摘要：Indigenous communities have significantly higher rates of suicide than non-Native communities in North America. Prevention and intervention efforts have failed to redress this disparity. One explanation is that these efforts are culturally incongruent for Native communities. Four prevalent assumptions that underpin professional suicide prevention may conflict with local indigenous understandings about suicide. Our experiences in indigenous communities led us to question assumptions that are routinely endorsed and promoted in suicide prevention programs and interventions. By raising questions about the universal relevance of these assumptions, we hope to stimulate exchange and inquiry into the character of this devastating public health challenge and to aid the development of culturally appropriate interventions in cross-cultural contexts. Suicide is a significant public health problem that accounts for approximately 30 000 deaths each year in the United States alone. 1 Striking cross-cultural variability, however, is found in prevalence of suicidal behavior. 1–7 For example, suicide disproportionately affects Native Americans, and young indigenous men have the greatest risk. 8–14 In some locales, these youths complete suicide at a rate of 17 times the US average. 13,15 This stands in marked contrast to the patterns of nonindigenous suicide in the United States, in which older men are at highest risk, 1 and in China, where suicide disproportionately afflicts young rural women. 16 These disparities suggest diverse motivations and meanings for suicidal behavior across cultural and demographic divides, underscoring the need for culturally specific interventions. 17,18 American Indian/Alaska Native (AI/AN) communities display a striking association between suicide and community-level factors, indicating a need for a broader approach to prevention. Indigenous suicide is associated with cultural and community disruptions, 12,19–21 namely, social disorganization, culture loss, and a collective suffering. 10,22–24 Conversely, lower suicide rates and increased well-being have been associated with community empowerment, connectedness, family cohesion, and cultural affinity among Native people. 25–27 Yet despite the connection between personal and community health in AI/AN communities, suicide prevention interventions are often individually focused and clinically based. Thus, mental health services in tribal communities are not always structured to be culturally meaningful 28,29 and are frequently underutilized. 13,30–32 Here we explore potential cultural misalignment by contrasting 4 normative assumptions that underpin standard suicide prevention interventions with indigenous understandings common in North America: (1) suicide expresses underlying psychological problems versus suicide expresses historical, cultural, community, and family disruptions; (2) suicide is primarily an agentic expression of personal volition versus suicide is primarily an enacted consequence of social obligation; (3) suicide prevention is best achieved by mental health professionals versus suicide prevention is best achieved by nonprofessional community members; and (4) suicide prevention most properly falls within the purview of formal mental health service delivery systems versus suicide prevention most properly falls within the purview of locally designed decolonization projects. Drawing on more than 30 years of combined experiences in clinical, administrative, and research settings in AI/AN communities, we examine the relevant meaning systems of both dominant prevention–intervention models as well as AI/AN perspectives concerning suicide because greater understanding of the cultural meanings of mental health problems such as suicide may help public health and mental health professionals improve access and remove barriers to treatment, develop culturally responsive practices, and improve the quality of care for vulnerable populations. 33 Although diverse indigenous beliefs and practices are necessarily conflated here, our comparison is intended to offer innovative ways to understand and effectively prevent suicide in indigenous communities in North America. Moreover, because different understandings of emotional expression and self-representation are associated with other issues, such as alcohol misuse, 34,35 our perspective may be similarly useful for promoting many culturally appropriate behavioral health interventions in tribal communities.
