At the core of program adaptation is the need 

to recognize a worldview that is consistent 

with AI/AN cultures, with worldview defined 

as “the collective thought process of a people 

or culture.”121

According to Cross, in Understanding the

Relational Worldview in Indian Families, there 

are two predominant worldviews globally: linear 

and relational.

• The linear worldview finds its roots in 

Western European and American thought. 

It is logical, time-oriented, and systematic, 

with cause-and-effect relationships at 

its core. To understand the world is to 

understand the linear cause and effect 

relationship between events.

• The relational worldview, sometimes 

called the cyclical worldview, finds its 

roots in Tribal cultures. It is intuitive, not 

Exhibit 11. Cultural Practices in American Indian 

Prevention Programs* 

All activities assume the participation of Elders and include the transmission of Tribal history, values, and beliefs.

Also, music, drumming, and singing are integral parts of most of these activities.

Ceremonies and Rituals

• Participating in sweatlodge ceremonies

• Smudging**

• Attending social dances

• Learning sacred dances

• Attending a Sundance

• Fasting

• Going on a vision quest***

• Paying attention to dreams

• Attending pow wows and other sober

community activities

• Storytelling and listening to stories

• Participating in a Talking Circle

Tribal Crafts 

• Making traditional attire for

pow wows and other ceremonies

• Tanning hides

• Making ribbon shirts

• Sewing quilts

• Learning the native language

• Cooking traditional foods

• Picking and drying herbs

• Making jewelry and moccasins

• Making cradle boards

Traditional Forms of Living 

• Hunting

• Fishing

• Shepherding

• Participating in Tribal sports

• Camping and participating in survival

retreats

• Picking berries and harvesting crops

* From Sanchez-Way, R., & Johnson, S. (2000). Cultural practices in American Indian prevention programs.

Juvenile Justice, 7(2), 21.

** Smudging involves the use of incense made of a local natural plant, such as sage, sweetgrass, or cedar, to

cleanse the air and change the mood of everyday life to one of respect and reverence suitable for prayer.

*** A vision quest is an extended meditation or retreat (typically 4 days long) that takes place in an isolated

area. The spiritual purposes of the vision quest are to renew faith, sacrifice, and seek guidance.
73

time-oriented, and fluid. The balance and 

harmony in relationships between multiple 

variables, including spiritual forces, make 

up the core of the thought system. Every 

event exists in relation to all other events 

regardless of time, space, or physical 

existence. Health exists only when things 

are in balance or harmony.122

In terms of adaptation, those who work with 

Native youth can show respect for the Native 

worldview when programs:

...build on young people’s connection to all 

other living entities; encourage and openly 

discuss their spiritual development; and 

recognize the vital role played by Elders, 

aunts, uncles, and other blood or clan 

relatives and seek their involvement. We also 

can make use of the outdoors, encourage 

generosity of spirit, incorporate more 

cooperative learning activities, respect the 

individual, allow for a longer response time 

[in conversations], be more flexible with 

timelines, and respect that learning also can 

occur through listening and in silence.123

Many AI/AN people are able to incorporate and 

move between these two worldviews. 

The primary constraint in adapting programs is 

to ensure that fidelity is maintained even while 

some program characteristics are altered to allow 

for cultural input. It can be difficult to establish a 

balance between fidelity and adaptation. To ensure 

that a program addresses everyone’s real needs, 

there should be open communication between 

funders, staff members, and other community 

stakeholders during the implementation and 

ongoing evaluation of a suicide prevention plan. 

Promising Program Databases 

and Descriptions

The following section identifies evidence- and 

culturally based programs for preventing suicide 

by AI/AN youth and young adults. Programs in 

the following list that have titles followed by two 

asterisks are included in SAMHSA’s NREPP. 

Programs marked with one asterisk have been 

rated as best practices by SAMHSA’s SPRC. 

Other programs are available through, or have 

been evaluated as being potentially useful to 

AI/AN communities by prevention specialists 

at the One Sky Center. SAMHSA has provided 

funding to this Center to identify, develop, and 

disseminate culturally sensitive materials for 

preventing and treating substance abuse and 

mental health problems in Indian Country. 

Many of the programs in the following list 

are school-based. Schools, in partnership with 

families, are in a unique position to promote 

the overall mental health of all young people as 

well as to identify those who may be at risk of 

suicide. Schools can directly address some risk 

factors for suicide, such as bullying and academic 

failure, within the context of improving school 

achievement. Youth also appear more likely 

to take advantage of services that are offered 

through a school rather than in other settings. 

This difference may be due to easy access or to a 

decrease in the stigma of seeking help.124 Other 

Chapter 7: Promising Suicide Prevention Programs

“Our worldview is the cultural lens 

through which we understand 

where we have come from, where 

we are today, and where we 

are going. Our cultural identity 

is our source of strength.”

 — Iris Heavyrunner, Blackfeet

 — Joann Sebastian Morris

Sault Ste. Marie Chippewa
74

research has shown that a sense of connection 

or belonging to their school community has a 

strong, protective effect against suicidal thoughts 

by youth.125 Furthermore, AI/AN communities 

often are geographically isolated and lack access 

to behavioral health services. School-based 

programs enable communities to overcome these 

challenges by centering the program and its 

services in the community.

The following programs focus specifically on 

suicide prevention. Other programs aimed 

specifically at promoting the mental health of 

youth (e.g., programs to strengthen family bonds) 

or to reduce any of the risk factors for suicide 

(e.g., programs to prevent and treat substance 

abuse and mental health problems) also may be 

effective in reducing suicide. It is beyond the 

scope of this document to include the broadest 

range of programs possible, but readers are 

encouraged to consider them as part of their 

suicide prevention plan. 

SAMHSA’s NREPP, at http://www.nrepp.

samhsa.gov, contains an extensive list of related 

programs. Other Federal agencies also maintain 

online databases. The U.S. Department of 

Justice, Office of Justice Programs, Office of 

Juvenile Justice and Delinquency Prevention, 

maintains a similar database—its Model Programs 

Guide—at http://www.dsgonline.com/mpg2.5/

mpg_index.htm. This database offers evidencebased programs to address a variety of youth 

problems, including delinquency; violence; youth 

gang involvement; alcohol, tobacco, and drug use; 

academic difficulties; family functioning; trauma 

exposure; sexual activity/exploitation; and other 

mental health issues.

Twelve Federal agencies make up the Interagency 

Working Group on Youth Programs. This work 

group promotes the achievement of positive 

results for at-risk youth by identifying and 

disseminating promising and effective strategies 

and practices that support youth. The group also 

encourages collaboration at the Federal, State, 

and local level, as well as with faith-based and 

community organizations, schools, families, and 

communities. It also has created a Web site on 

youth, at http://www.FindYouthInfo.gov, to 

help interested citizens and decisionmakers plan, 

implement, and participate in effective programs 

for at-risk youth. Resources and available on the 

Web site include:

• A searchable database of evidence-based 

programs to address risk and protective 

factors in youth; 

• Key elements of effective partnerships, 

including strategies for engaging youth; 

• Helpful community assessment tools; 

• Mapping tools that generate maps of local 

and Federal youth programs; and 

• An overview of Federal programs that 

serve youth, technical assistance resources, 

and grant application guidelines.

National Registry of Evidence-Based 

Programs and Practices

SAMHSA’s NREPP is a searchable online 

registry of mental health and substance abuse 

programs that have been rated by independent 

reviewers. The purpose of this registry is to 

assist the public in identifying approaches 

to preventing and treating mental health 

and substance use disorders that have been 

scientifically tested and that can be readily 

disseminated to the field. This registry represents 

just one way that SAMHSA is working to 

improve a community’s access to information 

on tested interventions. One goal of this effort 

is to reduce the lag time between the creation of 

scientific knowledge and its practical application 

in the field.

NREPP, however, is meant to be a decision 

support tool and not an authoritative list of 

effective interventions. Being included in 
75

NREPP, or in any other resource listed in this 

guide, does not mean a program is recommended 

or that it has been demonstrated to achieve 

positive results in all circumstances. NREPP is 

a voluntary, self-nominating system in which 

program developers have chosen to participate. 

There always will be some programs that are not 

submitted to NREPP. Not all that are submitted 

are reviewed. 

Programs in NREPP have been rated on two 

scales: Quality of Research and Readiness for 

Dissemination. Quality of Research ratings 

are indicators of the strength of the evidence 

supporting program outcomes. Each outcome is 

rated separately because interventions may target 

multiple outcomes (e.g., depression, feelings of 

hopelessness, drug involvement), and the evidence 

supporting the different outcomes may vary. 

NREPP uses very specific standardized criteria to 

rate programs and the evidence supporting their 

outcomes. All reviewers who conduct NREPP 

reviews are trained on these criteria and are 

required to use them to calculate their ratings.

Each reviewer independently evaluates the 

quality of research for a program’s reported 

results using the following six criteria:

• Reliability;

• Validity; 

• Intervention fidelity; 

• Missing data and attrition; 

• Potential confounding variables; and 

• Appropriateness of analysis. 

NREPP’s Readiness for Dissemination ratings 

summarize the amount and general quality 

of the resources available to support program 

use. Higher scores indicate more and higher 

quality resources are available. Readiness for 

Dissemination ratings apply to the program as a 

whole. Reviewers evaluate readiness according to 

three criteria: 

• Availability of implementation materials; 

• Availability of training and support 

resources; and

• Availability of quality assurance procedures.

Additional details about the NREPP review 

process are available at http://www.nrepp.samhsa.

gov/review.asp.

Suicide Prevention Resource Center 

Best Practices Registry

SAMHSA’s SPRC (described more fully 

in the following chapter) also maintains a 

searchable online database of suicide prevention 

strategies. Its Best Practices Registry (BPR) 

is a collaboration between the SPRC and the 

American Foundation for Suicide Prevention 

(AFSP). The purpose of the registry is to identify, 

review, and disseminate information about best 

practices that address specific objectives of the 

National Strategy for Suicide Prevention. The BPR 

has three sections:

• Section I: Evidence-Based Programs 

describes programs that have undergone 

rigorous evaluation through NREPP 

or SPRC and have demonstrated 

positive outcomes; 

• Section II: Expert and Consensus 

Statements summarizes the current 

knowledge in the field and provides “best 

practice” recommendations to guide 

program and policy development; and 

• Section III: Adherence to Standards

contains additional suicide prevention 

programs and practices, including awareness 

materials, educational and training 

programs, protocols, and policies that have 

been implemented in specific settings (as 

opposed to Section II statements, which 

offer general guidance to the field).

Chapter 7: Promising Suicide Prevention Programs
76

The three sections are not intended to represent 

levels of effectiveness. Instead, they include 

different types of programs and practices that 

have been reviewed according to specific criteria 

for that section. 

SPRC no longer reviews program effectiveness, 

which now is conducted through NREPP. 

Programs that were reviewed previously by 

SPRC and are included in the BPR were 

evaluated according to 10 quality-based criteria: 

theory, intervention fidelity, design, attrition, 

psychometric properties of measures, analysis, 

threats to validity, safety, integrity, and utility. 

Additional information on the BPR is available 

at http://www.sprc.org/featured_resources/bpr/

index.asp.

Promising Programs

The following programs are grouped according to 

their primary strategy for suicide prevention. The 

categories are:

• Life skills development;

• Screening;

• Public awareness/gatekeeper training;

• Counseling and support services; and

• Attempt response. 

Each program description includes a note 

on the program’s actual or potential use in 

AI/AN communities.

Life Skills Development

Life skills development programs help young 

people develop the social and emotional skills 

that promote healthy relationships and selfesteem. At the same time, these programs 

strengthen their resilience in coping with the 

challenges of life. 

American Indian Life Skills Development**

IOM classification: Universal

Population of focus: Male and female high 

school students, ages 14 to 19.

Description: American Indian Life Skills 

Development is a school-based suicide 

prevention curriculum designed to reduce suicide 

risk factors and improve protective factors among 

AI adolescents.

The curriculum includes anywhere from 28 to 

56 lesson plans covering topics such as building 

self-esteem, identifying emotions and stress, 

increasing communication and problem-solving 

skills, recognizing and eliminating selfdestructive behavior, learning about suicide, roleplaying around suicide prevention, and setting 

personal and community goals. The curriculum 

typically is delivered over 30 weeks during the 

school year, with students participating in lessons 

three times per week. Lessons are interactive and 

incorporate situations and experiences relevant 

to AI adolescent life, such as dating, rejection, 

divorce, separation, unemployment, and problems 

with health and the law. Most of the lessons 

include brief, scripted scenarios that provide a 

chance for students to problem-solve and apply 

the suicide-related knowledge they have learned.

Lessons are delivered by teachers working with 

community resource leaders and representatives 

of local social services agencies. This teamteaching approach ensures that the lessons have 

a high degree of cultural and linguistic relevance, 

even if the teachers are not AI/ANs or not of 

the same Tribe as the students. For example, the 

community resource leaders can speak to students 

in their own language to explain important 

concepts and can relate curriculum materials and 

exercises to traditional and contemporary Tribal 

activities, beliefs, and values. A school counselor 

(typically of the same Tribe) serves as the onsite 

curriculum coordinator.
77

Application to AI/AN communities: This 

curriculum is the currently available version of 

the Zuni Life Skills Development curriculum. 

This original curriculum was first implemented 

with high school students in the Zuni Pueblo, 

an AI reservation with about 9,000 Tribal 

members located about 150 miles west of 

Albuquerque, NM. The American Indian Life 

Skills Development curriculum, an adaptation 

of the Zuni version, has been implemented with 

a number of other Tribes, with appropriate and 

culturally specific modifications. Adaptations 

of the curriculum have been developed for 

middle school students on a reservation in the 

Northern Plains area; for Sequoyah High School 

in Tahlequah, OK, a boarding school on the 

reservation of the Cherokee Nation that enrolls 

students from about 20 Tribes across the country; 

and for young women of the Blackfeet Tribe. 

The process of cultural adaptation incorporated 

into the program appears transferable to 

other populations.

2009 Cost: The American Indian Life Skills 

Development manual is available for $30 plus 

shipping and handling from the Chicago 

Distribution Center (1–800–621–2736). Training 

for school staff costs about $3,000 for a 3-day 

training program conducted by the developer 

(exclusive of travel expenses).

Contacts: 

For information about implementation or studies: 

Teresa D. LaFromboise, Ph.D.

Senior Research Scientist

School of Education, Cubberley 216, 3096

Stanford University

Stanford, CA 94305

Phone: 650–723–1202

Fax: 650–725–7412

E-mail: lafrom@stanford.edu

Screening

Screening involves the identification of youth 

who may be at risk of suicide. Consent from 

parents of children younger than age 18 should 

be obtained before the children participate in a 

screening program.

Columbia University TeenScreen** 

IOM classification: Universal

Population of focus: Male and female middle 

and high school students who may be at risk for 

suicide and undetected mental illnesses.

Description: The Columbia University 

TeenScreen program identifies middle schooland high school-aged youth in need of mental 

health services due to risk for suicide and 

undetected mental illness. The program’s main 

objective is to assist in the early identification of 

problems that might not otherwise come to the 

attention of professionals. TeenScreen can be 

implemented in schools, clinics, doctors’ offices, 

juvenile justice settings, shelters, or any other 

youth-serving setting. Typically, within a setting, 

all youth in the age group of focus are invited 

to participate. 

The program involves the following stages.

• Before any school-based screening is 

conducted, parents’ written consent is 

required. Parental consent is strongly 

recommended for screenings in non-schoolbased sites. Teens also must agree to the 

screening. Both the teens and their parents 

receive information about the process of 

the screening, confidentiality rights, and 

the teens’ rights to refuse to answer any 

questions they do not want to answer. 

• Each teen completes a 10-minute paperand-pencil or computerized questionnaire 

covering anxiety, depression, substance 

and alcohol abuse, and suicidal thoughts 

and behavior. 

Chapter 7: Promising Suicide Prevention Programs
78

• Teens whose responses indicate risk for 

suicide or other mental health needs 

participate in a brief clinical interview with 

an onsite mental health professional. If the 

clinician determines the symptoms warrant 

a referral for an indepth mental health 

evaluation, parents are notified and offered 

assistance with finding appropriate services 

in the community. Teens whose responses 

do not indicate a need for clinical services 

receive an individualized debriefing. The 

debriefing reduces the stigma associated 

with scores indicating risk and provides 

an opportunity for the youth to express 

any concerns not reflected in their 

questionnaire responses. 

Application to AI/AN communities: The 

TeenScreen program has been studied in a 

variety of school settings and with students of 

diverse ethnicity. The program also has been 

implemented in foster care, primary and pediatric 

care, shelters, drop-in centers, and residential 

treatment facilities. Although its use in Native 

communities is unknown, the program is an 

option for AI/AN communities. 

2009 Cost: Costs involved in implementing 

TeenScreen include staffing (screener, clinician, 

case manager), supplies and equipment 

(computers, headphones, printers, photocopies), 

and mailing. Costs will vary by site. The 

program manual includes a budget planning 

exercise. At this time, the developers of 

TeenScreen offer free consultation, training, and 

technical assistance to qualifying communities 

that wish to implement their own screening 

programs using the TeenScreen model.

Contacts: 

Web site: http://www.teenscreen.org

For information about implementation or studies:

Director

Columbia University TeenScreen Program

1775 Broadway, Suite 610

New York, NY 10019

Phone: 212–265–4453

Fax: 212–265–4454

E-mail: teenscreen@childpsych.columbia.edu

QPR Institute Suicide Triage Training/QPRT

Suicide Risk Assessment Training

IOM classification: Selective, Indicated

Population of focus: Any person at risk 

of suicide.

Description: The QPR (Question, Persuade, 

Refer) Institute is a multidisciplinary training 

organization with a primary goal of providing 

suicide prevention educational services and 

materials to professionals and the general public. 

The QPR Institute has developed an 8-hour 

QPR Suicide Triage Training Course for all 

“first responders,” including crisis line workers, 

law enforcement, firefighters, emergency medical 

technicians, clergy, case managers, correctional 

personnel, school counselors, residential staff, and 

others who come in contact with people at risk 

for suicide.

The QPR Institute also offers the QPRT 

(Question, Persuade, Refer, Treat) Suicide Risk 

Assessment and Training Course. This course 

is an award-winning suicide risk assessment 

training program developed by clinicians for 

clinicians. The QPRT Suicide Risk Assessment 

and Training Course is for all primary health 

care professionals, counselors, social workers, 

psychiatrists, psychologists, substance abuse 

treatment providers, clinical pastoral counselors, 

and licensed and certified professionals who 

evaluate and treat suicidal persons. 

Application to AI/AN communities: The QPR 

Institute, Eastern Washington University, and 

Camas Path, which is a Tribally chartered entity 

of the Kalispel Tribe of American Indians, have 

collaborated to offer both the QPR Suicide 
79

Triage Training Course and the QPRT Suicide 

Risk Assessment and Training Course online, 

with or without college credit. Courses can be 

accessed through Eastern Washington University 

at http://www.ewu.edu/x40902.xml.

2009 Cost: Cost of training ranges from $125 

for non-credit or continuing education credits to 

$229 for Eastern Washington University credits. 

Contacts:

Web site: http://www.qprinstitute.com

For program information:

QPR Institute

P.O. Box 2867

Spokane, WA 99220

Phone: 509–536–5100 or 1–888–726–7926 (toll-free)

Fax: 509–536–5400

E-mail: qinstitute@qwestoffice.net

Public Awareness/Gatekeeper Training 

A gatekeeper is someone in a position to 

recognize the warning signs that someone 

may be contemplating suicide. According to 

the National Strategy for Suicide Prevention, 

potential gatekeepers include parents, friends, 

neighbors, teachers, ministers, doctors, nurses, 

office supervisors, squad leaders, foremen, police 

officers, advisors, caseworkers, firefighters, and 

many others who are in a position to recognize 

someone at risk of suicide and refer them 

to services.

Applied Suicide Intervention Skills 

Training (ASIST)*

IOM classification: Universal

Population of focus: Any individual at risk 

of suicide.

Description: ASIST is a 2-day workshop 

designed to teach the skills that enable an 

adult to competently and confidently intervene 

with a person at risk of suicide. Developed by 

LivingWorks, Inc., the workshop is intended 

to help all caregivers (i.e., any person in a 

position of trust, including professionals, 

paraprofessionals, and laypeople) become more 

willing, ready, and able to help persons at risk. 

The workshop is suitable for mental health 

professionals, nurses, physicians, pharmacists, 

teachers, counselors, youth workers, police and 

correctional staff, school support staff, clergy, and 

community volunteers. 

Workshops are 14 hours long and are held over 

2 days. The ASIST curriculum includes suicide 

intervention skill development, confidential 

and trainer-facilitated small-group learning 

environments, established trainer protocols 

to address vulnerable or at-risk participants, 

knowledge of local resources that can be accessed, 

consistent use of positive feedback, a blend of 

larger group experiential challenges and the 

safety of small-group opportunities to test new 

skills, no-fault simulation exercises, and the use 

of adult learning principles.

Workshops are delivered to a maximum of 

30 participants by a minimum of two trainers. 

Almost 2,000 ASIST workshops are conducted 

annually. In addition, a train-the-trainer program 

is available so that organizations can have their 

own trainers.

Application to AI/AN communities: The 

ASIST program has been implemented at 

several Native sites, both in reservation and 

urban settings.

2009 Cost: ASIST training is provided by 

LivingWorks Education, Inc., of Alberta, 

Canada. The average program cost is $175 

(Canadian) per person, which includes program 

materials. The cost will vary depending on the 

availability of trainers and other circumstances. 

Visit the Web site for a schedule of 

upcoming training. 

Chapter 7: Promising Suicide Prevention Programs
80

Contacts: 

Web site: http://www.livingworks.net/AS.php

For program information:

LivingWorks Education, Inc. 

P.O. Box 9607

Fayetteville, NC 28311

Phone: 910–867–8822

Fax: 910–867–8832

E-mail: usa@livingworks.net or info@

livingworks.net

Lifelines*

IOM classification: Universal

Population of focus: All students in a school, 

ages 12 to 17.

Description: Lifelines is a school-based 

prevention curriculum comprised of four 

45-minute lessons. Lesson content includes:

• Information and attitudes about suicide, 

help seeking, and school resources;

• Discussion of warning signs of suicide and 

role-playing exercises for students who 

may encounter a suicidal peer (with an 

emphasis on seeking adult help); and

• Two videos, with one that depicts 

appropriate and inappropriate responses 

to a suicidal peer and one that documents 

the actual response of three 8th-grade 

boys to a suicidal peer after they had 

participated in Lifelines.

The program also includes model schoolbased policies and procedures for responding 

to at-risk youth, suicide attempts, and suicide 

completions; presentations for educators and 

parents; and a 1-day workshop to train teachers 

in the curriculum.

Application to AI/AN communities: The 

Lifelines program was studied in two suburban, 

middle-class schools in the Northeast, with 

positive outcomes. Although its use in Native 

communities is unknown, the program is an 

option for AI/AN communities.

2009 Cost: The Lifelines curriculum manual is 

available from Rutgers University for $45.

Contacts:

Rutgers University

Graduate School of Applied and Professional 

Psychology

152 Frelinghuysen Road

Piscataway, NJ 08854

Phone: 732–445–2000, ext. 109

Native H.O.P.E. (Helping Our People Endure)

IOM classification: Universal

Population of focus: All Native youth.

Description: Native H.O.P.E. is a curriculum 

based on the theory that suicide prevention can 

be successful in Indian Country when Native 

youth become committed to breaking the “code 

of silence” that is prevalent among all youth. The 

program also is premised on the foundation of 

increasing “strengths” among Native youth as well 

as increasing their awareness of suicide warning 

signs. The program supports the full inclusion of 

Native culture, traditions, spirituality, ceremonies, 

and humor. 

The 3-day Native H.O.P.E. youth leadership 

curriculum takes a proactive approach to suicide 

prevention. Training provided to natural peer 

helpers is designed to build their capacity and 

awareness to help youth through referral and 

support. Participants are taught to:

• Show they care by listening and 

acknowledging the other person’s pain;

• Make the person aware that he or she does 

have choices;

• Get peers at risk to a counselor or other 

source of health support; and
81

Chapter 7: Promising Suicide Prevention Programs

• Set limits on their natural helper role in 

the peer counseling process.

This program also is used to train local 

community members to be facilitators who 

encourage Native youth to take a leading role in 

prevention. A key to mobilizing peer counseling 

programs for Native youth is to identify and 

train adults from their communities who will 

be committed to wellness. These adults also will 

assist their youth in leadership development. 

Application to AI/AN communities: This 

curriculum was piloted in the Billings, MT, 

area and through the Indian Health Service 

(IHS) National Suicide Prevention Network in 

Standing Rock, ND and Red Lake, MN. 

2009 Cost: The youth manual and 

faculitator guide are available free of 

charge through the One Sky Center and 

may be downloaded from http:/www.

oneskycenter.org/education/documents/

NativeHOPEYouthManualCoverandIndex.pdf.

Contacts: 

Web site: http://www.oneskycenter.org

For program information: 

One Sky Center

Oregon Health & Science University

3181 SW Sam Jackson Park Road, GH 151

Portland, OR 97239

Phone: 503–494–3703

Fax: 503–494–2907

E-mail: onesky@shsu.edu

QPR Gatekeeper Training

IOM classification: Universal

Population of focus: Any person at risk of suicide.

Description: QPR is an acronym for Question, 

Persuade, Refer—three steps that a person can 

take in helping to save a life. Topics covered by 

the online program are: 

• How to get help for yourself or learn more 

about preventing suicide; 

• Common causes of suicidal behavior; 

• Warning signs of suicide; 

• How to “Question, Persuade, and Refer” 

someone who may be suicidal; and 

• How to get help for someone in crisis. 

Course participants receive resources and a 

certificate of completion after completing a postcourse survey and evaluation and passing a 15-

item quiz. The online course takes approximately 

1 hour to complete.

Application to AI/AN communities: The QPR 

training content identifies current resources and 

Web sites related to AI/AN suicides, including 

current research data. The Aberdeen Area 

IHS adapted the QPR suicide triage method 

by incorporating Native American scenarios 

and actors. 

2009 Cost: An online course offered through 

QPR is $29.

Contacts:

Web site: http://www.qprinstitute.com

For program information:

QPR Institute

P.O. Box 2867

Spokane, WA 99220

Phone: 509–536–5100

Toll-free: 1–888–726–7926

Fax: 509–536–5400

E-mail: qinstitute@qwestoffice.net

Signs of Suicide (SOS)* 

IOM Classification: Universal

Population of focus: All students within a 

high school.
82

Description: SOS incorporates two prominent 

suicide prevention strategies into a single 

program, combining a curriculum that aims to 

raise awareness of suicide and its related issues 

with a brief screening for depression and other 

risk factors associated with suicide.

This is a 2-day secondary school-based 

intervention. The basic goal of the program is 

to teach high school students to respond to 

suicide as an emergency, much as one would 

react to the signs of a heart attack. Students view 

a video that teaches them to recognize signs 

of depression and suicide in others. They learn 

that the appropriate response to these signs is 

to acknowledge them, let the person know they 

care, and tell a responsible adult (either with the 

person or on that person’s behalf ). Students also 

participate in guided classroom discussions about 

suicide and depression. For screening, students 

self-complete the SOS student screening 

form. A parent version of the screening form is 

provided for parents to use in evaluating possible 

depression in their children.

The intervention strives to prevent suicide 

attempts, increase knowledge about suicide and 

depression, and increase help-seeking behavior. 

Schools should be prepared to respond to an 

increased number of referrals for depression 

and suicide.

Application to AI/AN communities: The 

SOS program has been administered in more 

than 1,000 high schools and with culturally 

diverse students. Program effectiveness has been 

studied in urban settings, and efforts currently 

are underway to evaluate its effectiveness in 

suburban and rural populations. Although its use 

in Native communities is unknown, the program 

is an option for AI/AN communities. 

2009 Cost: Teachers implementing the program 

will require 1 to 2 hours of training. The program 

also will require a site coordinator (usually a 

counselor). Program resources are provided 

through Screening for Mental Health for $300 

for the high school kit, which includes materials 

for 300 students, parents, and school staff. 

(A middle school kit also is available for the 

same cost.)

Contacts:

Web site: http://www.mentalhealthscreening.org

For program information:

Screening for Mental Health, Inc.

One Washington Street, Suite 304

Wellesley Hills, MA 02481

Phone: 781–239–0071

Fax: 781–431–7447

E-mail: highschool@mentalhealthscreening.org

Sources of Strength

IOM classification: Universal

Population of focus: AI/AN youth and 

young adults.

Description: Sources of Strength is a strengthbased, comprehensive wellness program initially 

developed for Tribal and rural settings, which 

has been expanded for diverse populations 

and settings. The program focuses on suicide 

prevention, but impacts other issues such as 

substance abuse and violence. Core elements for 

Tribal communities include:

• A move from a singular suicide prevention 

focus on mental health treatment referrals 

to a model of developing village-based 

supports and institutional health and 

mental health supports; 

• A holistic model of eight sources of 

strength that encourages multiple strengths 

reflected in the Medicine Wheel, Red Road 

approach, and many other teachings of 

Elders in a variety of Tribal traditions; 

• A core focus on strengths, with a 

realization that leading with risk factors 
83

can be disempowering for many tribal 

communities; and

• A core value that health and healing is 

best passed through the interconnection of 

relationships within family, kinships, clans, 

and especially among teens and their 

friendship groups. 

Application to AI/AN populations: Sources 

of Strength has worked with many different 

Tribal communities and schools and has 

developed middle school, high school, and 

college-level programs, including accredited 

classes in partnership with Tribal colleges. 

Sources of Strength is not intended as a standalone program but is designed to blend into 

other community efforts, especially those efforts 

strengthening cultural identity and language. 

Sources of Strength currently is partnering with 

the University of Rochester, NY in one of the 

Nation’s largest randomized evaluations of a 

population-based suicide prevention project. 

Opportunities exist for Tribal communities 

to partner in this community-based 

research process. 

2009 Cost: Training costs vary, depending on 

how many adult advisors and peer teams will 

be trained. Training costs for individual schools 

are approximately $1,500 plus trainer travel 

costs; costs for regional or multi-community 

trainings range from $5,000 to $12,000 plus 

trainer travel costs. Training includes regular 

follow-up teleconferencing calls. Materials are 

made available electronically for local printing 

at no cost or can be purchased. Contact Sources 

of Strength for more information about training 

options and program materials and their use. 

Contacts:

Web site: http://www.sourcesofstrength.info

For program information:

Mark LoMurray

Executive Director 

Sources of Strength

15506 Sundown Drive

Bismarck, ND 58503

Phone: 701–471–7186

E-mail: marklomurray@gmail.com 

Yellow Ribbon Suicide Prevention Program

IOM classification: Universal

Population of focus: All members of a school 

and its community.

Description: The Yellow Ribbon Suicide 

Prevention Program is a school- and communitybased suicide prevention program that uses a 

collaborative, grassroots model to decrease suicide 

risk by promoting help-seeking behavior. This is 

accomplished by (1) increasing public awareness 

of suicide prevention; (2) training gatekeepers; 

and (3) facilitating help-seeking behavior.

Yellow Ribbon expands public awareness of the 

problem of suicide through educational materials, 

school-wide assemblies, and community-wide 

collaboration efforts. Gatekeeper activities are 

promoted through use of a simple, three-step 

rubric of “stay, listen, and get help.” This rubric 

is reinforced at all levels of training through 

Yellow Ribbon’s Be-A-Link® curriculum and the 

distribution of It’s OK to Ask for Help® cards 

that contain directions for seeking help and 

the phone number for the National Suicide 

Prevention Lifeline. Yellow Ribbon incorporates 

a community-wide prevention model that 

encourages the development of partnerships to 

increase program impact and sustainability. 

Application to AI/AN communities: The 

Yellow Ribbon program has been widely used 

in schools and communities throughout the 

United States, including in Native communities 

and schools. A strength of this program is its 

inclusion of students and family involvement 

and leadership. 

Chapter 7: Promising Suicide Prevention Programs
84

2009 Cost: Program costs are based on a sliding 

scale: contact Yellow Ribbon for details.

Contacts:

Web site: http://www.yellowribbon.org 

For program information:

Yellow Ribbon Suicide Prevention Program

P.O. Box 644

Westminster, CO 80036-0644

Phone: 303–429–3530

Fax: 303–426–4496

E-mail: ask4help@yellowribbon.org

Counseling and Support Services

The following programs target youth who have 

been identified as being at high risk for suicide. 

They are designed to help the youth develop or 

strengthen positive social and coping skills (i.e., 

resilience) and reduce behaviors that place them 

at risk of suicide.

CARE (Care, Assess, Respond, Empower)**

IOM classification: Selective, Indicated

Populations of focus: 

• Male and female high-school students, 

ages 14 to 20, who are at high risk 

of suicide; and

• Male and female young adults, ages 20 to 

24, who are at high risk of suicide and are 

being counseled in non-school settings, 

such as health care clinics.

Description: CARE (formerly called Counselors 

CARE [or C-CARE] and Measure of 

Adolescent Potential for Suicide [or MAPS]) is 

a high school-based suicide prevention program 

targeting high-risk youth. CARE includes a 

2-hour, individual computer-assisted suicide 

assessment interview. This interview is followed 

by a 2-hour motivational counseling and social 

support intervention. The counseling session is 

designed to deliver empathy and support, provide 

a safe context for sharing personal information, 

and reinforce positive coping skills and helpseeking behaviors. CARE makes it easier for 

youth to obtain help by connecting each highrisk youth to a school-based caseworker or a 

favorite teacher and by establishing contact with 

a parent or guardian chosen by the youth. The 

program also includes a follow-up reassessment 

of broad suicide risk and protective factors and a 

booster motivational counseling session 9 weeks 

after the initial counseling session. 

The goals of CARE are threefold: to decrease 

suicidal behaviors, to decrease related risk 

factors, and to increase personal and social 

assets. CARE assesses the adolescent’s needs, 

provides immediate support, and then serves as 

the adolescent’s crucial communication bridge 

with school personnel and the parent or guardian 

of choice. The CARE program typically is 

delivered by school or advanced-practice nurses, 

counselors, psychologists, or social workers who 

have completed the CARE implementation 

training program and certification process.

Although CARE was originally developed 

to target high-risk youth in high 

school—particularly those at risk of school 

dropout or substance abuse—its scope has been 

expanded to include young adults (ages 20–24) 

in settings outside of schools, such as in health 

care clinics. 

Application to AI/AN communities: CARE 

was piloted and tested with participants ages 

14 to 20 and has since been adapted for young 

adults (ages 20 to 24). Originally tested with 

diverse racial and ethnic groups, the program 

also has been adapted specifically for Native 

American and Hispanic students. 

2009 Cost: Required online training in 

CARE implementation is being developed for 

interventionists, program coordinators, and 

administrators. Costs include (1) the training 

registration fee, (2) the purchase of a license 

for the use of the computer-assisted CARE 
85

program; and, (3) follow-up training and 

certification process fees. Length of training 

may vary depending on the competency levels of 

participants and the time required for them to 

achieve and maintain a level of “distinguished” 

implementation performance. 

Contacts:

Web site: http://www.reconnectingyouth.com

For information about implementation or 

research studies:

Reconnecting YouthTM Inc.

P.O. Box 20343

Seattle, WA 98102

Phone: 425–861–1177

Fax: 1–888–352–2819

CAST (Coping and Support Training)**

IOM classification: Indicated

Population of focus: Male and female high 

school students, ages 14 to 19, who are at high 

risk of suicide.

Description: CAST is a high school-based 

suicide prevention program. CAST delivers life 

skills training and social support in a smallgroup format (6 to 8 students per group). The 

program consists of 12 55-minute group sessions 

administered over 6 weeks by trained, masterslevel high school teachers, counselors, or nurses 

with considerable school-based experience. 

CAST serves as a follow-up program for youth 

who have been identified through screening 

as being at significant risk for suicide. In the 

original trials, identification of youth was done 

through a program known as CARE (Care, 

Assess, Respond, Empower), but other evidencebased suicide risk screening instruments can 

be used. 

CAST’s skills training sessions target three 

overall goals: increased mood management 

(depression and anger), improved school 

performance, and decreased drug involvement. 

Group sessions incorporate key concepts, 

objectives, and skills that inform a groupgenerated implementation plan for the CAST 

leader. Sessions focus on group support, 

goal setting and monitoring, self-esteem, 

decisionmaking skills, better management of 

anger and depression, “school smarts,” control 

of drug use with relapse prevention, and selfrecognition of progress through the program. 

Each session helps youth apply newly acquired 

skills and increase support from family and other 

trusted adults. Detailed lesson plans specify the 

type of motivational preparation, teaching, skills 

practice, and coaching activities appropriate for 

at-risk youth. Every session ends with “Lifework” 

assignments that call for the youth to practice 

the session’s skills with a specific person in their 

school, home, or peer-group environment. 

Application to AI/AN communities: Originally 

piloted and tested in youth ages 14 to 19 years 

old, the CAST program is currently being tested 

with middle school-aged youth. CAST has been 

evaluated with racially and ethnically diverse 

groups of high school youth at risk of dropping 

out of school. Although its use in Native 

communities is unknown, the program is an 

option for AI/AN communities. 

2009 Cost: The CAST curriculum, which 

includes one copy of the CAST student 

notebook, CAST leader guide, and all related 

teaching aids, is $699 plus shipping and 

handling. CAST Student Notebooks are $26.50 

each plus shipping and handling, or $190.80 for 

a set of 8 Student Notebooks. 

Registration for a 4-day training workshop for 

CAST leaders and coordinators is $16,000 for 

14 to 16 participants. A 1-day training workshop 

for the administrators responsible for establishing 

the infrastructure to support implementation 

of the CAST program runs $400 per person. A 

2-day advanced training for CAST coordinators 

costs $800 per person and is designed to follow 

Chapter 7: Promising Suicide Prevention Programs
86

the prerequisite 4-day and 1-day trainings. The 

advanced training is intended for individuals 

responsible for the day-to-day support and 

supervision of staff to ensure program fidelity. 

Consult the Reconnecting YouthTM Inc. Web 

site for costs of curriculum materials and 

evaluation tools. 

Free consultation is available from the developer 

by phone, and many materials and information 

are available at no cost from the program 

Web site. 

Contacts:

For information about implementation and 

research studies: 

Reconnecting YouthTM Inc.

P.O. Box 20343

Seattle, WA 98102

Phone: 425–861–1177

Fax: 1–888–352–2819

Reconnecting YouthTM (RY)*

IOM classification: Selective, Indicated

Population of focus: Male and female students, 

grades 9 through 12, who demonstrate suicide 

risk behaviors.

Description: RY is a school-based prevention 

program that targets high school students who 

show signs of poor school achievement, potential 

for school dropout, and other at-risk behaviors 

including suicide-risk behaviors. RY teaches 

skills to build resiliency with respect to risk 

factors and to moderate early signs of substance 

abuse, depression, and aggression. The program 

incorporates social support and life skills training. 

Classes include 10 to 12 students who meet daily, 

or on a block schedule, for an entire semester. The 

class is part of the high school curriculum, and 

students receive credit for participation. The class 

is led by a teacher who excels in working with 

high-risk youth and has completed RY training. 

The focus of the class is on skills training within 

the context of adult and peer support. 

The RY class is delivered in five modules: 

1. Getting started;

2. Self-esteem enhancement;

3. Decisionmaking;

4. Personal control; and

5. Interpersonal communication.

Forty-one class sessions and 23 booster/review 

sessions are included in the curriculum, leaving 

16 class sessions for the social activities/school 

bonding components. The class involves:

• Small-group work and life skills training 

models to enhance personal and social 

protective factors of high-risk youth; 

• Social activities and school bonding for 

establishing drug-free social activities 

and friendships, and healthy, pleasant 

activities for decreasing depression as well 

as for improving the teens’ relationship 

with school;

• School system crisis response plan that 

addresses schoolwide prevention and 

intervention approaches; and

• Parent involvement that includes active 

parental consent for student participation 

and at-home support of RY goals for 

their children.

Application to AI/AN communities: The 

program has been studied in six urban schools, 

but it has been put into place in a variety of 

schools in both urban and suburban settings and 

for diverse student populations. Although its use 

in Native communities is unknown, the program 

is an option for AI/AN communities. 

2009 Cost: Costs vary depending on number of 

teachers trained, training-related costs (e.g., travel 

and substitute teacher payments), and materials. 

Cost estimates and a schedule of upcoming 
87

trainings are provided on the RY Web site.

Contacts:

Web site: http://www.reconnectingyouth.com

For RYTM Co. information, implementation 

consultation, or to schedule trainings:

Reconnecting YouthTM Inc.

P.O. Box 20343

Seattle, WA 98102

Phone: 425–861–1177

Fax: 1–888–352–2819

Attempt Response

A previous suicide attempt is a risk factor for 

suicide. According to one study of individuals 

who had survived a serious suicide attempt, 

almost half made another fatal or nonfatal 

attempt within 5 years.126 The following programs 

are designed to ensure that parents understand 

the seriousness of an attempt (or their child’s 

risk) and seek the help their children need.

Emergency Department Means Restriction 

Education for Parents*

IOM classification: Selective, Indicated

Population of focus: Youth at high risk and 

attempt survivors.

Description: The goal of this program is to 

educate parents of youth at high risk for suicide 

about limiting access to lethal means for suicide. 

Lethal means covered include firearms, over-thecounter and prescribed medications, and alcohol.

Education takes place in emergency departments 

and is conducted by department staff (an 

unevaluated model has been developed for 

use in schools). The content of the parent 

instruction includes:

• Informing parents, apart from the child, 

that their child is at risk of suicide and 

about the warning signs their child 

is exhibiting;

• Informing parents that they can reduce 

the risk by limiting access to lethal means, 

especially firearms; and

• Educating parents and problem-solving 

with them about how to limit access to 

lethal means.

Application to AI/AN communities: This 

program was evaluated with the parents of 

children of various ethnicities and with an 

average age of 14. Although its use in Native 

communities is unknown, the program is an 

option for AI/AN communities. 

2009 Cost: Protocols are available free from the 

primary program developer. Training costs for 

emergency room staff will vary. 

Contacts:

For materials and information on implementation:

Dr. Markus Kruesi 

Department of Psychiatry and Behavioral Sciences

Medical University of South Carolina

171 Ashley Avenue

Charleston, SC 29425

Phone: 843–792–0135

E-mail: Kruesi@musc.edu

Specialized Emergency Room Intervention for 

Suicidal Adolescent Females*

IOM classification: Indicated

Population of focus: Adolescent females who 

have attempted suicide and their mothers.

Description: This intervention provides 

specialized emergency room care for adolescent 

suicide attempters and their mothers or female 

guardians. It involves three primary components.

1. Emergency room physicians and staff 

engage in a single 2-hour training 

session. The session has three goals: 

Chapter 7: Promising Suicide Prevention Programs
88

to enhance staff/patient interactions, 

reinforce the importance of outpatient 

treatment, and recognize the seriousness of 

suicide attempts.

2. Suicide attempters and their mothers 

view a 20-minute video. The video is 

designed to highlight the importance of, 

and instill realistic expectations about, 

outpatient treatment.

3. Suicide attempters and their mothers meet 

with a crisis therapist who discusses the 

video, screens for additional suicide risk, 

conducts a therapy session, and contracts 

for follow-up outpatient treatment. 

Application to AI/AN communities: This 

program has been evaluated primarily with 

Hispanic mothers and is currently being used 

and evaluated by the White Mountain Apache 

Tribe working together with the Johns Hopkins 

University Center for American Indian Health.

2009 Cost: Protocols are free and available online 

at http://chipts.ucla.edu/interventions/manuals/

interer.html. Training costs for emergency 

department staff training varies.

Contacts:

For program information:

Joan Asarnow, Ph.D.

University of California, Los Angeles

760 Westwood Plaza

Los Angeles, CA 90024-1759

Phone: 310–825–0408

E-mail: jasarnow@mednet.ucla.edu

Future Program Development

Research into programs that hold promise for 

AI/AN communities is expanding, bringing 

hope to many Native communities that solutions 

can be found that have both science and 

culture as their foundation. This research is an 

evolving process. The development of prevention 

programs that work is similar to life itself in that 

it is a cycle. Within the scientific community, 

this is referred to as the science-to-service 

cycle (see Exhibit 12), in which programs are 

developed, tested, and improved in response 

to how effectively the program worked for 

the people being served. Far more feedback is 

needed from individual AI/AN communities 

on what they need and how well an existing 

program worked, given their own unique culture 

and values.

One potential bridge between program 

development that is evidence-based or culturally 

based may be through what is called practicebased evidence. This approach is gaining ground 

in many sectors because it emphasizes the study 

of what frontline people actually are doing to 

determine what is working. Practice-based 

research represents a significant shift in how 

research is conducted, including what is to be 

measured as evidence of effectiveness. It provides 

a greater voice to the people who actively engage 

in prevention and are applying practices that they 

Exhibit 12. The Science-to-Service 

Cycle

Research and

development

Monitoring and

feedback

Dissemination

and

implementation
89

believe are working. This practice-based approach 

may evolve into what the American Indian Policy 

Center calls “reality-based research.” As described 

by the Center, this approach:

... reflects the reality of American Indians 

and tells their stories, from an Indian point 

of view and from an Indian oral history 

standpoint. This reverence for oral history 

is particularly important because American 

Indian societies are based on oral tradition. 

Oral tradition preserves history, language and 

culture for American Indian communities. 

Using a method of research which respects 

and incorporates such basic tenets of a 

people’s culture makes our research more 

meaningful to Indian communities. In 

the past, Indians had a high distrust for 

researchers.... This ability to communicate 

with Indian communities and their leaders 

adds a critical component toward capacity 

building and self empowerment of American 

Indian communities.127

Another important aspect of engaging AI/AN 

communities in future program development 

and evaluation is the use of community-based 

participatory research. As the name implies, this 

form of research may involve the community in 

all aspects of the process, from determining what 

is to be studied to how the information is to be 

used. Under this approach, community-based 

organizations—such as a Tribal government— 

play a direct role in the design and conduct of the 

research study by: 

• Bringing community members into the 

study as partners, not just as subjects;

• Using the knowledge of the community to 

understand health problems and to design 

activities (i.e., programs) to improve 

health care;

• Connecting community members directly 

with how the research is done and what 

comes out of it; and

• Providing immediate benefits from the 

results of the research to the community 

that participated in the study.128

Perhaps the best way to characterize the 

principle of participatory research is “research 

which recognizes the community as a social and 

cultural entity with the active engagement and 

influence of community members in all aspects 

of the research process.”129 The best programs will 

emerge from the broadest possible involvement 

of all members of a community in developing, 

implementing, evaluating, and improving 

prevention programs.

Chapter 7: Promising Suicide Prevention Programs
90
91

Chapter 8: Federal Suicide Prevention Resources

Introduction

Collaboration has been a key theme throughout 

this guide. Just as every child should have the 

support of family and others in dealing with life’s 

challenges, every community should have help in 

promoting the mental health and well-being of 

its members. The Substance Abuse and Mental 

Health Services Administration (SAMHSA), as 

the Federal agency charged with leading national 

efforts to reduce, prevent, and improve treatment 

of mental and substance abuse disorders, takes 

its role in collaboration seriously. As directed by 

law, Federal mandate, and the compassion of its 

professionals, SAMHSA is working to provide 

States and communities with the tools that can 

help them prevent suicide.

The preceding chapter described suicide 

prevention programs listed in SAMHSA’s 

National Registry of Evidence-Based Programs 

and Practices (NREPP) and its Suicide 

Prevention Resource Center’s (SPRC’s) Best 

Practices Registry. This chapter describes 

SAMHSA programs open to American Indian 

and Alaska Native (AI/AN) community 

applicants. It also provides more detail about 

the SPRC, the National Suicide Prevention 

Lifeline, and other resources available to AI/AN 

communities in developing, implementing, 

and evaluating their suicide prevention plans. 

All of SAMHSA’s efforts are consistent with 

the 11 goals of the National Strategy for Suicide 

Prevention (see Exhibit 13).

The SAMHSA partner in many efforts 

is the Indian Health Service (IHS). The 

IHS views such collaboration as essential 

to its responsibility to uphold the Federal 

Government’s obligation to promote healthy 

AI/AN people, communities, and cultures and 

to honor and protect the inherent sovereign 

rights of Tribes. This chapter also lists IHS 

suicide prevention resources and contact 

information for IHS regional offices. 

Other Federal agencies that may offer possible 

funding of programs aimed at reducing risk 

factors related to suicide also are identified. 

Suicide Prevention Programs

In 2005, Congress passed the Garrett Lee Smith 

Memorial Act (GLS) in memory of Garrett 

Smith, the son of former Senator Gordon Smith, 

who died by suicide while at college. This Act 

passed both houses of Congress unanimously. 

“Substantial progress has been made in developing plans and 

delivering programs, but it is still only the beginning of a long-term, 

concerted effort among Federal, Tribal, State, and local community 

agencies to address the crisis. We have recognized [at the Federal level] 

that developing resources, data systems, and promising programs, 

as well as sharing information across the system, requires national 

coordination and leadership.”

 — Rober t G. McSwain, Director, Indian Health Service

Testimony Before the U.S. Senate Committee on Indian Affairs,

February 26, 2009
92

Under GLS, Congress charged SAMHSA 

with creating programs to enhance suicide 

prevention efforts at the State and local level 

and on college campuses. Since 2005, Congress 

has placed increasing emphasis on, and given 

increased funding for, suicide prevention among 

AI/AN youth and young adults. SAMHSA 

currently supports suicide prevention grants for 

AI/AN Tribes and Villages under GLS through 

its State and Tribal Youth Suicide Prevention 

and Early Intervention Grant Program, and 

for AI/AN communities through its Native 

Aspirations Program. 

AI/AN youth also are served as members of a 

larger population through SAMHSA’s Linking 

Adolescents at Risk of Suicide to Mental 

Health Services Grant Program and its Campus 

Suicide Prevention Grant Program. Additional 

information about all of SAMHSA’s suicide 

prevention programs is below. 

For up-to-date information on new requests for 

applications (RFAs), the application process, and 

due dates for each grant program, consult the 

grants homepage on the SAMHSA Web site at 

http://www.samhsa.gov/grants. Information also 

may be requested from:

Substance Abuse and Mental Health 

Services Administration

Center for Mental Health Services 

Division of Prevention, Traumatic Stress, 

and Special Programs

Suicide Prevention Branch

1 Choke Cherry Road

Rockville, MD 20857

State and Tribal Youth Suicide 

Prevention and Early Intervention 

Grant Program

This grant program supports States and Tribes 

in developing and implementing statewide or 

Tribal suicide prevention and early intervention 

strategies. Efforts funded by these grants must 

involve public and private collaboration among 

youth-serving systems, such as education, juvenile 

justice, and foster care, as well as substance abuse 

and mental health service providers. 

Exhibit 13. Goals of the National 

Strategy for Suicide Prevention

1. Promote awareness that suicide

is a public health problem that

is preventable.

2. Develop broad-based support for

suicide prevention.

3. Develop and implement strategies

to reduce the stigma associated

with being a consumer of mental

health, substance abuse, and suicide

prevention services.

4. Develop and implement suicide

prevention programs.

5. Promote efforts to reduce access to

lethal means and methods of self-harm.

6. Implement training for recognition of

at-risk behavior and delivery of

effective treatment.

7. Develop and promote effective

clinical and professional practices.

8. Improve access to and community

linkages with mental health and

substance abuse services.

9. Improve reporting and portrayals of

suicidal behavior, mental illness, and

substance abuse in the entertainment

and news media.

10. Promote and support research on

suicide and suicide prevention.

11. Improve and expand surveillance

systems.

From U.S. Public Health Service, (1999). The Surgeon 

General’s Call To Action To Prevent Suicide. 
93

Grant eligibility is open to:

1. States; 

2. Federally recognized Indian Tribes, Tribal 

organizations (as defined in the Indian 

Self-Determination and Educational 

Assistance Act), or urban Indian 

organizations (as defined in the Indian 

Health Care Improvement Act) that are 

actively involved in the development and 

continuation of a Tribal youth suicide early 

intervention and prevention strategy; and 

3. Public or private nonprofit organizations 

designated by a State, federally recognized 

Indian Tribe, Tribal organization, or urban 

Indian organization to develop or direct 

the State/Tribal-sponsored youth suicide 

prevention and early intervention strategy.

Successful applicants must: 

• Develop and implement collaborative 

prevention and early intervention strategies 

in youth-serving organizations;

• Support public and private organizations 

actively involved in such efforts;

• Provide early intervention and assessment 

services to youth who are at risk for mental 

and emotional disorders that may lead to 

suicide or a suicide attempt;

• Provide timely referrals for appropriate 

community mental health care and 

treatment to youth who are at risk for 

suicide or suicide attempts;

• Provide immediate support and 

information resources to families of youth 

who are at risk for suicide;

• Offer timely post-suicide intervention 

services, care and information to families, 

friends, and organizations affected by a 

recent youth suicide; and

• Participate in data collection and analysis 

activities and prepare an evaluation report.

Summaries, successes, and contact information 

from ongoing State and Tribal Suicide 

Prevention and Early Intervention grants are 

available at http://www.sprc.org/grantees/

statetribe/desc/S_Tdescriptions.asp.

Native Aspirations

In 2005, SAMHSA funded Native Aspirations, 

a training and technical assistance project that is 

designed to help AI/AN communities develop, 

implement, and evaluate a comprehensive, 

community-based youth violence, bullying, and 

suicide prevention program. To select eligible 

communities, the Native Aspirations project 

team developed a list of high-risk sites based 

on statistics for poverty, suicide, homicide, and 

motor vehicle accidents among youth. From that 

list, behavioral health experts from IHS, Bureau 

of Indian Affairs, and State programs identified 

those communities where the need for prevention 

resources appeared greatest. 

For each of its selected communities, Native 

Aspirations provides consultation and financial 

support and conducts facilitated events and 

training to implement a community’s prevention 

plan. Activities include site visits for project 

planning, passage of Tribal resolutions or 

executive orders, and an onsite Gathering of 

Native Americans (GONA). By providing a 

safe place to share, heal, and plan for action, 

the GONA offers hope and a positive start 

to communities. Additional onsite activities 

include a youth visioning event to gain youth 

input and involvement. GONA activities 

also include a community mobilization and 

planning event to engage as many stakeholders 

as possible—including Tribal Elders, youth, 

and representatives of local youth-serving 

systems—and to strengthen collaborations across 

IHS, States, and Native communities. 

Chapter 8: Federal Suicide Prevention Resources
94

Native Aspiration grant sites are included in the 

ongoing cross-site evaluation of State and Tribal 

Youth Suicide Prevention and Early Intervention 

sites. Preliminary lessons learned that are 

applicable to current and future prevention 

efforts are:

• A grassroots focus is essential when 

working with Tribal communities; 

• Programs and activities need to respond to 

the unique strengths and barriers that exist 

within each individual community; 

• Program development must be 

community-driven so that community 

buy-in and ownership is fostered from the 

very beginning; and 

• Involving youth leaders in community 

planning not only gets youth involved, 

but also has led to sustained funding for 

youth planning.

Linking Adolescents at Risk to Mental 

Health Services Grant Program

The Adolescents at Risk grant program provided 

funding to evaluate and document voluntary 

school-based suicide prevention programs 

being implemented in high schools. Its primary 

objective was to determine the extent to which 

these programs lead to successful referrals for 

treatment and other sources of help or the extent 

to which families are engaged in and accept the 

programs. All activities undertaken as part of this 

program were developed with respect to the ages 

of the adolescents, their cultural backgrounds, 

and the cultural backgrounds of their parents, 

legal guardians, and other caregivers.

Campus Suicide Prevention 

Grant Program

The Campus Suicide Prevention grant program 

provides funds to institutions of higher education 

to prevent suicide and suicide attempts and 

to enhance services for students who may 

experience academic challenges due to mental 

and behavioral health problems such as 

depression or substance abuse. 

Activities funded by the program include:

• Providing gatekeeper training for students 

and campus personnel;

• Conducting educational seminars related 

to suicide;

• Creating informational materials for 

campus personnel and students and 

their families;

• Operating local hotlines or promoting the 

National Suicide Prevention Lifeline; and

• Increasing student access to mental health 

services on campus or in the community.

Summaries of individual campus programs are 

available through the SPRC at http://www.sprc.

org/grantees/campus/desc/C_Udescriptions.asp.

Suicide Prevention 

Resource Center

The SPRC is a congressionally mandated, 

federally funded grant program that is managed 

through SAMHSA. The primary services offered 

by SPRC are to:

• Support the technical assistance and 

information needs of SAMHSA’s State 

and Tribal Youth Suicide Prevention 

and Early Intervention and Campus 

Suicide Prevention grantees and 

associated programs; 
95

• Develop and conduct training on 

prevention products, materials, services, 

and strategies;

• Assist States, Territories, and Tribes in 

their efforts to plan for the development, 

implementation, and evaluation of suicide 

prevention programs; 

• Collect and distribute information on best 

prevention practices;

• Facilitate informational exchanges and 

peer-to-peer mentoring using listservs and 

other technologies;

• Support the field of suicide prevention by 

developing and providing access to needed 

resources for implementing a public health 

approach; and

• Promote suicide prevention as a component 

of mental health transformation.

In addition to the Best Practices Registry 

described in the previous chapter, services and 

resources available from the SPRC include 

the following.

• Prevention support: Prevention 

specialists are available to assist the 

suicide prevention efforts of State and 

Tribal suicide prevention coalitions and 

other agencies and organizations. These 

specialists can be consulted by telephone, 

e-mail and, in some situations, are available 

for presentations and training at meetings 

and conferences.

• SPRC Training Institute: The SPRC 

Training Institute offers an array of 

training programs, including a 1-day 

workshop for mental health professionals 

on assessing and managing suicide risk, 

periodic Web-based seminars (Webinars) 

to foster dialog on a variety of topics, and a 

series of self-paced online workshops about 

youth suicide prevention. A free online 

workshop, “Planning and Evaluation for 

Youth Suicide Prevention,” is available at 

http://training.sprc.org.

• Customized information: Each 

customized page provides information 

on recognizing and responding to the 

warning signs of suicide, resources, and 

other information chosen for its relevance 

to a particular audience (including 

parents, teens, first responders, and 

attempt survivors).

• Online library: The online library is 

a searchable collection of Web-based 

resources, including data, State prevention 

plans, and information on interventions, 

funding, grant-writing, planning and 

evaluation, and public education.

• Suicide prevention news: This compilation 

of news, funding opportunities, and 

abstracts of selected research articles 

is updated weekly. A news archive also 

is available.

• SPRC mailing list: Individuals who sign 

up for the SPRC mailing list will receive 

the Weekly Spark, a newsletter with updates 

on current news and other resources, as 

well as other occasional announcements. 

Additional information about the SPRC is 

available from:

SPRC/EDC

55 Chapel Street

Newton, MA 02458-1060

Phone: 617–618–2572 or 

1–877–GET-SPRC (1–877–438–7772) 

(toll-free)

http://www.sprc.org

Chapter 8: Federal Suicide Prevention Resources
96

SPRC and State Resources

The SPRC Web site also provides links to 

individual State suicide prevention plans 

and data sheets, which can inform AI/AN 

communities about local activities, service 

gaps, and opportunities for funding and 

collaboration. SPRC maintains a complete 

listing of State planning team leaders and 

contact information. A printed copy of this list 

is included in Appendix D: Decisionmaking 

Tools and Resources. 

National Suicide Prevention 

Lifeline 

SAMHSA’s National Suicide Prevention Lifeline 

initiative is aimed at crisis centers that respond to 

callers in extreme emotional crisis. Crisis center 

workers listen to callers, assess the nature and 

severity of their crisis, and link or refer callers to 

services. Accurate assessment and response can 

be life-saving. 

The goals of this initiative are to:

• Enhance the training of crisis workers;

• Increase the number of crisis centers that 

are certified in crisis intervention;

• Improve crisis center referrals and follow 

through on referrals; and

• Encourage a consistent and clinically 

accepted approach for callers who appear 

to be at imminent risk of suicide.

Certified crisis centers are linked together 

through the National Suicide Prevention 

Lifeline at 1–800–273–TALK (8255). Telephone 

technology enables anyone in the United States 

who is in crisis to call this number and be 

forwarded to the closest crisis center. As a result 

of this initiative, there now are more than 140 

certified crisis centers in the national network. 

To ensure that veterans in emotional crisis have 

round-the-clock access to trained professionals, 

the U. S. Department of Veterans Affairs (VA) 

operates a hotline for veterans in partnership 

with SAMHSA and the National Suicide 

Prevention Lifeline. Veterans can call 1–800–

273–TALK (8255) and press “1” to reach the 

Veterans Suicide Prevention Hotline, which is 

staffed by mental health professionals. 

The National Suicide Prevention Lifeline 

initiative provides organizations and 

communities with resources to make the public 

more aware of suicide and the help that is 

available through the Lifeline. For example, 

SAMHSA has wallet cards and brochures 

that list the warning signs of suicide. Items 

such as these can be distributed in community 

centers, school-based counseling centers, and 

other locations where they will be available to 

young people contemplating suicide and to 

those who may be concerned that someone they 

know may need help. Most materials, such as 

the poster developed for AI/AN communities 

(see image), can be customized by adding 

the logos and contact information for local 

collaborating organizations.

Feeling alone, angry, hopeless?

It’s important to talk to someone. You can call right now. We are available all 

hours of the day and night, and the call is completely free and confidential.

If you or someone you know is thinking about suicide, 

call the National Suicide Prevention Lifeline: 

1-800-273-TALK (8255)

Honor Your Life

When it seems like there’s

no hope, there is help .
97

The Lifeline also offers publications for local 

distribution, such as a series of brochures 

for attempt survivors and those who care for 

them, including: 

• After an Attempt—A Guide for Taking 

Care of Yourself After Your Treatment in the 

Emergency Department;

• After an Attempt—A Guide for Taking Care 

of Your Family Member After Treatment in 

the Emergency Room; and

• After an Attempt—A Guide for Medical 

Providers in the Emergency Department 

Taking Care of Suicide Attempt Survivors. 

Although most Lifeline materials were developed 

for the general public, they provide valuable 

information for AI/AN communities. SAMHSA 

encourages these communities to adapt the 

materials and provide feedback to SAMHSA 

(Division of Prevention, Traumatic Stress, and 

Special Programs, Suicide Prevention Branch, 1 

Choke Cherry Road, Rockville, MD 20857) on 

the need for and content of materials specially 

designed for their members.

Appendix E: Web Site Resources and 

Bibliography includes a complete listing of 

resources available through the National 

Suicide Prevention Lifeline and ordering 

information. Orders can be placed online at 

http://www.samhsa.gov/shin or by calling 

SAMHSA’s Health Information Network at 

1-877-SAMHSA-7 (1-877-726-4727). All 

orders are free. 

The National Suicide Prevention Lifeline reaches 

out to new media users through a variety of 

social networking sites. Its online Lifeline Gallery: 

Stories of Hope and Recovery (http://www.lifelinegallery.org) is a safe space for survivors of suicide, 

suicide attempt survivors, those who struggled 

with suicidal thoughts, and those in the suicide 

prevention field to share their stories of hope 

and recovery. 

National Suicide Prevention Lifeline 

Initiative for AI/AN Communities

Providing access to AI/AN communities remains 

a Lifeline challenge. For some communities, 

phone service is lacking and the community 

has limited resources to start a crisis center. 

There also are cultural concerns. Off-reservation 

service providers may be unfamiliar with Tribal 

culture, and on-reservation service providers may 

feel constrained from taking action by issues 

of confidentiality. 

In 2006, SAMHSA initiated a pilot program 

to enhance Lifeline access in Indian Country. 

Lifeline crisis centers in Montana, Wyoming, 

Minnesota, North Dakota, and South Dakota 

participated in the pilot. Objectives of the pilot 

program were to:

• Facilitate relationships between 

crisis center staff and stakeholders in 

Tribal communities;

• Develop cultural awareness and sensitivity 

training for crisis workers that serve a 

designated community;

• Strengthen the effectiveness of the local 

referral systems;

• Promote culturally sensitive social 

marketing and educational materials for 

Tribal communities; and

• Identify lessons learned from the pilot 

initiative for wider application to other 

AI/AN communities.

SAMHSA also is working collaboratively with 

IHS to promote the Lifeline nationwide in 

Indian Country. 

Additional information about SAMHSA’s 

Lifeline initiative for AI/AN communities is 

available from:

Chapter 8: Federal Suicide Prevention Resources
98

Lifeline/Link2Health Solutions

Project Director

50 Broadway, 19th Floor

New York, NY 10004

Phone: 212–614–6357

http://www.suicidepreventionlifeline.org

Indian Health Service Resources

The following resources are available through 

the IHS, in support of its mission to raise the 

physical, mental, social, and spiritual health of 

AI/ANs to the highest level. 

IHS National Suicide Prevention 

Initiative

The IHS has sponsored a National Suicide 

Prevention Initiative since 2003. This initiative:

• Builds on the goals and objectives of the 

National Strategy for Suicide Prevention;

• Strives to ensure that its efforts honor and 

respect AI/AN traditions and practices;

• Acknowledges the role and wisdom of 

Elders and spiritual leaders in healing and 

wellness; and

• Works to create collaborative, holistic, 

culturally appropriate efforts between 

AI/AN communities, government 

agencies, and nonprofit organizations in 

order to prevent suicide effectively.

The IHS has made substantial progress in 

planning and delivering suicide prevention 

programs, but recognizes that this is just the 

beginning of a long-term, concerted, and 

coordinated effort among Federal, Tribal, 

State, and local community agencies. National 

coordination and leadership is required for 

the development of resources, data systems, 

and promising programs, as well as sharing 

information across the system.

As a result, the IHS initiative focuses on 

three approaches:

• Assist IHS, Tribes, Tribal organizations, 

or urban Indian organizations (I/T/Us) 

in addressing suicide through cultural 

approaches at the community level;

• Strengthen and enhance IHS’ 

epidemiological and research capabilities 

in the areas of suicide and suicide 

prevention; and

• Promote collaboration between I/T/Us 

regarding suicide prevention.

To guide overall IHS/Tribal efforts under the 

initiative, the IHS has established a National 

Suicide Prevention Committee (SPC). 

Members of the SPC represent affected AI/AN 

communities through a variety of clinical 

professions, including therapists, psychologists, 

psychiatrists, agency administrators, injury 

prevention specialists, social workers, and 

traditional practitioners from a broad geographic 

distribution and from mixed IHS, Tribal, and 

urban settings. It is the responsibility of the 

SPC to provide recommendations and guidance 

to the IHS regarding suicide prevention and 

intervention in Indian Country. 

SPC efforts include the development of an 

IHS National Suicide Prevention Strategic 

Plan and the development of Guidelines for 

Responding to I/T/U Requests for Assistance. 

The IHS National Suicide Prevention Strategic 

Plan is a first step in describing and promoting 

the accumulated practice-based wisdom in 

AI/AN communities. At its best, the plan will 

be a living and constantly changing reflection 

of the collaborative and focused efforts of the 

many people throughout AI/AN communities 

who are working to reduce suicide. The response 

guidelines will establish procedures and 

responsibilities for responding to requests for 

assistance from I/T/U organizations in the area 

of suicide prevention.
99

The IHS Suicide Prevention Initiative is 

complemented by the IHS Behavioral Health 

Initiative, which also seeks to address suicide 

prevention through a holistic, communitycentered approach. Two other focus areas that are 

closely linked to the Behavioral Health Initiative 

are the IHS Chronic Disease Management 

and Health Promotion and Disease Prevention 

Initiatives. All three of these initiatives are 

pertinent to suicide prevention efforts and seek 

to address the underlying causes of poor physical 

and mental health rather than just treat the 

symptoms. They also stress the empowerment 

and full engagement of individuals, families, and 

communities in their own health care.

IHS Community Suicide Prevention 

Web Site

IHS maintains a Community Suicide Prevention 

Web site to provide AI/AN communities with 

culturally appropriate information about best 

and promising practices, training opportunities, 

and other relevant information regarding suicide 

prevention and intervention. This site is an 

information portal in that it does not list existing 

suicide prevention programs but, instead, links 

users to the sites of program developers and to 

current research articles. The goal of the Web site, 

at http://www.ihs.gov/NonMedicalPrograms/

nspn, is to provide Native communities with the 

tools and information to create or adapt their 

own suicide prevention programs.

Additional information about the IHS Suicide 

Prevention Initiative and the Community 

Suicide Prevention Web site is available from:

Indian Health Service Headquarters

Office of Clinical and Preventive Services

801 Thompson Avenue, Suite 300

Rockville, MD 20852

E-mail: http://www.ihs.gov/

NonMedicalPrograms/nspn 

Additional resources and information about local 

IHS activities may be available through IHS 

area offices. Contact information follows. You 

also can find a current listing at http://www.ihs.

gov/FacilitiesServices/AreaOffices/AreaOffices_

index.asp. 

IHS Regional Area Offices

North Dakota, South Dakota, Iowa, and 

Nebraska

Aberdeen Area Indian Health Service

Office of Professional Services

115 4th Avenue, SE

Aberdeen, SD 57401

Phone: 605–226–7582

Fax: 605–226–7321

Alaska

Alaska Area Native Health Service

4141 Ambassador Drive, Suite 300

Anchorage, AK 99508-5928

Phone: 907–729–3686

Fax: 907–729–3689

New Mexico, Colorado, and portions of Texas 

Albuquerque Area Indian Health Service

5300 Homestead Road, NE

Albuquerque, NM 87110

Phone: 505–248–4500 

Fax: 505–248–4115

Indiana, Minnesota, Michigan, and Wisconsin

Bemidji Area Indian Health Service

522 Minnesota Avenue, NW, Room 119

Bemidji, MN 56601

Phone: 218–444–0458

Fax: 218–444–0461

Chapter 8: Federal Suicide Prevention Resources
100

Montana and Wyoming

2900 4th Avenue North

Billings, MT 59101

or

P.O. Box 36600

Billings, MT 59107

Phone: 406–247–7248

Fax: 406–247–7230

California and Hawaii

California Area Indian Health Service

650 Capitol Mall, Suite 7–100

Sacramento, CA 95814

Phone: 916–930–3927

Fax: 916–930–3952

Eastern United States and portions of Texas

Nashville Area Indian Health Service

711 Stewarts Ferry Pike

Nashville, TN 37214-2634 

Phone: 615–467–1500

Fax: 615–467–1501

Arizona, New Mexico, and portions of Utah

Navajo Area Indian Health Service 

P.O. Box 9020

Window Rock, AZ 86515

Hwy. 264 and St. Michael Road

St. Michael, AZ 86511

Phone: 928–871–5811

Fax: 928–871–5866

Oklahoma, Kansas, and portions of Texas

Oklahoma City Area Indian Health Service

701 Market Drive

Oklahoma City, OK 73114

Phone: 405–951–3820

Fax: 405–951–3780

Arizona, Nevada, and portions of Utah

Phoenix Area Indian Health Service

Two Renaissance Square

40 North Central Avenue

Phoenix, AZ 85004-4424

Phone: 601–634–5039

Fax: 601–634–5042

Idaho, Oregon, and Washington

Portland Area Indian Health Service

1220 SW Third Avenue, #476

Portland, OR 97204 

Phone: 503–326–2020

Fax: 503–326–7280 

Southern Arizona

Tucson Area Indian Health Service

7900 S. J. Stock Road

Tucson, AZ 85746-7012 

Phone: 520–295–2405

Fax: 520–295–2602

Other Federal Resources

Support for prevention programs that reduce 

suicide risk factors may be available from other 

Federal agencies, such as the online databases of 

prevention programs described in the previous 

chapter. Some agencies have funding available 

for prevention programs. Possible funding 

sources include the Office of Safe and Drug-Free 

Schools (OSDFS), part of the U.S. Department 

of Education, which funds school-based efforts 

that include projects designed to decrease drug 

involvement and youth violence. The Web site 

homepage for OSDFS is http://www.ed.gov/

about/offices/list/osdfs/index.html.

The National Center for Injury Prevention 

and Control (NCIPC), part of the Centers for 

Disease Control and Prevention (CDC), offers 

extensive information about the nature of the 

problems of youth violence and youth suicide, 

both at the local and national levels, as well as 

funding opportunities for prevention research. 

There is a direct link to CDC funding initiatives 

on the NCIPC homepage at http://www.cdc.

gov/ncipc.

The Office of Juvenile Justice and Delinquency 

Prevention (OJJDP), U.S. Department of 

Justice, has as a focus the prevention of juvenile 

delinquency and victimization. Possible support 
101

for community-based prevention efforts may be 

identified by visiting http://ojjdp.ncjrs.org and 

clicking on “funding” or “programs.” The Title 

V Community Prevention Grants Program, 

for example, funds collaborative, communitybased delinquency prevention efforts designed 

to reduce risk factors associated with juvenile 

delinquency and decrease the incidence of 

juvenile problem behavior. Many risk factors 

associated with juvenile delinquency, such as 

excessive exposure to violence, family disharmony, 

and school dropout, also are risk factors for 

suicide. Similarly, protective factors that help 

youth avoid delinquency and suicide, such as 

strong family bonds, are shared. 

U.S. Federal/Canada Collaboration

In 2003, the U.S. Department of Health and 

Human Services and Health Canada first signed 

a Memorandum of Understanding (MOU) to 

promote the health of AI/ANs in the United 

States and First Nations people and Inuit in 

Canada. A direct outcome of the MOU is the 

Ad Hoc Working Group on Suicide Prevention. 

The purpose of the working group is to make it 

easier for the countries to share knowledge about 

suicide prevention and intervention and the 

relationship of alcohol abuse to suicidal behavior. 

Working group activities may include the 

exchange of personnel as well as information and 

the hosting of workshops, conferences, seminars, 

and meetings. 

The two government agencies renewed the 

MOU in 2007. Since then, Health Canada has 

launched its youth suicide prevention Web site, at 

http://honouringlife.ca. This trilingual Web site 

(English, French, and Inuktitut) provides a place 

for Aboriginal youth to read about others dealing 

with similar issues and for those working with 

Aboriginal youth to connect, discuss, and share 

suicide prevention resources and strategies.

Conclusion

SAMHSA has established a clear vision for its 

work—a life in the community for everyone. 

To realize this vision, SAMHSA is gearing 

all of its resources—programs, policies, and 

grants—toward that outcome. 

SAMHSA currently maintains four suicide 

prevention programs that directly or indirectly 

serve AI/AN youth and young adults: State 

and Tribal Youth Suicide Prevention and 

Early Intervention, Native Aspirations, 

Linking Adolescents at Risk for Suicide to 

Mental Health Services, and Campus Suicide 

Prevention. Regardless of whether a community 

has one of these grants, its members can access 

planning, implementation, and evaluation 

support through SAMHSA’s SPRC. Additional 

services and resources that encourage individuals 

experiencing an emotional crisis to seek help 

are available through the National Suicide 

Prevention Lifeline.

SAMHSA’s prevention efforts aimed at 

AI/AN communities are still evolving as new 

information and opportunities become available. 

For example, SAMHSA is exploring the 

potential of using telepsychiatry to make mental 

health care more accessible to residents, including 

AI/ANs, living in remote and underserved areas. 

An overarching goal of all of these efforts is to 

develop a better knowledge base of what works 

best in promoting mental health and preventing 

mental illnesses and suicide among AI/ANs. To 

achieve this goal, collaboration and information 

sharing among AI/AN communities and the 

organizations and government agencies involved 

is necessary. Breaking the code of silence around 

suicide is one crucial step forward in helping 

AI/AN youth and young adults on their path 

toward a mentally healthy and promising future. 

Communities have a variety of resources to draw 

from after taking this first step.

Chapter 8: Federal Suicide Prevention Resources

103

Chapter 9: Conclusion to the Guide 

This guide is more than a summary of available 

information about preventing suicide by American 

Indian and Alaska Native (AI/AN) youth and 

young adults. It also is an acknowledgement 

that more is yet to be discovered about culturally 

appropriate prevention and far more is yet to be 

done. One of the Substance Abuse and Mental 

Health Services Administration’s (SAMHSA’s) 

objectives in developing this guide is to create a 

document that will serve as a starting point for 

both discovery and action.

It is our hope that any discussions about suicide 

prevention that this guide stimulates will go 

beyond the narrow definitions of prevention and 

risk factors. Instead, we encourage you to move 

the conversation toward mental health promotion 

and a more positive focus on protective factors. 

The goal of any community should be to help its 

members achieve a state of mental health called 

“flourishing.”130 Flourishing is characterized not 

only by an absence of mental illness but also 

by a person’s emotional well-being and positive 

functioning in daily life. It supports a life that is 

well-lived. Approaching suicide prevention from 

this perspective can transform mental health care 

in this country. 

Many of you who read this guide already will 

know a great deal about suicide prevention. Some 

of you will possess wisdom that exceeds what 

this guide offers. We encourage you to share your 

knowledge with us so that we can continue to 

learn and can help others learn more about what 

works in preventing suicide by young people. You 

can send your input directly to: 

Captain Maria Dinger, R.N., M.S.

Chief, Suicide Prevention Branch

Substance Abuse and Mental Health 

Services Administration

Center for Mental Health Services 

Division of Prevention, Traumatic Stress, 

and Special Programs

1 Choke Cherry Road

Rockville, MD 20857

Phone: 240–276–2016

E-mail: maria.dinger@samhsa.hhs.gov

For others who read this guide, the idea that 

suicide can be prevented or that you can have 

any involvement in its prevention may be new. 

We urge you to speak with those who are 

working to prevent suicide. Many lives have been 

saved because someone similar to you offered 

caring and hope to those who had lost hope or 

felt alone.

Regardless of your past experience, your future 

involvement in prevention efforts within your 

community is crucial. Suicide is a complex 

issue, and it will take an entire community 

coming together to address it successfully. 

Everyone is needed, and everyone has a role in 

suicide prevention. 

As we began this guide by quoting Inuit wisdom, 

we will end it by quoting the wisdom of White 

Buffalo Calf Woman of the Lakotas:

When one sits in the Hoop of People, 

One must be responsible because

All of Creation is related.

And the hurt of one is the hurt of all.

And the honor of one is the honor of all. And 

whatever we do affects everything in the universe.131

105

Appendix A: List of Contributors and Reviewers

Contributors

Ben Camp, M.S. Ed. was principal author; 

Charlotte Ball, M.P.A. was coauthor.

SAMHSA gratefully acknowledges the impetus 

and foundational work provided by the One Sky 

Center and R. Dale Walker, M.D., the center 

director, in creating a guide that specifically 

addresses suicide prevention of American Indian 

and Alaska Native youth and young adults. The 

One Sky Center has conducted groundbreaking 

work aimed at improving the prevention and 

treatment of substance abuse and mental health 

disorders for Native Americans. As a leader in 

this area, the center is contributing significantly 

to the development of programs that both 

recognize and build upon the traditional values, 

practices, and strengths of Native cultures. 

SAMHSA Contributors

SAMHSA staff who provided professional 

guidance and support include:

• Cynthia K. Hansen, Ph.D., Special Expert, 

CMHS, SAMHSA;

• Eileen Zeller, M.P.H., Special Expert, 

Suicide Prevention Branch, CMHS, 

SAMHSA;

• Maria Dinger, R.N., M.S., Chief, Suicide 

Prevention Branch, CMHS, SAMHSA;

• Richard McKeon, Ph.D., M.P.H., Team 

Lead, Suicide Prevention Branch, CMHS, 

SAMHSA;

• Anne Mathews-Younes, Ed.D., Director, 

Division of Prevention, Traumatic 

Stress, and Special Programs, CMHS, 

SAMHSA; and

• Estelle Bowman, J.D., Senior Advisor for 

Tribal Affairs, SAMHSA.

Oversight and Production Teams

Contractor staff members who were instrumental 

in the development and production at the end of 

this guide include:

• Mary Yakaitis, Principal Investigator, 

Gallup;

• Yvette Joseph-Fox, Project Manager, 

Kauffman & Associates, Inc.;

• Patrick Cook, Project Manager, Macro 

International Inc.;

• Gregg Deal, Graphic Designer, Kauffman 

& Associates, Inc. (book design);

• Molly Hardin, Graphic Designer, Gallup;

• Anna Morgan, Graphic Designer, 

Kauffman & Associates, Inc.;

• Kim Vigue, Communication Specialist, 

Kauffman & Associates, Inc.; and

• Christina H. Zurla, Communication 

Specialist, Gallup.

Reviewers

CMHS also wishes to acknowledge the following 

individuals for contributing their time and 

expertise in the development, review, and revisions 

of this guide. Their input was invaluable in 

developing a guide to promote the mental health 

and well-being of American Indian and Alaska 

Native youth, young adults, and communities.

Douglas Bigelow, Ph.D., One Sky Center, 

Portland, OR

Marilyn J. Bruguier-Zimmerman, M.S.W., 

Director, National Native Children’s Trauma 

Center, University of Montana, Missoula, MT

Susan W. Casias, M.S.W., ACSW ( Jicarilla 

Apache), Member of the Indian Health Service 

Suicide Prevention Committee and New Mexico 

Suicide Prevention Coalition Albuquerque, NM
106

Alexander Crosby, M.D., M.P.H., Division of 

Violence Prevention, Centers for Disease Control 

and Prevention, Atlanta, GA

Mary Cwik, Ph.D., M.A., Johns Hopkins Center 

for American Indian Health, Baltimore, MD

Barbara Franks, A.A.S. (Tlingit), Alaska Native 

Tribal Health Consortium and member of the Alaska 

Suicide Prevention Council, Anchorage, AK

Connie O’Marra Goodluck, LCSW, Community 

Coordinator, Native Aspirations, Kauffman & 

Associates, Inc., Albuquerque, NM

Betty A. Hastings, Public Health Advisor, Indian 

Health Service, Rockville, MD

Laura Louden, M.S., One Sky Center, Portland, OR

Denise Middlebrook, Ph.D., Community 

Intervention Director, Kauffman & Associates, Inc., 

Spokane, WA

Elaine Miller, M.D., FAACAP, FAAP, Indian 

Health Service, Aberdeen, SD

Lorenzo Olivas, M.P.H., Regional Minority 

Health Consultant, U.S. Public Health Service, 

Region VIII, Office of Minority Health, Denver, 

CO 80294

Project staff, Native Youth Suicide Prevention 

Program, Portland, OR

Paulette Running Wolf, Ph.D., Babb, MT

Helen Stafford, B.S.W., Ed.M., Injury Prevention 

Program Coordinator, Alaska Native Tribal Health 

Consortium, Anchorage, AK

Patricia Silk Walker, Ph.D., One Sky Center, 

Portland, OR

Rose L. Weahkee, Ph.D. (Navajo), Public Health 

Advisor, Division of Behavioral Health, and former 

director, Indian Health Service, Rockville, MD
107

Access to services – The extent to which an 

individual who needs behavioral health care and 

services is able to receive them. Access is not 

defined simply as having insurance coverage or 

the ability to pay for services. Instead, access 

also is determined by the availability and 

acceptability of services as well as their cultural 

appropriateness, location, hours of operation, 

transportation needs, and cost. 

Acculturation – The process by which 

individuals choose to remain firmly rooted in 

their natal cultural group but also may adapt 

or adopt attitudes, beliefs, and norms of a new 

(perhaps dominant) cultural group or groups.

Adaptation – Modification of a program 

or intervention so that it incorporates 

specific cultural values of a community 

while still maintaining the program’s 

principal characteristics.

Advocacy groups – Organizations that work in a 

variety of ways to foster change with respect to a 

societal issue.

Alternation – The notion that an individual 

(who may be bi-racial, mono-racial, or multiracial) can be anchored securely in one primary 

cultural identity (usually of a “minority status” 

group) while also having mastered the culture of 

a secondary group (usually, a “dominant status” 

group). In alternation, the individual will have 

formed the capacity and skills to seamlessly, or 

nearly seamlessly, shift between the two identity 

statuses with ease and comfort, depending on 

social context.

American Indian or Alaska Native – A person 

having origins in any of the original peoples of 

North and South America (including Central 

America) and who maintains Tribal affiliations or 

community attachment.

Appropriateness – The extent to which a 

particular procedure, treatment, test, or service 

is needed, adequate, and provided in the setting 

best suited to the needs of each individual. 

Assimilation – The process by which individuals 

voluntarily or involuntarily give up their 

identity with their natal cultural group and 

become absorbed into a new (usually dominant) 

cultural group.

Behavioral health disorder – Mental health or 

substance abuse disorder that affects a person’s 

ability to realize his or her full potential as a 

contributing member of the community.

Best practices – Activities or programs that 

are in keeping with the best available evidence 

regarding what is effective.

Biculturalism – The idea that individuals 

can hold and integrate two different cultural 

identities (typically, one that is of a minority 

status and one that is a majority status), taking 

from the two cultures attitudes, beliefs, and 

norms that are purposeful and meaningful 

to them.

Causal factor – A condition that alone is 

sufficient to produce a disorder. 

Community – A group of people residing in the 

same locality or sharing a common interest.

Community assessment – A comprehensive 

examination of factors that can contribute to or 

reduce the risk of behavioral health disorders, 

including suicide. A community assessment also 

identifies who is most at risk and the resources 

and partnerships that a community can access to 

reduce risk factors and increase protective factors. 

Community-based services – Services that are 

provided in a community setting. 

a This glossary is a selection of terms taken primarily from the 

National Strategy for Suicide Prevention: Goals and Objectives for 

Action. Rockville, MD: U.S. Department of Health and Human 

Services, Public Health Service, 2001.

Appendix B: Glossary of Termsa
108

Comprehensive suicide prevention plans – 

Plans that use a multifaceted approach 

to addressing the problem; for example, 

including interventions targeting social and 

environmental factors.

Connectedness – Closeness to an individual, 

group, or people within a specific organization; 

perceived caring by others; satisfaction with 

relationship to others or feeling loved and 

wanted by others.

Consumer – A person using or having used a 

health service.

Culture – The integrated pattern of human 

behavior that includes thoughts, communication, 

actions, customs, beliefs, values, and institutions 

of a racial, ethnic, faith, or social group.

Cultural sensitivity (also known as cultural 

competence or cultural appropriateness) – A 

set of values, behaviors, attitudes, and practices 

reflected in the work of an organization or 

program that enables it to be effective across 

cultures; includes the ability of the program 

to honor and respect the beliefs, language, 

interpersonal styles, and behaviors of individuals 

and families receiving services.

Culturally based – Programs based on 

traditional beliefs, values, and practices of a 

specific ethnic or cultural group.

Depression – A constellation of emotional, 

cognitive, and somatic signs and symptoms, 

including sustained sad mood or lack of pleasure.

Early intervention – A process used to recognize 

and respond to warning signs for mental health 

problems. Early intervention can reduce a 

person’s risk of developing a mental illness or 

reduce its symptoms and consequences. 

Effective – Programs that have been scientifically 

evaluated and shown to decrease an adverse 

outcome or increase a beneficial one in the target 

group more than in a comparison group.

Environmental approach – An approach 

that attempts to influence either the physical 

environment (such as reducing access to lethal 

means) or the social environment (such as 

providing work or academic opportunities).

Evaluation – The systematic investigation of the 

value and impact of an intervention or program.

Evidence-based – Programs that have undergone 

scientific evaluation and have proven to be 

effective. “Evidence” often is defined as findings 

established through scientific research, such as 

controlled clinical studies, but other methods 

of establishing evidence are considered valid as 

well. Evidence-based practice stands in contrast 

to approaches that are based on tradition, 

convention, belief, or anecdotal evidence.

Evidence-based practice (EBP) – A term 

generally used in the health care field to refer 

to approaches to prevention or treatment that 

are validated by some form of documented 

scientific evidence. 

Fidelity – The degree to which a program is 

implemented as designed. 

First responders – Law enforcement officers, 

firefighters, emergency medical technicians 

(EMTs), Tribal leaders, and others who may be 

the first to respond to a medical emergency such 

as suicide. 

Flourishing – A state of mental health that is 

characterized not just by the absence of mental 

illness but by feelings of emotional well-being 

(e.g., happiness, satisfaction with life) and 

positive functioning (e.g., self-acceptance, 

purpose in life, rewarding relationships with 

others) in daily life.

Frequency – The number of occurrences of a 

disease or injury in a given unit of time; with 

respect to suicide, frequency applies only to 

suicidal behaviors that can repeat over time.

Gatekeepers – Those individuals in a community 

who have face-to-face contact with large 

numbers of community members as part of their 

usual routine; they may be trained to identify 

persons at risk of suicide and refer them to 

treatment or supporting services.
109

Goal – A broad and high-level statement of 

general purpose to guide planning around an 

issue; it is focused on the end result of the work.

Health – The complete state of physical, mental, 

and social well-being and not merely the absence 

of disease or infirmity.

Indicated prevention intervention – 

Intervention designed for individuals at high risk 

for a condition or disorder or for those who have 

already exhibited the condition or disorder.

Intervention – A strategy or approach that is 

intended to prevent an outcome or alter the 

course of an existing condition (such as providing 

lithium for bipolar disorder or strengthening 

social support in a community).

Means – The instrument or object whereby a 

self-destructive act is carried out (e.g., firearms, 

poison, medication).

Means restriction – Techniques, policies, 

and procedures designed to reduce access or 

availability to means and methods of deliberate 

self-harm, such as building barriers on bridges to 

prevent jumping.

Methods – Actions or techniques that result 

in an individual inflicting self-harm (e.g., 

asphyxiation, overdosing, or jumping).

Mental disorder – A diagnosable illness 

characterized by alterations in thinking, mood, 

or behavior (or some combination thereof ) 

associated with distress that significantly 

interferes with an individual’s cognitive, 

emotional, or social abilities; often used 

interchangeably with mental illness.

Mental health – The capacity of individuals to 

interact with one another and the environment in 

ways that promote subjective well-being, optimal 

development, and use of mental abilities (e.g., 

cognitive, affective, and relational).

Mental health problem – Diminished cognitive, 

social, or emotional abilities that exist but do not 

meet the criteria for a mental disorder.

Mental health services – Health services that 

are specially designed for the care and treatment 

of people with mental health problems, including 

mental illnessness; includes hospital, emergency 

department, and other 24-hour services, intensive 

community services, ambulatory or outpatient 

services, medical management, case management, 

intensive psychosocial rehabilitation services, and 

other intensive outreach approaches to the care 

of individuals with severe disorders.

Mental illness – See mental disorder.

National Registry of Evidence-Based Programs 

and Practices (NREPP) (http://nrepp.samhsa.

gov) – Online database maintained by the 

Substance Abuse and Mental Health Services 

Administration of peer-reviewed programs 

and practices that have achieved measurable 

outcomes in reducing and preventing behavioral 

health disorders in children and adults. 

Objective – A specific and measurable statement 

that clearly identifies what is to be achieved in a 

plan; it narrows a goal by specifying who, what, 

when, and where or clarifies by how much, how 

many, or how often.

Outcome – A measurable change in the health 

of an individual or group of people that is 

attributable to an intervention.

Outreach programs – Programs that send 

staff into communities to deliver services or 

recruit participants.

Postvention – A strategy or approach that is 

implemented after a crisis or traumatic event 

has occurred.

Prevention – A strategy or approach that reduces 

a person’s risk of developing a mental illness, 

including a substance abuse problem, that may 

contribute to suicidal and self-harm behaviors. 

Protective (or buffering ) factors – Factors that 

make it less likely that individuals will develop 

a disorder; protective factors may encompass 

biological, psychological, or social factors in the 

individual, family, and environment.

Appendix B: Glossary of Terms
110

Public information campaigns – Largescale efforts designed to provide facts to the 

general public through various media such as 

radio, television, advertisements, newspapers, 

magazines, and billboards.

Rate – The number per unit of the population 

with a particular characteristic, for a given unit 

of time.

Resilience – Capacities within a person that 

promote positive outcomes, such as mental health 

and well-being, and provide protection from 

factors that might otherwise place that person at 

risk for adverse health outcomes.

Risk factors – Those factors that make it more 

likely that individuals will develop a disorder; risk 

factors may encompass biological, psychological, 

or social factors in the individual, family, 

and environment.

School-based services – School-based treatment 

and support interventions designed to identify 

and respond to emotional disturbances in 

children. School-based services may include 

counseling or other school-based programs for 

emotionally disturbed children, adolescents, 

and their families within the school, home, and 

community environment.

Screening – Administration of an assessment 

tool to identify persons in need of more in-depth 

evaluation or treatment.

Screening tools – Those instruments and 

techniques (e.g., questionnaires, checklists, selfassessment forms) used to evaluate individuals 

for increased risk of certain health problems.

Selective prevention intervention – 

Intervention targeted to subgroups of the 

population whose risk of developing a health 

problem is significantly higher than average.

Self-harm – The various methods by which 

individuals injure themselves, such as selflaceration, self-battering, overdoses, or 

deliberate recklessness.

Self-injury – See self-harm.

Social services – Organized efforts to advance 

human welfare, such as home-delivered meal 

programs, support groups, and community 

recreation projects.

Social support – Assistance that may include 

companionship, emotional backing, cognitive 

guidance, material aid, and special services.

Stakeholders – Entities, including 

organizations, groups, and individuals, who 

are affected by and contribute to decisions, 

consultations, and policies.

Stigma – An object, idea, or label associated with 

disgrace or reproach.

Substance abuse – A maladaptive pattern of 

substance use manifested by recurrent and 

significant adverse consequences related to 

repeated use; includes maladaptive use of legal 

substances such as alcohol; prescription drugs 

such as analgesics, sedatives, tranquilizers, and 

stimulants; and illicit drugs such as marijuana, 

cocaine, inhalants, hallucinogens, and heroin.

Suicidal act (also referred to as suicide attempt) 

– A potentially self-injurious behavior for which 

there is evidence that the person probably 

intended to kill himself or herself; a suicidal act 

may result in death, injuries, or no injuries.

Suicidal behavior – A spectrum of activities 

related to thoughts and behaviors that include 

suicidal thinking, suicide attempts, and 

completed suicide.

Suicidal ideation – Self-reported thoughts of 

engaging in suicide-related behavior.

Suicidality – Suicidal thoughts, ideation, plans, 

suicide attempts, and completed suicide.

Suicide – Death from injury, poisoning, or 

suffocation where there is evidence that a selfinflicted act led to the person’s death.

Suicide attempt – A potentially self-injurious 

behavior with a nonfatal outcome, for which 

there is evidence that the person intended to kill 

himself or herself; a suicide attempt may or may 

not result in injuries.
111

Appendix B: Glossary of Terms

Suicide attempt survivors – Individuals who 

have survived a prior suicide attempt. 

Suicide cluster – When a group of suicides or 

suicide attempts occur closer together in time 

and space than would normally be expected in a 

given community.

Suicide contagion – A phenomenon whereby 

susceptible persons are influenced towards 

suicidal behavior through knowledge of another 

person’s suicidal acts.

Suicide survivors – Family members, 

significant others, or acquaintances who have 

experienced the loss of a loved one due to suicide; 

sometimes this term is also used to mean suicide 

attempt survivors.

Surveillance – The ongoing, systematic 

collection, analysis, and interpretation of health 

data with timely dissemination of findings.

Telephone hotline (or crisis line) – A dedicated 

telephone line that is advertised and may be 

operated for emergency counseling or as a 

referral resource for callers with mental health 

problems. The number for the National Suicide 

Prevention Lifeline is 1–800–273–TALK (8255). 

Traditional healing – Ways of restoring a person 

to physical and mental health that are based on a 

group’s spiritual and cultural beliefs. 

Universal preventive intervention – 

Intervention targeted to a defined population, 

regardless of risk; this could be an entire school, 

for example, and not the general population 

per se.

Unmet needs – Identified treatment needs of 

the people that are not being met; also refers to 

treatment that is inappropriate or not optimal for 

improving a person’s behavioral health.

113

This appendix presents general statistics related 

to suicide and self-harm among American Indian 

and Alaska Native (AI/AN) youth and young 

adults. Statistics related specifically to Alaska 

Natives also are given. 

These statistics are useful in directing media 

attention to the issue of suicide—without a 

precipitating tragedy—and in completing a 

needs assessment for grant applications to 

address the broad spectrum of factors known to 

contribute to or protect against suicidal behavior. 

To the maximum extent possible but without 

violating family or Tribal privacy, statistics 

should be accompanied by real-life stories to 

ensure that the faces behind the numbers always 

are remembered. 

Local statistics should be used whenever possible 

to increase relevancy and impact and to eliminate 

the perception that all Tribes and Villages can be 

viewed as one culture or community. There are 

562 federally recognized Tribes; of these, 229 are 

AN Villages.a The circumstances of each Tribe 

or Village are shaped by its own unique location, 

culture, economy, social services, and history. 

Organizations that may have community-based 

statistics include State and county departments 

of health and Indian Health Service (IHS) 

regional and area offices and local universities. 

Note that, while grim, suicide-related statistics 

are not the primary reason that Tribal 

communities need and deserve immediate, better 

behavioral health programs for their youth and 

young adults. Instead, the reason is more basic 

and enduring: AI/AN youth and young adults are 

the living spirit of their people, their culture, and 

our Nation’s history. We must value and protect 

their health as the foundation for ensuring that 

they have equal access to the same promising 

future that we wish for all of America’s children. 

Suicide and Self-Harm Among 

American Indians and Alaska 

Native Youth and Young Adultsb

• Injuries and violence—intentional or 

accidental—were the leading causes of 

death in 2004 for AI/AN youth and young 

adults from ages 10 through 34. Injuries 

and violence account for:

– 71.6 percent of the deaths of 10–14 

year olds;

– 84.6 percent of the deaths of 15–19 

year olds; 

– 79.3 percent of the deaths of 20–24 

year olds; and 

– 60.2 percent of the deaths of 25–34 

year olds.

• Suicide was the second leading cause of 

death (after accidents) for AI/ANs for 

all age groups in 2004, and exceeded the 

Appendix C: Statistics Related to Suicide by 

American Indian and Alaska Native Youth and 

Young Adults

a Federal Register: April 4, 2008, Vol.73, No. 66, pp. 18553-18667. Available online at http://edocket.access.gpo.gov/2008/E8-6968.htm.

b Statistics represent the most recent reports as of January 2009. For more recent or additional information, check the cited data source. Web site 

links are given for all citations. 

“Suicide is not a single problem; 

rather, it is a single response 

to multiple problems.”

 — Former U.S. Surgeon General

Richard Carmona

Testimony Before the U.S. Senate

Committee on Indian Affairs,

June 15, 2005
114

rates for the general population for all age 

groups. Suicide was the reported cause of:

– 13.5 percent of the deaths of 10–14 

year olds (nearly double the percent of 

7.2 percent for all races);

– 26.5 percent of the deaths of 15–19 

year olds;

– 15.9 percent of the deaths of 20–24 

year olds; and 

– 14.7 percent of the deaths of 25–34 

year olds.c

• Suicide rates were highest for 

AI/AN male youth and young adults. 

(Comparison percentages for all males 

are in parentheses.) The rate of suicide for 

AI/AN males was:

– More than 21⁄2 times higher than the 

average rate for 15–19 year olds (32.2 

percent vs. 12.6 percent);

– Nearly 11⁄2 times higher than the 

average rate for 20–24 year olds (29.1 

percent vs. 20.8 percent); and

– More than 11⁄2 times higher than the 

average rate for 25–34 year olds (31.1 

percent vs. 20.4 percent).d

• Young people ages 15–24 make up 40 

percent of all suicides in Indian Country.e

• 234 AI/AN youth and young adults died 

by suicide in 2004 alone: 174 males and 60 

females.f These numbers most likely were 

under-reported.

• The patterns of suicide among AI/AN youth 

and young adults suggest that they usually 

and most frequently were responding to 

external stimuli (including significant family 

or interpersonal problems); had been using 

alcohol, drugs, or both; and tended not to 

have been seen previously in any behavioral 

health clinical setting.g

• Lack of available, high-quality behavioral 

health care has a profound effect on suicide: 

evidence suggests that more than 90 

percent of all youth who die by suicide had 

mental health needs before their deaths.h

Suicide and Self-Harm Among 

Alaska Native Youthi 

Readers should give special attention to the 

way in which suicide and self-harm statistics 

are reported for Alaska youth overall. Youth 

violent death rates in Alaska are based on a 

small number of actual deaths. This is due, in 

part, to the fact that both the total population of 

Alaska and the actual number of children ages 

1 through 14 are relatively small compared to 

other States. In addition, rates are reported by 

deaths per 100,000. Given the small number of 

actual deaths by suicide among ANs, (an average 

of 30.7 per year from 2001–2005)j, even a small 

change in the actual number of deaths can 

cause the rates to fluctuate substantially. For this 

reason, many of the rates reported in this section 

will be either in 5- or 10-year periods. 

Alaska had the highest death rate for youths ages 

15–19 in the Nation for 3 of the 5 years between 

c Centers for Disease Control and Prevention. (2007). Deaths: Leading causes for 2004, National Vital Statistics Reports, 56(5), November 20, 2007. 

Available online at http://www.cdc.gov/nchs/data/nvsr/nvsr56/nvsr56_05.pdf. 

d Ibid.

e Carmona, R. H. (2005). U.S. Surgeon General’s testimony on suicide prevention among Native American youth, before the Indian Affairs Committee, 

U.S. Senate, June 15, 2005. Available online at http://www.surgeongeneral.gov/news/testimony/t06152005.html.

f Centers for Disease Control and Prevention. (2007). Deaths: Leading causes for 2004, National Vital Statistics Reports, 56(5), November 20, 2007. 

Available online at http://www.cdc.gov/nchs/data/nvsr/nvsr56/nvsr56_05.pdf.

g Carmona, R. H. (2005). U.S. Surgeon General’s testimony on suicide prevention among Native American youth, before the Indian Affairs Committee, 

U.S. Senate, June 15, 2005. Available online at http://www.surgeongeneral.gov/news/testimony/t06152005.html.

h National Indian Child Welfare Association. (2005). Testimony on suicide prevention among Native American youth, before the Indian Affairs 

Committee, U.S. Senate, June 22, 2005. Available online at http://www.nicwa.org/legislation/S556_HR2440/T24000-0.pdf.

i Much of the information in this section comes from Kids Count Alaska, a multiyear project to report on the health and safety of Alaska children. 

The project is a collaboration between the Annie E. Casey Foundation and the Institute of Social and Economic Research at the University of 

Alaska-Anchorage. For more information about the project and its publications, visit http://www.kidscount.alaska.edu. 

j Alaska Bureau of Vital Statistics, http://www.hss.state.ak.us/DPH/bvs.
115

2001 and 2005. In 2004, the rate was almost 70 

percent higher than the national average. 

Of the 269 Alaska teenagers who died during 

this period, more than three-quarters died 

violently. Accidents were the most common 

cause (38 percent), followed closely by suicide 

(31 percent).

Some of these deaths can be attributed to 

environmental factors. Young people in Alaska 

face environmental conditions that may not be 

experienced by young people living in the lower 

48 States. As described in Kids Count Alaska 

2006–2007: Children in Danger, 

We have very long winters with extended 

periods of darkness and cold, and icy roads 

create dangerous driving conditions for much 

of the year. Alaska has thousands of lakes and 

rivers, as well as a very long coastline—so 

Alaskans spend a lot of time on the water. 

But waters in Alaska are deadly cold yearround. Also, much of the State is remote 

and sparsely populated, and dozens of small 

communities are accessible only by air or 

water. Advanced medical or trauma care can 

be hours away. The use of snow machines 

and all-terrain vehicles (ATVs) is widespread 

in rural areas, among both children and 

adults—and every year children are hurt or 

even killed using off-road vehicles.k

• The 5-year average for violent death rates 

across Alaska for youth (2001–2005) was 

79 per 100,000. However, violent death 

rates, including suicide, varied widely. 

Rates by region were:

– 54.1 in Anchorage;

– 64.2 in Mat-Su Borough;

– 61.9 Gulf Coast;

– 71.7 Interior;

– 240 Northern;

– 36.7 Southeast; and

– 258.5 Southwest.l

• Violent deaths appear to be on the 

increase. The 10-year average for violent 

death rates across Alaska for youth 

(1996–2005) was 34 per 100,000. Rates by 

region were:

– 14.7 in Anchorage;

– 23.2 in Mat-Su Borough;

– 14.6 Gulf Coast;

– 34.8 Interior;

– 204.9 Northern;

– 8.9 Southeast; and

– 132.4 Southwest.m

• Further analysis of the Alaska Bureau of 

Vital Statistics information for this 10-year 

period shows that, just as in other areas in 

the Nation:

– Suicide rates are higher in the 

rural areas than in urban areas such 

as Anchorage;

– The suicide rate for teen males (51 per 

100,000) was more than triple the rate 

for teen females (16 per 100,000);

– AN males represent 53 percent of all 

youth suicides in Alaska compared to 

24 percent for non-Native male youth; 

– AN females represent 16 percent of all 

youth suicides compared to 6 percent 

for non-Native female youth; and 

– Similar trends exist for suicide 

attempts and other nonfatal injuries 

throughout Alaska.n

• Hospital admissions for various kinds of 

nonfatal injuries for Alaska youth (ages 

1 to 19) by race from 2000–2005 indicate 

Appendix C: Statistics Related to Suicide by American Indian and Alaska Native Youth and Young Adults

k University of Alaska-Anchorage, Institute of Social and Economic Research (2007). Kids Count Alaska 2006–2007: Children in Danger, available 

online at http://kidscount.alaska.edu/2006-2007db/Children%20in%20dangerLL.pdf.

l Alaska Division of Public Health, Alaska Bureau of Vital Statistics, http://www.hss.state.ak.us/dph/bvs/data/default.htm.

m University of Alaska-Anchorage, Institute of Social and Economic Research (2007). Kids Count Alaska 2006–2007: Children in Danger, available 

online at http://kidscount.alaska.edu/2006-2007db/Children%20in%20dangerLL.pdf.

n Ibid.
116

that while admissions of children of all 

races equaled 5.6 per 1,000:

– AI/AN equaled 11.7 per 1,000;

– Whites equaled 3.9 per 1,000;

– Asian/Pacific Islander equaled 3.3 

per 1,000; and

– Black equaled 3.4 per 1,000.o

– As a point of reference, 67 percent of 

Alaska youth ages 1 to 19 are White, 

about 23 percent are Alaska Native, 

and 10 percent are of other races.

• Out of 1,011 hospital admissions for 

suicide attempts in Alaska Native youth 

ages 1 to 19 from 2000–2005: 

– 564 or 55.8 percent were AN;

– 364 or 36 percent were White; and

– 83 or 8.2 percent were other races.p

Background Statistics

The following statistics present a general 

overview of AI/ANs and their circumstances. 

Statistics on issues such as poverty, substance 

abuse, and child neglect are included only for the 

purpose of illustrating the complex issues that 

AI/AN communities confront in reducing risk 

factors that may contribute to suicide. Nurturing 

of children is one of the most basic aspects of 

Native cultures. Protection of children against 

harm is embedded in centuries-old spiritual 

beliefs, child-rearing methods, extended family 

roles, and systems of clans, bands, or societies. 

It is these very traditional values that will lend 

strength to Tribal and Village efforts to prevent 

suicide among their youth and young adults. 

General Demographics

Unless otherwise noted, general demographic 

figures are from the U.S. Census Bureau’s

American Community—AI and ANs: 2004.

American Community Survey Reports.

q

 Refer to 

this publication for a broader picture of AI/AN 

lifestyle characteristics.

• There are approximately 1.7 million 

American Indians. The largest Tribal group 

is Cherokee, with 331,000 Tribal members. 

• There are approximately 89,000 Alaska 

Natives. The largest Village is Eskimo, with 

about 36,000 members. 

• About one-third of AI/ANs live on 

designated reservations or Tribal and 

Village areas.r

• In 2003, nearly 80 percent (76.6 percent) 

of AI/ANs had at least a high school 

diploma, while 14.2 percent had at least 

a bachelor’s degree. (In comparison, the 

statistics for non-Hispanic White were 

88.6 and 29.7 percent, respectively.)

Health Care, Employment, and Poverty

• In 2006, 38 percent of AI/ANs under age 

65 lacked health insurance coverage.s

• The majority of those who receive IHS 

services live mainly on reservations and 

in rural communities in 35 States, mostly 

in the western United States and Alaska. 

Thirty-six percent of the IHS service area 

population resides in non-Indian areas. 

Urban Natives tend to have less access to 

hospitals, health clinics, or contract health 

services provided through the IHS and 

Tribal health programs. Studies on the 

o University of Alaska-Anchorage, Institute of Social and Economic Research (2007). Kids Count Alaska 2006-2007: Children in Danger, available 

online at http://kidscount.alaska.edu/2006-2007db/Children%20in%20dangerLL.pdf.

p Ibid.

q U.S. Census Bureau. (2007). American Community—American Indian and Alaska Natives: 2004. American Community Survey Reports. Issued May 

2007. ACS-07. Available online at http://www.census.gov/prod/2007pubs/acs-07.pdf.

r Snipp, C. M. (2005). American Indian and Alaska Native Children: Results from the 2000 Census. August 2005. Prepared by the 

Population Reference Bureau with support from the Annie E. Casey Foundation. Available online at http:// www.prb.org/pdf05/

AmericanIndianAlaskaChildren.pdf.

s Adams, P. F., Lucas, J. W., & Barnes, P. M. (2008). Summary Health Statistics for the U.S. Population: National Health Interview Survey, 2006.

National Center for Health Statistics. Vital Health Stat 10(236). Available online at http://www.cdc.gov/nchs/data/series/sr_10/sr10_236.pdf.
117

urban AI/ANs have documented frequent 

poor health and limited health care options 

for this group.t

• There are fewer than 200 doctoral-level AI 

psychologists in the U.S., far fewer than 

are needed to serve the approximately 1.6 

million AI/ANs eligible for health care 

from the IHS.u

• In 2003, the AI/AN unemployment rate 

was 15 percent, in comparison to the 

unemployment rate of 6 percent for the 

general population.v These rates are higher 

among non-gaming Tribes and may be as 

high as 80 percent on some reservations.w

• In 2003, about 29.6 of the AI/AN 

population was under age 18. (In 

comparison, about 22.3 percent of the 

non-Hispanic Whites were under age 18.) 

• In 2003, about 1 out of every 4 AI and 

ANs were living below the poverty level, 

compared to 1 out of 10 non-Hispanic 

Whites. In numbers, more than 608,000 

AI and ANs were living in poverty. The 

poverty rate among AI/AN families is 

highest among families on reservations.x

• In 1999, 20.7 percent of AI/AN families 

with children lived in poverty (compared 

with 13.6 percent for all families and 

9.4 percent for non-Hispanic White 

families). The poverty rate was higher for 

AI/AN families with children under age 5.

• In 2003, over 30 percent of AI/AN 

children under the age of 18 were living in 

poverty. In numbers, more than 250,000 

AI/AN children were living in poverty.

• Poverty among children is strongly linked 

to poorer mental health, and minority and 

uninsured children have high unmet needs 

for mental health services.y

• Compared with children living in families 

at or above the poverty line, children living 

below the poverty line are more likely to 

have difficulty in school, to become teen 

parents, and, as adults, to earn less and be 

unemployed more frequently.z, aa

• In 2003, the percentage of 16- to 24-yearold AI/ANs who were out of school and 

who had not earned a high school diploma 

or General Educational Development 

(GED) credential was 15 percent—higher 

than the 6 percent for Whites and 4 

percent for Asian/Pacific Islanders. Young 

adults who do not finish high school are 

more likely to be unemployed and earn less 

when they are employed than those who 

complete high school.bb

• In 2004, the rate of teenage pregnancy 

for AI/ANs ages 15–19 was 53 per 1,000 

births. While lower than the rate for 

Hispanic females (83/1000) and Black 

(63/1000), this rate was higher than 

that for all teenage females ages 15–19. 

Teenagers who have children are less likely 

to complete high school than their peers 

who do not have children.cc

Appendix C: Statistics Related to Suicide by American Indian and Alaska Native Youth and Young Adults

t

U.S. Department of Health and Human Services, Office of Minority Health. (n.d.) American Indian, Alaska Native Profile. Available online at 

http://www.omhrc.gov/templates/browse.aspx?lvl=2&lvlID=52.

u

American Psychological Association. (2003). Psychology in Indian Country. The Rural Psychologist, 34(6), 56. June 2003. Available online at 

http://www.apa.org/monitor/jun03/indian.html.

v

National Center for Education Statistics, U.S. Department of Education. (2005). Status and Trends in the Education of American and Alaska 

Natives. August 2005. Available online at http://nces.ed.gov/pubs2005/nativetrends/ind_8_2.asp.

wNorth American Indian Housing Council. (n.d.) Indian Housing Fact Sheet. Available online at http://www.naihc.net/news/index.asp?bid=6316.

x

National Center for Education Statistics, U.S. Department of Education. (2005). Status and Trends in the Education of American Indians and 

Alaska Natives. August 2005. Available online at http://nces.ed.gov/pubs2005/nativetrends/ind_8_2.asp.

y

Agency for Healthcare Research and Quality. (2003). Assessing Health Care Quality for Minority and Other Disparity Populations. AHRQ Pub. No. 

03-007-EF. May 2003. Available online at http://www.ahrq.gov/qual/qdisprep.pdf.

z

National Center for Education Statistics, U.S. Department of Education. (2005). Status and Trends in the Education of American Indians and 

Alaska Natives. August 2005. Available online at http://nces.ed.gov/pubs2005/nativetrends/ind_8_2.asp. 

aaIbid. 

bbIbid.

ccIbid.
118

Other Factors Contributing to Suicide 

and Behavioral Health Disorders

• Among AN students ages 15–18 

who participated in the 2007 Youth 

Risk Behavioral Surveillance System 

(YBRSS) survey:

– 31.7 percent reported feeling so sad or 

hopeless almost every day for 2 weeks or 

more in a row during the past year that 

they stopped doing some usual activities; 

– 22.5 percent had seriously considered 

attempting suicide during the previous 

12 months; 

– 18.8 percent had made a plan for 

attempting suicide during the previous 

12 months; and

– 20.2 percent reported that they had 

actually attempted suicide one or more 

times during the previous 12 months.dd

• Alcohol abuse is an intergenerational 

problem:

– More than 28 percent (28.2) of 

AI/ANs ages 12 and over binge drink, 

the highest rate of all racial groups. 

(Comparative rates are 24.6 percent 

for Whites, 23.4 percent for Hispanics, 

19.1 percent for Blacks, and 12.6 

percent for Asians.)ee

– AI/AN youth ages 12–17 have the 

highest rate of drinking of all racial 

groups. In 2006, 20.5 percent of 

AI/AN youth were current drinkers. 

(Comparative rates are 7.6 percent of 

Asian youth, 10.5 percent of Black 

youth, 15.3 percent of Hispanic youth, 

and 19.2 percent of White youth.)ff

• Substance abuse is an intergenerational 

problem:

– In 2007, the rate of current illicit 

drug use by AI/ANs ages 12 and 

older (12.6 percent) was higher than 

that of any other racial/ethnic group. 

(Comparative rates are 9.5 percent 

for Blacks, 8.2 percent for Whites, 

6.6 percent for Hispanics, and 4.2 

percent for Asians.)gg In 2007, the rate 

of substance abuse or dependence by 

persons ages 12 or older was higher 

for AI/ANs at 13.4 percent than 

for any other racial/ethnic group. 

(Comparative rates are 9.4 percent for 

Whites, 8.5 percent for Blacks, 8.3 

percent for Hispanics, and 4.7 percent 

for Asians.)hh

– In 2006, past month marijuana use, 

at 9.8 percent, was higher among 

AI/ANs ages 12 and older than for all 

other racial groups. (Comparative rates 

are 1.6 percent of Asians, 7.6 percent 

of Blacks, 5.1 percent of Hispanics, 

and 6.1 percent of Whites.)ii

– In 2006, past month marijuana use, at 

14.9 percent, among AI/ANs ages 12–

17 was more than double the rate for 

ddCenters for Disease Control and Prevention. (2008). Youth Risk Behavior Surveillance—United States, 2007. Morbidity and Mortality Weekly 

Report, 57(SS-4). June 6, 2008. Available online at http://www.cdc.gov/HealthyYouth/yrbs/pdf/yrbss07_mmwr.pdf.

eeU.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Office of Applied Studies 

(2008). Results from the 2007 National Survey on Drug Use and Health: National Findings (NSDUH Series H-34, DHHS Publication 

No. SMA 08-4343). Available online at http://oas.samhsa.gov/nsduhLatest.htm.

ffU.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Office of Applied Studies. 

(2008). National Survey on Drug Use and Health, 2006. Available online at http:// http://www.oas.samhsa.gov/NSDUH/2k6NSDUH/2k6Results.

pdf. 

ggU.S. Department of Health and Human Services Substance Abuse and Mental Health Services Administration, Office of Applied Studies 

(2008). Results from the 2007 National Survey on Drug Use and Health: National Findings (NSDUH Series H-34, DHHS Publication No. SMA 

08-4343). Available online at http://oas.samhsa.gov/nsduhLatest.htm.

hhIbid. 

ii U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Office 

of Applied Studies. (2008). National Survey on Drug Use and Health, 2006. Available online at http:// http://www.oas.samhsa.gov/

NSDUH/2k6NSDUH/2k6Results.pdf. 
119

Appendix C: Statistics Related to Suicide by American Indian and Alaska Native Youth and Young Adults

any other racial group. (Comparative 

rates were 1.5 percent of Asian youth, 

7.2 percent of Black youth, 6.3 percent 

of Hispanic youth, and 7.2 percent of 

White youth.)jj

• Violence and trauma—both historical and 

current—have significant and long-term 

effects on the mental health and well-being 

of AI/ANs across generations. AI/AN 

youth and young adults experience violence 

as witnesses and as victims at rates higher 

than those for the general population. 

– According to the National Violence 

against Women survey, at least one out 

of every three AI/AN females has been 

subject to intimate partner violence. 

Intimate partner violence includes 

rape, physical assault, or stalking. 

AI/AN women have the highest rates 

of intimate partner violence compared 

to all other groups.kk

– In Alaska, 36 percent of the victims of 

domestic violence between 2000-2003 

were AN, compared with a Native 

share of less than 20 percent of the 

adult population. Alcohol was a factor 

in an estimated 85 percent of reported 

cases of domestic violence.ll

– During the years 2000 and 2001, ANs 

were 7.6 times more likely than others 

to be victims of sexual assault.mm

– There are approximately 405,000 AI 

children in the United States today. 

An estimated 7 percent (28,000) may 

be at risk for abuse and neglect each 

year. According to the National Indian 

Child Welfare Association Web site, 

95 percent of these cases are related to 

substance abuse.nn

– About 40 percent of AI/AN child 

abuse and neglect is not reported to 

State authorities. Available statistics 

suggest rates that are more than 

twice that for other racial groups. 

According to the National Child 

Abuse and Neglect Data System, child 

maltreatment rates for Native children 

were 19.8 cases per 1,000 children. The 

U.S. Children’s Bureau recorded rates 

of 8.5/1,000 for White children and 

10.6 for Hispanic children.oo

– According to the Office of Children’s 

Services, Alaska Department of Health 

and Social Services, 1,859 or 51 

percent of all victims of substantiated 

abuse (including mental injury, neglect, 

physical abuse, and sexual abuse) 

under the age of 18 in 2006 were AN. 

Out of these cases of substantiated 

abuse 1,192 or 64 percent were 

from neglect.pp

– Alcohol plays a part in an estimated 

80 percent of all child abuse cases 

in Alaska.qq

– Between 1993 and 2001, 31.2 percent 

of AI high school students in grades 

9–12 reported carrying a weapon.rr

jjIbid. 

kkNational Women’s Health Information Center, U.S. Department of Health and Human Services. (n.d.) Minority Women’s Health: Violence. 

Available online at http://www.4woman.gov/minority/americanindian/violence.cfm.

ll University of Alaska-Anchorage, Institute of Social and Economic Research, (2004). The Status of Alaska Natives Report 2004. Available online at 

http://www.iser.uaa.alaska.edu/Home/ResearchAreas/statusaknatives.htm.

mmRosay, A., & Langworthy, R. (2003)., Descriptive Analysis of Sexual Assaults in Anchorage, Alaska. Alaska Justice Statistical Analysis Center, 

Justice Center, University of Alaska-Anchorage.

nnNational Indian Child Welfare Association. (n.d.) Child Abuse Prevention. Available online at http://www.nicwa.org/child_abuse_prevention.

ooEarle, K. (2000). Child Abuse and Neglect: An Examination of American Indian Data. National Indian Child Welfare Association. December 2000. 

Available online at http://web.archive.org/web/20061006184212/http://www.nicwa.org/resources/catalog/research/2001/04.Child%20Abuse01.

Rpt.pdf.

pp Kids Count Alaska (n.d.). Children in Danger, Kids Count Alaska 2006-2007. Available online at http://kidscount.alaska.edu/2006-2007db/

Children%20in%20dangerLL.pdf.

qq University of Alaska-Anchorage, Institute of Social and Economic Research. (2004). The Status of Alaska Natives Report 2004, Available online at 

http://www.iser.uaa.alaska.edu/Home/ResearchAreas/statusaknatives.htm.

rr U.S. Census Bureau. (2007). American community—American Indian and Alaska Natives: 2004. American Community Survey Reports. Issued 

May 2007. ACS-07. Available online at http://www.census.gov/prod/2007pubs/acs-07.pdf.
120

Federal Sources for State and 

Local Statistical Data

Substance Abuse and Mental Health Services 

Administration (SAMHSA), National Survey 

on Drug Use and Health (NSDUH)

The National Survey on Drug Use and Health 

(NSDUH) provides yearly national and statelevel data on the use of alcohol, tobacco, illicit, 

and non-medical prescription drugs in the 

United States. Other health-related questions 

also appear from year to year, including questions 

about mental health.

http://nsduhweb.rti.org/.

Indian Health Service (IHS) Area Offices 

http://www.ihs.gov/FacilitiesServices/

AreaOffices/AreaOffices_index.asp.

Suicide Prevention Resource Center

This SAMHSA-sponsored center offers 

information on suicide and suicide prevention 

activities by State as well as contact information 

for State suicide prevention planning team leaders. 

http://www.sprc.org.

Centers for Disease Control and Prevention 

(CDC), National Center for Chronic Disease 

Prevention and Health Promotion, Youth Risk 

Behavior Surveillance System

The Youth Risk Behavior Surveillance System 

(YRBSS) monitors priority health-risk behaviors 

and the prevalence of obesity and asthma among 

youth and young adults. The YRBSS includes a 

national school-based survey conducted by the 

CDC and State, Territorial, Tribal, and local 

surveys conducted by State, Territorial, and 

local education and health agencies and Tribal 

governments. YRBSS information is available 

online at http://www.cdc.gov/HealthyYouth/

yrbs/index.htm.

U.S. Census Bureau

The U.S. Census Bureau conducts regular 

surveys of the U.S. population. It analyzes 

and presents demographic data according to 

numerous variables. 

http://www.census.gov.

Some U.S. Census Bureau reports on AI/ANs 

and their communities are:

• American Community Survey - American 

Indians and Alaska Natives: 2004.

The American Community Survey is a 

new nationwide survey by the U.S. Census 

Bureau designed to provide reliable timely 

information to communities on how they 

are changing. The ACS survey is conducted 

every year. 

http://www.census.gov/prod/2007pubs/

acs-07.pdf.

• American Indian and Alaska Native 

Populations: 2000.

This report provides data on Tribal 

numbers and State locations as well as 

general information about how the U.S. 

Census Bureau compiled this information. 

http://www.census.gov/prod/2002pubs/

c2kbr01-15.pdf.

• We the People: American Indians and Alaska 

Natives in the United States, February 2006. 

This report presents a portrait of AI/ANs in 

the United States and discusses the largest 

specific Tribal groupings, reservations, 

and AN Village statistical areas as well as 

areas outside of these boundaries. It is part 

of the Census 2000 Special Report series 

that presents demographic, social, and 

economic characteristics collected from the 

2000 census. 

http://www.census.gov/prod/2006pubs/

censr-28.pdf.
121

Appendix D: Decisionmaking Tools and Resources

AMERICAN INDIAN COMMUNITY

 SUICIDE PREVENTION ASSESSMENT TOOL

Contents:

1.	 Community Identification

2.	 History of the Reservation

3.	 Life on the Reservation

4.	 Population Data

5.	 Government

6.	 Land

7.	 Environment	

8.	 Reservation Water System

9.	 Tribal Economy

10.	Recreation Activities

11.	Medical Facilities

12.	Housing

13.	Education

14.	Mortality Data

15.	Community Cohesion

16.	Family Integration Factors

17.	Identification of the Current Status of the Community

18.	Healing Process

19.	Review of Community, Tribal, Social, and Mental Health Services Delivery

20.	Community Self-Helping Process

21.	Identification of Community Infrastructure Issues

22.	Review of Self-Continuity Factors

23.	Community Treatment Plan

Developed by R. Dale Walker, MD (2005)

Adapted from SAMHSA at http://www.sprc.org/library/catool.pdf and Acting on What We Know: Preventing Youth Suicide in

First Nations (Canada) www.hc-sc.gc.ca/fnihb-dgspni/fnihb/cp/publications/preventing_youth_suicide.pdf


INSTRUCTIONS:

This document is designed as a TEMPLATE for use by a variety of American Indian

organizations. BLUE TEXT is used to highlight information and phrases that differ across

organizations. This text is included in this assessment tool as an EXAMPLE of content that can

be revised to fit specific Tribal or organizational needs.

SUGGESTED USES OF THIS TOOL: 

♦ Use for internal program assessment and planning

♦ Use as background material for grant applications

♦ Extract selected sections and include in grant applications

♦ Use the entire tool as an appendix to a grant applications

Please let us know your experience with this tool.

Also, you may contact us at the One Sky Center for information on how to access an interactive

Word document or with questions about the uses of this tool.

Phone: 503.494.3703

Fax: 503.494.2907

E-mail: oneskycenter@ohsu.edu


1. COMMUNITY IDENTIFICATION

Original _____(Insert Tribe(s) Name_____________ Lands

Insert photograph of map showing original Tribal lands

The ___(Insert Tribe(s) Name _____ Reservation or Community

Insert photograph of map showing Current Tribal lands or Reservation


2. HISTORY OF THE RESERVATION (COMMUNITY)

The terms of the _(name)______ Treaty of _(Date)____ placed the __(tribe)_______ on one large

reservation that encompassed parts of _(State)_________, and _(#)___ other states. After the

United States defeated the Indian (tribe’s name) the U.S. Government broke the _______(Tribe’s

name)_____ original reservation into several smaller ones. Not only did the U.S. government

reduce the Indians’ acreage, it also splintered the Tribe. In _(year)____ the United States reclaimed

____ million acres of the ___(tribe’s)___ and moved the _______ to the ________ Reservation.

Although the Reservation originally occupied ____ million acres, subsequent land confiscations

by the government reduced the Reservation’s size to ____ million acres.

3. LIFE ON THE RESERVATION (IN THE COMMUNITY; NATION)

The main economic activities on the ______________ Reservation are ______________. The

Tribe has established variousindustriesincluding a fairly successful casino and some light industry.

Despite these efforts to establish greater economic activity on the Reservation, Tribal members

still face high unemployment and poverty. As a matter of principle, the __________ tribes never

complied with the Indian Reorganization Act of 1935 and therefore do not receive their full share

of government funding. This lack of government dollars, meager per capita income, and high

unemployment intensify the housing and health problems on the Reservation. Many residents live

in remote areas, far away from medical care and healthy food. Housing, both in remote areas and

in towns, is in short supply, forcing many families to live in overcrowded conditions. Two out of

three Tribal members are jobless and residents’ annual income averages only $______.

Insert photograph of typical picture of the environment


4. POPULATION

Total Population:	 _________

Residing “On Reservation”:	 _________

“Registered”:	 _________

Insert photograph of typical picture of the environment

Reservation: (insert Number) Districts and District Population:

Insert District names & Population Data

District Name Population District Name Population

5. TRIBAL GOVERNMENT 

The Tribal Council consists of a ______, _________, a _____ and ____ additional Council

people who are elected by the Tribal members. The Tribal Council Chair is the head of

administration of the Tribe. The Tribal Council Chair and Council serve a term of four years, six

of them without regard to residence in any district or state. Each of the remaining members is

elected from their District. The At-large Council members are elected by the Tribe.


Statistics at a Glance

Tribal/Agency Headquarters: (Insert name of town/city )

Counties: (List Counties) Federal Reservation established: (List Year)

Population of enrolled members: ____#______

Reservation Population: ____#__

Density: ______ persons per square mile

Labor Force: ___#____

Unemployment percentage rate: _______ (#%)

Language: _____________ and English __________ Bands (or Clans): (give names of bands/clans)

6. LAND 

The ____________ Tribal members are descendants of the ____________. The Reservation

is __(name non-rez city or town & state)______________. The ________ River runs along

the _________ of the reservation and __________Creek in the ___________. The reservation

ends at the __________ County lines in the west and the __________ on its east side. The

southern line of ___________ Reservation ends with the ___________ line. The total land area

of the _______________ is ___________ million acres and of that _______________ million

is Tribally owned. The land is an important part _________ people’s life. ____(insert other

pertinent facts)_____.

Land Status: Acres

Total Area ###,###

Tribal Owned

Tribal Owned Allotted

Total Tribal owned

Non-Indian Owned

Reservoir Taken area


7. ENVIRONMENT

The following infrastructure (exists or was lost) to _____________ Tribes due to __________

(insert treaty, Act, other reasons for loss of land)___________________:

# domestic water systems # acres of waterbed # rodeo arenas

# ranch water systems # miles of main roads # race tracks

# acres of land # housing units # sawmills

8. WATER 

Water is the key to increasing the quality of life and promoting full economic development on

the ____________ Reservation. An adequate supply of good quality water is needed by many of

the ___ ( # ) __Indians and __( # )__ non-Indians living on the reservation. Problems with water

quality and inadequate supply are common throughout the reservation and have a detrimental

effect on health and quality of life as well as deterring economic growth. The availability of a

plentiful and high quality water supply is vital to the health and well being of those living on

the ___________ Reservation. The level of health and quality of life of the general population

is directly related to the quality of their domestic water supply. Many residents currently depend

on poorly constructed or low capacity individual wells or have water hauled to __(underground

cisterns, Other locations)___. These sources are often contaminated with bacteria or undesirable

minerals, provide an inadequate quantity of water, and are costly to maintain and operate.

_(Surface; Ground)_______ water is the major water source for the reservation with the

__(Water source)______ providing by far the largest part of the surface water supply. Other

reservation streams have extremely variable flow patterns and are not reliable enough for a yearround water supply. Groundwater is not as abundant as surface water and where available it is

usually adequate for only small-scale use. For these reasons, __(Name)__ is the obvious sources

for a reservation water supply system.

There has been a serious water shortage over the past three years with drinking water being

imported. The US and the Tribal government are trying to resolve the difficulties using

_____________(insert information as appropriate)________.

9. TRIBAL ECONOMY

The _________________ Tribe’s major economic occupation is _____________.

_____________ Tribe established various industries for the Tribe on the reservation (in the

Nation) and plans to develop more enterprises. In the area of economic development, the

Tribe currently operates the ______________________(name economic enterprises)_____.

The district also operates businesses such as the _______________________________their

local districts. __________ has a grocery store, ___________ has a convenience store/

gas station, ____________ has a trading post and _________ has a laundromat. Enrolled


members of ___________ own their own businesses: ___(name business owned by Tribal

members)_________________________. There are non-Indian owned businesses throughout the

reservation, primarily in ________________________________.

(List type of industry, e.g., agriculture)____________is the primary industry on the

____________ Reservation and the key to the full development of this industry is water.

Surface water in small streams, lakes, and dugouts is scattered throughout the area. Surface

water, however, is an unreliable year-round supply and generally available only during the

wet periods of spring. During drought periods, these sources of ten dry up, and livestock must

be sold or moved off the reservation. Shallow groundwater is scarce and unreliable and deep

groundwater, while generally more plentiful, is highly mineralized and of poor quality. This lack

of an adequate water supply has also reduced the livestock production on the reservation. The

grazing lands cannot be fully utilized and valuable resource is wasted. The lack of stability in

the production of feeder-cattle also discourages related industrial development such as packing

plants, cattle feeding and canneries.

Hydrologic Setting: Shallow groundwater is not obtainable on much of the

______________________Indian Reservation, and where it is found, it is often of poor quality.

Surface water, with the exception of the _____________ Rivers, though valuable and widely

distributed resources, are undependable because of scanty and erratic precipitation. Artesian

water from deeply buried bedrock aquifers underlies all of the reservation. These aquifers are

not, and probably will not become highly developed sources of water because of the high-tovery-high salinity of artesian water in most of the area.

10. RECREATION ACTIVITIES

The ______________________ Tribe has __(#)___ Casinos, the ____________ Casino located

near ______________ and the _________ near ____________.

Give information about when recreational facilities were developed. They are developing

plans to build an _____________. Hotel and motel accommodations are located in

__________________, the ___________ largest towns nearest the reservation.


Tribe/District Pow Wows (or major cultural events)

Date Type of event/Name Location

2nd Weekend in June Memorial Day Pow Wow Any town, State

______________________College sponsors a Graduation Pow Wow ________.

Chemical Prevention Program Annual Sobriety __________

Elementary School ________________

Veteran’s Day _______________

Tribal Days _________________

Other recreational and honoring activities that have special meaning:

1.	 _________ in _________ in memory of __________

2.	 _________ in _________ in memory of __________

3.	 Annual _________ events are held in the surrounding _________

4.	 Annual ______________at __________ (when)________

5.	 _______________________________

During the year, other sports activities such as basketball, softball, volleyball and horseshoe

tournaments are also held in the districts. Water sports such as boating and fishing are popular

along _______________________________ River.

11. MEDICAL FACILITIES

The reservation is located in the U.S. Indian Health Service’s __________ Area. The I.H.S.

operates a hospital at _________ and smaller clinics in the __________________________

districts. The Tribal Health Department provides a number of health services including the

Community Health Representative Program, health education, eye examinations, eyeglasses,

and Emergency Health Care including ambulance services. The Tribe also provides an elderly

nutrition program and youth recreational activities.

______________________Reservation Hospital: The 12-bed hospital at ____________, has a

staff of ________ physicians and a ________ unit that opened in ____________. Dental care

is provided in the main hospital clinic by ________ dental officers, and in a mobile clinic by

one dental officer. There are three LPN nurses and 13 registered nurses. An outpatient health

center at ___________ has ___________staff physician. There are also health stations at

_________________________. The health stations provide minimal outpatient care and are

staffed by a physician’s assistant, a public health nurse, and a community health representative.

The health stations are visited at least once per week by a physician from the _____________

hospital.


12. HOUSING 

The ______________________Housing Authority constructs and manages over 650 homes for

Tribal members living on the reservation. This includes homes on scattered sites built through

the HUD Mutual Help home ownership program on individual land or Tribal land leased for

home sites. The other housing in the districts is low-income HUD Low Rent for individual

Indian residents in reservation communities. As private housing stock is limited, some of the

______________________members own their own homes in the rural areas through other

private financing. The Bureau of Indian Affairs and the Indian Health Service have some housing

available in __________ and ____________ for their employees. The Tribe plans to build a

number of apartment complexes in the future.

The need for housing is great on _________________. The Tribe is looking into Habitat for

Humanity homes and the government Home Grant project. The average number of persons

per household in the ______________________Service Area is __________ compared to

_________ for ___(name state(s) or counties as appropriate)_____________. The average

number of persons per household for all races in the U.S. is __(obtain data from Census

Bureau)___________.

13. EDUCATION 

Schools providing K-12 educational services are located in every community on the

reservation. The Bureau of Indian Affairs operates elementary and secondary schools in

__________________. The Tribe also provides preschool education through the Head Start

program. Public schools located in __________________________. A private parochial

school, ____________, provides K-6 education in ___________. Post secondary education

is available on reservation at _____________, which offers Associate Degrees including

___________________. A bachelor’s degree in teacher education is also offered in conjunction

____________ on the ___________________ Reservation in South Dakota. Four year colleges

include:_____________________

For the __________ school year, there were _______ students enrolled in K – 12 schools on the

______________________ reservation. Of this group, _________(__%) are American Indian

students. Three elementary schools (_________________________-) and one high school

(________ High School) have a student population that is ____% American Indian. Two school

districts (_____________ and ________- Public Schools) have school populations that are ___%

American Indian. On the other end of the spectrum, one school district (____ Public Schools) has

an American Indian enrolment of ___%.

Within all the schools on the ______________________ reservation, for the 200_ – 200_ school

year, there were _______ teachers. There were _______ American Indian teachers, or ______%

of the total faculty. ______ schools had no American Indian teachers. _______ schools have

_______ American Indian teacher. The greatest number of American Indian teachers was found

in the Bureau of Indian Affairs School that has _____American Indian teachers in a faculty of

____________.


Districts Funding Source Type of School

Name Number Tribal Federal

(BIA) State Church Elementary Middle High

State or

County

14. MORTALITY DATA

Descriptive information is provided _____ of the ____ completed suicides on or at the

______________.

1)	 (Give history of medical, mental health, substance use, family, academic achievement,

previous attempts and method used. Completed through_____ (method used).

2)	

3)	

4)	


Aggregated Suicide Data

______________________Reservation

Act Occurred: Month Day, 200X – Month Day, 200X

Age Range: 15-19 years Total: 54 Report Totals

(N) (%)

Self-Destructive Act:	 Ideation with Plan	 __	 __

And attempt	 __	 __

Complete Suicide	 __	 __

Data not Entered	 __	 __

Event Logged by:	 Medical Social Worker	 __	 __

Mental Health Tech	 __	 __

Sex:	 Male	 __	 __

Female	 __	 __

Employed:	 No	 __	 __

Yes	 __	 __

Data Not Entered __	 __

Community of Residence:	 _____________ __	 __

_____________ __	 __

_____________ __	 __

_____________ __	 __

_____________ __	 __

_____________ __	 __

_____________ __	 __

_____________ __	 __

_____________ __	 __

Relationship:	 Single	 __	 __

Data Not Entered	 __	 __

Education:	 Less than 12 years	 __	 __

Some College	 __	 __

_______________	 __	 __

High School Grad/GED1	 __	 __

Data Not Entered __	 __

Method:	 Gunshot	 __	 __

Hanging	 __	 __

Stabbing/Laceration	 __	 __

Overdose	 __	 __


Car crash	 __	 __

Other	 __	 __

Previous Attempts:	 None	 __	 __

1	 __	 __

2	 __	 __

3	 __	 __

4	 __	 __

_______________	 __	 __

Data Not Entered	 __	 __

Substance Abuse Involved:	 None	 __	 __

Alcohol	 __	 __

Drugs	 __	 __

_______________	 __	 __

Location of Act:	 Home or Vicinity	 __	 __

Other	 __	 __

Jail/Prison	 __	 __

Data Not Entered	 __	 __

Contributing Factors:	 Suicide of Friend/ relative	 __	 __

Death of Friend/Relative	 __	 __

Victim of Abuse (current)	 __	 __

Victim of Abuse (past)	 __	 __

Occupational/education prob.	 __	 __

History of Substance Abuse/

Dependence	 __	 __

Divorce/Separation/Breakup	 __	 __

Financial Stress	 __	 __

History of Mental Illness	 __	 __

History of Physical Illness	 __	 __

_______________	 __	 __

Other	 __	 __

Intervention (Ideation/Att):	 No Action Taken	 __	 __

Inpatient (voluntary)	 __	 __

Inpatient (involuntary)	 __	 __

Outpatient	 __	 __

Other	 __	 __

Data Not Entered	 __	 __


15. COMMUNITY COHESION

a)	 Number of high-risk individuals (e.g., previous attempts as identified by community

workers): Please explain:

(Example: With high unemployment, isolation and a fragile economy, the use of alcohol

and drugs are a major problem).

b)	 Number of “children in care”, “in community” placements:

____(#) reported from child protective services.

c)	 ____(#) “out of community” placements at a given point in time.

d)	 Number of non suicide deaths in the past two years through “non-natural means” by type

(i.e., vehicle crashes, accidents, violence):

___________

e)	 Percentage of youth/children with addiction issues: at least ___%

f)	 Percentage of adults with addiction issues: __%

g)	 ___ (#) of family units with more than one family member with addiction issues (____ %,

by issue)

h)	 Anecdotal accounting by community workers of abuse indicators present (i.e., physical,

sexual and emotional): _______

i)	 Number of reported sexual assaults in past two years: ______________

j)	 Number of reported physical assaults in past two years: ____________

k)	 Number of family violence reports in past two years: _______________

l)	 Traumatic events that have happened in and to community include: _________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

_______________________________

m)	 Loss of respected Elders, leaders or others: Loss is _______________, but there have

been some _______________________________________________________________

________________________________________________________________________

____________________________________________

16. FAMILY INTEGRATION FACTORS

a)	 Role of Elders in extended family systems (advisors, counselors, healers)?

________________________________________________________________________

________________________________________________________________________

____________________________________


b)	 Interaction patterns (conflict, cooperation) between extended family systems/factions?

________________________________________________________________________

________________________________________________________________________

____________________________________

c)	 Familial instability (marital & family breakups)?

________________________________________________________________________

________________________________________________________________________

____________________________________

d)	 Childhood separation and loss?

________________________________________________________________________

________________________________________________________________________

____________________________________

e)	 Interpersonal and inter-familial conflict?

________________________________________________________________________

________________________________________________________________________

____________________________________

17. IDENTIFICATION OF THE CURRENT-STATUS OF THE COMMUNITY

a)	 Community ownership over “child-in-care” decision-making, involvement in supporting

“at-risk” families, role and functioning of social support systems.

________________________________________________________________________

________________________________________________________________________

____________________________________

b)	 Role of community Elders in community decision-making processes?

________________________________________________________________________

________________________________________________________________________

____________________________________

c)	 Role of positive adult role models in assisting children/youth “at-risk”?

________________________________________________________________________

________________________________________________________________________

____________________________________

d)	 Extent to which the community embraces individual members as belonging to the

collective (as opposed to “not belonging”)?

________________________________________________________________________

________________________________________________________________________

____________________________________

e)	 Extent of customary healing practices within the community based on traditional

customary practices?

________________________________________________________________________

________________________________________________________________________

____________________________________


f)	 Accepting responsibility for and addressing past sexual or physical abuse at the

community level (e.g., healing circles)?

________________________________________________________________________

________________________________________________________________________

____________________________________

g)	 Identifying and supporting individuals with friends or relatives that have committed

suicide?

________________________________________________________________________

________________________________________________________________________

____________________________________

18. HEALING PROCESS

a)	 Community ownership over “child-in-care” decision-making, involvement in supporting

“at-risk” families, role and functioning of social support systems.

________________________________________________________________________

________________________________________________________________________

____________________________________

b)	 Role of community Elders in community decision-making processes?

________________________________________________________________________

________________________________________________________________________

____________________________________

c)	 Role of positive adult role models in assisting children/youth “at-risk”?

________________________________________________________________________

________________________________________________________________________

____________________________________

d)	 Extent to which the community embraces individual members as belonging to the

collective (as opposed to “not belonging”)?

________________________________________________________________________

________________________________________________________________________

___________________________________

e)	 Extent of customary healing practices within the community based on traditional

customary practices?

________________________________________________________________________

________________________________________________________________________

____________________________________

f)	 Accepting responsibility for and addressing past sexual or physical abuse at the

community level (e.g., healing circles)?

________________________________________________________________________

________________________________________________________________________

____________________________________


g)	 Identifying and supporting individuals with friends or relatives that have committed

suicide?

________________________________________________________________________

________________________________________________________________________

____________________________________

19. REVIEW OF COMMUNITY AND TRIBAL SOCIAL AND MENTAL HEALTH 

SERVICE DELIVERY

a)	 Community relationship with the Indian Health Service (IHS):

________________________________________________________________________

________________________________________________________________________

____________________________________

b)	 State support and funding:

________________________________________________________________________

________________________________________________________________________

____________________________________

c)	 Mental health therapist contract:

1.	 Community level:

2.	 Tribal Council level:

3.	 1HS-funded:

d)	 Is access to the 1HS-funded mental health therapist on a per client fee for service basis? 

_________

e)	 Access to State mental health services: __________

f)	 Alcohol and Drug Abuse Program:

________________________________________________________________________

________________

g)	 Describe community recreation facilities or programming:

________________________________________________________________________

________________


20. COMMUNITY SELF HELPING PROCESSES

a)	 Is there a linkage between suicidal behaviors and youth development processes: response

from community workers to youth in crises; youth activities community inclusion and

involvement?

________________________________________________________________________

________________________________________________________________________

____________________________________

b)	 Efficacy of current community worker resources in identifying and monitoring high-risk

individuals; level of support proactively provided to high-risk individuals?

________________________________________________________________________

________________________________________________________________________

____________________________________

c)	 Worker or volunteer response to suicide attempts/verbalizations/gestures, organization of

response strategy, allocation of resources, community education and outreach efforts?

________________________________________________________________________

________________________________________________________________________

____________________________________

d)	 Frequency of community worker team meetings, effectiveness in identifying and serving

high risk clients, case conferencing and management procedures, task assignment and

monitoring, remedial mechanisms to improve service delivery?

________________________________________________________________________

________________________________________________________________________

____________________________________

e)	 Community worker team commitment to promoting positive mental health of high-risk

individuals by connecting them to community social structure (individual home visits,

assertive outreach, facilitating Elder involvement with high risk individuals)?

________________________________________________________________________

________________________________________________________________________

____________________________________

f)	 Strengths and weaknesses of community health and suicide service delivery system?

1.	 Strengths: _________________________________________________________

__________________________________________________________________

_____________________________________________

2.	 Weaknesses: ______________________________________________________

__________________________________________________________________

________________________________________________


21. IDENTIFICATION OF COMMUNITY INFRASTRUCTURE ISSUES

a)	 Number of persons who are homeless and “near homeless” (especially adolescents/

young adults previously “in -care”):

________________________________________________________________________

________________________________________________________________________

____________________________________

b)	 Does the community resource team ensure that its team members carry out the work?

________________________________________________________________________

________________________________________________________________________

____________________________________

c)	 Are steps being taken to ensure the continuity of culture in the community (e.g., assisting

youth to feel connected to their traditional and cultural origins)?

________________________________________________________________________

________________________________________________________________________

____________________________________

d)	 Existence of cultural facility, traditional customary practices, involvement of youth in

community culture?

________________________________________________________________________

________________________________________________________________________

____________________________________

e)	 Community history:

________________________________________________________________________

________________________________________________________________________

____________________________________

f)	 Does the community have control over finances?

________________________________________________________________________

________________________________________________________________________

____________________________________

22. REVIEW OF SELF-CONTINUITY FACTORS:

a)	 Does the community have the ability to maintain and support a sense of self-continuity by

adolescents? (e.g., help youth feel “rooted” in the customs of the community):

________________________________________________________________________

________________________________________________________________________

____________________________________

b)	 Does the community support, through individuals, transitional challenges - adolescence

to adulthood? (e.g., sense of belonging/connectedness):

________________________________________________________________________

________________________________________________________________________

____________________________________


c)	 Self identify promotion within cultural context (degree of integration/traditional customs

and practices exercised); is a cultural home provided?

________________________________________________________________________

________________________________________________________________________

____________________________________

d)	 Capacity of community culture to ground adolescents undergoing self-identity/

transitional issues; how is this addressed?

________________________________________________________________________

________________________________________________________________________

____________________________________

e)	 Degree of loss of sense of connectedness to the future (e.g., multiple placements of

children/youth in care?

________________________________________________________________________

________________________________________________________________________

____________________________________

f)	 Describe how well the current social and mental health delivery system is responding to

the community problem situation:

________________________________________________________________________

________________________________________________________________________

____________________________________

23. COMMUNITY TREATMENT PLAN

a)	 What challenges need to be addressed? 

b)	 What strengths does the community have, that can be built on to address the current

situation?

c)	 How can “cultural continuity” within the community be strengthened? 

d)	 What is the “treatment plan” for the community? 

e)	 What is the estimated duration/timeline of the plan? 

f)	 What resources are needed based on effective use of existing resources?

g)	 What are the desired outcomes and when and how progress towards these outcomes will be

measured? Please explain.


143

State Prevention Planning 

Contact Informationa

The following is an alphabetical listing of States 

and Territories along with contact information 

for the persons who are taking the lead in the 

State plan development or implementation 

process. This information is intended for use 

by anyone who would like to be involved in his 

or her State team. Some States have multiple 

leaders, and we have made an effort to include 

all of them. State coalition members may send 

updated contact information to info@sprc.org. 

Individuals also may request updated contact 

information for their area from info@sprc.org.

Alabama

Dollie Hambrick

Director

Alabama Department of Public Health

201 Monroe Street, Suite 1010

Montgomery, AL 36104

Phone: 334–206–5226

Fax: 334–206–5663

E-mail: dhambrick@adph.state.al.us

Judith Harrington, Ph.D.

AL Suicide Prevention Task Force

The Crisis Center

3600 8th Avenue South, Suite 501

Birmingham, AL 35222

Phone: 205–226–2400

E-mail: judithharrington@att.net

Alaska

L. Diane Casto

Manager

Department of Health and Social Services

P.O. Box 110620

Juneau, AK 99811

Phone: 907–465–1188

Fax: 907–465–1189

E-mail: diane.casto@alaska.gov

a

 Contact information current as of 2009. Updated contact information can be found at www.sprc.org/stateinformation.

James Gallanos

Project Coordinator

Department of Health and Social Services

P.O. Box 110620

Juneau, AK 99811

Phone: 907–465–8536

Fax: 907–465–1189

E-mail: james.gallanos@alaska.gov

Arizona

Lisa Shumaker, M.A.

Prevention Manager–ADHS, Division of 

Behavioral Health Services

Arizona Department of Health Services

150 North 18th Avenue, #220

Phoenix, AZ 85007

Phone: 602–364–4594

Fax: 602–364–4767

E-mail: SHUMAKL@azdhs.gov

Arkansas

Shelby Chandler

Executive Director

Northwest Arkansas Crisis Intervention Center

614 E. Emma Avenue, Suite 213

Springdale, AR 72764

Phone: 479–756–1995

E-mail: schandler@nwacrisiscenter.org

Carol Robinson

Instructor, Community Relations Division

State of Arkansas Attorney General’s Office/

Community Relations Division

323 Center Street, Suite 200

Little Rock, AR 72201

Phone: 501–682–3654

E-mail: carol.robinson@arkansasag.gov

California

Linda Borders–Killian

Volunteer Chief Executive Officer

The Jacquelyn Bogue Foundation for 

Suicide Prevention

18627 Brookhurst Street, #328

Fountain Valley, CA 92708

Phone: 714–964–4886

E-mail: Bordersls@aol.com
144

Dave Neilsen

Chief, Children and Family Services

Department of Mental Health

1600 9th Street, Room 151

Sacramento, CA 95814

Phone: 916–654–2952

Fax: 916–654–2147

E-mail: dneilsen@dmhhq.state.ca.us

Colorado

Brenda Gierczak

Program Coordinator

Suicide Prevention Coalition of Colorado

Mental Health Association of Colorado

1385 South Colorado Blvd., Suite 610

Denver, CO 80222

Phone: 720–208–2251

E-mail: bgierczak@mhacolorado.org

Jarrod Hindman, M.S.

Program Manager

Colorado Department of Public Health 

and Environment

4300 Cherry Creek Drive South 

PSD–ISVP–A4

Denver, CO 80246

Phone: 303–692–2539

Fax: 303–691–7901

E-mail: jarrod.hindman@state.co.us

Connecticut

Margie Hudson

Violence Prevention Program Coordinator

Department of Mental Health and 

Addiction Services

410 Capitol Avenue, #11PRE

P.O. Box 340308 

Hartford, CT 06134

Phone: 860–509–7805

E-mail: margie.hudson@ct.gov

Delaware

Renata Henry

Director

Delaware Department of Health and 

Social Services

1901 North Dupont Highway

New Castle, DE 19720

Phone: 302–255–9399

Victoria Kim

Project Director of Suicide Prevention

Mental Health America of Delaware

100 West 10th Street, Suite 600

Wilmington, DE 19801

Phone: 302–654–6833

E-mail: vkim@mhainde.org

District of Columbia

Sherry Billings, M.Ed.

Division Manager

District of Columbia Department of 

Public Health

825 North Capitol Street, NE 

3rd Floor, Room 3150

Washington, DC 20002

Phone: 202–442–9173

Fax: 202–442–4796

E-mail: sherry.billings@dc.gov

Florida

Allyson Adolphson

Suicide Prevention Specialist

Florida Office of Drug Control

Statewide Office of Suicide Prevention, 

Executive Office of the Governor

The Capitol, Suite 2105

Tallahassee, FL 32399

Phone: 850–922–9350

E-mail: Allyson.Adolphson@eog.MyFlorida.com

Erin MacInnes

Director

Florida Office of Drug Control

Statewide Office of Suicide Prevention, 

Executive Office of the Governor 

The Capitol, Suite 2105 

Tallahassee, FL 32399

Phone: 850–922–0498

E-mail: Erin.MacInnes@eog.MyFlorida.com 

Georgia

Lisa Dawson

Director

Department of Public Health

2 Peachtree Street, NW, Suite 407

Atlanta, GA 30303

Phone: 404–657–6335

Appendix D: Decisionmaking Tools and Resources

(Note: Contact information current as of 2009. Updated contact information can be found at www.sprc.org/stateinformation.)
145

Martha Vogt

Chair

Suicide Prevention Coalition of Georgia

10510 Waters Ridge Drive

Alpharetta, GA 30022

Phone: 678–405–2277

E-mail: mvogt@mindspring.com

Guam

Barbara Benavente

Supervisor

Guam Department of Mental Health 

and Substance Abuse

Prevention and Training Branch

790 Governor Carlos G. Camacho Road

Tamuning, GU 96913

Phone: 671–477–9079

E-mail: barbara.benavente@mail.dmhsa.guam.gov

Hawaii

Art Tani

Suicide Prevention Coordinator

Hawaii Department of Health—Mental Health

Injury Prevention & Control Program

1250 Punchbowl Street, Suite 214

Honolulu, HI 96813

Phone: 808–586–5939

E-mail: arthur.tani@doh.hawaii.gov

Idaho

Ross Edmunds

CMH Program Specialist

Idaho Department of Health and Welfare

450 West State Street

P.O. Box 83720

Boise, ID 83720

Phone: 208–334–5726

E-mail: edumndsr@dhw.idaho.gov

Kim Kane

Executive Director

SPAN Idaho

816 West Bannock Street, Suite 303

Boise, ID 83702

Phone: 208–860–1703

E-mail: kkane@spanidaho.org

Illinois

Jennifer L. Martin

Injury Prevention Coordinator

Illinois Department of Public Health

535 West Jefferson, 2nd Floor

Springfield, IL 62761

Phone: 217–558–4081

Fax: 217–524–2831

E-mail: Jennifer.L.Martin@illinois.gov 

Carol Wozniewski

Chair Elect, Illinois Suicide Prevention Alliance

Mental Health America of Illinois

70 East Lake Street, Suite 900

Chicago, IL 60601

Phone: 312–368–9070

Fax: 312–368–0283

E-mail: cwoz@mhai.org

Indiana

Colleen Carpenter, M.A., M.P.H.

Project Coordinator, Indiana Suicide 

Prevention Coalition

Indiana University–Purdue University Fort Wayne

2101 East Coliseum Blvd., Neff 130F

Fort Wayne, IN 46805

Phone: 260–481–4184

Fax: 260–481–5767

E-mail: carpentc@ipfw.edu

Iowa

Dale Chell

Youth Suicide Prevention Coordinator

Iowa Department of Public Health

321 E. 12th Street

Des Moines, IA 50319

Phone: 515–242–5122

Fax: 515–281–4535

E-mail: dchell@idph.state.ia.us

(Note: Contact information current as of 2009. Updated contact information can be found at www.sprc.org/stateinformation.)
146

Binnie LeHew

Bureau Chief, Disability and Violence Prevention

Iowa Department of Public Health

321 East 12th Street

Des Moines, IA 50319

Phone: 515–281–5032

Fax: 515–281–4535

E-mail: blehew@idph.state.ia.us

Kansas

Marcia Epstein, L.M.S.W.

Director

Headquarters Counseling Center

211 East 8th Street, Suite C

P. O. Box 999

Lawrence, KS 66044

Phone: 785–841–9900

E-mail: me@hqcc.lawrence.ks.us

Kentucky

Michael McFarland

Kentucky State Suicide Prevention Coordinator

Kentucky Cabinet for Health Services

100 Fair Oaks Lane, 4E–D

Frankfort, KY 40621

Phone: 502–564–4456

Fax: 502–564–9010

E-mail: michael.mcfarland@ky.gov

Jan Ulrich

Marketing & Training Coordinator

Department for Mental Health & Mental 

Retardation Services

100 Fair Oaks Lane, 4E–D

Frankfort, KY 40621

Phone: 502–564–4456

E-mail: jan.ulrich@ky.gov

Louisiana

Trina Evans Williams

State Project Director

Louisiana Department of Health

628 N. 4th Street, 4th Floor

P. O. Box 4049

Baton Rouge, LA 70821

Phone: 225–342–9457

Fax: 225–342–8687

E-mail: tevans@dhh.la.gov

Maine

Cheryl DiCara, B.S.W.

Project Director

Maine Department of Health and 

Human Services

11 State House Station

Key Bank Plaza, 286 Water Street, 5th Floor

Augusta, ME 04333

Phone: 207–287–5362

Fax: 207–287–7213

E-mail: cheryl.m.dicara@maine.gov 

Maryland

Henry Westray, Jr., L.C.S.W.

Director

State of Maryland

55 Wade Avenue

Catonsville, MD 21228

Phone: 410–402–8494

E-mail: westrayh@dhmh.state.md.us

Massachusetts

Kimberly D. Gleason

Co–Chair

Massachusetts Coalition for Suicide Prevention

American Foundation for Suicide Prevention

56 Broad Street

Boston, MA 02109

Phone: 617–439–0940

Roberta Hurtig

Co–Chair

Massachusetts Coalition for Suicide 

Prevention Samaritans

141 Tremont Street, 7th Floor

Boston, MA 02111

Phone: 617–536–2460

Michigan

Larry Lewis

Chair

Michigan Suicide Prevention Coalition

24760 Arsenal Road

Brownstown, MI 48134

Phone: 734–782–1641

E-mail: spanmich@comcast.net

Appendix D: Decisionmaking Tools and Resources

(Note: Contact information current as of 2009. Updated contact information can be found at www.sprc.org/stateinformation.)
147

Patricia Smith, M.S.

Coordinator, Violence Prevention Program

Michigan Department of Community Health

P.O. Box 30195

Lansing, MI 48909

Phone: 517–335–9703

Fax: 517–335–9669

E-mail: smithpatk@michigan.gov

Minnesota

Dr. Dan Reidenberg

Executive Director

Suicide Awareness Voices of Education

8120 Penn Avenue South, Suite 470 

Minneapolis, MN 55431

Phone: 952–946–7998

E-mail: dreidenberg@save.org

Mississippi

Roderick Richardson, Ed.M., M.S.

Director, Mississippi Department of Health

Department of Mental Health

570 East Woodrow Wilson Ave, Annex 301

P.O. Box 1700

Jackson, MS 39215

Phone: 601–576–7781

Fax: 601–576–7444

E-mail: Roderick.Richardson@msdh.state.ms.us

Missouri

Joseph Parks

Director, Comprehensive Psychiatric Services

Missouri Department of Mental Health

1706 East Elm Street

P.O. Box 687

Jefferson City, MO 65102

Phone: 573–751–2794

Fax: 573–526–7929

E-mail: joe.parks@dmh.mo.gov 

Scott Perkins, M.S.W.

Project Coordinator–MO Inst. of Mental Health

Missouri Department of Mental Health

1706 East Elm St, P.O. Box 687

Jefferson City, MO 65102

Phone: 573–751–8155

Fax: 573–751–7815

E-mail: scott.perkins@dmh.mo.gov

Montana

Deborah Henderson

Manager, Child, Adolescent, and Community 

Health Services

Montana Department of Public Health 

and Human Services

1400 Broadway, Room C314

Helena, MT 59620

Phone: 406–444–2794

Fax: 406–444–2606

E-mail: dhenderson@mt.gov

Karl Rosston, L.C.S.W.

Suicide Prevention Coordinator

Montana Department of Public Health 

and Human Services

555 Fuller

P.O. Box 202905

Helena, MT 59620

Phone: 406–444–3349

E-mail: krosston@mt.gov

Nebraska

David Miers

Manager, Program Development & Outpatient 

Mental Health

Bryan LGH Medical Center West

2300 South 16th Street

Lincoln, NE 68502

Phone: 402–475–1011

E-mail: Dave.Miers@BryanLGH.org

Nevada

Misty Vaughan Allen

Suicide Prevention Coordinator

Nevada Department of Health and Human 

Services, Nevada Office of Suicide Prevention

4126 Technology Way, Room 100

Carson City, NV 89706

Phone: 775–684–3475

E-mail: mvallen@dhhs.nv.gov

(Note: Contact information current as of 2009. Updated contact information can be found at www.sprc.org/stateinformation.)
148

Linda Flatt

Facilitator–Office of Suicide Prevention

Nevada Department of Health and Human 

Services, Nevada Office of Suicide Prevention

4220 South Maryland Parkway, Building B, 

Suite 302B

Las Vegas, NV 89119

Phone: 702–486–8225

Fax: 702–486–3533

E-mail: lflatt@dhhs.nv.gov

New Hampshire

Elaine Frank

Co–chair of State Council

NH Suicide Prevention Council

Program Director

One Medical Center Drive 

Lebanon, NH 03756

Phone: 603–653–1135

E-mail: Elaine.M.Frank@Dartmouth.edu

Jo Moncher

Co–Chair of State Council

Suicide Prevention State Council of 

New Hampshire

129 Pleasant Street 

Concord, NH 03301

Phone: 603–271–4402

E-mail: JAMoncher@dhhs.state.nh.us

New Jersey

Kathleen Mackiewicz, R.N.

Supervising Program Development Specialist

Department of Health and Senior Services 

50 East State Street

P.O. Box 364

Trenton, NJ 08625

Phone: 609–292–8104

E-mail: Kathleen.Mackiewicz@doh.state.nj.us

New Mexico

Joan Murphy

Chair

New Mexico Suicide Prevention Coalition

1301 Siler Road, Building F

Santa Fe, NM 87505

Phone: 505–476–8238

Fax: 505–476–8201

E-mail: jmurphy@nmsuicideprevention.org

Gwendolyn Packard

Executive Director 

New Mexico Suicide Prevention Coalition

P.O. Box 3631

Albuquerque, NM 87190

Phone: 505–401–9382

E-mail: gwen@nmsuicideprevention.org

New York

John A. Owens

Assistant Director

Office of Mental Health New York

44 Holland Avenue

Albany, NY 12229

Phone: 518–408–2139

Fax: 518–486–7988

E-mail: jowens@omh.state.ny.us

North Carolina

Jane Ann Miller, M.P.H.

Violence Prevention Program Consultant

State of North Carolina

1915 Mail Service Center

Raleigh, NC 27699

Phone: 919–707–5430

E-mail: Jane.Miller@ncmail.net

North Dakota

Mary Dasovick, R.N.

Division Director

North Dakota Department of Health

Department 301 

600 East Blvd. Avenue 

Bismarck, ND 58505

Phone: 701–328–3340

Fax: 701–328–1412

E-mail: mdasovic@nd.gov

Appendix D: Decisionmaking Tools and Resources

(Note: Contact information current as of 2009. Updated contact information can be found at www.sprc.org/stateinformation.)
149

Gail Erickson

Suicide Prevention Director

North Dakota Department of Health

Division of Injury Prevention and Control

600 East Blvd. Avenue, Department 301

Bismarck, ND 58505

Phone: 701–328–4580

Fax: 701–328–1412

E-mail: gherickson@nd.gov

Ohio

Carolyn Givens

Executive Director

Ohio Suicide Prevention Foundation

1900 Kenny Road

Columbus, OH 43210

Phone: 614–292–9268

E-mail: givens.62@osu.edu

Cheryl Holton

Program Administrator

Ohio Suicide Prevention Foundation

1900 Kenny Road

Columbus, OH 43210

Phone: 614–688–4480

E-mail: holton.32@osu.edu 

Oklahoma

Jessica Hawkins

Prevention Program Manager

Oklahoma Department of Mental Health and 

Substance Abuse

1200 Northeast 13th

Oklahoma City, OK 73152

Phone: 405–522–5952

Fax: 405–522–3767

E-mail: jhawkins@odmhsas.org

Phil Lowe, L.P.C.

Chair

Oklahoma Youth Suicide Prevention Council

860 South Aspen

Broken Arrow, OK 74012

Phone: 918–258–6545

Fax: 918–251–9539

E-mail: plowe@yst.org

Oregon

Lisa Millet, M.S.H.

GLS Project Director

Oregon Public Health Division, DHS

800 Northeast Oregon Street, Suite 772

Portland, OR 97232

Phone: 971–673–1059

Fax: 971–673–0990

E-mail: Lisa.M.Millet@state.or.us

Donna Noonan

Youth Suicide Prevention Coordinator

Oregon Public Health Division, DHS

800 Northeast Oregon Street, Suite 772

Portland, OR 97232

Phone: 971–673–1023

Fax: 971–673–0990

E-mail: donna.noonan@state.or.us 

Pennsylvania

Sherry Peters

Chief, Division of Policy and 

Program Development

Office of Mental Health and Substance 

Abuse Services

Bureau of Children’s Behavioral Health Services

Beechmont Building, 2nd Floor

P.O. Box 2675

Harrisburg, PA 17105

Phone: 717–772–7855

E-mail: shepeters@state.pa.us

Rhode Island

Beatriz Perez

Manager, Safe Rhode Island

Rhode Island Department of Health

3 Capitol Hill, Room 409

Providence, RI 02908

Phone: 401–222–7627

Fax: 401–222–4415

E-mail: beatriz.perez@health.ri.gov

(Note: Contact information current as of 2009. Updated contact information can be found at www.sprc.org/stateinformation.)
150

South Carolina

Mary S. Kelly, L.M.S.W.

Social Work Consultant

Department of Health and Environmental Control

P.O. Box 1987

Columbia, SC 29202

Phone: 803–545–4102

Fax: 803–545–4445

E-mail: kellyms@dhec.sc.gov

South Dakota

Franklin Cook, M.A.

Community Liaison

South Dakota Council of Mental Health Centers

S.D. Strategy for Suicide Prevention

617–1/2 St. Joseph, #10

Rapid City, SD 57701

Phone: 605–209–0292

Fax: 1–866–415–7841

E-mail: franklin@unifiedcommunities.com

Janet Kittams–Lalley, M.A., L.P.C.

Clinical Coordinator

South Dakota Department of Human Services

HELP!Line Center

1000 North West Avenue

Sioux Falls, SD 57104

Phone: 605–274–1419

Fax: 605–332–1333

E-mail: Janet@helplinecenter.org

Tennessee

Scott Ridgway, M.S.

Executive Director

Tennessee Suicide Prevention Network

2008 8th Avenue,

P.O. Box 40329

Nashville, TN 37204

Phone: 615–297–1077

Fax: 615–313–9981

E-mail: sridgway@tspn.org

Texas

Merily Keller, M.A.

Consultant

Texas Department of State Health Services

Mental Health Association in Texas

1414 Circle Ridge Drive

Austin, TX 78746

Phone: 512–327–8689

Fax: 512–327–1752

E-mail: mhkeller@onr.com

Amanda Summers–Fox

Suicide Prevention Officer

Texas Department of State Health Services

909 West 45th Street

Austin, TX 78751

Phone: 512–206–5087

Fax: 512–206–4784

E-mail: Amanda.Summers–Fox@dshs.state.tx.us

Utah

Sherri Wittwer, M.P.A.

Executive Director 

NAMI Utah Chapter

450 South 900 East, #160

Salt Lake City, UT 84102

Phone: 801–323–9900

E-mail: sherriwittwer@msn.com 

Vermont

Edith Munene, M.A.

Public Health Specialist, Injury Control 

and Prevention

Vermont Department of Health

101 Cherry Street

P.O. Box 70

Burlington, VT 05402

Phone: 802–651–1978

Fax: 802–651–1634

E-mail: emunene@vdh.state.vt.us

Virginia

Christy Letsom

Chair, Virginia Suicide Prevention Coalition

The Crisis Line

P.O. Box 3278

Norfolk, VA 23514

Phone: 757–622–1309

E-mail: cletsom@theplanningcouncil.org

Appendix D: Decisionmaking Tools and Resources

(Note: Contact information current as of 2009. Updated contact information can be found at www.sprc.org/stateinformation.)
151

Calvin Nunnally, Sr., M.S.

Suicide Prevention Manager

Virginia Department of Health

109 Governor Street, Suite 200

Richmond, VA 23219

Phone: 804–864–7736

Fax: 804–864–7748

E-mail: Calvin.Nunnally@vdh.virginia.gov

Washington

Sue Eastgard, M.S.W.

Executive Director

Youth Suicide Prevention Program Washington

444 Northeast Ravenna Blvd., #401

Seattle, WA 98115

Phone: 206–297–5922

Fax: 206–297–0818

E-mail: suee@yspp.org

Debbie Ruggles, M.B.A.

Violence Prevention Specialist, WA 

Department of Health

Department of Public Health—State of Washington

310 Israel Road South East

Tumwater, WA 98501

Phone: 360–236–2859

Fax: 360–236–2830

E-mail: Debbie.ruggles@doh.wa.gov 

West Virginia

David Majic

Director, Division of Children’s Mental Health

West Virginia Department of Health 

and Human Resources

350 Capitol Street, Room 350

Charleston, WV 25301

Phone: 304–558–0627

Fax: 304–558–1008

E-mail: dmajic@wvdhhr.org

Bob Musick

Director

West Virginia Council for Prevention of Suicide 

Valley HealthCare

301 Scott Avenue

Morgantown, WV 26505

Phone: 304–296–1731

Fax: 304–293–5322

E-mail: bmusick@valleyhealthcare.org

Wisconsin

Shel Gross, M.P.A.

Director of Public Policy

Mental Health America of Wisconsin

133 South Butler Street

Madison, WI 53704

Phone: 608–250–4368

Fax: 608–442–7907

E-mail: shelgross@tds.net

Wyoming

R. Keith Hotle, J.D., M.P.A.

Project Director, WY Youth Suicide 

Prevention Initiative 

Wyoming Department of Health

6101 Yellowstone Road, Room 220

Cheyenne, WY 82001

Phone: 307–777–3318

E-mail: keith.hotle@health.wyo.gov

(Note: Contact information current as of 2009. Updated contact information can be found at www.sprc.org/stateinformation.)
152

Additional Tools for Assessment 

and Planning, School-Based 

Program Planning, and Coalition 

Building

Assessment and Planning Tools

Assessing and Planning Toolkit for Suicide 

Prevention in First Nations Communities

This publication has been developed to help 

individuals and groups interested in addressing 

the issue of suicide in their communities. 

It is a framework to guide First Nations in 

assessing and planning a suicide prevention plan. 

Communities are encouraged to adapt the tool to 

meet their own needs. The toolkit also provides 

information and research on suicide prevention 

to increase awareness and encourage discussion.

http://www.naho.ca/firstnations/

english/documents/toolkits/FNC_

SuicidePreventionToolkit.pdf. 

Coming Together To Care: A Suicide 

Prevention Toolkit for Texas Communities 

This suicide prevention toolkit for Texas 

communities is organized in two parts. The first 

covers the basic knowledge that people need to 

have in order to act effectively on this issue, and 

the second covers actions they can take once 

they have that basic knowledge. The authors’ 

goal is to make this a very practical resource that 

community leaders can easily use in efforts to 

prevent suicide deaths in Texas.

http://www.mhatexas.org/

SuicidePreventToolkit8_04.htm.

Updates to the toolkit will be posted periodically 

on the Mental Health Association in Texas 

Web site and the Texas State Strategic Health 

Partnership Web site.

http://www.mhatexas.org

http://mhatexas.org/2006SuicidePreventToolkit

UPDATE.htm. 

Data-Driven Prevention Planning Model

This model has been developed by Richard 

Catalano and David Hawkins at the University 

of Washington. The model is based on 

certain assumptions:

1. A broad-based coalition of stakeholders 

has been formed;

2. The coalition has identified suicide 

prevention as the area that it would like to 

focus on; and

3. The coalition is sufficiently organized and 

has the infrastructure necessary to take 

on a project. A Strengths, Weaknesses, 

Opportunities, and Threats (SWOT) 

assessment can ensure this.

http://www.sprc.org/featured_resources/

trainingandevents/conferences/co/pdf/

DataDrivenModel.pdf. 

Embrace Life Resources Toolkit

The idea behind the “Embrace Life” approach 

is that people and organizations within 

communities will cooperate in finding solutions 

that meet real local needs and circumstances. The 

Embrace Life Council was created to support 

communities in sharing ideas and resources to 

create their own solutions.

http://www.gov.nu.ca/education/COEWebsite/

images/library/Arctic%20suicide%20%C9%20

workshop%20e.pdf.

Preventing Youth Suicide in Rural America: 

Recommendations to States 

The Suicide Prevention Resource Center and the 

State and Territorial Injury Prevention Directors 

Association formed a workgroup to generate 

recommendations to prevent suicide among rural 

youth. This report details the recommendations 

for State-level agencies to address promotion of 

help-seeking behaviors, data and surveillance, 

services, screening and identification, gatekeeper 

training, bereavement, and survivor issues. 

http://www.sprc.org/library/ruralyouth.pdf.

Appendix D: Decisionmaking Tools and Resources
153

Prevention Suicide: Program Activities Guide

This publication by the Centers for Disease 

Control and Prevention (CDC) National Center 

for Injury Prevention and Control is designed 

to move the injury and violence prevention field 

toward primary prevention and early intervention 

by exploring ways to prevent suicide before 

it occurs. 

http://www.cdc.gov/ncipc/dvp/

PreventingSuicide.htm.

Suicide Prevention Community 

Assessment Tool

This tool, available from the Substance Abuse 

and Mental Health Services Administration 

(SAMHSA) Suicide Prevention Resource 

Center, is intended to be used in collaboration 

with a local Prevention Network. Prevention 

Networks are coalitions of change-oriented 

organizations and individuals working together 

to promote suicide prevention. Prevention 

networks might include statewide coalitions, 

community task forces, regional alliances, or 

professional groups. Prevention networks may be 

organized at the national, State, regional, Tribal, 

or local level. 

http://www.sprc.org/library/catool.pdf.

School-Based Program Planning Tools

Youth Suicide Prevention: Strengthening State 

Policies and School-Based Strategies

This publication is an April 2005 Issue Brief 

from the National Governors Association. It 

describes five main areas in which Governors and 

other State officials can take action to prevent 

suicide: increasing public awareness, being 

involved in suicide prevention planning, giving 

schools a greater role in identifying students 

at risk and in providing services, appropriating 

funds to prevention, and fostering Statelevel collaborations. 

http://www.spanusa.org/files/General_

Documents//0504suicideprevention.pdf.

Youth Suicide Prevention School-Based Guide 

This online resource was developed by the 

Florida Mental Health Institute at the University 

of South Florida. It provides a framework for 

schools to assess their existing or proposed 

suicide prevention efforts (through a series 

of checklists) and provides resources and 

information that school administrators can use 

to enhance or add to their existing program. 

Information is offered in a series of issue briefs 

corresponding to a specific checklist. Each brief 

offers a rationale for the importance of the 

specific topic together with a brief overview 

of the key points. The briefs also offer specific 

strategies that have proven to work in reducing 

the incidence of suicide, with references that 

schools can use to explore these issues in 

greater detail. 

http://theguide.fmhi.usf.edu/pdf/ResearchMaterials.pdf.

Coalition Building Tools

Coalitions 101: Getting Started 

This guide presents a seven-step approach 

to organizing a coalition and is published by 

Community Anti-Drug Coalitions of America 

(CADCA), a membership organization of more 

than 5,000 community coalitions whose purpose 

is to prevent substance abuse and violence. 

http://cadca.org.

Community Coalition Suicide Prevention 

Checklist

This document is the result of a Scientific 

Consensus Meeting, held in 2001, that was 

sponsored by several of the National Institutes of 

Health, SAMHSA, and the CDC through grants 

to the University of Rochester Center for the 

Study and Prevention of Suicide. The document 

is a list of suggested actions that various 

community-based organizations (e.g., schools 

and businesses) can take to prevent suicide.

http://www.sprc.org/library/ccspchecklist.pdf.
154

Community Mobilization for Prevention 

Online Guide

This is a Web-based guide for community 

coalitions and prevention providers that was 

developed with funding from SAMHSA’s Center 

for Substance Abuse Prevention. It provides 

information, tools, and resources for supporting 

leveraged community organizing, planning, 

and action. 

http://captus.samhsa.gov/southwest/cmpguide/

cmpguide.cfm.

Community Toolbox

This toolbox is available through a Web site 

created and maintained by the Work Group 

on Health Promotion and Community 

Development at the University of Kansas, in 

collaboration with AHEC/Community Partners 

in Amherst, MA. The “Create Coalitions and 

Partnerships” section of the site includes:

• An outline of how to create a coalition; 

• Case studies; 

• Guidance on creating and maintaining 

coalitions; and

• Tools for defining membership, diversity, 

and principles for success. 

http://ctb.ku.edu/en.

Partnership Self-Assessment Tool

This tool is a Web-based resource from the 

Center for the Advancement of Collaborative 

Strategies in Health at the New York Academy 

of Medicine. The tool assesses how well a 

collaborative process is working in three areas: 

leadership, efficiency administration and 

management, and sufficiency of resources. 

Coalitions can use the tool to: 

• Assess how well the collaborative process 

is working; 

• Learn how to improve this process; 

• Demonstrate the strengths of the coalition 

to partners, funders, and the community; 

• Make the coalition more responsive to its 

partners and the community; and 

• Involve partners in the leadership and 

management of the coalition. 

http://www.partnershiptool.net. 

Appendix D: Decisionmaking Tools and Resources
Help Prevent Suicide

Promotional Materials Available From the National Suicide Prevention Lifeline

You can play a valuable role in helping to reduce suicide by promoting the National Suicide Prevention Lifeline, 

1-800-273-TALK (8255). To assist you, the Lifeline has developed a full set of materials, available free of charge, to help raise 

awareness about the Lifeline. Please see the reverse side of this form for information on how to order the materials from 

SAMHSA’s Health Information Network. These materials are also available to download in camera-ready and customizable 

formats on our Web site, www.suicidepreventionlifeline.org/materials. 

Complete order form on reverse to fax or mail

Gives risk assessment tips for counselors 

and other professionals.

Counselor Wallet Card

There are three different posters 

intended for males ages 25–54, 

males ages 65+, and American 

Indian/Alaska Native youth. 

Spanish versions of the males ages 

25–54 and males ages 65+ posters 

are also available.

Lifeline Posters Feeling lost, lonely, desperate?

If you or someone you know is thinking about suicide, 

call the National Suicide Prevention Lifeline:

1-800-273-TALK (8255)

With help comes hope.

When it seems like there’s

no hope, there is help .

Printed 2006 • Reprinted 2009 • CMHS-SVP06

U.S. DE

-0162

PARTMENT OF HEALTH AND HUMAN SERVICES

Substance Abuse and Mental Health Services Administration

www.samhsa.gov

Feeling alone, angry, hopeless?

It’s important to talk to someone. You can call right now. We are available all 

hours of the day and night, and the call is completely free and confidential.

If you or someone you know is thinking about suicide, 

call the National Suicide Prevention Lifeline: 

1-800-273-TALK (8255)

Honor Your Life

When it seems like there’s

no hope, there is help .

Printed 2006 • Reprinted 2009 • CMHS-SVP06-0164

Feeling blue, hopeless, alone?

If you or someone you know is thinking about suicide, 

call the National Suicide Prevention Lifeline: 

1-800-273-TALK (8255)

With help comes hope.

When it seems like there’s

no hope, there is help .

Printed 2006 • Reprinted 2009 • CMHS-SVP06-0163

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Substance Abuse and Mental Health Services Administration

www.samhsa.gov

Lists suicide warning signs for the general 

public. Available in both English and Spanish. 

Warning Signs Wallet Card

3.5 x 4-inch magnet features the Lifeline 

logo and contact number.

Lifeline Magnet

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Substance Abuse and Mental Health Services Administration

www.samhsa.gov

Printed 2005 • Reprinted 2009 • CMHS-SVP05-0125

Intended to be given out in emergency 

departments, these booklets are for attempt 

survivors, families, and medical care providers. 

Spanish versions of the booklets for survivors and 

families are also available. 

A Guide for Taking 

After an Attempt Booklets Care of Your 

Family Member After Treatment 

in the Emerge

After an Attempt

ncy Department

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Substance Abuse and Mental Health Services Administration

www.samhsa.gov

A Guide for Medical Providers 

in the Emergency Department

Taking Care of Suicide Attempt 

Survivors

After an Attempt

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Substance Abuse and Mental Health Services Administration

www.samhsa.gov

After an Attempt A Guide for Taking Care of 

Yourself After Your Treatment

in the Emergency Department

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Substance Abuse and Mental Health Services Administration

www.samhsa.gov

The Lifeline Co-Pilot cards 

help crisis line workers 

assess suicide risk and 

offer intervention options to 

those who could be at risk 

of suicide.

Lifeline Co-Pilot Cards

Pens and writing pads feature 

the Lifeline logo and number.

Lifeline Pen and Writing Pad

Other Lifeline Materials

Designed to look like a 

basketball, this squeezable 

stress ball features the 

Lifeline logo and number.

Lifeline Stress Ball 

¿Tiene 

dificultades para 

lidiar con sus 

problemas después 

de un desastre?

Hay esperanza.

Con la ayuda, llega la esperanza.

RED

NACIONAL

de

para la

1-888-628-9454

Impreso en agosto de 2007 • CMHS-SVP-155s

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Substance Abuse and Mental Health Services Administration

www.samhsa.gov

Having Trouble

Coping 

After 

a Disaster?

There Is Hope.

With Help Comes Hope.

Printed: August 2006 • CMHS-SVP-0155

These cards identify problems associated with having difficulty coping with challenging 

situations, such as a disaster. Two versions are available. One version includes “disaster” on the 

cover (available in English and Spanish). The other version does not (available in English only). 

Coping Tips Wallet Cards

Having 

Trouble

Coping?

There Is Hope. With Help Comes Hope.

Printed: August 2008 • CMHS-SVP-0155r 

National Suicide Prevention Lifeline Promotional Materials Order Form
You can order up to 50 pieces of each item. If you are a Lifeline crisis center, a grantee funded under the Garrett Lee Smith 

Memorial Act, or a VA Suicide Prevention Coordinator, you can order up to 500 pieces of each item. Please indicate your 

affiliation by checking the applicable box below. 

National Suicide Prevention Lifeline 

Promotional Materials Order Form

SAMHSA’s Health Information Network

P.O Box 2345

Rockville, MD 20847-2345

To order material, please fax this form to SAMHSA’s Health Information Network at 240-221-4292 or mail it to the address 

below. You can also order by phone at 1-877-726-4727 or 1-800-487-4889 (TDD), by email (shin@samhsa.hhs.gov) 

or online (www.mentalhealth.samhsa.gov). Please note that not all products will be in stock at all times. Delivery of

materials can take up to 4 weeks. You can request more than 500 items by sending an email to lifeline@samhsa.hhs.gov

and specifying the item code, quantity needed, and distribution plan.

Subs at nce Abuse and Mental Health Services Administration

 Quantity

A Guide for Funeral Directors

SVP09-0194

After an Attempt Booklets

 For Attempt Survivors:

 English SVP06-0157 

 Spanish SVP06-0158SP 

 For Families: 

 English SVP06-0159 

 Spanish SVP08-0160S 

 For Medical Care Providers:

 English SVP06-0161 

Lifeline Posters

Men 25-54 SVP06-0162 

Men 25-54 (Spanish) SVP06-0166SP 

Men 65+ SVP06-0163 

Men 65+ (Spanish) SVP06-0167SP 

 American Indian/Alaska Native

SVP06-0164 

	 	

																																																																									Quantity

Lifeline Warning Signs Wallet Card

English SVP05-0126 

Spanish SVP05-0126SP 

Lifeline Counselor Wallet Card

SVP06-0153 

Lifeline Coping Tips Wallet Cards

English (Disaster) SVP06-0155 

Spanish (Disaster) SVP06-0155S

English (Coping—no “Disaster”) 

SVP08-0155R 

Lifeline Magnet

SVP05-0125 

Lifeline Co-Pilot Cards

SVP08-0187 

Lifeline Stress Ball

SVP08-0171 

Lifeline Writing Pad

SVP06-0172 

Lifeline Pen

SVP06-0173 

Revised: July 2009

Name: ________________________________________Title: __________________________________________

Organization: __________________________________________________________________________________

Address: _____________________________________________________________________________________

City: ______________________________________ State: ____________________ ZIP: __________________

Phone: ________________________________________E-mail: __________________________________

(please provide this information so we can update you on the order status)

Ship to:

Lifeline crisis center Garrett Lee Smith grantee VA Suicide Prevention Coordinator

National Suicide Prevention Lifeline Promotional Materials Order Form
157

Appendix E: Web Site Resources and Bibliography 

Suicide Prevention Web Sites 

U.S. and Canadian Government

SAMHSA’s Health Information Network

This resource provides information about mental 

health services and topics by phone, on its 

Web site, and through more than 600 available 

publications. Staff members will direct callers to 

Federal, State, and local organizations dedicated 

to treating and preventing mental illness, as 

well as fulfilling orders for helpful resources 

and publications.

http://www.samhsa.gov/shin. 

Centers for Disease Control (CDC) and 

Prevention Injury Center: Suicide Prevention

This Web site offers general information 

about suicide in different formats, including 

podcasts, on terminology, risk and protective 

factors, consequences of suicide, and prevention 

strategies. The site also contains links to 

numerous statistical reports and databases on 

suicide prevalence. 

http://www.cdc.gov/ncipc/dvp/Suicide/default.htm.

Indian Health Service (IHS) Community 

Suicide Prevention Web Site

The purpose of the IHS Web site is to provide 

American Indian and Alaska Native 

(AI/AN) communities with culturally 

appropriate information about best and 

promising practices, training opportunities, and 

other relevant information regarding suicide 

prevention and intervention. The goal of the Web 

site is to provide Native communities with the 

tools and information to create, or adapt to, their 

own suicide prevention programs. 

http://www.ihs.gov/NonMedicalPrograms/nspn/

index.cfm.

National Suicide Prevention Lifeline 

The National Suicide Prevention Lifeline 

provides immediate assistance to individuals 

in suicidal crisis by connecting them to the 

nearest available crisis center through a toll-free 

telephone number: 1-800–273–TALK (8255). 

Technical assistance, training, and other resources 

are available to the crisis centers that participate 

in the network of services linked to the National 

Suicide Prevention Lifeline. 

http://www.suicidepreventionlifeline.org.

Suicide Prevention Resource Center

The Suicide Prevention Resource Center (SPRC) 

provides prevention support, training, and 

materials to strengthen suicide prevention efforts. 

Among the resources found on its website is 

the SPRC Library Catalog (http://library.sprc.

org/), a searchable database containing a wealth 

of information on suicide and suicide prevention, 

including publications, peer-reviewed research 

studies, curricula, and Web-based resources. 

Many of these items are available online. 

http://www.sprc.org.

Honouring Life Network

This site, funded by Health Canada, is a project 

of the National Aboriginal Health Organization. 

The Web site offers culturally relevant 

information and resources on suicide prevention 

to help Aboriginal people deal with a problem 

that has reached crisis proportions in some 

First Nations, Inuit, and Métis communities 

in Canada. In addition to providing a place for 

Aboriginal youth to go and read about others 

dealing with similar issues, the site allows those 

working with Aboriginal youth to connect, 

discuss, and share suicide prevention resources 

and strategies. The site’s directory of suicide 

prevention resources will be updated on a regular 

basis with the hopes of providing Aboriginal 

communities with a comprehensive inventory of 

suicide prevention materials.

http://honouringlife.ca.
158

Non-Federal

American Association of Suicidology

The American Association of Suicidology 

is a nonprofit organization dedicated to the 

understanding and prevention of suicide. It 

promotes research, public awareness programs, 

public education, and training for professionals 

and volunteers and serves as a national 

clearinghouse for information on suicide. 

http://www.suicidology.org.

American Foundation for Suicide Prevention 

The American Foundation for Suicide Prevention 

(AFSP) is dedicated to advancing our knowledge 

of suicide and our ability to prevent it. AFSP’s 

activities include supporting research projects; 

providing information and education about 

depression and suicide; promoting professional 

education for the recognition and treatment of 

depressed and suicidal individuals; publicizing 

the magnitude of the problems of depression and 

suicide and the need for research, prevention, and 

treatment; and supporting programs for suicide 

survivor treatment, research, and education. 

http://www.afsp.org.

Jason Foundation, Inc. 

The Jason Foundation, Inc., educates young 

people, parents, teachers, and others who 

work with young people about youth suicide. 

The foundation offers programs, seminars, 

and support materials on suicide awareness 

and prevention.

http://www.jasonfoundation.com.

One Sky Center

One Sky Center is a national resource center 

for AI/ANs. It is dedicated to improving 

prevention and treatment of substance abuse and 

mental health across Indian Country. Current 

initiatives of the center include meth and 

suicide prevention.

http://www.oneskycenter.org.

Suicide Prevention Action Network USA 

Suicide Prevention Action Network USA (SPAN 

USA) is the Nation’s only suicide prevention 

organization dedicated to leveraging grassroots 

support among suicide survivors (those who have 

lost a loved one to suicide) and others to advance 

public policies that help prevent suicide. 

http://www.spanusa.org.

Survivors of Suicide.com 

This Web site is designed to help those who have 

lost a loved one to suicide resolve their grief and 

pain in their own personal way. 

http://www.survivorsofsuicide.com/help_heal.shtml.

Turtle Island Native Network 

The Turtle Island Native Network is an online 

source of Aboriginal news and information. 

The Web site includes a Healing and Wellness 

Suicide Prevention Page.

http://www.turtleisland.org/healing/healingsuicide.htm.

Suicide Prevention Crisis Lines

National Suicide Prevention Lifeline 

(1–800–273–TALK [8255]) is a 24-hour, tollfree suicide prevention service available to 

anyone in the United States in suicidal crisis 

or emotional distress. Callers are routed to the 

closest crisis center.

http://www.suicidepreventionlifeline.org.

Veterans Suicide Prevention Hotline 

To ensure veterans in emotional crises have 

round-the-clock access to trained professionals, 

the U.S. Department of Veterans Affairs 

(VA) operates a national suicide prevention 

hotline for veterans in partnership with the 

Substance Abuse and Mental Health Services 

Administration (SAMHSA) and the National 

Suicide Prevention Lifeline. Veterans can call 

1–800–273–TALK (8255) and press “1” to 

reach the VA hotline, which is staffed by mental 

health professionals. 

http://www.suicidepreventionlifeline.org/

Veterans/Default.aspx.
159

Appendix E: Web Site Resources and Bibliography

Native American Health 

Research Web Sites

Indian Health Service

The Reyes Building

801 Thompson Avenue, Suite 400

Rockville, MD 20852–1627

Phone: 301–443–3593

http://www.ihs.gov

Association of American Indian Physicians

1225 Sovereign Row, Suite 103

Oklahoma City, OK 73108

Phone: 405–946–7072

Fax: 405–946–7651

http://www.aaip.com

California Rural Indian Health Board

Native American AIDS Advisory Board

4400 Auburn Blvd., 2nd Floor

Sacramento, CA 95841

Phone: 916–929–9761

http://www.crihb.org

Center for American Indian Health

Johns Hopkins School of Public Health

621 North Washington Street

Baltimore, MD 21205

Phone: 410–955–6931

http://ih.jhsph.edu/cnah

Circles of Care Evaluation Technical 

Assistance Center

University of Colorado Health Sciences Center

4455 East 12th Avenue, Campus Box A011–13

Denver, CO 80220

Phone: 303–372–0000

http://www.uchsc.edu/ai/coc

National Center for American Indian and 

Alaska Native Mental Health Research

University of Colorado Health Sciences Center

Department of Psychiatry, North Pavilion

4455 East 12th Avenue, Campus Box A011-13

Denver, CO 80220

Phone: 303–315–9232

http://www.uchsc.edu/ai/ncaianmhr/

ncaiainmhr_index.htm

National Indian Child Welfare Association

5100 S. Macadam Avenue, Suite 300

Portland, OR 97201

Phone: 503–222–4044

Fax: 503–222–4007

http://www.nicwa.org

National Indian Health Board

101 Constitution Avenue NW, Suite 8B09

Washington, DC 20001

Phone: 202–742–4262

http://www.nihb.org

National Native American AIDS 

Prevention Center

436 14th Street, Suite 1020

Oakland, CA 94612

Phone: 510–444–2051

http://www.nnaapc.org

Native American Fatherhood & Families 

Association (NAFFA)

123 North Centennial Way, Suite 150

Mesa, AZ 85201

Phone: 480–833–5007

Fax: 480–833–009

E-mail: aznaff@aol.com

http://nativeamericanfathers.org

Tri-Ethnic Center for Prevention and Research

Colorado State University

100 Sage Hall

Fort Collins, CO 80523-1879

Phone: 1–800–835–8091 

or 970–491–7902

Fax: 970–491–0527

E-mail: tecweb@lamar.colostate.edu

http://www.triethniccenter.colostate.edu/

about.shtml
160

Suicide Legislation

The Library of Congress Web site offers a 

searchable database of legislation related to 

national suicide prevention that is currently 

proposed in Congress. Visit http://thomas.loc.

gov and enter “suicide” as the search word.

For the most recent State legislative action, 

readers should refer to the corresponding State 

legislature’s home page at http://www2a.cdc.gov/

phlp/suicidelegislation.asp.

Suggested Bibliography, 

by Chapter

The following journal articles, reports, books, 

and Web-based resources provide additional 

information on topics discussed throughout the 

guide. Links to the publications are provided 

whenever this information is available online.

Chapter 1: Introduction to the Guide

Achieving the Promise: Transforming Mental 

Health Care in America. President’s New 

Freedom Commission on Mental Health. (2003). 

http://www.mentalhealthcommission.gov/

reports/FinalReport/downloads/downloads.html.

National Strategy for Suicide Prevention. 

The National Strategy for Suicide Prevention 

(NSSP) represents the combined work of 

advocates, clinicians, researchers, and survivors 

around the Nation. It lays out a framework for 

action to prevent suicide and guides development 

of an array of services and programs that must 

be developed. It is designed to be a catalyst 

for social change with the power to transform 

attitudes, policies, and services. The NSSP was 

published by the U.S. Department of Health and 

Human Services in May of 2001, with leadership 

from the Surgeon General. A summary can be 

ordered from SAMHSA’s Health Information 

Network (Inventory No. SMA01-3518). The 

full document also is available (Inventory No. 

SMA08-3517). Both documents are free. Place 

orders online at http://www.samhsa.gov/shin or 

call 1-877-SAMHSA-7 (1-877-726-4727).

Reducing Suicide: A National Imperative. 

Institute of Medicine (2002). Goldsmith, S. K., 

Pellmar, T. C., Kleinman, A.M., & Bunney, 

W. E. (Eds.) Washington, D.C.: National 

Academies Press.

http://www.nap.edu/catalog.php?record_

id=10398.

Fostering Resiliency in Kids: Protective 

Factors in the Family, School, and Community.

Bonnie Benard, National Resilience Resource 

Center National Resilience Resource Center, 

202 Wesbrook, 77 Pleasant Street S. E., 

Minneapolis, MN

http://www.cce.umn.edu/nrrc/research/index.

html#cartercenter.

Chapter 2. Culture, Community, 

and Prevention

Cultural continuity as a hedge against suicide 

in Canada’s First Nations. Lalonde, C., 

& Chandler, M. J. (1998). Transcultural 

Psychiatry. http://web.uvic.ca/~lalonde/

manuscripts/1998TransCultural.pdf.

Culture, selves, and time: Theories of personal 

persistence in Native and non-Native youth.

Lalonde, C., & Chandler, M. J., (2004). In C. 

Lightfoot, C. Lalonde, & M. Chandler (Eds.), 

Changing Conceptions of Psychological Life, Vol. 

30, 207-229. Jean Piaget Symposium Series. 

Mahwah, NJ: Lawrence Erlbaum.

Culture, continuity, and the limits of 

narrativity: A comparison of the self-narratives 

of Native and Non-Native youth. Chandler, 

M., Lalonde, C., & Teucher, U. (2004). In C. 

Daiute & C. Lightfoot (Eds.), Narrative Analysis: 

Studying the Development of Individuals in Society, 

pp. 245-265. New York: Sage Publications.

Personal persistence, identity development, 

and suicide: A study of Native and Non-Native 

North American adolescents. Chandler, M. 

J., Lalonde, C., Sokol, B., & Hallett, D. (2003). 

Monographs of the Society for Research in Child 

Development, Serial no. 273, 68 (2).

http://web.uvic.ca/~lalonde/manuscripts/2003-

Monograph.pdf.
161

Appendix E: Web Site Resources and Bibliography

Counting the costs of failures of personal 

and cultural continuity. Lalonde, C. (2003). 

Human Development, 46(2-3). Available for order 

from the journal at http://content.karger.com/

ProdukteDB/produkte.asp?Doi=68586. 

Chapter 3: Breaking the Silence Around 

the Suicide Conversation

Darkness Calls: Suicide Prevention Comic 

Book for Native Americans. The Healthy 

Aboriginal Network. 

http://www.thehealthyaboriginal.net.

Lifting the Silence on Suicide: Together 

We Can Make a Difference. (Conference 

Report from the Aboriginal Suicide Prevention 

Conference in Alberta, Canada, February 

6–7, 2002.) 

http://www.suicideinfo.ca/csp/assets/

sptpabconfreport.pdf.

Chapter 4: Responding to Suicide

Community Resources

The Basics: Facilitating a Suicide Survivors 

Support Group. Flatt, L. (2007). 

http://www.spanusa.org/files/General_

Documents/The_Basics_Facilitator_Guide.pdf.

The Story of the Community of West Carleton: 

How the Community Helpers Program 

Evolved from a Community’s Experience 

with Youth Suicide. This paper explores key 

concepts in youth mental health promotion, 

demonstrating how these concepts can and have 

been put into practice at the community level. 

Key concepts in youth mental health promotion 

are first defined, including community capacity 

building, community mobilization, and youth 

mental health promotion. The experience of 

youth suicide in a rural community is used to 

illustrate, in practical terms, how these concepts 

have real-life application. Specifically, in the 

context of a community’s response to a tragic 

event, the importance of developing a shared 

vision and creating a common community 

language around youth mental health will 

be emphasized. 

http://www.phac-aspc.gc.ca/mh-sm/mhp-psm/

pub/community-communautaires/pdf/commcap-build-mobil-youth.pdf.

White Earth Suicide Intervention Team, 

White Earth Chippewa Tribe. The White 

Earth Suicide Intervention Team was created 

in 1990 in response to an extraordinarily high 

rate of suicide attempts and completions on 

the White Earth Reservation. The all-volunteer 

team provides many services previously absent 

or lacking, including 24-hour support for the 

attempter and his/her family, encouragement of 

voluntary or involuntary hospital admission for 

all attempters, referrals to mental health services, 

and suicide education. 

http://www.hks.harvard.edu/hpaied/hn/

hn_2000_intervention.htm.

Winnebago Response to Crisis. This document 

provides example of crisis protocols, including 

suicide crisis. Protocols link found on the 

IHS Web site. http://www.ihs.gov/Misc/

links_gateway/sub_categories.cfm?sub_cat_

id=06080914.

School Resources

Crisis response and postvention. Lerner, M., 

Volpe, J., & Lindell, B. (2003). In A Practical 

Guide for Crisis Response in Our Schools (5th 

ed.). This book is a guide to preparing for and 

managing crises in schools. It covers traumatic 

stress management, responding to suicidal or 

violent students, grief counseling, and other 

issues. Of special interest to teachers will be the 

section titled “Teacher Guidelines for Crisis 

Response.” Commack, NY: American Academy 

of Experts in Traumatic Stress.

Sherman Indian High School (SIHS) 

Holistic Health Program Mental Health 

Crisis Protocol. This protocol is designed to 

assist dorm staff, counselor techs, and other 

SIHS staff with guidelines and resources to assess 

the severity of a mental health crisis on this 

campus and to find the most appropriate manner 

of resolving the crisis. http://www.ihs.gov/Misc/

links_gateway/sub_categories.cfm?sub_cat_

id=06080914.
162

Youth Suicide Prevention Intervention and 

Postvention Guidelines: A Resource for School 

Personnel. These guidelines were developed by 

the Maine Youth Suicide Prevention Program 

and designed for schools to use within existing 

protocols to assist at-risk students and to 

intervene appropriately in a suicide-related crisis.

http://www.state.me.us/suicide/guidelines02.pdf.

Suicide Survivor Resources

The Survivors of Suicide Handbook. This 

handbook is designed to be a pocket-sized, 

quick-reference booklet for suicide survivors. 

Written by fellow survivor Jeffrey Jackson, it is 

brief, clear, and packed with essential information 

covering nearly every aspect of the survivor 

ordeal—from the emotional roller-coaster, to the 

elusive quest for “Why?,” to how to find support 

groups in your area.

http://www.suicidology.org/associations/1045/

files/SOS_handbook.pdf.

After an Attempt: A Guide for Taking 

Care of Your Family Member after 

Treatment in the Emergency Department.

This brochure may be downloaded from 

http://www.suicidepreventionlifeline.

org/App_Files/Media/PDF/Lifeline_

AfterAnAttempt_ForFamilyMembers.pdf. 

Free copies also can be ordered online at 

http://www.samhsa.gov/shin or by calling 

SAMHSA’s Health Information Network at 

1-877-SAMHSA-7 (1-877-726-4727). 

Suicide Attempt Survivor Resources

After an Attempt: A Guide for Taking 

Care of Yourself After Your Treatment 

in the Emergency Department. This 

brochure may be downloaded at http://www.

suicidepreventionlifeline.org/App_Files/Media/

PDF/Lifeline_AfterAnAttempt_ForYourself.

pdf. Free copies also can be ordered online 

at http://www.samhsa.gov/shin or by calling 

SAMHSA’s Health Information Network at 

1-877-SAMHSA-7 (1-877-726-4727). 

Media Guidance

At-a-Glance: Safe Reporting on Suicide. This 

two-page guide for reporters and editors provides 

a list of recommendations on how to report on 

suicide while minimizing the risk of contributing 

to “copycat” suicides. In addition to offering 

guidelines (based upon Reporting on Suicide, 

below), this publication includes additional 

resources on suicide and suicide prevention for 

reporters, editors, and others in the media. 

http:// www.sprc.org/library/at_a_glance.pdf

Guide to Engaging the Media in Suicide 

Prevention.

http://www.spanusa.org/files/General_

Documents//media.pdf.

Reporting on Suicide: Recommendations 

for the Media. A collaborative effort of the 

CDC and Prevention, National Institute of 

Mental Health, Office of the Surgeon General, 

SAMHSA, American Foundation for Suicide 

Prevention, American Association of Suicidology, 

and the Annenberg Public Policy Center. 

http://www.sprc.org/library/sreporting.pdf.

The Role of the Media in Preventing Suicide.

This guide includes information on how the 

media can help with a community’s efforts to 

prevent suicide, their reporting responsibilities, 

and resources for the media. 

http://www.sprc.org/featured_resources/

customized/pdf/media.pdf.

Safe and Effective Messaging for Suicide 

Prevention. This document offers evidencebased recommendations for creating safe and 

effective messages to raise public awareness 

that suicide is a serious and preventable public 

health problem. 

http://www.sprc.org/library/SafeMessagingfinal.pdf.

Chapter 5: Community Readiness

Community Readiness and Prevention 

Programs. Donnermeyer, J. F., Plested, B. A., 

Edwards, R. W., Oetting, E. R., & Littlethunder, 

L. (1997). Journal of the Community Development 

Society, 28 (1), 65-83.

http://www.triethniccenter.colostate.edu/docs/

Article1.pdf.

Community Readiness: Research to Practice.

Edwards, R. W., Jumper-Thurman, P., Plested, B. 
163

Appendix E: Web Site Resources and Bibliography

A., Oetting, E. R., & Swanson, L. (2000). Journal 

of Community Psychology, 28(3), 291-307.

http://www.triethniccenter.colostate.edu/docs/

Article2.pdf.

Community Readiness: A Promising Model for 

Community Healing. (Native American topic 

specific monograph series). Jumper-Thurman, 

P. (2000). In D. Bigfoot (Ed.), The University 

of Oklahoma Health Sciences Center, U.S. 

Department C Justice.

http://www.triethniccenter.colostate.edu/docs/

Article3.pdf.

Community Readiness: A Model for Healing in 

a Rural Alaskan Community. Jumper-Thurman, 

P. J., & Plested, B. (2000). The Family Psychologist, 

(Summer), 8-9.

http://www.triethniccenter.colostate.edu/docs/

Article5.pdf.

Using the Community Readiness Model in 

Native Communities. Jumper Thurman, P., 

Plested, B. A., Edwards, R. W., Helm, H. M., 

& Oetting, E. R. (2001). In J. E. Trimble & F. 

Beauvais (Eds.), Health Promotion and Substance 

Abuse Prevention Among American Indian and 

Alaska Native Communities: Issues in Cultural 

Competence (CSAP Monograph, Cultural 

Competence Series No. 9, DHHS Publication 

No. SMA 99-3440, pp. 129-158). Rockville, 

MD: U.S. Department of Health and 

Human Services. 

http://www.triethniccenter.colostate.edu/docs/

Article7.pdf.

(Additional articles on community readiness 

are available through the Tri-Ethnic Center 

for Prevention at http://www.triethniccenter.

colostate.edu.)

Chapter 6: Community Action

From the Ground Up: Improving Community 

Health, Inspiring Community Action. This 

article is part of Grantmakers in Health’s (GIH’s) 

portfolio, From the Ground Up: Improving 

Community Health, Inspiring Community Action.

Each article focuses on an approach grantmakers 

are using to improve health in communities. The 

entire portfolio is available at the GIH Web site. 

http://www.gih.org.

Suicide Prevention: Prevention Effectiveness 

and Evaluation. This document, a collaborative 

effort by the CDC National Center for Injury 

Prevention and Control, SPAN USA, Inc., and 

Educational Development Center, Inc., contains 

evidence-based and best practice methods for 

developing State suicide prevention plans. 

http://www.spanusa.org/files/General_

Documents/prevtoolkit.pdf.

The Tension of Turf: Making It Work for 

the Coalition. Developed by the Prevention 

Institute, this paper builds upon the article 

Developing Effective Coalitions: An Eight 

Step Guide. and it also responds to a concern 

repeatedly encountered in training on this 

approach, a concern generally described as 

among the hardest issues faced in collaborating: 

turf struggle.

http://www.preventioninstitute.org/pdf/

TURF_1S.pdf.

Chapter 7: Promising Suicide 

Prevention Programs 

Program Evaluation

Report of the Workshop on Best Practices in 

Suicide Prevention and the Evaluation of Suicide 

Prevention Programs in the Arctic. (2003). 

http://www.gov.nu.ca/education/COEWebsite/

images/library/Arctic%20suicide%20%C9%20

workshop%20e.pdf.

Transferring whose knowledge? Exchanging 

whose best practices?: On knowing about 

indigenous knowledge and aboriginal suicide.

Chandler, M. J., & Lalonde, C. (2004). In 

Aboriginal Policy Research: Setting the Agenda 

for Change, Vol.II, pp.111-123. J. White, P. 

Maxim, & D. Beavon (Eds.). Toronto: Thompson 

Educational Publishing.

http://web.uvic.ca/~lalonde/manuscripts/

2003INAC.pdf.
164

Cultural Adaptation of Programs

Cultural Practices in American Indian 

Prevention Programs. Sanchez-Way, R., & 

Johnson, S. (2002). Juvenile Justice, VII(2). 

http://www.ncjrs.gov/html/ojjdp/jjnl_2000_12/

cult.html.

Making Cultural Adaptations to Model 

Substance Abuse Prevention Programs. This 

document describes why issues of inclusion and 

marginalization need to be addressed when 

training for cultural competence and adaptation. 

http://captus.samhsa.gov/western/resources/tip/

documents/tip-2004-04.rtf.

Suicide Prevention Inuit Traditional Practices 

That Encourage Resilience and Coping.

Published by the Ajunnginiq Centre of the 

National Aboriginal Health Organization, which 

was established to promote practices that will 

restore a healthy Inuit lifestyle and improve 

the health status of Inuit through research and 

research dissemination, education and awareness, 

human resource development, and sharing 

information on Inuit-specific health policies 

and practices. 

http://www.naho.ca/inuit.

Native American Programs in Action

Aboriginal Youth: A Manual of Promising 

Suicide Prevention Strategies is distributed 

by the Centre for Suicide Prevention in 

Alberta, Canada. 

Free for downloading (but almost 300 pages) at 

http://www.suicideinfo.ca/csp/go.aspx?tabid=144

Available for ordering at 

http://www.suicideinfo.ca/csp/assets/promstrat_

order.pdf.

Aboriginal Healing and Wellness Strategy 

(AHWS): Draft Guidelines for Traditional 

Healing Programs. The Aboriginal Healing 

and Wellness Strategy (AHWS) promotes 

a culturally based and holistic environment 

addressing the physical, emotional, mental 

and spiritual aspects of Aboriginal community 

members growth and development. As part 

of this process, AHWS-funded projects are 

committed to having Aboriginal Elders and 

Traditional people participate as an integral part 

of their approach to healing and wellness. 

http://www.ahwsontario.ca/publications/

Traditional%20Healing%20Guidelines_2004.pdf.

National Inuit Youth Suicide Prevention 

Framework. This document describes the work 

and research undertaken by the Qikiqtani Inuit 

Association, on behalf of the Inuit Tapiriit 

Kanatami and the National Inuit Youth Council, 

on the National Inuit Youth Suicide Prevention 

Project. It also presents background information 

on how the project came about, how it has 

been managed and coordinated and presents 

recommendations for future action on suicide 

prevention for Inuit Youth.

http://www.communitylifelines.ca/niyspf-en[1].pdf.

Planting Seeds of Hope (PSOH). This is the 

Montana Wyoming Tribal Leaders Council 

program that is funded by SAMHSA through 

the Garrett Lee Smith Memorial Act. The 

PSOH program includes Montana’s Blackfeet, 

Crow, Northern Cheyenne, Fort Peck and 

Fort Belknap, and Wyoming’s Wind River 

Indian populations. 

http://www.mtwytlc.com/plantingseedsofhope.htm.

What Is Working, What Is Hopeful: 

Supporting Community-Based Suicide 

Prevention Strategies Within Indigenous 

Communities (and Any Other Community 

That Is Interested). This work represents one 

part of the work by the author and others 

who are interested in learning about what 

communities are doing to prevent suicide and 

more specifically, those efforts that have been 

successful in reducing suicide; and its impact. 

http://www.communitylifelines.ca.

American Indian/Alaska Native Resource 

Manual. This manual, produced by the National 

Alliance on Mental Illness (NAMI), emphasizes 

the need for outreach to AI/ANs so that their 

needs also are represented in efforts to improve 

mental health services in the United States. The 

manual covers issues such as the importance 

of cultural competence and how to develop it, 

creation of an AI/AN outreach plan, evaluation 

of outreach, and sharing experiences with 

other NAMIs.

http://www.nami.org/Content/ContentGroups/

Multicultural_Support1/CDResourceManual.pdf.
165

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413-430. 

36. Garroutte, E. M., Goldberg, J., Beals, J., Herrell, 

R., Manson, S. M., & the AL-SUPERPFP 

Team). (2003). Spirituality and attempted 

suicide among American Indians. Social Science 

and Medicine, 56(7), 1571-1579. 

37. White, J., & Jodoin, N. (2003). Aboriginal 

Youth: A Manual of Promising Suicide Prevention 

Strategies. Calgary: Centre for Suicide 

Prevention.

38. Chandler, M. (2005). Suicide & the Persistence of 

Identity in the Face of Radical Cultural Change. 

Presented at the Assembly of First Nations 

Policy Forum, April 19, 2005, Ottawa, Quebec. 

39. Chandler M. J., & LaLonde, C. (1998). Cultural 

continuity as a hedge against suicide in Canada’s 

First Nations. Transcultural Psychiatry, 35, 191-219. 

40. See note 39 above. 

41. See note 39 above. 

42. Bathgate, D. (2003). Psychiatry, religion and 

cognitive science. Australian and New Zealand 

Journal of Psychiatry, 37, 277-285.

43. Kehoe, N. C., & Gutheil, T. G. (1994). Neglect 

of religious issues in scale-based assessment 

of suicidal patients. Hospital and Community 

Psychiatry, 45, 366-369.

44. Kettl, P. A., & Bixler, E. O. (1991). Suicide in 

Alaska Natives, 1979-1984. Psychiatry, 54, 55-63.

45. Malchy, B., Enns, M. W., Yang, T. K., & Cox, B. 

J. (1997). Suicide among Manitoba’s aboriginal 

people, 1988 to 1994. Canadian Medical 

Association Journal, 156, 1133-1138.

46. Simon, R., & Hales, R. (2006). The American 

Psychiatric Publishing Textbook of Suicide 

Assessment and Management (pp.123). 

Arlington, VA: American Psychiatric Publishing. 

47. Lee, C. S., Chang, J. C., & Cheng, A. T. A. 

(2002). Acculturation and suicide: A casecontrolled, psychological autopsy study. 

Psychological Medicine, 32, 133-1441.

48. See note 47 above. 

49. Seiden, R. H. (1981). Mellowing with age: 

Factors influencing the nonwhite suicide rate. 

International Journal of Aging and Human 

Development, 13, 265-284.

50. Shaffer, D., Gould, M., & Hicks, R. C. (1994). 

Worsening suicide rate in black teenagers. 

American Journal of Psychiatry, 151, 1810-1812. 

51. Berry, J. W. (1985). Acculturation among 

circumpolar people: Implications for health 

status. Arctic Medical Research, 40, 21-27.

52. Urban Indian Health Commission. (2007). 

Invisible Tribes: Urban Indians and Their Health in 

a Changing World. Available online at http://www.

itcmi.org/pdfdocs/07urbanindianhealthrpt.pdf.

53. Freedenthal, S. & Stiffman, A. R. (2004). 

Suicidal behavior in urban American Indian 

adolescents: A comparison with reservation 

youth in a southwestern State. Suicide and LifeThreatening Behavior, 34(2), 160.

54. See note 53 above. 
167

Chapter 3: Breaking the Silence Around the Suicide 

Conversation

55. LaFromboise, T. D., & Lewis, H. (2008). 

The Zuni life skills development program: A 

school/community-based suicide prevention 

intervention, Suicide and Life-Threatening 

Behavior, 38(3).

56. Goffman, E. (1967). On facework: An analysis of 

ritual elements in social interaction. In Jawrski, 

A., & Coupland, N. (Eds.), The Discourse Reader 

(pp. 306-321). London: Roterledge.

57. U.S. Public Health Service. (2001). National 

Strategy for Suicide Prevention: Goals and 

Objectives for Action (SMA01-3517). Rockville, 

MD: U.S. Department of Health and Human 

Services, Substance Abuse and Mental Health 

Services Administration. 

58. See note 57 above.

59. Freedenthal, S., & Stiffman, A. R. (2007). They 

might think I was crazy: Young American Indians’ 

reasons for not seeking help when suicidal. Journal 

of Adolescent Research, 22(1), 58-77. 

60. Barlow, A., Aday, N. K., Mullany, B. l., Baker, E. V., 

Norton, K., et al. (2007). Unique patterns of suicide 

completions and attempts among the White Mountain 

Apache Tribal youth. Presentation at the American 

Public Health Association 135th annual meeting, 

Nov. 3–7, 2007, Washington, D.C. 

61. U.S. Public Health Service. (1999). The Surgeon 

General’s Call To Action To Prevent Suicide. 

Washington, DC: U.S. Department of Health 

and Human Services, Office of the Surgeon 

General.

62. Kalafat, J., & Elias, M. (1992). Adolescents’ 

experience with and response to suicidal peers. 

Suicide and Life-Threatening Behavior, 22, 315-321.

63. See note 62 above.

64. Centers for Disease Control and Prevention. 

(1992). Youth Suicide Prevention Programs: A 

Resource Guide. (1992). Atlanta, GA: Author. 

65. See note 64 above. 

66. Potter, L., Powell, K. E., & Kacher, S. P. 

(1995). Suicide prevention from a mental 

health perspective. Suicide and Life-Threatening 

Behavior, 25, 82-91.

67. Ciffone, J. (1993). Suicide prevention: A 

classroom presentation to adolescents. Social 

Work, 38, 196-203.

68. Eggert, L. L., Thompson, E. A., Herting, J. R., & 

Nicholas, L. J. (1995). Reducing suicide potential 

among high-risk youth: Tests of a school-based 

prevention program. Suicide and Life-Threatening 

Behavior, 25, 276-296. 

69. Kalafat, J., & Elias, M. (1994). An evaluation of 

adolescent suicide intervention classes. Suicide 

and Life-Threatening Behavior, 24, 224-233.

70. Kalafat, J., & Gagliano, C. (1996). The use 

of simulations to assess the impact of an 

adolescent suicide response curriculum. Suicide 

and Life-Threatening Behavior, 26, 359-364.

71. Orbach, I., & Bar-Joseph, H. (1993). The 

impact of a suicide prevention program 

for adolescents on suicidal tendencies, 

hopelessness, ego identity, and coping. Suicide 

and Life-Threatening Behavior, 23, 120-129.

72. Aseltine, R. H., & DeMartino, R. (2004). 

An outcome evaluation of the SOS suicide 

prevention program. American Journal of Public 

Health, 94, 446-452.

73. Kalafat, J. & Ryerson, D. M. (1999). The 

implementation and institutionalization of a 

school-based youth suicide prevention program. 

Journal of Primary Prevention, 19, 157-175.

74. Zenere, F. J., III, & Lazarus, P. J. (1997). The 

decline of youth suicidal behavior in an urban, 

multicultural public school system following 

the introduction of a suicide prevention and 

intervention program. Suicide and Life-Threatening 

Behavior, 4, 387-403.

75. U.S. Public Health Service. (1999). The Surgeon 

General’s Call To Action To Prevent Suicide. 

Washington, DC: U.S. Department of Health 

and Human Services, Office of the Surgeon 

General. 

76. Miller, M. (1978). Geriatric suicide: The Arizona 

study. The Gerontologist, 18, 488-495.

77. Osgood, N. J. (1985). Suicide in the Elderly: A 

Practitioner’s Guide to Diagnosis and Mental 

Health Intervention. Rockville, MD: Aspen.

78. Shneidman, E. S., Farberow, N. L., & Litman, 

R. (1970). The Psychology of Suicide. New York: 

Science House.

79. Shneidman, E. S. (1996). The Suicidal Mind. New 

York: Oxford University Press.

Chapter 4: Responding to Suicide

80. American Association of Suicidology. (n.d.). 

Survivors of Suicide Fact Sheet. Available 

online at http://www.suicidology.org/

associations/1045/files/SurvivorsFactSheet.pdf.

81. Shaughnessy, L., Doshi, S. R., & Jones, S. E. 

(2004). Attempted suicide and associated health 

risk behaviors among Native American high 

school students. Journal of School Health, 75(5), 

177-182. 
168

82. Survivors of Suicide.com. (n.d.). Helping a 

Survivor Heal. Available online at http://www.

survivorsofsuicide.com/help_heal.shtml.

83. American Association of Suicidology (n.d.). 

Survivors of Suicide Fact Sheet, Available 

online at http://www.suicidology.org/

associations/1045/files/SurvivorsFactSheet.pdf. 

84. Selbig, A. (2008). Triumph comes out of the 

ashes of personal tragedy. Arctic Sounder, June 

5, 2008.

85. Velting, D., & Gould, M. (1997). Suicide 

contagion. In Cavetto, S., Maris, R., & 

Silverman, M. (Eds.), Review of Suicidology (pp. 

96-137). New York: Guilford Press.

86. Phillips, D. P., & Carstensen, L. L. (1986). 

Clustering of teenage suicides after television 

news stories about suicide. New England Journal 

of Medicine, 315(11), 685–689.

87. Gould, M. S., Wallenstein, S., Kleinman, M. 

H., O’Carroll, P., & Mercy, J. (1990). Suicide 

clusters: An examination of age-specific effects. 

American Journal of Public Health, 80(2), 211-212.

88. Gould, M. S., Jamieson, P., & Romer, 

D. (2003). Media contagion and suicide 

among the young. American Behavioral 

Scientist, 46(9),1269-1284.

89. U.S. Department of Health and Human 

Services. (n.d.). What does “suicide contagion” 

mean and what can be done to prevent it?

Available online at http://www.hhs.gov/FAQ/

healthprograms/mental health/1704.html.

90. Centers for Disease Control and Prevention. 

(1988). Recommendations for a community 

plan for the prevention and containment of 

suicide clusters. Morbidity and Mortality Weekly 

Report, August 19, 1988, 37(S-6), 1-12.

91. See note 90 above. 

92. U.S. Department of Health and Human 

Services, Office on Women’s Health. (n.d.). 

Minority Women’s Health: American Indians 

and Alaska Natives. Available online at http://

www.4woman.gov/minority/americanindian.

93. Suicide Prevention Resource Center. (n.d.) At-aGlance: Safe Reporting on Suicide. Available online 

at http://www.sprc.org/library/at_a_glance.pdf.

94. Sonneck, G., Etzersdorfer, E., & Nagel-Kuess, 

S. (1994). Imitative suicide on the Viennese 

subway. Social Science and Medicine, 38, 453-457.

95. Etzersdorfer, E., & Sonneck, G. (1998). 

Preventing suicide by influencing mass-media 

reporting. The Viennese experience 1980-1996. 

Archives of Suicide Research, 4, 67-74.

96. American Association of Suicidology. 

(n.d.). U.S.A. Suicide: 2006 Official Final 

Data. Available online at http://www.

suicidology.org/c/document_library/get_

file?folderId=228&name=DLFE-142.pdf.

97. Substance Abuse and Mental Health Services 

Administration, Office of Applied Studies. 

(2009). The NSDUH Report: Suicidal Thoughts and 

Behaviors Among Adults. Rockville, MD.

98. SPAN USA. (n.d.) About SPAN USA: Who We 

Are. Available online at http://www.spanusa.org. 

99. U.S. Department of Health and Human Services, 

Substance Abuse and Mental Health Services 

Administration. (2008). Final report of the Attempt 

Survivor Advisory Summit Meeting and Individual 

Interviews. Rockville, MD.

Chapter 5: Community Readiness

100. Plested, B. A., Edwards, R. W., & JumperThurman, P. (2006). Community Readiness: A 

Handbook for Successful Change. Fort Collins, CO: 

Tri-ethnic Center for Prevention Research.

101. Prochaska, J. O., DiClemente, C. C., & Norcross, 

J. C. (1992). In search of how people change: 

Applications to addictive behaviors. American 

Psychologist, 47(9), 1102.

102. Miller. W. R., & Rollnick, S. (2002). 

Motivational Interviewing: Preparing People for 

Change (2nd ed.). New York: Guilford Press.

103. See note 102 above. 

104. Thurman, P. J. (2000). Community Readiness: A 

Promising Model for Community Healing. Fort 

Collins, CO: Tri-Ethnic Center for Prevention 

and Research, Colorado State University.

105. Duran, E. E. (2006). Healing the soul wound: 

Counseling with American Indians and other 

Native peoples. New York: Teachers College 

Press, Columbia University. 

106. See note 105 above. 

107. Kettl, P. A., & Bixler, E. O. (1991). Suicide in 

Alaska Natives, 1979-1984. Psychiatry, 54, 55-63.

108. Malchy, B., Enns, M. W., Yang, T. K., & Cox, B. 

J. (1997). Suicide among Manitoba’s aboriginal 

people, 1988 to 1994. Canadian Medical 

Association Journal, 156, 1133-1138.
169

Chapter 6: Community Action

109. May, P. A., Serna, P., Hurt, L., & DeBruyn, 

L. M. (2005). Outcome evaluation of a public 

health approach to suicide prevention in an 

American Indian Tribal Nation. American 

Journal of Public Health, 95(7), 1238–1244.

110. See note 109 above. 

111. Substance Abuse and Mental Health Services 

Administration. (2008). The NSDUH report: 

Risk & Protective Factors for Substance Use 

Among American Indian or Alaska Native Youth. 

Rockville, MD: Author. 

112. Alcántara, C., & Gone, J. P. (2007). Reviewing 

suicide in Native American communities: 

Situating risk and protective factors within 

a transactional-ecological framework. Death 

Studies, 31, 457-477.

113. See note 112 above. 

114. U.S. Public Health Service. (2001). National 

Strategy for Suicide Prevention: Goals and 

Objectives for Action (SMA01-3517). Rockville, 

MD: U.S. Department of Health and Human 

Services, Substance Abuse and Mental Health 

Services Administration.

115. See note 114 above. 

116. May, P. A., Serna, P., Hurt, L., & DeBruyn, 

L. M. (2003). Outcome evaluation of a public 

health approach to suicide prevention in an 

American Indian Tribal nation. American Journal 

of Public Health, 95(7). 1238-1244.

Chapter 7: Promising Suicide Prevention Programs

117. Bains, J. (2005). Race, culture and psychiatry: 

A history of transcultural psychiatry. History of 

Psychiatry, 16(2), 139-154.

118. Isaacs, M. R., Huang, L. N., Hernandez, M., & 

Echo-Hawk, H. (2005). The road to evidence: 

The intersection of evidence-based practices and 

cultural competence in children’s mental health. 

Report of the National Alliance of Multi-ethnic 

Behavioral Health Associations.

119. Cross, T., Earle, K., Echo-Hawk, H., Solie, H., 

& Manness, K. (2000). Cultural strengths and 

challenges in implementing a system of care 

model in American Indian communities. Systems 

of Care: Promising Practices in Children’s Mental

Health, 2000 Series, Volume I. Washington, DC: 

Center for Effective Collaboration and Practice, 

American Institutes for Research.

120. Zickler, P. (1999). Ethnic identification and 

cultural ties may help prevent drug use. NIDA 

Notes, 14(3), 7-9.

121. Cross, T. (1997). Understanding the Relational 

Worldview in Indian Families. Available online at 

http://www.casanet.org/program-services/Tribal/

relational-worldview-Inidan-families.htm.

122. See note 120 above. 

123. HeavyRunner, I., & Morris, J. S. (1997). 

Traditional Native culture and resilience. In 

Center for Applied Research and Educational 

Improvement’s Research/Practice Newsletter, 5(1) 

Spring 1997. 

124. Harvard University, John F. Kennedy School of 

Government. Government Innovators Network. 

School-Based Youth Services Program. Available 

online at http://www.innovations.harvard.edu/

awards.html?id=3526.

125. National Institute of Mental Health. (2007). 

New Insights on how mental health is 

influenced by culture and immigration status: 

Culturally-relevant research provides clues 

that may help reduce health disparities. Science 

Update, July 11, 2007. 

126. Beautrais, A. L. (2004). Further suicidal behavior 

among medically serious suicide attempters. 

Suicide and Life-Threatening Behavior, 34(2), 1-11.

127. American Indian Policy Center (2008). Realitybased research. Available online at http://www.

airpi.org/reality.html.

128. U.S. Department of Health and Human 

Services, Agency for Healthcare Research 

and Quality. (2003). Creating Partnerships, 

Improving Health: The Role of Community-Based 

Participatory Research. AHRQ Pub. No. 03-0037, 

June 2003. 

129. Schulz, A. J., Israel, B. A., Selig, S. M., & Bayer, 

I. S. (1998). Development and implementation 

of principles for community based research in 

public health. In McNair, R. H. (Ed.) Research: 

Strategies for Community Practice, pp. 83-110; 

New York: Haworth Press.

Chapter 9: Conclusion to the Guide

130. Keyes, C. (2007). Promoting and protecting 

mental health as flourishing: A complementary 

strategy for improving national mental health. 

American Psychologist, 62(2), pp. 95-108. 

131. The Sioux Poet—Native American Poetry Web 

site. (n.d.). Available online at http://siouxpoet.

tripod.com.

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