Suicide risk

CALD Child and Adolescent Mental Health Resource

eCALD Supplementary Resources

Culture shapes people’s view of suicide. Different cultures understand suicide and suicidal thinking in different ways. In some cultures, there is a strong stigma attached to suicide and the families and carers associated with a suicidal person. This section explores aspects of suicide risk assessment particular to Asian youth. It presents the findings of Asian suicide studies in New Zealand, as well as approaches to Asian suicide risk assessment based on Asian cultural values. In this context, the issues of acculturation, the experiences of immigration, intergenerational relationships, collectivist cultural values and perfectionism, which are psychosocial commonalities across Asian groups, contribute to risk. Culturally informed considerations for suicide risk assessment and ways to manage related confidentiality issues are provided. The overarching goal is to promote sensitivity and an understanding of suicidal Asian youth in their social context and, to thereby enhance collaboration in the assessment process at the time of a suicidal crisis.

Asian suicide research in New Zealand

A study of suicide in Asian communities in New Zealand highlights youth as a vulnerable group for suicide risk (Ho, Au & Amerasinghe, 2015). Academic pressures, unrealistic parental expectations, parent-child conflicts and possible identity and sexuality crises, are noted as risk factors for Asian youth, with international students being mentioned as a high-risk group (Ho, Au & Amerasinghe, 2015). With regard to early intervention, informants suggested, in particular, the need to address underlying mental health issues at an early stage. Because of the stigma associated with mental illness in Asian communities, even where specialist mental health services are available, many Asian people with depression and related mental health conditions may choose to visit GPs where they are more likely to report physical complaints rather than psychiatric symptoms. General practitioners were believed to have a particularly important role to play in the recognition and treatment of vulnerable youth.

Academic pressures from family, which generated an intense fear of failure, were mentioned repeatedly by some informants, as a dominant factor influencing suicidal behaviours for Asian youth (Ho, Au & Amerasinghe, 2015). International students are a high-risk group as reduced social support and English language difficulties, in addition to academic pressures, can increase the risk of suicide. Concerns were voiced particularly for Chinese international students as they were likely to come from one-child families and therefore be the sole point of focus of parental pressures. During exam times, there is an increase in referrals of international students to CAMHS and it is recognised that this is a high-risk period for suicidal behaviours, as the outcomes of exams could determine their further stay in the country.

Unrealistic parental expectations were emphasised by the majority of informants as a major source of distress and low self-esteem for Asian youth in general. Examples of parent-child conflicts specified by two clinicians included both emotional and physical abuse, such as negative, invalidating comments, hitting and throwing objects when expected grades had not been achieved, as well as acting in an authoritative manner over their children’s career path. They proposed that Asian youth with such family backgrounds were more likely to have emotional dysregulation problems and to engage in self-harming behaviours, but they were not necessarily considered suicidal at this early stage (Ho, Au & Amerasinghe, 2015). A GP added that self-harming and suicidal behaviours for Asian youth tended to be unpredictable and impulsive, and that they were more likely to present at the Emergency Department (ED) than at the GP clinic. Young South Asian women had particularly high rates of presenting at ED for self-harming (Ho, Au & Amerasinghe, 2015).

There are hidden issues which are thought to elevate the risk of suicide for Asian youth. Mental health service providers indicate that clients are reluctant to disclose sexual identity issues and sexual abuse issues due to stigma, the fear of shaming and, repercussions from their families. Clinicians in the following interview stated that even clients they had engaged with for over a year, were unwilling to disclose these issues (Ho, Au & Amerasinghe, 2015, p. 38-39):

His parents had given up a lot to come here, for them to have better opportunities. Both parents were working two jobs. I think there was a lot of pressure on him academically … Not only that, I think he started to decline academically, he was going through very severe identity crisis, he was disillusioned with what the church said - quite religious parents - and what science said. I think he was struggling and in all that stuff there was his sexuality and body dysmorphia and he just, … [method of suicide withheld] … And again we think that this was pre-meditated. His family weren't letting him out of their sight. And he described this kind of chronic, you know, thoughts of 'I’d rather be dead than deal with this.'… we knew there was more going on but he just wouldn't tell us. Interestingly, because I saw him twice at home and on both occasions I asked his mum, 'Could we speak with him alone?' She refused to leave his room.

The internet has had an effect on Asian youth on the forming of suicide pacts and peer-influenced suicidal behaviours, as has the influence of emerging methods of suicide in Asian countries, such as hydrogen sulphur poisoning. The copycat effect has a considerable influence on youth suicidal behaviours.

The New Zealand Youth 2007 study found that mental health Issues were a significant concern among Asian youth, especially among female students (Parackal, et al., 2011). Significant depressive symptoms were reported by 18% of females and 7-8% of male Chinese and Indian students in the study (N= 1,310 students, between 13 and 17 years old) who identified with an Asian ethnic group (Chinese = 537; Indian = 365). The findings of the study showed that 13% reported depressive symptoms (12% Chinese; 12% Indian); 15% had suicidal thoughts (15% Chinese; 17% Indian); 8% had planned to kill themselves (9% Chinese; 10 Indian); 4% had attempted suicide (4% Chinese; 6% Indian) and 2% reported inflicting self-harm requiring treatment (3% Chinese; 2% Indian) (Parackal, et al., 2011).

Ministry of Health data on suicide deaths for Asian populations between 1996 and 2010 show that the total number of suicide deaths has increased from 80 between 1996 and 2000, to 84 in 2001-2005, with a further rise to 98 in 2006-2010; annual Asian suicide rates fluctuated between 3.3 and 11.4 per 100,000 people over this period (Au & Ho, 2014):

The suicide rate for Asian people for the period 2009–2013 is 5.3 per 100,000 (Ministry of Health, 2016).
In the New Zealand total population, suicide rates for males are about three times higher than those for females. For Asian people, the gender ratio is 1.2:1 in the five years from 2006-2010.
For Asian groups, suicide rates for 15- 24 years of age are 7.2 per 100,000 for males and 3.7 per 100,000 for females (Ministry of Health, 2016).
Between 1996 and 2010, suicides in the three Auckland DHBs accounted for increasing proportions of the total suicide deaths among Asians, from 52.5 percent in 1996-2000 and 61.9 percent in 2001-2005, to 67.3 percent in the five years between 2006 and 2010.

Risk factors

(Au & Ho, 2014).

Individual risk factors for suicide among Asian populations are similar to those found in Western studies, namely the presence of depression or related mental disorders.
Additionally, a history of substance or alcohol abuse or misuse, and previous suicide attempt(s) are noted risk factors.
Acute life events which create stress can be risk factors for suicide. Job or financial losses, family conflict, relational losses, and academic pressure are some common risk factors for suicide in Asian communities.
Culture and the impact of acculturation play a key role in influencing suicidal behaviour. Migration is accompanied by major cultural transitions such as the disruption of traditional family structures and the changing roles of its members. A wide range of risk factors associated with migration has been recognised: acculturation and settlement stress, family conflict, social isolation, discrimination, loss of social support networks; as well as barriers to accessing mental health services. These factors can contribute to suicidal behaviours directly, but they can also contribute indirectly by influencing individual susceptibility to mental disorders.

Perfectionism

Among suicide risk factors, perfectionism has been emerging as an important consideration (Choi et al., 2009; Dean, Range, & Goggin, 1996). Perfectionism is described as “harboring excessive personal standards” (Castro & Rice, 2003, p. 64) and is conceptualised in three dimensions: self-oriented perfectionism, other-oriented perfectionism, and socially-prescribed perfectionism (Hewitt & Flett, 1991). Self-oriented perfectionism refers to a tendency to set high, unrealistic personal standards while having difficulty accepting one’s flaws; other-oriented perfectionism refers to having an unrealistic standard for one’s significant others; and socially-prescribed perfectionism refers to a belief that others hold high, unrealistic expectations of the individual (Hewitt & Flett, 1991). Some studies have found that in youth, socially prescribed perfectionism predicts suicide ideation above and beyond hopelessness and depression (Choi et al., 2009; Dean et al., 1996).

Culturally informed risk assessment and prevention

Addressing cultural factors is very important in developing strategies to prevent suicide in Asian clients (Ho, Au & Amerasinghe, 2015.

Behavioural definitions

Expresses a generalised fatalism about life and an absence of hope for the future
Displays symptoms of depressive disorder (eg lack of energy, anhedonia, or social withdrawal).
Has a history and current practice of substance abuse.
Extremely invested in pleasing others to gain affirmation.
Demonstrates a life-long pattern of an inability to access or process emotions.
Expresses despair over the inability to meet the expectations of the extended family which results in losing family support, affirmation, and a sense of belonging.
Life-long pattern of impulsive behaviours and poor problem-solving ability.
Verbalises extreme feelings of self-devaluation, isolation, aloneness, and self-hate.
Experiences a chronic pattern of suicide ideation with or without a plan.

Long–term goals

Embrace life with hope for the future.
Enhance the development of coping strategies and problem-solving skills.
Resolve feelings of worthlessness, self-hate, and isolation that contribute to depressive reactions and the impulse to suicide.
Respect vulnerability to depression and remain on physician-monitored prescription medication.
Resolve feelings of perfectionism and develop intrinsic self-worth.
Enhance access to emotions that allow involvement in intimate relationships.

Cultural considerations for therapists (Choi, Rodgers & Werth, 2009).
To facilitate self-disclosure with Asian youth, therapists should openly discuss the importance in the assessment process, provide appropriate assurances related to confidentiality, and explore and identify specific barriers to disclosure as perceived by the client. This process should result in strengthening the therapeutic alliance and should improve the validity of the assessment information. In the case of international student ensure that the young person’s guardian is identified and engaged. Consider that an Asian clients’ reluctance to disclose does not necessarily convey an unwillingness to engage in the assessment process. It is prudent to actively explore potential suicide-related thoughts, feelings, and behaviours in a culturally sensitive way (eg, one might say “Other patients with these symptoms sometimes lose hope, do you have thoughts of giving up?” (Chen et al., 2002, p.241). Asian clients often underreport their psychological symptoms and deny previous suicide attempts for fear of shame. Therapists may find it useful to ask about “any unusual injuries or accidents that have occurred to family members” (Chen, Chen & Chung, 2002, p. 242), when exploring possible suicidal behaviour with Asian youth or their relatives. In addition to the potential psychological consequences of acculturation (see the intergenerational conflict section), understanding the client’s level of acculturation and role as a cultural broker may facilitate effective work with suicidal clients. For example, when therapists find a suicidal client to be a cultural broker in the family, they may need to pay greater attention to adequately preparing the family to access resources and to use appropriate referrals in the community. Exploring clients’ experiences of acculturation, may provide important risk assessment information. For example, when an Asian client appears “too” dependent and “overly” concerned with his or her parents’ reactions, it could be a reflection of cultural values rather than a sign of immaturity. Therefore, discussing independence and autonomy might not be appropriate. In fact, it may be that focusing on interdependence rather than independence can be helpful in moving the client away from the conclusion that death is the only way out of an irreconcilable culture clash. Somatic presentations of emotional distress reflect the Asian concept that mind and body are part of one system. Individuals with traditional Asian beliefs would likely express emotional distress as health concerns. Asian youth may feel misunderstood if therapists conceptualise presenting symptoms as defence reactions that call for deeper insight to make “real” progress. In dealing specifically with suicidal clients, Chen, Chen and Chung (2002) suggest that clinicians frame depression as a medical illness associated with a neurochemical imbalance in the brain, to couch inquiries with cultural sensitivity and to treat psychological illness from the unified perspective of mind and body. Therapists should assess the impact of intergenerational conflict as a potential indicator of suicidal risk. However, it is also important to recognise that such conflicts can be a normative consequence of acculturation. Intergenerational conflict is a salient suicide risk factor for Asian youth. Therapists can help Asian young people to normalise their intergenerational conflicts by helping them to recognise conflict as a common component of cultural adaptation (Chung, 2001). This can help to minimise the shame associated with seeking counselling and can increase the therapist’s credibility with Asian clients. Therapists should help set realistic goals and reduce self-doubts. Asian youth are more likely to be anxious about making mistakes, experience more parental criticism, and have more self-doubt than European students. To assist students in better managing their stress, therapists could implement specific treatment plans to teach stress-management skills and to encourage developing realistic goals. In addition, when working with clients’ families, therapists may want to assist students in setting priorities by helping them to see that academic work can wait, while psychological health cannot. When working with Asian youth, therapists need to seek consultation from others with expertise in the specific cultural variables associated with suicide (Kleespies et al., 1999).

Cultural considerations for therapists

(Choi, Rodgers & Werth, 2009).

To facilitate self-disclosure with Asian youth, therapists should openly discuss the importance in the assessment process, provide appropriate assurances related to confidentiality, and explore and identify specific barriers to disclosure as perceived by the client. This process should result in strengthening the therapeutic alliance and should improve the validity of the assessment information.
In the case of international student ensure that the young person’s guardian is identified and engaged.
Consider that an Asian clients’ reluctance to disclose does not necessarily convey an unwillingness to engage in the assessment process. It is prudent to actively explore potential suicide-related thoughts, feelings, and behaviours in a culturally sensitive way (eg, one might say “Other patients with these symptoms sometimes lose hope, do you have thoughts of giving up?” (Chen et al., 2002, p.241).
Asian clients often underreport their psychological symptoms and deny previous suicide attempts for fear of shame. Therapists may find it useful to ask about “any unusual injuries or accidents that have occurred to family members” (Chen, Chen & Chung, 2002, p. 242), when exploring possible suicidal behaviour with Asian youth or their relatives.
In addition to the potential psychological consequences of acculturation (see the intergenerational conflict section), understanding the client’s level of acculturation and role as a cultural broker may facilitate effective work with suicidal clients. For example, when therapists find a suicidal client to be a cultural broker in the family, they may need to pay greater attention to adequately preparing the family to access resources and to use appropriate referrals in the community.
Exploring clients’ experiences of acculturation, may provide important risk assessment information. For example, when an Asian client appears “too” dependent and “overly” concerned with his or her parents’ reactions, it could be a reflection of cultural values rather than a sign of immaturity. Therefore, discussing independence and autonomy might not be appropriate. In fact, it may be that focusing on interdependence rather than independence can be helpful in moving the client away from the conclusion that death is the only way out of an irreconcilable culture clash.
Somatic presentations of emotional distress reflect the Asian concept that mind and body are part of one system. Individuals with traditional Asian beliefs would likely express emotional distress as health concerns. Asian youth may feel misunderstood if therapists conceptualise presenting symptoms as defence reactions that call for deeper insight to make “real” progress. In dealing specifically with suicidal clients, Chen, Chen and Chung (2002) suggest that clinicians frame depression as a medical illness associated with a neurochemical imbalance in the brain, to couch inquiries with cultural sensitivity and to treat psychological illness from the unified perspective of mind and body.
Therapists should assess the impact of intergenerational conflict as a potential indicator of suicidal risk. However, it is also important to recognise that such conflicts can be a normative consequence of acculturation. Intergenerational conflict is a salient suicide risk factor for Asian youth. Therapists can help Asian young people to normalise their intergenerational conflicts by helping them to recognise conflict as a common component of cultural adaptation (Chung, 2001). This can help to minimise the shame associated with seeking counselling and can increase the therapist’s credibility with Asian clients.
Therapists should help set realistic goals and reduce self-doubts. Asian youth are more likely to be anxious about making mistakes, experience more parental criticism, and have more self-doubt than European students.
To assist students in better managing their stress, therapists could implement specific treatment plans to teach stress-management skills and to encourage developing realistic goals. In addition, when working with clients’ families, therapists may want to assist students in setting priorities by helping them to see that academic work can wait, while psychological health cannot.
When working with Asian youth, therapists need to seek consultation from others with expertise in the specific cultural variables associated with suicide (Kleespies et al., 1999).

Cultural considerations for general practitioners when working with a CALD young person assessed with high suicide risk
Allow as much time as possible, speak slowly and clearly, use short sentences, and repeat yourself regularly. Where the young person is accompanied by a parent, try to see the young person on their own and explain to the parents your reasons for doing this. Be aware that this may be considered culturally inappropriate and disrespectful of the parental role. Seek parental permission first before you seek the young person’s consent. When helping a young person at risk of suicide who is non-English speaking or who speaks English as a second language, communicate clearly. Encourage the person to use their preferred language, especially in stressful situations. People often lose their skills in a second language in stressful situations. Use a professional interpreter to assist communication if needed. If a face to face interpreter is not available use a telephone interpreter. Try to establish a relationship and build a sense of trust.Trust, confidentiality and respect for individual beliefs and attitudes are paramount. Clearly explain your role, services, how the health system works and confidentiality. The person may express themselves in ways you are not used to. Be aware that people interpret suicidal experiences though a range of cultural, spiritual and religious understandings. Be aware of different values and idioms of distress. Provide close monitoring and appropriate support.

Cultural considerations for general practitioners when working with a CALD young person assessed with high suicide risk

Allow as much time as possible, speak slowly and clearly, use short sentences, and repeat yourself regularly.
Where the young person is accompanied by a parent, try to see the young person on their own and explain to the parents your reasons for doing this. Be aware that this may be considered culturally inappropriate and disrespectful of the parental role. Seek parental permission first before you seek the young person’s consent.
When helping a young person at risk of suicide who is non-English speaking or who speaks English as a second language, communicate clearly. Encourage the person to use their preferred language, especially in stressful situations. People often lose their skills in a second language in stressful situations.
Use a professional interpreter to assist communication if needed. If a face to face interpreter is not available use a telephone interpreter.
Try to establish a relationship and build a sense of trust.Trust, confidentiality and respect for individual beliefs and attitudes are paramount.
Clearly explain your role, services, how the health system works and confidentiality.
The person may express themselves in ways you are not used to. Be aware that people interpret suicidal experiences though a range of cultural, spiritual and religious understandings. Be aware of different values and idioms of distress.
Provide close monitoring and appropriate support.