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INTRODUCTIONBetween2009and2011,twotribalcommunitieslocatedapproximately3,000milesapart—anAmericanIndiantribeonareservationinNewMexicoandagroupofcloselyknitAlaskaNativevillagesinwesternAlaska—experiencedclustersofyouthsuicides.Acrossthesecommunities,25youngpeople,allAmericanIndianorAlaskaNative(AI/AN),tooktheirownlives.Atleast28othersattemptedsuicide,19ofwhomwerehospitalized,andmorethan60otheryoungpeoplewereidentifiedasbeingsuicidal.Manyotherreservationsandtribalvillageshaveexperienced,andcontinuetoexperience,similartragedies,includinganAlaskanvillageinthesameregion,wherenineyoungpeopleattemptedsuicidein2013.

Researchersnotethatoneofthemostdistinctivefeaturesaboutsuicideclustersisthattheyoccuralmostexclusivelyamongteenagers(Gould,2003;Hazel,1993).Whilesuicideclustersarerelativelyrareevents,accountingforfewerthan5percentofallsuicidesinteenagersandyoungadults(Gould,Wallenstein,andKleinman,1987;Gould,2003),onestudyfoundthattherelativeriskofsuicidefollowingexposuretoanotherindividual’ssuicidewas2to4timeshigheramong15-to19-year-oldsthanamongotheragegroups(Gouldetal.,1990).Similarage-specificpatternshavebeenreportedforclustersofattemptedsuicides(Gouldetal.,1994).Someresearchersreportthat,comparedtoadults,youtharemoresusceptibletosuicidebehaviormodeling,socialnormingofsuicidalbehavior(oftendescribedas“contagion”),andimitatingsuicidemethods(Hawetal.,2013).ThissusceptibilityhasbeendescribedasparticularlyacuteamonghigherrisksubgroupsofyouthsuchasAI/ANyoungpeople(BraveHeart&DeBruyn,1998;Bechtold,1988;Wissow,Walkup,Barlow,Reid,&Kane,2001),especiallythosewholiveinsmall,intensesocialnetworksinremotevillagesoronruralreservations(Goldstonetal.,2008).ResearchersfoundthatAmericanIndianyouthwhospenttwo-thirdsormoreoftheirlivesonareservationwereathigherriskforsuicidalideationandsuicideattemptscomparedtoAmericanIndianyouthwhospentthemajorityoftheirlivesinanurbanarea(Freedenthal&Stiffman,2004).Whileadditionalresearchisneededtounderstandthecontributingfactors,someresearchhaspointedtoconsiderableexposurethatAI/ANyouthhavetosuicideonisolatedreservationsandinruralvillages(Bender,2006).

Withinanumberoftribalcommunitiesexperiencingclusters,includingsomeinNewMexicoandAlaska,localandregionalleadershavedeclaredstatesofemergencyanddispatchedcrisisresponseteamstocontainandpreventadditionalsuicides.Theteamsprovidesupportforfamiliesandcommunitymembersastheyworktowardrecovery.Localandregionalleadershavealsointensifiedefforts,inpartnershipwithstateandfederalgovernments,todirectsuicidepreventionfundingandprogramming

What is a suicide cluster?

A suicide cluster “can be defined as a group of suicides or suicide attempts, or both, that occur closer together in time and space than would normally be expected on the basis of statistical prediction or community expectation.” (CDC, 1988)

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todisproportionatelyimpactedcommunities,manyofwhicharelocatedinisolated,ruralareaswithlimitedhealthinfrastructureandcrisisresponseresources.

Thepurposeofthisreportistolearnaboutsuicideclustersandresponsesintribalcommunities;identifystrength-basedapproachestoprevention,response,andrecovery;exploreexistingandneededresourcesforprevention,response,andrecovery;andproviderecommendationsfortribalcommunities,andforfederal,state,andpartners.

TheauthorsofthisreportusedaqualitativemethodologytolearnmoreabouttheeventsandresponseswithinthetwotribalcommunitiesinAlaskaandNewMexicothatexperiencedclustersbetween2009and2011.TheprincipalsourcesofinformationwerecommunitymembersidentifiedthroughtheirinvolvementwithSAMHSA-fundedprograms(i.e.,NativeAspirationsorGarrettLeeSmithYouthSuicidePreventionandEarlyInterventionProgram),recommendedbytribal/villageleadership,orboth.Individualschosentobeinterviewedreflectedavarietyofperspectivesandincludedelders;triballeaders;teachersandschoolpersonnel;mentalhealthandotheryouthserviceproviders;youngpeoplewholostpeerstosuicide;andmothers,fathers,grandparents,andothertribalmemberswholostfamilymemberstosuicide.Thecategoriesarenotmutuallyexclusive,withmanyintervieweesprovidingmultipleperspectives.

Thisreportincludes:

� Backgroundinformationbasedonresearchliterature,mediareports,andsurveillancedataregardingsuicideratesintheaffectedcommunities;clustersandcontagion;riskandprotectivefactorsintribalcommunities;andcontextualinformationabouttheregionswheretheclustereventsoccurred.Thisincludesthelocalhealthserviceinfrastructureandaccesstobehavioralhealthresources,aswellastheimpactandresponsetotheclustersineachcommunity;

� Adescriptionofdatasourcesusedforthisreport,includinginterviewsanddocumentreviews;

� Findingsrelatedtotheimpactofclustersonindividualsandcommunities,communityresponseandrecovery,suicidepreventionstrategies,andexistingandneededcommunityresources;and

� AdiscussionofthefindingsastheyrelatetofutureresourcestopreventandrespondtosuicideclustersinAI/ANcommunities.

BACKGROUNDNationalBackdropSuicideisasignificantpublichealthproblemintheUnitedStates,withtheratesofsuicidewithinsomepopulationsbeingparticularlyhigh.Suicideisthesecond-leadingcauseofdeathforAI/ANyouthandyoungadultsaged10–24years(NCHS,

Exhibit1.SuicideRatesamongYouthsAged10to24,byRace/EthnicityandSex,UnitedStates,2005–2011*

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2011a).ThesuiciderateforthisgroupistwotofourtimestherateofotherAmericansinthisagegroup(NCHS,2011b;Exhibit1).WhilethesuicideratedecreasedslightlyforAI/ANpeopleintheUnitedStatesbetween2010and2011,thispopulationcontinuestoexperienceoneofthehighestsuicideratesofallracialandethnicgroupstrackedbytheCentersforDiseaseControlandPrevention(CDC;NCHS,2011b).Withinsomestates,overallsuicideratesaremuchhigherthanthenationalaverage,withthehighestratesoccurringinAlaska,theRockyMountainstates,andintheSouthwestregion,includingNewMexico(NCHS,2011b;AmericanFoundationforSuicidePrevention,2014;Exhibit2).Ingeneral,statesintheWestconsistentlyexperiencehighersuicideratesthanstatesintheNortheast,Southeast,andMidwest.Forexample,between2005and2011,fivewesternstateshadaverageage-adjustedratesthatweremorethan19per100,000:Alaska(21.24),Montana(21.01),Wyoming(20.88),NewMexico(19.40),andNevada(19.06).ThisisnearlydoubletheoverallU.S.age-adjustedrateof11.57per100,000,overthesametimeperiod(Exhibit2).

Exhibit2.NationalSuicideRates

*Age-adjusted suicide rates per 100,000 population by state, 2005-2011 (NCHS, 2011b) InAlaskaandNewMexico,suicideratesamongAI/ANyoutharesignificantlyhigherthanratesamongyouthfromotherculturalorethnicgroups.SuicideiscurrentlytheleadingcauseofdeathforAI/ANyouthaged15–24livinginAlaska(NCHS,2011a),witharatemorethanninetimesthatofallyouthwithinthatagerangeintheUnitedStates(98.88and10.04per100,000,respectively).At152.83per

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100,000,thesuiciderateforAI/ANmalesaged15–24yearsinAlaskaisnearlyninetimesthatforallmalesaged15–24intheUnitedStates(16.23per100,000).YoungAI/ANfemalesinAlaskadiebysuicide11timesmoreoftenthanallU.S.femalesinthatagegroup(41.02and3.53,respectively;NCHS,2011b).

WhileyouthsuicideratesarelowerinNewMexicothaninAlaska,NewMexiconeverthelessexhibitsasimilartrend.ThesuiciderateforAI/ANyouthaged15–24yearsismorethanthreetimestherateforallyouthwithinthatagegroupintheUnitedStates(33.03and10.04per100,000,respectively).ForyoungAI/ANmales,therateis49.15per100,000,overthreetimestherateforallmalesthatageintheUnitedStates.ForyoungAI/ANfemales,therateis16.44per100,000,overfourtimestherateforallfemalesthatageintheUnitedStates(NCHS,2011b).

SuicideClustersandContagionAsuicideclustercanbedefinedas“agroupofsuicidesorsuicideattempts,orboth,thatoccurclosertogetherintimeandspacethanwouldnormallybeexpectedonthebasisofstatisticalpredictionorcommunityexpectation”(CDC,1988;Gould,Jamieson&Romer,2003).Therearetwomaintypesofsuicideclusters:pointandmass(Haw,Hawton,Niedzwiedz,&Platt,2013;Joiner,1999;Rezaeian,2012).Pointclustersarecloseinbothlocationandtime,occurinsmallcommunities,andinvolveanincreaseinsuicidesaboveabaselinerateobservedinthecommunityandsurroundingarea(Haw,Hawton,Niedzwiedz,&Platt,2013;Joiner,1999;Rezaeian,2012;Coxetal.,2012).Massclustersinvolveatemporaryincreaseinsuicidesacrossawholepopulation,closeintimebutnotnecessarilylocation.Massclustershavebeendocumentedfollowingsuicidesofhigh-profilecelebritiesorotherswhoreceiveconsiderablemediaattention(Coxetal.,2012;Joiner,1999).

Inherliteraturereviewoftheimpactofmediacoverageonsuicide,Gouldprovidesevidencethatextensivenewspapercoverageofsuicideisassociatedwithasignificantincreaseintherateofsuicide,withthemagnitudeoftheincreaseproportionaltotheamount,duration,andprominenceofmediacoverage(2001).Youngpeopleappeartobeparticularlysusceptibletoheightenedriskbroughtaboutbycertaintypesofmediareportingofsuicide(Gould,Jamieson,&Romer,2003).Aretrospective,case-controlstudyofsuicideclustersinyoungpeopleintheUnitedStatesbetween1988and1996(beforethearrivalofsocialmedia)indicatedanassociationbetweencertainkindsofnewspaperreportsaboutsuicideandthebeginningofclusters(Gouldet.al.,2014).Storycharacteristicsinvolvingfront-pageplacement,headlinescontainingthewordsuicideoradescriptionofthemethodused,anddetaileddescriptionsofthesuicidalpersonappearedmoreoftenforcluster-relatedsuicidesthannon-clustersuicides(Gouldetal.,2014).

Whilethemechanismsunderlyingsuicideclustersareunclear,ithasbeenproposedthatpointclustersmayresultfromaprocessof“contagion,”wherebyoneperson’ssuicidalthoughtsandbehaviorsaretransmittedfromonevictimtoanotherthroughsocialorinterpersonalconnections(Coxetal.,2012;Joiner,1999).Accordingtosomeresearchers,asuicidecontagionissimilartothespreadofinfectiousdisease(Haw,Hawton,Niedzwiedz,&Platt,2013).Justasfluismostlikelytoaffectindividualswithweakenedimmunity,inpoorhealth,andinclosecontactwithsomeonewhoissick,suicideismorelikely

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toaffectindividualswithahistoryofmentalillness,whoareclosefriendsorrelativesofthepersonwhodiedbysuicide,andwhoareexperiencingpoormentalhealth(Haw,Hawton,Niedzwiedz,&Platt,2013).Otherresearchershavecautionedthatsuicidecontagionhasyettobeclearlydefined(Joiner,1999).

Thesuicideclustersdiscussedinthisreportarepointclustersthatoccurredintwotightlyknitandgeographicallyisolatedcommunities.TheaffectedAlaskanvillagesarenotontheroadsystemandareaccessibleonlybysmallplane,whichforcesahigherlevelofself-andcommunalreliance.Mostindividualsarerelatedthroughbloodormarriage.InthecaseoftheAlaskacommunity,extendedfamilyandrelationsliveinnearbyvillagesthatessentiallyfunctionasasinglecommunity.Thus,whenasuicideoccursinonevillage,itimmediatelyimpactsresidentsinneighboringcommunities.

RiskandProtectiveFactorsSuicideriskfactorsamongAI/ANyoutharewell-knownandhavebeenwidelyreported.ManyAI/ANyouthfacepoverty,isolation,historicaltrauma,discriminationandracism,disruptedfamilyunits,previoussuicideattempt(s),accesstolethalmeans,exposuretootherswhohavediedbysuicide,physicalorsexualabuse,barrierstocare,highratesofalcoholanddruguse,andinterpersonalviolence(AlakanukCommunityPlanningGroupetal.,2009;BigFoot,2007;Borowsky,Ireland,&Resnick,2001;Borowsky,Resnick,Ireland,&Blum,1999;Christman,2012;Duran&Duran,1995;Yoder,2006).Growingupintwoculturesthathaveverydifferentworldviewscancreatecumulativestressesthatmayincreasesusceptibility(LaFromboise&BigFoot,1988).Moreover,theestimatedprobabilityofattemptingsuicidedramaticallyincreasesasthenumberofriskfactorstowhichyouthareexposedincreases(Borowskyetal.,1999;Borowskyetal.,2001).

Hawandcolleagues(2012)reviewedtheliteratureonsuicideclusterstodescribetheriskfactorsandproposedpsychologicalmechanismsunderlyingpointclusters.Theauthorsidentifiedtwokindsofliterature:(1)papersdescribingindividualsuicideclusters,whichincludedcharacteristicsofclustervictimsandenvironmentalriskfactors;and(2)papershypothesizingthemechanismsunderlyingclusterformationand,whichinafewcasesalsoprovidedempiricaldatatestingaspecifichypothesis.Thereviewfoundthatriskfactorsforsuicideclustersaresimilartoriskfactorsforsuicideingeneral.Theauthorsconcludethatnearlyallclusterstudieswereuncontrolledandinvolvedrelativelysmallnumbersofsuicides,andthatfurtherresearchisneededtoimproveunderstandingofthemechanismsinvolved.

“Circlesofvulnerability”(Exhibit3)isamodelthatmayprovideinsightintomechanismsofsuicideclusters.Developedtoassesscommunitytrauma,themodelconsidersgeographicalproximity,psychosocialproximity,andpopulationatrisk(Lahad&Cohen,2006;Zenere,2008,2009).Geographicalproximityisthephysicaldistancefromtheinitialsuicide;psychosocialproximityistheclosenessoftherelationshipwiththeperson

Exhibit3.CirclesofVulnerability

GeographicProximityto

Suicide

PsychosocialProximityto

PopulationatRiskfor

Suicide Suicide

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“Multiple traumas in Indian Country are cumulative and can increase feelings of hopelessness and helplessness that can lead to suicide.”

(BigFoot, 2007)

whodied;andpopulationatriskreferstoanindividual’sriskfactors,suchasmentalillness,historyoftrauma,substancemisuse,andhistoryofsuicidalthoughtsandbehaviors(Zenere,2008,2009).Theintersectionofthethreecirclesreflectsthepointofhighestvulnerability.

Throughthelensofthismodel,theriskprofileofNativeyouthisoftenquitehigh.Communitymemberstypicallyliveincloseproximityandarerelatedtooneanother;adolescentsocialnetworksaresmallandintense(Goldstonetal.,2008);andindividualriskfactors(e.g.,alcoholuse,depression,thedeathoffamilyandfriendsbysuicide)tendtomountandmultiply(BigFoot,2007).Whileyouthconnectednesstofamilyandcommunityisgenerallyaprotectivefactor,itcanalsobecomepartofthecontagionprocessifyoungpeoplebegintoperceivesuicidalbehaviorasnormalamongtheirpeersorpeopletheyadmire(ActionAlliance,2014).

Asocialecologicalmodelisalsousefulforunderstandingriskandprotectivefactorsacrossfourlevels:individual,relationship,community,andsocietal(U.S.HHSandNAASP,2012).Somefactorsareattheindividuallevel,butmanytranscendthepersonandareinfluencesofthelargercommunity.AsGoneandAlcántara(2007)stateinaparaphraseofFelnerandFelner’s(1989)transactionalecologicalframework,the“rootsofpathologycanbeandoftenareoutsideoftheperson.”Categorizingriskandprotectivefactorswithinthemodel’slevelsshowsthefactors’complexity,theinteractionandrelationshipbetweenandacrosssuchlevels,andpossiblestrategiesandentrypointsforpreventionandintervention.

Considerationofcommunity-andsocietal-levelriskfactorsisparticularlyimportantforAI/ANpopulations,as“indigenoussuicideisassociatedwithculturalandcommunitydisruptions,namely,socialdisorganization,cultureloss,andacollectivesuffering”(Wexler&Gone,2012,p.800).AmongtheriskfactorsforsuicideuniquetoAI/ANyouth,thesecommunitiescontinuetobeimpactedbyhistoricaltraumastemmingfromcolonizationandlossofconnectiontospiritualandculturalpractices(BraveHeart,Chase,Elkins,&Altschul,2011).

Historicaltraumaisthe“cumulativeemotionalandpsychologicalwoundingoverthelifespanandacrossgenerations,emanatingfrommassivegrouptraumaexperiences”(BraveHeart,2003).Aprimaryfeatureofhistoricaltraumaisthat“thepsychologicalandemotionalconsequencesofthetraumaexperiencearetransmittedtosubsequentgenerationsthroughphysiological,environmentalandsocialpathwaysresultinginanintergenerationalcycleoftraumaresponse”(Sotero,2006).Suicidalideationandbehavior,substancemisuse,depression,anxiety,lowself-esteem,anger,anddifficultyrecognizingandexpressingemotionshaveallbeenidentifiedascomponentsofthehistoricaltraumaresponse(BraveHeart,2003).

EffortsbytheUnitedStatestoassimilateAmericanIndiansintotheEuropean-Americanmainstreamcultureand“toendthetribeasaseparatepoliticalandculturalunit”(Cohen,1982ed.,p.139)arewell-documentedandincludepolicessuchascriminalizingtraditionaltribalgovernanceandcultural

CDC Lessons Learned In Responding to Suicide Clusters

Potential opportunities for prevention were often missed during the early stages of the [suicide cluster] response as community leaders searched for information on how best to respond to suicide clusters.… In the early days of an evolving suicide cluster, there has typically been a great deal of confusion. There is often a sense of urgency in the community that something needs to be done to prevent additional suicides, but there has usually been little initial coordination of effort in this regard (CDC, 1988, p.2). 7

practices,suchasfuneralproceduresandspecificdancesandceremonies(Cohen,1982ed.,pp.128-145).EffortstouseboardingschoolstoforceassimilationofNativechildrenspannedfrom1790through1920(Hoxie,1984).Childrenwereremovedfromtraditionalfamilies(includingextendedfamilyandclansystemcultures)andfromothertraditionalformsofsocialorganizationandsourcesforidentitydevelopment,toliveinboardingschools,wheretheywereoftenverbally,physically,andsexuallyabused(Napoleon,1996).BraveHeart(1999)discussestheprocessofboardingschoolsdeprivingfamiliesoftraditionalNativeparentingrolemodels,“impairingtheircapacitytoparentwithinanindigenoushealthculturalmilieu.”Theculturalanchorsthatshouldhaveservedtogroundandenhancehealthydevelopment—fromchildhoodthroughadulthoodandparenthood—weremissing,and,inmanycases,dysfunctionwasleftinitsplace.

AnumberofstudieshavealsolookedatprotectivefactorsamongAmericanIndianandAlaskaNativeyouth.Perceivedconnectednesstofamily;discussingproblemswithfriendsorfamily;consistent,healthyattachmenttofamilyandschool;traditionalculturalvaluesandpractices;emotionalhealthandwell-being;andaccesstomentalhealthserviceshaveallbeenidentifiedasprotectiveagainstsuicideattempts(Borowskyetal.,1999;Borowskyetal.,2001;Kraletal.,2011).Similarly,Wolskoandcolleagues(2009)foundthattribalmemberswhofollowamoretraditionalwayoflifereportedgreaterhappiness,morefrequentuseofreligionandspiritualitytocopewithstress,andlessfrequentuseofdrugsandalcoholtocopewithstress.Garroutteetal.(2003)found“astrongandpersistentprotectiveassociationbetweenculturalspiritualorientationsand[lifetimeself-reported]suicideattempts”(p.1576),evenwhenriskfactorssuchassubstancemisuseandpsychologicaldistressareexperienced.Theydefined“Culturalspiritualorientations”notasbeliefsystems,butas“waysofencounteringandinterpretingself,world,andexperiences….[that]reflectAmericanIndianculturalviewsoftheconnectednessofhumanstoallotherphysicalandtranscendentalentities”(Garroutteetal.,p.1573).Moreover,connectednessisprotectivewhenitoccurswithinandbetweenmultiplelevelsofthesocialecology—betweenindividuals,families,schoolsandotherorganizations,neighborhoods,culturalgroups,andsocietyasawhole(ActionAlliance,2014).

PreventingandRespondingtoSuicideClustersOneofthemostwidelyciteddocumentsaboutpreventingandmanagingsuicideclustersisCDC’s“RecommendationsforaCommunityPlanforthePreventionandContainmentofSuicideClusters”(CDC,1988).Therecommendationsunderscorethecriticalimportanceofdevelopingcommunityplansbeforesuicideclustersoccurandtheyguidecommunityleadersandstakeholdersindevelopingspecificstrategies.Thishelpsacceleratepreventioneffortsandfacilitatesswift,coordinated,andeffectiveresponseintheeventofacluster.Thedocument

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suggeststhatsucharesponseplanshouldbeimplementedintwocircumstances:(1)whenasuicideclusteroccursinthecommunityor(2)whenoneormoretraumaticdeaths1occurinthecommunity,especiallyamongadolescentsoryoungadults,whomaybeathigherriskforcontagion.Relatedtothesecondcircumstance,CDCnotesthat“severalclustersofsuicidesorsuicideattempts(havebeen)precededbyoneormoretraumaticdeaths—intentionalorunintentional—amongtheyouthofthecommunity”(CDC,1988,p.5).

CDC’srecommendationsarebasedontheexperts’experiencesandlessonslearnedassistingvariouslocalcommunitiesinaddressingsuicideclusters.Onekeyexampleisthefactthatcommunityleadersrespondingtoanevolvingsuicideclusterfacethesimultaneoustasksofattemptingtopreventtheclusterfromexpanding,whilealsomanagingtheexistingcrisis(Askland,Sonnenfeld&Crosby,2003;OfficeofSafeandDrug-FreeSchools,2007).Toensurethetimeliestreactionpossible,therecommendationsurgethattheresponseplanandrolesofeachparticipantbedeveloped,agreedupon,andunderstoodbyallrelevantparticipantsbeforetheonsetofacrisis.

Therecommendationsemphasizetheneedforincludingallsectorsofthecommunity(e.g.,publichealth,mentalhealth,education,localgovernment,clergy,parentgroups,themedia,communityorganizations)inplanningandtheimplementingthepreventionandresponseeffort.Withthegoalofbuildingacoordinated,collaborativeinitiative,CDCurgesthat“[e]veryeffortshouldbemadetopromoteandimplementtheproposedplanasacommunityendeavor.…Nosingleagency…hastheresourcesorexpertisetoadequatelyrespondtoanevolvingsuicidecluster”(CDC,1988,p.3).Thedocumentstressestheneedtoincluderepresentativesofthelocalmediaindevelopingtheplan,toensurethatthe“legitimateneedforinformation”canbesatisfiedwithoutthekindofsensationalizedreportingthathasbeenshowntocontributetosuicidecontagion.

Overall,thedocumentpresentsasetofbroadprinciplesandsequentiallyorderedstepsthatlocalcommunitiescanundertaketopreventandplanforclustersaspartoftheiroverallsuicidepreventionplanningprocess.Therecommendationsemphasizethatcommunitypreventionandresponseplansmustbeadaptedtotheparticularneeds,resources,andculturalcharacteristicsofthecommunity.

A2012literaturereviewaimedatunderstandingeffectivepreventionand

1Traumaticdeathreferstoanydeathinthecommunitythatisnottheresultofoldageorsickness.

Common Response to Contain a Youth Suicide Cluster

1) Development of a community response plan

2) Educational/psychological debriefings

3) Individual and group counseling for affected peers

4) Screening of high-risk individuals

5) Responsible media reporting of the suicide cluster

6) Promotion of health recovery within the community

(Cox et al., 2012)

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postvention2strategiesforsuicideclusters(Coxetal.)foundthatfewstudiesactuallydocumentedresponsestrategiesandonlyoneevaluateditsefforts.However,theauthorsidentifiedanumberofstrategiesthatshowpromise,includingsixcommonapproachestoclustercontainmentfrequentlyadoptedbycommunitiesandschools(seetextbox).

SuicideSettingsofFocus:ClusterLocationsandResponses

TribeinNew Mexico

InNewMexico,thesuicideclusteroccurredonatribalreservation3locatedintheU.S.IndianHealthService’s(IHS’s)AlbuquerqueArea.TheAlbuquerqueArea,whichextendsovermostofNewMexicoandallofColorado,provideshealthservicestoAmericanIndiansinnumeroustribalgroups,eachwiththeirownhistory,language,andculture(IHS,n.d.).IntheNewMexicoportionoftheAlbuquerqueArea(Exhibit4),thetribesservedincludethe19Pueblos,theJicarillaandMescaleroApaches,andtheAlamo,Canoncito,andRamahchaptersoftheNavajoNation.Whilethepreviousgenerationsoftheaffectedtribewerenomadichuntersandgatherers,tribalmembersnowfish,hunt,manageranches,andsupportanactivetouristindustry(IHS,n.d.).

Exhibit4.NewMexicoIHSAlbuquerqueServiceAreaandTribalLands

Inresponsetothesuicidecluster,whichinvolvednotonlymultipledeathsbutmanyattemptsandexpressionsofsuicidalideation(strongthoughtsofengaginginsuicidalbehavior),thecommunityformedacrisisresponseteamtodeterminepriorities,strategies,andstepsforpreventionandcontainment.ConsistentwithCDCrecommendations,theresponsereflectedbroadcollaborationamongtribal,local,county,stateandfederalprogramsandpartneragencies.Examplesofactionsincludedprovidingassessmenttrainingandsupportforemergencymedicalserviceproviders,BureauofIndianAffairslawenforcementofficers,tribalconservationofficers,andmedicalproviders.LawenforcementofficialsagreedtonotifyandinvolvetheIHSwithin24hoursofanysuicideattemptorthreat.Thecrisisresponseteamplannedsuicidepreventionawarenesstrainingsinschoolsandothercommunitysettings.Thecommunityprovidedoutreachtotribalyouthintribalandpublicschools

2Suicidepostventionisdefinedas“Responsetoandcareforindividualsaffectedintheaftermathofasuicideattemptofsuicidedeath”(U.S.DepartmentofHealthandHumanServices(HHS)OfficeoftheSurgeonGeneralandNationalActionAllianceforSuicidePrevention,2010,p.141).Thegoalsofpostventionmayinclude(1)supportingthebereavedsurvivors,(2)preventingimitativesuicidesbyidentifyingotherindividualsatriskforself-destructivebehaviorandconnectingthemtointerventionservices,(3)reducingsurvivoridentificationwiththedeceased,and(4)providinglong-termsurveillance(Gould&Kramer,2001).3Thespecificlocationoftheclustersandrelateddetailswillnotbedisclosedinthisdocumenttomaintaintheconfidentialityofinterviewparticipants.

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acrossfourcommunities,offeringhealthservices,mentalhealthservices,andsuicidepreventionactivities,includingeveningevents.

Justpriortothecluster,thetribehadbegundevelopingasuicidepreventionteamwithfederalgrantfundingfromtheSubstanceAbuseandMentalHealthServicesAdministration(SAMHSA).Astheclusterevolved,theteamimplementednumeroussuicidepreventionprograms,includingapeer-to-peerprogrammodeledafter“NaturalHelpers,”whichhadbeenpreviouslyusedwithsuccessinatribalcommunity(Mayetal.,2005).SernadescribesNaturalHelpersasa“peer-helpingandleadershipdevelopmentprogrambasedonthepremisethatwithineveryschoolaninformal‘helpingnetwork’existsamongpeers.Studentswithproblemsseekoutotherstudentswhomtheytrust.”(2011)Inadaptingtheprogramtotheircommunity,theNewMexicotribalsuicidepreventionteamsurveyedstudentstounderstandsourcesofdistressintheirlivesandidentified“natural”peersupportersamongstudents.Theteamtaughtthepeershowtomentorstudentswhowerestruggling,encouragethemtotalkwiththeirsupportnetworks,andseekoutadultcounseling.Theteamalsointegratedsocialmediatoreachyouthandidentifystudentsatriskofsuicide.

ThetribefallswithintheIHSAlbuquerqueArea,whichisdividedintotenserviceunits,eachofwhichprovidesservicesatthecommunitylevel(IHS,n.d.).ThelocalIHSServiceUnitincludesinpatientandoutpatientservices,aswellasfieldhealthprograms.Specializedservices(e.g.,surgicalandorthopediccare)arereferredtocontracthospitalsintheregion.Atthetimeofthecluster,theIHSServiceUnitmentalhealthclinicemployedtwoindependentlylicensedcounselors.Othermentalhealthresources,includingclinicalpsychologists,psychiatrists,socialworkers,etc.weremorethan200milesfromthetribalsettingforthiscluster—notanuncommonscenarioforrural,tribalcommunities.Accesstobehavioralhealthserviceswasfurtherlimitedbecauseseveraltribalsubstanceuseproviderpositionswerevacant.

Whentheclusterdeveloped,theIHSdirector,inconcertwiththetribe,requestedandreceiveda90-daydeploymentofUnitedStatesPublicHealthServicementalhealthteamstostabilizeandaddressthehighnumberofattemptedandcompletedsuicides.Theteamsworkedwithfourschooldistrictsandcommunities,providingcounselingservicestostudentsandstaff,andimplementingprocessestotrackandmonitorsuicide-relateddata(e.g.,numbersofsuicideattempts,theageoftheperson,whetherdrugsoralcoholwereinvolved).Additionally,IHSinstitutedatelebehavioralhealthservicetoconnectlocalresidentswithbehavioralhealthstaffinotherareas.

Villagesin Western AlaskaThisreportfocusesonthreeYup’ikorCup’ikcommunitieslocatedontheBeringSeacoast,withpopulationsrangingfrom530to1,100.

Thehighratesofsuicide—beyondwhatwouldbeexpected—acrossmanyvillagesintheYukon-Kuskokwim(YK)TribalHealthRegion(Exhibit5)meanthattherearealmostcontinualsuicideclustersintheregion.OftenreferredtoastheYKDelta,thisareahasoneofthehighestsuiciderates(58.2per100,000)inthestateandthecountry.Therateisnearly3timeshigherthanAlaskaasawhole(21.28)

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andmorethan5timeshigherthantheUnitedStates(11.38)(AlaskaBureauofVitalStatistics,2002—2011;NCHS,2011b).

TheYKTribalHealthRegioncoversapproximately58,000squaremilesandishometo58federallyrecognizedYup’ik,Cup’ik,andAthabascantribes(Yukon-KuskokwimHealthCorporation[YKHC],n.d.).Theregion’s25,555residents,82percentofwhomareAlaskaNative,livein50villagesranginginsizefrom6to1,100residents(U.S.CensusBureau,2012;YKHC,2011–2014).Allofthevillageswithintheregionareaccessibleonlybysmallplaneorbysnowmachinetrailsinwinter.ThetownofBethelservesastheregionalhubcommunityandishometo6,080residents(U.S.CensusBureau,2012).Variousairtaxisprovide

Exhibit5.Yukon-KuskokwimTribalHealthRegion

regular,albeitexpensive,servicebetweenBethelandthevillages.Round-tripticketsbetweenBethelandthevillagescostbetween$200and$700,dependingonthedistance(ERAAlaska,2014).

IntheYup’ikorCup’ikcommunitiesimpactedbycontinualsuicideclusters,theregion’smainhealthcareprovider(YKHC)deploysacrisisresponseteamofbehavioralhealthproviders.Theteamprovidesmentalhealthcounseling(includingtalkingcircles4)forfamilieswholoselovedonestosuicide,anddebriefingandpostventionservicesforfirstresponders.YKHCandfederalandstateprograms,includingsuicidepreventionprograms,haveworkedwiththecommunitiestodeveloppreventionplansthatengageyouthandlimithigh-riskbehaviorssuchasalcoholanddruguse.Villageschoolstakeanactiveroleincommunityresponsebyincreasingtheiremphasisonthesocialandemotionalwell-beingofstudents.TheschoolspositivelyacknowledgeyouthandimplementtheNaturalHelperspeer-to-peerprogram.

Villagetribalcouncilsrespondtosuicideclustersbycallingcommunitymeetingstodiscusstheimpactofsuicide,itsrelationtohistoricaltraumaandtodrugandalcoholuse,andcontemporaryandtraditionalwaystoheal.Indirectresponsetothehighnumbersofsuicidethataffectedtheregionin2010,AlaskaSenatorLisaMurkowskiconvenedasummit,ajointeffortinvolvingthegovernor,membersoftheAlaskaSuicidePreventionCouncil,theSAMHSAtribalaffairsadvisor,andmembersoftheU.S.SenateIndianAffairsCommittee.SummitparticipantsdiscussedthehighratesofsuicideinwesternAlaskaandheardfromyoungpeopleaboutwaystobetteraddresstheproblem(DeMarban,2010).

TheYKHC,locatedinthehubcommunityofBethel,istheregionaltribalhealthconsortiumandmainhealthcareproviderforthevillagesintheYKservicearea(Exhibit6),provideshospital,dental,and

4Thetalkingcircleisatraditionalwayfortribalpeopletosolveproblems.Thereisnobeginningnorendinacircle;thus,noonepersonisinapositionofprominence.Thetalkingcirclecreatesanenvironmentwherepeoplecanspeakfreely,airtheirdifferences,andresolveproblems.

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behavioralhealthcare;healthpromotionanddiseaseprevention;andenvironmentalhealthservices(YKHC,2014).YKHCalsoprovidesbasichealthserviceswithinthevillages,throughclinicsstaffedbyCommunityHealthAides(CHAs).Theselocalindividualsarethefrontlineofmedicalcareandsupportwithintheirvillages.CHAsarecertifiedattheCHAI,II,IIIandPractitioner(CHAP)levelsandareselectedbytheircommunitiestoreceivetrainingfortheirroles.Foreachlevel,thetraininglastsapproximately3weeks(AlaskaCHAP,n.d.).CHAsoperateinanestablishedreferralrelationshipwithmid-levelproviders,physicians,andtheregionalhospitals(AlaskaCHAP,n.d.).WithintheYKDelta,therearealsofivesubregionalclinics,eachofwhichservesthevillageswithinitssubregion.Subregionalclinicsofferahigher

Exhibit6.Yukon-KuskokwimServiceArea

levelofservicethanthevillageclinicsandincludepreventativeandurgentcare,aswellaslaboratoryandX-rayservices.Thesubregionalclinicsarestaffedwithatleastonemid-levelprovider,typicallyanursepractitionerorphysicianassistant.Subregionalclinicsprovideancillaryservices(e.g.,dental,behavioralhealth),oftenintheformoftravelingcaretothehandfulofvillagesintheirsub-region.Comprehensivementalhealthandsubstanceuseservices(includinginpatientandoutpatientservices)areavailableattheYKHCinBethel.However,accesstocomprehensivebehavioralhealthservicesrequiresleavingthevillageviabushplane.

Toincreaseaccesstomentalhealthservicesinvillages,in2004theAlaskaNativeTribalHealthConsortium(ANTHC)collaboratedwithIHStoinstituteastatewidebehavioralhealthworkforcemodelthatwassimilartotheCHA.By2008,theBehavioralHealthAide(BHA)programhadbeenincorporatedintothefederallyrecognizedCommunityHealthAideProgram.TheexistingCommunityHealthAideCertificationBoardStandardsandProcedureswereamendedtoincludestandardsforBehavioralHealthAides(BHAI,II,IIIandBehavioralHealthPractitioner(BHP)certificationandpractice(ANTHC,2005–2014).LikeCHA/Ps,BHA/Ps’shavealimitedscopeofpracticeandserveashealtheducatorsandadvocateswithintheircommunities(ANTHC,2005–2014;vanHecke,2012).Practicingunderthesupervisionoflicensedcliniciansbasedintheregionalhubs,BHAsI,IIandIIIprovidecasemanagement,referral,communityeducation,andpreventionservices;BHPsalsoprovidetreatmentplanningandcommunityevaluations(vanHecke,2012).

WhileeverywesternAlaskavillagedoesnothaveaBHAprogram,thosethatdoselectresidentsoftheirownvillage,fluentinthecultureofthecommunity,whoisawelcomingandfamiliarface.However,giventheclose-knitnatureofthecommunities,concernsaboutconfidentialityandshameaboutbehavioralhealthmaylimitserviceutilization.Communitymembersareoftenreluctanttoseekcarefromindividualstheyhaveknown,inmanycases,theirentirelives(vanHecke,2012).

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Availableinsomevillagesfor10years,telebehavioralhealthisanalternativevenueforreceivingcareandmayhelpallayprivacyconcerns.ButevenwiththeadditionoftheBHAprogramandaccesstotelebehavioralhealth,accesstobehavioralhealthcareisextremelylimitedandsimplyoutofreachformanyAlaskaNatives.

SOURCES OF INFORMATIONSAMHSAandtheauthors(federalcontractors)ofthisreportselectedcommunitiesbasedonclustersreportedwithinthepast5years.Theauthorsthenengagedthecommunitiestodiscussthepurposeofthestudy,answerquestions,anddeterminetheirinterestinparticipating.Whenacommunityexpresseditsinterest,theauthorsmetwiththetribalcouncilorvillageleadershipandsignedaMemorandumofunderstanding(MOUs)betweenthetribe/villageandthefederalcontractor.Thecontractorsoughtandobtainedinstitutionalreviewboardapprovalforallproceduresusedinthisstudy.

Thisreportisinformedbymultiplesources,includingqualitativedatacollection,reviewandanalysisofexistingdata(YRBS,BRFSS,NVDRS),andarchivalrecords.ThecontractorrecruitedninecommunitymembersfromthetribeandAlaskavillagestoparticipateinindividualtelephoneinterviews,securinginformedconsentbeforetheinterviews.InterviewswereconductedbetweenJune2013andFebruary2014,andrecorded,transcribed,andanalyzedusingstatisticalsoftware.Thecontractoralsoreviewedandanalyzedarchivalrecords,includingtestimony;meetingminutesfromcommunityandlegislativemeetings;newspaperandmediasources;andotherdocumentsande-mails.

Whiletheindividualsthatparticipatedintheinterviewsarediverseintermsofage,gender,roleinthecommunity,andlevelofinvolvementinsuicidepreventionworkinthecommunity,thesamplewasnotintendedtoberepresentativeofthevillageortribeperspective.Rather,arangeofinformationwasgatheredtounderstandandinformpreventionandresponsetosuicideclustersfromdirectexperiencesanduniqueculturalandtribal/villagecontexts.Inaddition,thesamplesizesacrossthesettingsarenoteven(i.e.,moreinterviewstookplacewithvillagemembersinAlaskathanwithNewMexicotribalmembers).

FINDINGSBasedontheinterviewsandotherdatasources,thissectionpresentsfindingsrelatedtotheimpactofsuicideclustersonthecommunity,andexistingandneededsuicidepreventionresources(bothcommunity-basedandexternal).Thesummaryincludesrecommendationsfromcommunitymembersonfactorsthathinderedorfacilitatedsuicidepreventionandresponsetosuicideclusters.

EffectofSuicideClustersontheCommunityInboththetribeandvillagesettings,relationshipsinthecommunitiesareclose—individualsknowtheirneighbors,andinmanycasestheyarerelated.Asonerespondentdescribed,“Ourcommunityisonebigfamily.”Thus,theeffectofthesuicideclustersandsuicideattemptswaspervasiveandpersonal.Theimpactwasreflectedinparticipants’stories,intheirreactionstotherepeatedsuicidesandattempts,in

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theirdescriptionofthecontagion,andinthewaysthatthecommunityresponsewasremarkablyunifiedandhealing.

Allrespondentsindicatedthatthey,alongwithothersinthecommunity,weredeeplyandpersonallyimpactedbythesuicides,attempts,and“nearmisses”—suicideattemptsandpotentialsuicidesnarrowlyaverted.Inadditiontotherecentclusters,somerecalledearliertimeswhensuicidesoccurredwithshockingfrequency.Onerespondentrecalled,“Backinthe‘90s,IwasaVPSO[firstresponder]inmyvillage,andwehadasuicideaweekforalongtime,overayearorforsomemonths.”5Respondentsalsodescribedtheacuteandcumulativepaincausedbyexperiencingandrespondingtomultiplesuicidesinthecommunityovertheyears.Onerespondentrecalled,

“WeusedtogotoAnchorage…anddouseourselveswithboozeforoneandtryto forget everythingbecausewe’ve handled toomanybodies.We’d cleanandwashofftheblood(accumulated)overtheyears.”

InwesternAlaska,somedescribedarhythmoflifeinterruptedwithregularemergenciesrelatedtoimminentsuicideattempts.Arespondentrecalledoneoccasion:“Ayoungladycalledme,shewasabouttohangherself.SoIrantoherhouseandspokewithheratlength,greatlength.”Hewentontosay,

“Mywifewasrunningsuperfasttowardshersister’shouse,mysister’shouse.AndIcalledmyfolks.Iwaslikewhat’sgoingon?Andoneofmynephewsislockedinhisroomscreaming,screaming,screaming….Icalledmysisterrightawayandtheywerecryingsohard….Ithoughtmynephewwasdead.”

Sincemanycommunitymembershelpothersduringaresponsetosuicideclusters,manyexperience“burnout”andexhaustionfromconstantlybeinginastateofemergency:“Wehadasuicideaweekforalongtime,overayearorforsomemonths….Wedidn’thave[any]debriefing…sometimesIfeellikeIneedalittlebreak,butthenIgoforthagain.”

Respondentsconsistentlydescribedorreferencedthecontagioneffect—thetransmissionofsuicidalthoughtsandbehaviorsfromonevictimtoanother—indescribingthatasuicideinonecommunity

5VPSOistheacronymforVillagePublicSafetyOfficer.VPSOsaretrainedandemployedbytheAlaskaStateTroopers.Theyarelocal,villageresidentswhoserveasfirstresponderstovillagepublicemergenciessuchasfires,searchandrescues,emergencymedicalassistance,basiclawenforcementandcommunitypublicsafetyandcrimeprevention(AlaskaStateTroopers,n.d.).

Community responses reflected the frequency of deaths by suicide, the enduring pain these events have caused, the lack of healing experienced by the community, and the way in which the threat of additional suicides or attempts lingers in the community—injecting into everyday life elements of psychic pain and hyper-vigilance.

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seemedtotriggeradditionalsuicideseitherwithinthesamecommunityor,inthecaseofwesternAlaska,inneighboringvillages.Relatedobservationsincluded:

“It’sa small community,everyoneknowseachother.Whensuicidehappens inthecommunity,ithappenssequentially,likeinsequence.(Thesuicide)willmakeotherreallyclosefamilyandfriendsfeelreallydepressedanddown.”

Consistentwiththe“circlesofvulnerability”modeldiscussedintheBackgroundsectionofthisreport,onerespondentillustrateshowdegreeofpsychosocialproximitytosomeonewhohasdiedbysuicidecaninfluencethedegreeofriskforindividualcommunitymembers,contributingtocontagion:

“But,theclosertherelativesorthefriendsoftheindividualsthathavetakentheirownlife….theleveloftheimpactishigherthantheonesthatarenotrelated.So,theriskisthereforthosethatareclosertothefamily,especiallythefriendsoftheyoungperson.”

Communitymembersdescribedbeingimpactedbyandrespondingtosuicideclustersinremarkablysimilarways,moreasaunifiedgroupthanasindividualsorparticularsectorsofthecommunity.Villagersnotedthatthecommunityexperiencesacollectivedepressionwhenitlosesayoungpersontosuicide.Notedonevillagemember,“Sincewearecloseknitted,everyoneisbasicallyrelatedtoeverybodycloselyorrelativesorgoodfriends.Itreallyputsthemoraledownverymuch.”Anothersaid,“Peoplethatare‘suiciding’arepeoplethatwegrewupwith…andwhenthathappens,itreallymakesthewholecommunitylikedarkandlikesad.”Reflectingonthetraumaofpastsuicides,theongoingpainofsuicidesandattempts,andthefeelingofsharedsorrowwithothervillages,onerespondentsaid,

“That’sahardthingtoseewhensomeonelosestheirlovedone,especiallythroughsuicide.Andthatreallyaffectseachcommunitybecausewe’vegonethroughsomuchthesepastyearsanditseemslikeit’sstillgoing.AndthathurtsmewhenIhearothervillagesgoingthroughthesameeffectswehaveinthisvillage.”

Atthesametime,anotablecommunitystrength(describedfurtherinCommunity-BasedResources)isthatcommunitymembers—withinandacrossvillages,inthecaseofwesternAlaska—collaborateinunitytosupportthosewhoareclosesttotheyouthwhodiedbysuicide.Thesupportthatcommunitymembersprovideforoneanother,oftenconnectedbysharedspiritualityandculture,promoteshealing.Onepersondescribedhowcommunitymembersgatherwiththefamilywholostayoungperson,“talkingtooneanother,supportingeachother,comfortingandduringthosegatherings,youhavegospelsingingandsometimesstorieswillcomeupofmemories(of)thatperson.Inmostcases,it’sreallygood…wheneverybodycomestogetherandcomfortsoneanother.”Anotherrespondentdescribedthatvillagesreachoutandsupportothervillages,becausecommunitymembersacrossthesevillagescanrelatetothepainandtraumathatthesuicidescause.

“Whenasuicideoccurs,Iknowthere’slotsofsupportgoingonfromourvillagebecauseweknowhowitfeelswhenthere’seffectivesupportforeachother,like

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asupportsystem,whichisgoodtoseebecausethat’swhatwedo,dealwiththefamilysupportandseewhatwecandotohelpandjustbeasupportsystemtothem.”

CommunityPerspectivesonResourcesforSuicideClusterPreventionandCrisisResponseCommunitymembersprovidedtheirperspectivesabouttheresourcescriticalforstrengtheningsuicidepreventionandresponsetosuicideclusters.Theyalsoidentifiedimportantresourcesprovidedfromoutsideoftheircommunity.

Community-Based Resources(CrisisResponse)Community-basedresourcesforcrisisresponserangefromtheformal(e.g.,thetribe,behavioralhealthservices,schoolpolicies,VPSOs)tothesocialorcultural(e.g.,elders,families,naturalhealers,communitymembers),withsimilaritiesanddifferencesacrossthetribeandvillagecommunities.

FormalCommunityStructuresAmongthewesternAlaskacommunities,somehaveoneofthevillageshasasubregionalclinic,whichgivesaccesstoahigherlevelofhealthandbehavioralhealthcareservicesthanareavailableinmostvillagesorcommunityhealthaideclinics.Onerespondentnoted,“There’salotofhelpavailablehereatthevillage.We’reoneoftheluckiervillagesinthataspectofgettinghelp.”Hecontinued,“Wehaveourregionalclinichereandthere’smedicalpersonnel,mentalhealthpersonnel,twoVPSOsandapoliceforceforourvillagethatisopen24/7,365daysayear.AndIknowthat’sabigplusforanyvillage.”ThiscompareswithothervillagesthathaveasingleVPSOandnopolice,andonevillagethatreliessolelyonoutsideresourcesforbehavioralhealthservices.

Schoolsandtribalcouncilstakeanactiveroleintheircommunities,includingintimesofcrisis.Referencingarecentincidentinwhichayoungpersonwroteasuicidenote,onecommunitymemberexplainedhowcoordinationbetweenagenciesoccurs:

“Theschoolwasconcerned,ourtribalcouncilwasconcerned,andtheyactedonitrightaway….Theytalkedwiththeyoungindividual,starteddifferentthingsthathecandohereinthecommunity,talkedwiththeparents,madesure

Community-based Resources

Formal Community Structures

• Tribal council and declarations of emergency

• Schools

• Behavioral health resources

• VPSOs and first responders

Cultural/Social Resources

• Elders, traditional teachings

• Local clergy and faith community

• Community members, particularly from the schools

• Tribal medicine, natural healers

• Community gatherings

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everybodywasinvolved,sothat’swhattheydidwiththelastsuicidenote.Andwe’vebeenwatchingtheyoungboyforthepastfewweeksandjustthere’sbeenagoodturnaroundthepastfewweeks.”

Further,tribalcouncilsmayprovideimmediatefinancialsupporttofamiliesintheeventofasuicidetoassistwithpracticalmatters,suchasfuneralexpenses.

“They[thetribalcouncil]providebigsupport,especiallywiththepeople,familymemberswholiveoutoftown;theypaytheirfaresroundtripfromwheretheyare,beitlower48oraroundAnchorageorwhathaveyou,theothersurroundingvillage.Andtheyhelppayforcasketsandgivemoneyforfoodalso.Soit’satremendoussupportfinancially.”

Tribalcourts,withaholisticapproachtoproblemsandemphasisonrestorativejustice6,alsoserveasanindirectformalresourceforsuicidepreventionandresponse.Thecourtshandlecasesdealingwithchildprotection,juveniledelinquency,anddomesticviolence,andarethereforewell-positionedtoworkonrestoringbalanceandharmonywithinfamilyandcommunity.IntervieweesconsideredtribalcourtstobevaluablelocalresourcesinaddressingthesuicidecrisisinAlaska.Acommunitymembernoted,“ThetypeofservicesthatweprovidearethroughourIndianChildWelfareActthroughourtribalcourt.Wehavethreejudgesthatmeetwithfamilymemberandmeetwithdifferentproblemareashereinthecommunity.”

Cultural/SocialResourcesInadditiontotheservicesprovidedbyformalagencies,eachcommunityreliesonawealthofsocialandculturalresourcessuchasguidancefromeldersforculturallyrootedapproachestoaddressinggrief,naturalhealersandtraditionalmedicine,andformalorinformalcommunitygatherings.Atsuchgatherings,communitymemberscongregate,sharestories,singgospelsongs,anddrawonasharedsenseofspiritualityandculturalhistoryinattemptingtoovercomecrisesandimpactofthesuicidesandsuicideclusters.Acommunitymemberexplained,

“Thepurposeoftheeldersistoaddresstothecommunity…becausewhenitcomestoloss,again,someofthefamilywouldnothavetheinterestindoingwhattheyusuallydo.Soit’stoadvisethecommunityaswellasthefamilymembersinthecommunityhowtheyshoulddealwiththeirgriefculturally.”

Eldersarerespectedknowledge-bearersintheircommunities.Askeepersoftheircommunities’longhistory,theyplayasignificantroleinsupportingyouth.Byinteractingwithyouth,theyareabletopass

6Restorativejusticeisanapproachtojusticethatemphasizesrepairofharmdonebyoffendersthroughreconciliationwithvictimsand/orthecommunityatlarge.Thepurposeoftherestorativejusticeapproachistorestorebalanceinindividualsandcommunitiesprimarilyforharmdonethroughdrugandalcoholuseaswellasminorcriminaloffenses(DrugCourtsProgramOffice,1999).

onwisdomandtraditions—informationthathasallowedthevillagestosurviveandthriveinthefaceofaharshenvironmentandthreatsfromoutsidersofculturalextinctionandassimilation.Forexample,Elders’Councilsservethecommunity,inpartbyestablishingmechanismsandprogramsforculturaltransmission.Recountingtheroleofeldersininformingcommunityprojects,onecommunitymemberexplained,

“Therearesometeachingsthatarebroughtdownorallybytheeldersofhowthecommunitymembersshouldhelpthemselves….They’regiventheprinciplesthatarebroughtdownfromtheeldersfromthepast.Everythingisbroughtdownorallyandtraditional.It’slikeculturalevidence-basedteachingsthatpromotewellnesstothecommunities.”

Theinfluenceofelderscarriesintothecommunitysettingascommunitiesconsciouslyintegratecultureintoeverydayactivities(e.g.,school,work,andplay).Interviewparticipantsdescribetheclose-knitfeeloftheirsmall,ruralcommunitiesaskeycommunityassetsthatincludesinceremutualcareandconcernforothers;sharedpurpose;andanactivespiritofcooperationinaddressingcommoninterestsandhealingthecommunity,particularlyintimesofcrisis.Onerespondentstated,“Ithinkintermsofthesesocialissuesandthewaythatwe’vehandledsuicidesinthepast,communitymembersarealwaysinvolved.”Acrosstheboard,manyrespondentsexpressedsimilarsentiments.Onecommunitymemberdescribed,

“Intheeventofemergencies,ourvillagerisestotheoccasion.Thepeopleherearesostrong,sosupportive.Overtheyearswhenkidscommittedsuicide…thewholecommunityandthepeoplewhoareinneed,theybringfooddayafterdayafterday….Wehaveacustomhereinourvillagetoviewabodyfor3days,andinthemeantimeduringthat3days,peoplefromthewholevillageareconsistentlycontinuouslypresentwiththefamily24hoursadayforthose3daysuntiltheburial.”

Communitymembersalsodescribedthatindividualsskilledintraditionalmedicineandnaturalhealersareanimportantcommunityresourcewhoareoftenactivelyengagedduringasuicidecrisis.Inaddition,priortodeclaringastateofemergencyintheNewMexicotribe,keycommunitymemberswhocoordinatedtoaidthelocalcommunityincludedlocalclergyprovidingcommunityservicesforthoseinneed,andcommunitymembersfromtheschoolstopromotemessageswithasuicidepreventionlens.Forexample,theyattemptedtominimizethecontagionbyexplaininghowinformationaboutthemannerofdeathcouldincreaseriskandcontagion.Faithleadersalsoencouragedcommunitymembers

toreachoutforhelpiftheyneededsupport.

Spiritualityprovidesawaytoprocessandhealfromlife’straumasindividuallyandincommunionwithothers.Oneparticipantexplainedhowspiritualityoftenmanifestsinhiscommunity:“Spiritualityisoneofthethingsthatarevaluedinthevillagesystem.…Everybodyisinvitedtoshareasongandpeoplewithtalentsandtheabilityto

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Community Perspectives on Community Connectedness “Families look out for one another. People look out for one another. I think we’re a strong people.”

“Our village has been through so much, yet here we are still moving forth.”

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playmusicforthepeoplethathavethedesiretosharetheirsongs.Ibelievepeopleexpressingtheirfeelingsthroughsongsissomeofthewayofspiritualhealing.”

Atthesocietallevel,traditionalculturealsoservestogroundindividualsandprovideaframeworktoviewtheirplaceintheworld.Asonecommunitymemberstated,“Youngpeopleneedtoknowwhotheyare,haveaknowledgeofwheretheirancestorscamefrom,tobeproudofwhotheyare.”Communitiesareactivelytakingstepstoconnectyouthtoculturebecausetheyunderstandtheprotectiveeffectsofconnectionthatareenabledbycultureandtraditionalpractice.Onerespondentexplainedhiscommunity’sprocessas“usingevidence-basedinterventions,cultural-basedinterventions,likehavingeldersinvolvedandsharestoriesofhowtheyusedtodealwithcrisissituationsinthepastbeforeourgeneration.”

Community-Based Resources (Prevention)

Communitymembersdiscusseddirectandindirectsuicidepreventionactivities.Preventionactivitiesrangefromthecultural(culturecamps,elder/youthconnections)tocommunityandyouthgatherings,toformalschoolprograms(e.g.,thenationalpeer-to-peerNaturalHelpersprogram)andschool-basedpresentationsonsuicidesignsandriskfactors.Acommonaimacrosstheseresourcesandprogramsistostrengthenprotectivefactorsacrossthesocialecologybyconnectingyouthandcommunity,deepeningyouthknowledgeandpracticeoftraditionalculture,anddevelopingandpromotingprosocialadultandpeermentorsandrolemodels.

InthewesternAlaskacommunity,culturecampsareakeycomponentofeachofthecommunities’suicidepreventionstrategies.Inculturecamps,youthlearntraditionalskillsandinteractintensivelywitheldersandotherknowledge-bearersinordertogroundyouthinthousandsofyearsofplace-basedknowledge.Communitymembersdescribedcampactivitiesthatincludesurvivalcampinginthetundra,beading,harpoonmaking,andnaturewalks.Thecampsaretimedwithseasonalsubsistenceactivities,andforsomeyouth,arethefirstexposureandexperiencewiththeirtraditionallifeways.Asonecommunitymembersaid,“Wehavehadmultipleculturalcampshereinthecommunityattheschoollevel,andalsoatour[tribalcouncil]level.ThelastonethatwedidwaslastyearfalltimeandIthink[had]sixorseven—no,sixoreightyoungindividualswhohadnevergonetoculturalcamp[before]andtheyhadaverygoodtime.”Anothersaid,

“Iguesswhatactuallythecommunityhasbeentryingtodoisreestablishthecommunitybacktotheirtraditionalevidence-basedteachingsandoutreachactivitiesandhavingtheyouthbeconnectedwiththecommunitytribalmembers.”

Amongexistingresourcesforsuicidepreventionarefrequentpresentationsinschoolsonsuicideriskfactorsandwarningsigns,andtheNaturalHelpersprogram.Describinganapproachtopresenting,onerespondentsaid,“Thispastmonth,wemetingroups,abunchof[youth]—Italkedtherapytothemaboutsuicide.Imadealessonplanyesterday,and…ittalksabouttheway[that]there’snosingleproblemintheentireuniverse[thatwarrantsdyingby]suicide.”IntheNewMexicocommunity,sourcesdescribedanincreaseinschoolsurveys,assessments,andscreeningsasaresultoftheNaturalHelpers

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program.Inaddition,newschoolpoliciesweredevelopedtoimplementsuicidepreventionandresponseprotocols.

IntheAlaskavillages,communitygatheringsandyouthcenters—whereavailable—provideanothervenueforpositiveyouthconnectionwithcommunityandcaringadults.Describingtheimpactofcommunitygatherings,onerespondentstated“CommunitygatheringiswhatIhavebeenfocusingonbecauseitisalessonthatcanbeusedasatooltoconnectelders,youth,family,leaders[in]thecommunity,resourcememberstogethertoimplementempowermentforthespiritualwellnessofthecommunity.”Youthcentersintwoofthevillagesarevenuesforpositivesocialinteractionandactivitiesforyouth.Onevillagerdescribed,“[The]youthcenterhaspeopleworkingonweekendstotryandmotivatetheyoungpeoplefromgettingintoalcoholanddrugsbygivingthemhealthyactivitiesonFridaysandthosearesomeofthethingsthattheyhavesetupinregardstoprevention.”

AmidstalloftheeffortsofthesecommunitiestopositivelyengageyouthandreconnecttoYuuyaraq,thetraditionalwayoflifeknowninAlaska,participantsunderstandthatsuicidepreventiondoesnothappenovernight.Asonecommunitymembernoted,preventiontakestimeandeffort:“Andittakeseffortforatribetobringback—have[youth]regainbacktheircorevalues.”

IntheNewMexicotribe,sourcesalsosuggestedthatformaltribalactionthatpromotesthedevelopmentofsuicidepreventionresourcesandprogramshasbeenacriticalsupport.Asourcesuggested,“Thetribaladministrationfinallyunderstandsthatourcommunity-basedservicesarenotconnectinginavitalwaytomeetingthechallengesofchildrenandyouthwithseriousmentalhealthneedsandtheirfamilies.”

ExternalResourcesInadditiontothelocalresources,bothcommunitiesreceiveoutsidehelpinrespondingtoandpreventingsuicide.IntheAlaskasetting,thecommunityreceivedhelpfromothervillages,regionalcorporationsbasedinBethel(e.g.,YKHC),andeven,attimes,fromthe“lower48”(thecontiguousUnitedStates,asitisreferredtoinAlaska).Thisoutsidesupportoftentakestheformofagencyprovisionofbehavioralhealthservices,andmissiontripsfromvisitingchurchestoengageyouthor(re)buildlocalinfrastructure.

IntheNewMexicocommunity,aftertheadministrationdeclaredastateofemergency,outsidehelpincludeddeployingmentalhealthserviceprovidersandothercrisisworkersfromIHS.Crisisworkerswereavailableintheschoolandthecommunityatlarge.Inaddition,individualsfromalarge,urbanuniversitycametothecommunitytoprovidecounseling,crisisservices,andpostventionservicesforthecommunityingeneralandforthestudentpopulation.

InwesternAlaska,becausevillagesaresmallandrelativelyclosetogether,theregionitselftakesonacommunityfeel.Thus,whenoneofthevillagesexperiencesacrisis,communitymembersfromothervillagesstepforwardtoassisttheaffectedcommunityandfamily.Onecommunitymemberexplained,“Thevillagesaresosmallthatweknowmostofeachother.Sowhenacommunityisgoingthroughacrisis,theothercommunitieswillcomeoverandjustbeasupportofthatfamily.”

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IntheAlaskavillages,theregionalhealthcorporation,YKHC,locatedinBethel,provideson-callcrisissupportintheformofdebriefingteamsthatflyintocommunitiesfollowingaviolentdeathortrauma(e.g.,suicideorhomicide).Whensuchaneventoccurs,thecommunitynotifiestheYKHCBehavioralHealthDepartment,whichmobilizesacrisisresponseteam.Onerespondentnoted,

“[The]debriefingthatYK[HC]provides,thatreallymadeabigdifferencewhenalotofotherpeoplewanttohelptotalstrangers,evenorganizationslikeYK[HC],that’ssuchatremendoussupportforvillagesandforindividualfamiliesorindividuals.”

Inadditiontoprovidingpostventionorinterventionafterasuicide,YKHCsupervisesthelocalBHAsandhasateamofitinerantbehavioralhealthclinicianswhotravelmonthlyorbimonthlytothevillagesfor1–2daysatatime.AstheBHAsarelimitedinscope,theitinerantclinicianshelptoroundoutthebehavioralhealthservicesavailablewithinthevillage.OnerespondentdescribedanincreaseinvillagebehavioralhealthservicesprovisionasaresultofassistancefromtheYKHC:“YKHChasprovidedawholebunchofbehavioralhealthservicesafter,Ithink,2007andthey’regettingmorepeopleinvolvedintryingtogetbehavior-typeissuesunderstood.”

Missiontripsfromvisitingchurchescanalsobeformsofexternalsupport.Missiontripsareregardedasasuicidepreventionresourcebecauseofthepositiveengagementtheyprovide,particularlyforyoungpeople.Oneparticipantcitedanongoingrelationshiphiscommunityhashadwithachurchgroupfrom“thelower48.”Forthepastseveralyears,thechurchsentagroupofmemberstothevillageduringthesummertosupportyouthserviceprojectsandtoprovidepositiveactivitiesandengagementforyouth.Thisparticipantdescribes,“theywerehereworkingwithawholebunchofkids,givingthemawholebunchofactivitiestoworkon.”

Asvaluedasalloftheseexternalresourcesare,severalrespondentsinwesternAlaskavoicedconcernoverthelimitationsandlastingimpactoftemporaryhelpcominginfromtheoutside.Notedonecommunitymember,

“Oncetheyleave,eventhoughtheycame,itneedstobethecommunitythatcanworktogetherasacommunityalone.Becausethey’lljustcomeinandhelpus,butthat’swhereitbeginsthatthecommunityneedstounderstandthattheyneedtoworktogetherasateamtohelpeachotherout.”

BarriersandFacilitatorstoSuicideClusterPreventionandResponseCommunitymembersreflectedonthefactorsthathinderedorfacilitatedsuicideclusterpreventionandresponseeffortsintheirowncommunities.Respondentsreportedleadership,capacity(e.g.,humancapital,funding,andservices),andimplementationchallengesaffectingcommunity-levelpreventionandresponse/recoveryefforts.Respondentsalsoidentifiedshiftsinperceivedself-sufficiencyandsocialnorms(e.g.increasedroleofelders,decreasedindividualcomplacency)toexplainthecommunity’sresponsetosuicide.

Community Perspectives on Shame and Suicide Prevention “It’s like the word suicide is poisonous or something.”

“Most youth won’t go to the mental health clinic. The stigma and shame keeps people away.”

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Community-Level Barriers

• Limited human capital, funding, and services

• Need for surveillance

• Lack of coordination

• Lack of an evidence-base for suicide cluster prevention in tribal populations

• Role of the media during a suicide cluster

Barr i ersRespondentsidentifiedthefollowingbarrierstosuicideprevention:

� Lackofastandardizedorcommunity-basedreportingandsurveillancesystem.Suchasystem

isneededtohelpcommunitiesunderstandthenatureofsuicideclustersandhowtobestaddresstheproblem.

� Lackofcoordinationacrossgrantandtribalprograms.Lackofcoordinationresultsinmissedopportunitiestostreamlineandmaximizetheimpactofservices,resourcesandprograms.Onesourcenoted,“Thereweredefinitelyalotofserviceissuesintermsofwhichcommunityprogramswantedtoprovidewhichservicestodifferentpopulations…itseemsliketherewasacompetitivenessintermsofwhowantedtoprovideservicestowhom,andnobodyknewhoweachprogramshouldgoaboutdoingthat.”

� Accesstoappropriateevidence-basedservices.Evidence-basedsuicidepreventionservicesfortribalpopulationsarelimited.Onecommunitymemberexplainedthat,whileadaptationmayoftenbenecessaryacrosstribes,thetendencytoencouragea“tribaladaptation”thatcanbeappliedtoallAI/ANpopulationsisinappropriate.Fidelitytotheevidence-basedprogrammaybelostaseachcommunitymakestheirownadaptations,anda“one-sizefitsall”approachcannotaccountfortheuniquefactorsthatdistinguishonetribalcommunityfromanother(Wexler&Gone,2012).

� Theroleofthemediaandmediamessaging.LackofcoordinationonmediamessagingduringthesuicideclusterintheNewMexicoresultedininaccuratereportingabouttheevent.Inaddition,mediasourcesreleasedgraphicdetailsaboutthedeathsand“werereportingthesenumbersaboutthedevastatinglifeconditionsonthereservation,thenegativelifestylesthatweretakingplace”saidonecommunitymember.Communitymembersbelievedthistobeirresponsible.Eventually,communitymembersreachedouttonewsoutlets(televisionstationsandnewspaper/printjournalists)andinvitedthemintothecommunitytocorrectinaccuratereporting,aswellastodiscussthetypeofinformationthatneededtobewithheldfromthepublic.

� Ongoingshame.Shamearoundseekingbehavioralhealthresources,orevendiscussingsuicideandpreventionapproaches,ispervasiveinthesecommunities.Nearlyeveryrespondentidentifiedongoingembarrassment,fear,andshameasanimpedimenttoaccessingbehavioralhealthresources.Onerespondentnoted,

Community Perspective on Grants The shelf life for grants are pretty low. You only have a handful of years to make an impactful change. And it’s hard to really do that, especially in communities where maybe their readiness level just are not—they still need to be built up.

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“Nobodyjustwantstotalkaboutit;theyjustwanttoignoreitandhideitandnottalkaboutit.”Inonecommunity,somesuggestedthatshameisrootedina“cultureofsilence”onthetopicsofdeathanddyingthatultimatelycontributestoliveslost.Onecommunitymembersuggestedthatyouthexperienceacombinedsenseofhopelessnessandshamethatpreventsthemfromseekingbehavioralhealthcare:“theyfeelsohopeless,there’snohope….There’snotomorrows.”Otherrespondentssuggestedthatyouthfeelthat“peoplewilllookdownuponthem”andthatthereisa“myththatpeoplearecrazyiftheyaskforhelp.”

� Lackofexistingbehavioralhealthservicesandfunding.Evenwhenanindividualovercomesshameandself-identifiesas“atrisk,”theavailableservicesinruralcommunitiesareofteninsufficient.Inadequatecapacityintheformoffunding,humancapital,andserviceavailabilityimpedessuicidepreventionandresponse/recoveryefforts.IntheNewMexicocommunity,thereisamentalhealthclinicwithonefull-timepsychologisttoprovidementalhealthservicestothousandsofyouthandadults.Insufficientfundingforserviceswasalsoidentifiedasabarrier.Onecommunitymemberreported,“Toprovideservices,ittakeseithervolunteerworkorsomebodythatwantstohelpthecommunitybuttheywantcompensation.”Evenwhencommunitiesrequestassistancefromoutside,itcoststime,effort,andmoney.Asonevillagerexplained,“Tryingtogetotherstoseewhatthecommunityisgoingthrough,theyhavetogooutandtravel,talkwithothers,providecapacitybuildingtraining.Ifyouwantservicestocomeouthere,youhavetoprovidetravelforthemtocomeout.Youhavetogivethemaplacetostay.”Respondentsreportedalackofbehavioralhealthandlawenforcementpersonneltrainedinsuicidepreventionorasgatekeepers.Oneofthevillagersinacommunitywithoutasubregional-levelclinic,shared,“Wehaven’thadabehavioralhealthworkerforawhile.”

� Lackofsustainedinterestandengagementinsuicidepreventionasapriority.Communitymembersdescribedthatturnoverintriballeadershipoftenmeanttheendofsuicidepreventioneffortsthatwerenolongerconsideredtobeapriority.InwesternAlaska,respondentssawcurrentvillageleadershipasahindrancetoprevention,andresponseandrecoveryefforts.Amemberofonecommunityexplainedthattriballeadershipwastooreactive.Whereasleadersprovidedsupportduringacrisis,theydidnotanticipateneeds,plan,orimplementupstreamapproachestoprevention.Anupstreamapproach,whichtypicallyinvolvescollaborativeassessment,planning,andimplementation,wouldaddresstheunderlyingrootsofproblems,oftenbyprovidingopportunitiesforculturallearningandconnectedness.Somesuggestedthatsomeleadersengagedinself-destructivebehaviorsresultinginhighturnoverinthetribaladministratorposition.Accordingtoonecommunitymember,thelackofleadershiphasbeenaprobleminonecommunityfor,“giveortakeaboutthepast10years.”Indifferenttribalcommunities,lackofleadershipcanbebothliteral(i.e.,vacanciesintribaladministrationduetoturnover)andfigurative(i.e.,lackofgreatercommitmentbytriballeadersrelatedtosuicideasapriority).

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Sourcesnotedthatoncefundingforasuicidepreventiongrantends,thepeopleinvolvedinanygivenprogramseekoutnewsourcesofemployment:“[Theythink]‘We’vedoneit,themoneyisgone,let’smoveontosomethingelsethatwecangetemploymentwith.’”Onesourceexplainedthathavingagrantisnoassurancethatatribewillmakesuicidepreventionapriority.Prioritieschangewithtribalelectionsandtheebbandflowofgrants:“Thegrantisgone,thepeoplearegone,thepeoplethatweretrainedaregone,andlet’smoveontosomethingelse.”FowlerandcolleaguesnotedsimilarbarriersintheirepidemiologicalinvestigationofayouthsuicideclusterinDelaware(2013).

Facil i t atorsCommunitymembersidentifiedfactorsthatfacilitatethepreventionofandresponsetosuicideclusters:familiarityandclosenessbetweenfamiliesandvillagesandculturallycongruentandpositivemessaging.Relatedtomessaging,onepersonshared,“Allofourfamilieswanttohearsomethingpositivewhenwe’refeelingdownandoutanddepressed[duringasuicideclusterevent].”

Tofacilitateresponse/recoveryefforts(andechoingCDC’srecommendations),respondentsdescribedtheimportanceofcoordinationamonglocalentities(e.g.,regionalhealthclinics,VPSOs,andcommunitymembers)andhavingsubstanceuseandmentalhealthservicesavailableinthecommunity.Whendescribingthebenefitsofcoordination,onerespondentshared,“YKHChasprovidedbehavioralhealthservicesafter2007andthey’regettingmorepeopleinvolved.”Anotherrespondentdescribedtheadvicehereceived:“Weshouldnotkeepthisbigissuetoourselves,buttrytogetmorepeopleinvolvedattheregionalandstatelevel.”

Respondentsreflectedontheircommunities’growthasaresultofrespondingtoandrecoveringfromsuicides.Indoingso,theyidentifiedspiritualityasakeyassetintherecoveryprocess.Onerespondentdescribedgatheringsafterasuicide:“Theyhavemeetingsattheirpersonalhouse…totrytohelpourcommunityintimesoftragicmoments,likesuicides.Theydoitspirituallybysinging.…Thegroupgetsbiggerandbigger,sothegathering[isaccepted]andIdon’tseeanythingwrongwiththat.”Anotherrespondentdescribed:“I’venoticedourcommunityhasgrownalotmorespiritually.”

Facilitators of Suicide Cluster Prevention and Response/Recovery

• Familiarity and closeness between families and villages

• Culturally congruent and positive messaging

• Coordination between local, regional, and state-based health service providers

• Availability of subregional behavioral and mental health services

• Increased communication about suicide

• Coordination between community-based and external prevention programs

• Availability of cultural activities

• Support from the tribal council

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IntheNewMexicocommunity,oneofthemostsignificantfacilitatorsspurringrecoverywasthewillingnessofthetribalcounciltodeclareastateofemergencytosecureneededresourcesforthecommunity.Thetribalcouncilalsosentleaderstoeverydepartmentheadtoensurepresenceandrepresentationattribalmeetingswherethesuicideclusterwasdiscussed.

Respondentsidentified(1)increasedcommunicationaboutsuicideand(2)increasedwillingnesstotalkaboutpersonalproblemsingeneral,ascharacteristicsthatstrengthensuicidepreventionefforts.Onecommunitymemberreflected,“Thebiggesthelpisgettingthemessageout.”Communicationisstillamajorproblem,yetrespondentsnotethattherehavebeeninroads.Onerespondentcommented,“YouthinkEskimosdon’ttalkabouttheirproblemsalot,butinthesefewyearsthingsarestartingtochange,peoplearestartingtotalkmore.”

Respondentsdescribedtheimportanceofintegratingculturalactivitiesintothevillagelifetokeepyouthengagedandtospreadsuicidepreventionmessages.Examplesofsuchactivitiesincludedbeading,makingharpoons,makingparkasandmukluks(furboots),pickingberries,goingoncampingtrips,andtakingnaturewalks.Theseactivitiesservedasanopportunityforcommunitymembersandyouthtotalkaboutsuicideaswellasreestablishtiestoculturaltraditions.Onecommunitymemberreflected,“TherewasasuicideinAugustandthatwasaboutthetimethattheywerehavingtheannualtundrafestival.…Theybroughtupthesubjectofsuicideduringthefestival,whichwasgood.”Communitymembersfromsurroundingvillagesattendedsomeofthelargerevents,therebyincreasingthepotentialtospreadsuicidepreventionmessages.

Withtherecognitionthatschoolsareanidealsettingforreachingyouth,thecommunitieshaveworkedwiththeschoolstoformallyintegrateculturalprogramming,includingNativelanguageclasses,Nativestudies,andtraditionalartsandcrafts,intotheschoolcurriculum.

Onecommunityidentifiedlawenforcementasapotentialresourceandfacilitatorofprevention.Asthefirstresponderstoeveryattemptanddeathbysuicide,officershaveawealthofservice/calldataonfactorsthatcaninformprevention.Onerespondentnoted,“Theyrecordtonsofinformationabouttheactualeventitself.Sotheyhavealotofreallyricheventleveldataintermsofsay,demographicinformation.”Theyaddedthatlawenforcementknowswhetherdrugsoralcoholwereinvolvedandtheycollecthistoricalinformationfromfamilymembers.Thisinformationcouldbeusedtoidentifypatternsinideation,attempts,anddeathsbysuicide,tobetteridentifyat-riskyouthandfamilies.

CommunityRecommendationstoEnhanceSuicideClusterPreventionandResponseRecommendationstoenhancesuicideclusterpreventionandresponsearesummarizedbelow.

PrioritizeCollaborativeandCulturally-basedSui cidePreventionEfforts Prioritizingsuicidepreventionandrelatedactivitieswasastrongthemeacrosscommunities.Communitymemberssuggestedthatprogressrelatedtosuicideprevention—suchasthedegreeof

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communityemphasisandawarenessaboutriskfactorsforsuicide—seemedtoebbandflowbasedonthefundingforpreventionprogramsandcurrenttriballeadershippriorities.Whileadvocatingthatsuicidepreventionshouldbeaconsistentprioritywithinthetriballeadership,onesourcenoted,

“Weneedmoreleadershipactivitiestoinspireyouthtochangetheirlifecourse.SometimesIthinkourcommunityforgetsthatatribe’slegacyrestsinitschildrenandnotinhowwelltribalenterprisesoperate.”

Participantssuggestedthatthereisacriticalneedtoeducatecommunitymembersabouttherisksforsuicideandtobuildawarenessofprogramsandresourcesforsuicideprevention.Communitymembersreflectedthateducationandawarenessbuildingareimportanttoaddresstheshamesurroundingsuicidethatpreventshelp-seeking.Onepersonsaid,“It’stimetobreakthesilenceandtotallybustthattaboo.That’smyfirmbelief.Andeducateyoungkids,youth,andyoungadults.”

Communitymembersunderscoredtheimportanceofinvolvingyouthinpreventionefforts.OnecommunitymemberwhoattendedastatewideyouthleadershipsummitinAnchoragewithayoungpersonfromhercommunitysuggestedthatyoungpeopleneedmanymoresuchopportunities,sothattheycould“getideasonhowtousetheirthinkingcaps.”Othersstressedtheimportanceofinvolvingyouthinpreventionplanning.Avillagernoted,“IftheywouldinvolvetheyouthNaturalHelpersandstudentcouncil,iftheywouldinvitethatgrouptothemeeting,Ithinkitwouldbehelpfulbecausethoseyouthwouldhelpbringouttheawarenesstotheotherstudents.”Anotherdescribedthevalueofinvolvingyouth,“[Thisis]thefirsttimethatthecommunityactuallyaskedtheyouth.Ithinkthisisgoingtogoalongway.”Anotherrespondentdescribedanapproachtoconductingsuicidepreventionpresentationsforyouth:

“ItriedtogothrougheveryscenarioIcould[asto]whykidscommittedsuicideovertheyears,theonesthatstoodoutandwhykidsmighthavedonethis…[I]reiteratetothekidsiftheyseetheirfamilyorfriendsinsuicidalmode,nottoleavethemandseekfurtherhelpandnottofeellikeatattletaleaboutaskingformorehelp…Iaskthemtolookoutforoneanotherandnotfeellikeatattletaleiftheirfamilyorfriendisfeelingsuicidal.”

Moregenerally,severalrespondentsvoicedaneedforcommunitymemberstocometogetherandworkcooperativelyforthebenefitoftheyouth.Asonerespondentsaid,“Communityleadersandtheeldersareneededtocometogethertoassistandhelptheyoungpeoplesothatsuicidecanbeprevented.”Forsome,thisinvolvesstrengtheningleadershipandcommunicationchannels.Asonecommunitymembersaid,“Weneedmorerichleadershipinvolvementandcommunications,everybodycommunicatingmore.”Another,too,sawtheneedforleadershiptostepup:“Iguessit’sthepolicymakersthathavetodotheirpartintryingtohelp,alsoassistinsolvingtheproblemsinthecommunity,alongwiththeresourcesthatareavailablethatarewillingtohelpasawhole.”Inpart,thiswasseenasanissueoftribalself-determination:“Thecommunitymustcometogetherandacknowledgetheircapabilitiesandstrengthstosolveproblemsrelatingtosomethingsthatneedtobeaddressed,likeviolence.”Villagerespondentshadclearrecommendationsaboutwhichcommunitymembersshouldcometogetherandbeinvolvedincommunitywideplanningforsuicideclusterpreventionandresponse.Oneperson

Respondent Recommendations

• Prioritize collaborative, culturally-based suicide prevention

• Improve behavioral health services

• Develop community youth centers

• Improve surveillance

suggested,“Wewouldneedourtribalcouncil,ourschool,publicsafety,andourcommunities,Ithinkthatthat’sallweneedtomakeoursuicidepreventionplan,anditwouldworkfinethatwaywithlotsofcommunicationwitheachother.”

Communitymembersrepeatedlyemphasizedtheimportanceofensuringthatsuicidepreventionprogramsbedevelopedandimplementedwithaclearunderstandingofthespecificculturalcontextofagiventribalcommunity.Forexample,oneparticipantnoted,“Theconstructofdeathanddying[is]reallydifferentinNativecommunitiesversusmainstream.”Anothersourcefromthesamecommunitynotedthathiscommunitydidnotspeakofdeathanddyingand,thus,effortmustbemadetocollaboratewithandengagetriballeadershipandeldersindevelopingsuicidepreventionapproachesthatcouldbesuccessfulinthisculturalcontext.

IncreaseAccesstoBehavioral Healt hServicesCommunitymembersadvocatedforexpandedaccesstobehavioralhealthservices,includingincreasingtheavailabilityofbehavioralhealthworkers,programs,andservices,andbuildingawarenessofsuchprograms.Onerespondentexplained,“Weneedtobeidentifyingwhere[youth]cango,[whoyouth]cantalkto…orjustgotoaplacewhereyoucantalkto[someone]whoyoutrustcanbehelpfulorabenefitforyouforcalmingyourself.”Inthevillages,somesuggestedthatthesolutionmaybetoensurethatthereisaBHAineveryvillage.Overall,participantsprovidedmixedresponsesregardingwhethertheBHAneedstobesomeonewhoisacommunitymember.Whilesomesuggestedthiswasnotnecessary,otherssuggestedthatitiscriticalforbehavioralhealthservicestobeprovidedwithaclearunderstandingofcommunityvaluesandculture;thus,itwouldbeusefulandimportantfortheBHAtocontinuetobesomeoneinthecommunity.Thechallenge,onerespondentsaid,isthatconfidentialitycanbehardtomaintain:

“Itdoesn’thavetobesomeoneweknowbecausesomepeopleare—Idon’tknowhowtocomeupforawordforit,buttheydon’treallytrustthatworkerandtheydon’twanttogoovertothemandtalktothembecausetheyknowthem,youknowwhatImean?”

Inthetribalcommunity,participantssuggestedthathavingmorefull-timebehavioralhealthintheschoolsandcommunitywouldpromotesuicidepreventionasapriority.Onesourcenotedthatgreaterawarenessandcooperationisneeded,andrecommended“helpingthementalhealthclinicbecomefullystaffed,gettingfasterhiringapprovalfortheseclinicians,andensuringfasterMedicaidapprovalforpersonsreferredtoresidentialtreatmentcenters.”

DevelopCommunityYouthCentersInthewesternAlaskacommunityonly,participantsindicatedtheneedforanindoorcentralgatheringspaceorhallwhereyouthandcommunitymemberscouldmeetandholdeventsororganizeactivities.Indoorspaceforsuch

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activities,especiallyhighlyvaluedduringthelongwintermonths,isseverelylimitedacrosscommunities.Forexample,inonecommunity,youthactivitiesthatarenotschool-relatedareusuallyorganizedinthecommunity’slaundromat,acrampedandcrowdedspaceill-suitedforyouthevents.Onerespondentexplained,

“Ifthecommunityhadacommunityhallwherewecouldholdthesuicidepreventiongatherings,everythingwouldbemuchmoreaccessibleandreasonable,justbecauseespeciallyduringthelongwinterdays…thecommunitytendstogetboredandbecausethere’snotreallyanyotherthingstodo….There’sjustnothingtodoforyouthunlessschoolstartsandyougotoschool.”

Improve SurveillanceSomecommunitymemberssuggestedtheadoptionofmandatorysurveillanceortrackingsystemstohelpthecommunityunderstandthenatureoftheproblemandhowtobestaddresstheproblem.TheWhiteMountainApachesurveillancesystem—anationallyrecognizedsurveillancesystem—wasidentifiedbyaNewMexicotribecommunitymemberasamodeltobeemulated.TheWhiteMountainApacheTribeimplementedacommunity-basedSuicideandSelf-injuryReportingSystem.Thetribemandatesreportingofallknownincidenceofsuicideideationsorattemptsordeathsbysuicideaswellasotherintentionalself-injury(e.g.,cutting)andlife-threateningincidencesinvolvingdrugoralcoholintoxication(IHS,2013).Thiscommunitymemberwentontoexplainthat,whilesomecommunitymembershaveadvocatedforthistypeofsurveillancesystem,noformalsystemhasbeeninstitutedorsupportedbythetribalcouncil.

DISCUSSIONThetragedyofyouthsuicideandyouthsuicideclustersinindigenouscommunitiescontinuestobeacriticalpublichealthissue,addingnewlayersoftraumaincommunitiesalreadylivingwiththeimpactofhistoricaltrauma.Informationgatheredinthisreportshedssomelightonbarriersandfacilitatorstoprevention,neededresources,andstrength-basedapproachestoprevention,response,andrecovery.Basedoninformationguidingthisreport,thekeybarrierstoprogressinthesecommunitiesincludethefollowing.

InsufficientCommunityandClinicalBehavioralHealthResourcesNumeroussuicidepreventionprogramshavebeenimplementedacrosstribalcommunities.InSeptember2012,10of23grantsawardedbytheU.S.FederalGovernmenttopreventyouthsuicideswereawardedtoNA/ANtribesororganizations(Woodward,2012).Suchprogramsreachonlyasmallproportionofthecommunitiesthatcouldbenefitfromtheirassistance.Interviewparticipantsrecognizethattherehavebeeninroadsinaddressingtheproblemofyouthsuicideclustersandmanysuicidepreventionprogramshavebeenusefultocommunities.However,thesestakeholderssuggestthatprogresshasbeeninsufficienttoaddressthemagnitudeandcomplexityoftheproblemoryieldsustainable,lastingchange.Interviewparticipantsnote2–3yearsisnotlongenoughtoestablish

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sustainablechange.Examplesoflastingchangemayincludechangeincommunityreadinesstoaddresstheproblemofsuicide;changeincapacityorabilitytoidentifyandreferayouthforsuicide;moreservicesorinfrastructuretorespondtoyouthincrisis;orexpansionoftelebehavioralhealthcapabilities(e.g.,phoneandinternetcapabilities).

Inaddition,manysuggestthatIHSischronicallyunderfunded(Dorgan,2010;USET,2014),resultinginahostofhealthcaredeliveryproblems.Theseincludevacanciesinbehavioralhealthcareproviderpositions;insufficientbehavioralhealthcarespecialists;referralsforservicesgreatdistancesoffreservationsoroutofvillagesthatareoftencostly;andcomplicatedregionalofficeadministrativestructuresthatmayinhibitcreativesolutions(e.g.,Belluck,2009;Dorgan,2010;Young,2010).Somesuggestthatthecombinedeffectis“full-scalerationingofcriticalhealthservices,includingmentalhealthcareservices”(Dorgan,2010,p.215)inAI/ANcommunities.Communitymembersattesttothesignificantissueofaccessandadequacyofhealthcare,particularlyinruralorremotetribalcommunities.Suchcommunitiesareoftenbasedhundredsofmilesfromanurbanarea,makingadequatecareandoutreachtoNativeyouthproblematic.Thesedividescanalsomakeitdifficulttorecruitsufficientbehavioralhealthsupportstaff.Finally,emergencyhealthservices,suchasthoseneededtorespondtosuicideattempts,suicideclusters,orotherviolentdeaths,canbeespeciallydifficult.Transportationtoandfromruralareascanbechallengingbecauseofweatherorterrainandexpensivebecauseofdistance—bothconditionsmakingtimelyemergencyhealthservicesuncertain.

InsufficientCulturalTailoringinSuicidePreventionSomesuggestthatwidelyusedapproachestosuicidepreventionmaynotappropriatelyorsufficientlyreflectanunderstandingthat“suicideinindigenouscommunitiesisfrequentlyidentifiedastheterminaloutcomeofhistoricaloppression,currentinjustice,andongoingsocialsuffering”(Wexler&Gone,2012,p.801).AccordingtoaliteraturereviewbytheResearchPrioritizationTaskForceoftheNationalActionAllianceforSuicidePrevention,modelsofsuicidalbehaviorhaveevolvedoverthepast25years,butmanyarepsychologicallybasedandassumesometypeofcognitivedysfunctioninthesuicidalprocess(ActionAlliance,2014).Sometribalexpertssuggestthattheassumptionofcognitivedysfunctionastheprimarysymptomforsuicidepreventioneffortsisflawed.Theassumptionisculturallyincongruentforindigenouscommunities,inwhichsuicidemaybemoreappropriatelyframedasawayofexpressingsocialdistressanddespair(Wexler&Gone,2012).Inaddition,localizedresponsestoyouthincrisisareneededtoensureculturallycongruentapproachestosupportyoungpeople.Forexample,bestpracticesuggeststhatsuicidepreventionprogramsthatusesuicideriskscreeningsshouldhavecommunity-basedservicestoaddresstheneedsofidentifiedat-riskyouth.However,forruralandremotecommunities,supportforyouthincrisisoftenrequiresthattheyouthleavethevillageortribefortreatment.Thisapproachmayhavedevastatingeffectsattheindividual,family,andcommunitylevels,asyouthareremovedfromsettingsandpeoplethatprovideprotectivesocialrelationships.

Historicaltraumahasbeendescribedasrootedinalongandpresenthistoryinthatthecumulativeculturalstressesareunresolved.Ithasbeensuggestedthat“withoutresolution,indigenouspeoplecanbeseenassometimesmisattributingtheirpresentstrugglestopersonalandcollectivefailingsratherthantooppressivesystemsandstructures...[which]leavessomeAI/ANpeoplewithapervasivesense

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There are more than 560 federally recognized AI/AN tribal groups. Of these, 231 are in Alaska. These tribal groups have different social structures, individual and gender expectations, support systems, and conceptualizations of death (Novins, Beals, Roberts & Manson, 1999; Olson & Wahab, 2006). Support provided to AI/AN communities must be guided and informed by each unique cultural and geographic context.

ofhavingnofuture,asentimentthatcanbestronglylinkedtosuicide.”(Wexler&Gone,2012,p.802).Thisviewisconsistentwithonecommunitymember’ssuggestionthathopelessness,incombinationwithshamesurroundingdiscussionofsuicide,preventsNativeyouthfromseekingbehavioralhealthcare:“Theyfeelsohopeless,there’snohope...There’snotomorrows.”Thus,preventionandresponsestohigh-riskyouththatdon’tcontributetoongoingtraumaareessential.

LackofBasicStepsandConsistentSupportTiedtotheissuesnotedabove,theinterviewssuggestedthatlimitedprogresshasbeenmadetoformalizepreventionandresponsetosuicideclusters.Forexample,CDCrecommendsthatasanelementalfirststep,communitiesmustdevelopaplantopreventandcontainsuicideclusters(CDC,1988).Noneoftheclustersettingsinthisreporthadaformalcommunitypreventionorresponseplanpriortotheclusterevents.However,eachofthecommunitiesiscurrentlycollaboratingwithfederalandregionalpartnerstodevelopalocalcommunityplan,whichmayhelptoensureculturallycongruentpreventionandresponse.Lookingforward,otherAI/ANcommunitieswillneedconsistentsupportandpartnershipstodeveloptheirowncommunityplansforsuicideclusterpreventionandresponse.

RECOMMENDATIONSThefollowingrecommendationsareinformedbyinterviewswithAI/ANcommunitymembersaswellasliteratureonbestpracticesforpreventingandrespondingtosuicideclusters,including“CDC’sRecommendationsforaCommunityPlanforthePreventionandContainmentofSuicideClusters”(CDC,1988).Theserecommendationsareintendedprimarilyforlocal,state,andfederalagenciesandorganizationsthatmaycollaboratewithAI/ANcommunitiesindevelopingsuicideclusterpreventionandresponseplans,orassistingduringaclusterevent.Additionalrecommendationsandsupportsfortribalcommunitiesfollow.

� PartnerWithAI/ANCommunitiestoDevelopCulturallySpecificCommunityPlans.Manytribalcommunities,includingthecommunitiesinterviewedforthisreport,mayneedassistanceindevelopingcommunityplansforsuicideclusterpreventionandresponse.Foreffectiveplandevelopmentandimplementation,communitiesneedtechnicalassistancetosupportthefollowingcomponentsofplandevelopment:culturallycompetentneedsandresourceassessment,prioritymapping,coalitiondevelopment,identificationoflocallytailoredstrategies,andintegrationoftheplanwithinthecommunity’scurrentinfrastructure.Assuggestedbyinterviewparticipantsandresearchers(Wexler&Gone,2012)andrecommendedbyCDC(1988),communitypreventionandresponseplansforsuicideclustersmustbeadaptedtotheparticularneeds,resources,

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andculturalcharacteristicsofthecommunity.ThisisparticularlyrelevantforAI/ANcommunities,giventheresources,diverseculturalcontextsacrosstribalcommunities,andhistoricaltraumadiscussedabove.Attheinvitationoftribalcommunities,local,state,andfederalpartnerswiththisexpertiseshouldcollaboratewithAI/ANpopulations,andbuildingoncommunitystrengths,providetechnicalassistancetohelpthecommunitydevelopaplanthatreflectsitsowntraditionsandculture.

� SupportResearchtoImproveUnderstandingofSuicideClustersinAI/ANCommunities.ThefindingsinthisreportareconsistentwithrecommendationsfromtheResearchPrioritizationTaskForceoftheNationalActionAllianceforSuicidePrevention.Inparticular,therecommendationscallforresearchthatfocusesonunderstudied,hard-to-reach,and/orhigh-riskcommunitiesandcaresettings,includingAI/ANruralsettings.Additionalrecommendationsincludeafocusonstudiesdesignedtoimproveunderstandingaboutsuicidemitigationstrategiesandhowtosustainprogressthatreducessuiciderisk(ActionAlliance,2014).SincesomeAI/ANcommunitiessufferhighersuicideburdenthanothers—includingfrequentyouthsuicideclusters—researchisneededtounderstandthedifferencesbetweenthesecommunities,especiallystrength-basedfactorsthatmaytranslatetoothercommunities.Thefindingsinthisreportalsosuggesttheneedforresearchexaminingtheparticularmechanismsofsuicideclusters,whicharenotwellunderstoodwithinanypopulation.Suchresearchmayresultinmodelsthatbetterexplaincontagion,resilience,andprotectivesocialconnectionswithinAI/ANcommunities.

� SupporttheDevelopmentandEnhancementofSurveillanceSystems.Communitymembersandothershavepointedtotheneedfordataonthementalhealthoftribalcommunitiesandtheprevalenceofsuicideclustersingeneral,toinformprevention(Dorgan,2010).Thedearthofdatapresentsaseriousbarriertounderstandingthecontextualissuesandkeyvariablesthatmayinfluencesuicideclustersandinformclusterpreventionandresponseplanning.Emergingsurveillancesystems(suchasthosesupportedthroughtheSAMHSA’sNativeConnectionsgrantprogram[SAMHSARequestforApplicationsSM-14-013])maybeusefultolocal,state,andfederalpartnersinimprovingunderstandingaboutAI/ANsubpopulationswithparticularlyhighsuicideratesandrelatedneeds.

� EnsureanInclusiveandCoordinatedPlanningProcessInvolvingMultipleCommunitySectors.Local,state,federalagenciesandothersthatpartnerwithAI/ANcommunitiesshouldconsiderCDC’srecommendationforinclusionacrossallsectorsofthecommunity(e.g.,publichealth,behavioralhealth,education,parents,communitymembers,etc.)inplanningandimplementingsuicideclusterpreventionandresponseefforts(1988).Communitymembersinthisreporthadclearideasaboutwhomshouldbeincluded.Oneintervieweesuggested,“Wewouldneedourtribalcouncil,ourschool,publicsafety,andourcommunities,Ithinkthatthat’sallweneedtomakeoursuicidepreventionplan,anditwouldworkfinethatwaywithlotsofcommunicationwitheachother.”Moreover,CDCguidanceurgesthat“Everyeffortshouldbemadetopromoteandimplementtheproposedplanasacommunityendeavor…nosingleagency…hastheresourcesorexpertisetoadequatelyrespondtoanevolvingsuicidecluster”(CDC,1988,p.3).

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Lackofadvancedcoordinationmayresultindelayedelementsoftheresponsemaybedelayedoropportunitiesforpreventionmissed.Thus,itiscriticalforallrelevantlocallybasedparticipants,programs,andexternalpartners(e.g.,local,state,orfederalagencies,organizations,oruniversities)tohaveaclearsenseoftheirrespectiverolesandresponsibilitiesinadvance.Inaddition,regularcommunicationamongpartners(e.g.,thelocalcommunityandoutsidepartners)shouldoccursothatallpartnersarekeptapprisedofthestatusofavailableresources,plans,andprotocols.Effectivesuicidepreventionrequiresasustainedandcoordinatedresponse.Partnersmustcommittoandorganizethemselvesinsuchawaythatensuresongoingcoordinationofeffortsandthatsuicidepreventionremainsapriority.

� PartnerWithAI/ANCommunitiestoImproveYouthScreening.Screeningcanidentifyindividualsearlyinasuicidetrajectory,beforeasuicideattemptorsuicideoccurs.Suicidalthoughtsinyouthdonotincreaseasaresultofsuchscreening(Gouldetal.,2005).Individualsatheightenedriskforsuicideshouldbeidentifiedandscreened,andtheliteratureisclearthatpeoplewhohavepreviouslyattemptedsuicideandthosewhohavelostafamilymemberorfriendtosuicideareatheightenedrisk.Qualifiedbehavioralhealthcareprofessionalsshouldoverseethescreeningprocessandconductinterviewstodeterminelevelofriskforallyouthwhoscreenpositiveontheinitialscreen(SPRC,n.d.).Tribesandvillageswithfewavailableprovidersmayrequiresupportinidentifyingprofessionalstooverseetheprocess.Similarly,beforethescreeningbegins,thecommunityneedstoensure(1)thatresponseprotocolsforyouthincrisisarewellestablishedand(2)thatappropriatelytrainedbehavioralhealthprovidersareavailableforyouthwhoscreenpositiveandrequirefollowup(SPRC,n.d.).Ruralandfrontiertribalcommunitiesmayneedtoreachouttolocal,state,orfederalpartnerstocollaborateinfindingavailableproviders.Coordinatingfollow-upservicesforyouthat-riskorincrisisiscritical.

� PromoteYouthEmploymentandEngagement.Toaddressriskfactorsrelatedtoyouthboredomand“lackofthingstodo,”particularlyaftergraduatinghighschool,programsaimedatpromotingpositiveyouthdevelopmentshouldincludeopportunitiesforemployment—particularlygivenhighunemploymentratesinruraltribalcommunitiesandtheneedforeconomicdevelopment.Researchersfindthatworkandjobsatisfactionaresecondonlytopersonalrelationshipsindeterminingqualityoflife.Basedonsuchfindings,employmentcancontributetoamorefulfillinglife,particularlygivenitspositiveimpactonidentity,socialsupport,purpose,andchallenge(Linley,2004;Snyderetal.,2011).Foryouthwhoarestillinschool,somecommunitymemberstalkedabouttheneedforacommunity/recreationalcenterasahealthyplacetohangout.Communitymembershavealsostressedtheimportanceofengagingyouthandinvolvingtheminpreventionplanning.Anothercommunitymembernoted,“IftheywouldinvolvetheyouthNaturalHelpersandstudentcouncil,iftheywouldinvitethatgrouptothemeeting,Ithinkitwouldbehelpfulbecausethoseyouthwouldhelpbringouttheawarenesstotheotherstudents.”

� IncreaseAvailabilityofandEnhanceBehavioralHealthServices.Asdescribedinthisreport,theavailabilityofbehavioralhealthcareserviceshasimprovedinruraltribalcommunitiesinthe

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lastdecade—particularlyinremoteAlaskanvillages—withtheadventoftheBHAprogram,travelingclinicalcounselors,andtelebehavioralhealthcapabilities.InAlaska,theseadvancesmayhaveresultedinanincreaseintheuseofmentalhealthservices.AccordingtotheStateofAlaska's“CastingtheNet”reportfocusedonsuicideprevention,thenumberofAlaskanswhoreceivedmentalhealthservicesgrew17percentbetweenFiscalYears2009and2011.ThenumberofAlaskanswhoreceivedsubstanceusedisordertreatmentalsogrew5.7percentduringthisperiod.WhiletheincreaseinthenumberofAlaskansseekingtreatmentandrecoveryservicesispromising,theresourcesavailabletothebehavioralhealthsystemareunchanged(CTN,2013).Despiteprogressinsomecommunities,behavioralhealthcareisstilllargelyunavailableorinsufficientformanyruralandfrontiertribalcommunities.

� UpdateNationalRecommendationsfortheDevelopmentofaLocalCommunityPlantoPrevent,Contain,andRespondtoSuicideClusters.WhileCDC’s“RecommendationsforaCommunityPlanforthePreventionandContainmentofSuicideClusters”(1988)isaseminalresource,updatingittoincluderesearchfindingsandlessonslearnedoverthelast25+yearswouldbeofimmensebenefittothefield.Attentionmustbegiventouniquecharacteristicsofsuicideclustersindiversecommunitiesandpopulations,especiallyamongAI/ANyouth.

LookingForwardTribalcommunitiescanbenefitfromdevelopingandimplementingcommunityplanstopreventandrespondtosuicideclusters.However,strongandgenuinebarrierstoplandevelopmentexist,suchasculturaltaboosaroundtalkingaboutdeathorsuicide;shameaboutseekingmentalhealthtreatment;suicideandmentalhealthnotbeingcommunitypriorities;andinadequateformalresources/structuresfordevelopingtheplan(e.g.,vacanciesincrucialtribalagenciessuchaseducation,mentalhealth,localgovernment;orlackofbehavioralhealthandcrisisservices).Throughsupportofferedbyarangeoffederalprograms,includingSAMHSA’sTribalTrainingandTechnicalAssistanceCenterandSuicidePreventionResourceCenter,tribesandvillagescanaccessbestpracticesonplandevelopmentandhowtobuildaninfrastructureforcommunitysuicideprevention.

Inaddition,SAMHSA’sSuicidePreventionBranchoverseestheGarrettLeeSmithYouthSuicidePreventionandEarlyInterventionProgram,a5-yeargrantprogramintendedtosupporttribesandstatesinimplementingcomprehensivesuicidepreventionprogramsgroundedinpublic/privatepartnership.Theprogramsprovidesupporttotribes(andstates)toimplementprogramsthatincludecoordinationacrossyouth-servingorganizationstoexpandthecapacitytoidentify,refer,andserveyouthincrisisandatriskforsuicide.Inpart,thesegrantsareintendedtoensurecontinuityofcareforyouthatriskforsuicide.Inaddition,thesefundscanbeusedtoimplementtrackingsystemstomonitorsuicideattemptsaswellasdeathsbysuicidetoidentifypatternsofriskandprioritizepreventionefforts.

In2014,SAMHSAreleasedanRFAforanewgrantprogram—NativeConnections—designedtosupportAI/ANgranteesintheireffortstoreducetheimpactofsubstancemisuse,mentalillness,andtraumaintheircommunitiesthroughapublichealthapproach.ThepurposeofthisprogramistopreventandreducesuicidalbehaviorandsubstanceabuseandpromotementalhealthamongAI/ANyoungpeople

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throughage24.These5-yearcooperativeagreementsaredesignedtoallowfortribalspecific-goalgenerationandplanningbasedonCommunityReadinessAssessments(CRAs)conductedannuallyacrossthelifespanoftheprogram.Tribes,workinginclosecollaborationwithSAMHSAandtheirTribalTrainingandTechnicalAssistanceCentercontractors,willdevelopandimplementplansspecifictotheircommunity’sneedsandreflectiveoftheircommunity’slevelofreadiness.

Thecommunityreadinessmodel(CRM)isanine-stagemodelthatassessesacommunity’slevelofreadinesstodevelopandimplementpreventionprograms.Themodelisaprogressiveassessmentofacommunity’sabilitytoimplementsystematicchangeofkeypublichealthissues.Acommunitycanincreaseanddecreasetheirreadinesslevelforanissuedependingupontheappropriatenessandstrengthoflocalefforts.TheCRMhasfivedimensionsthat,togetherwiththestages,provideacomprehensivecommunityassessmentandservesasaninformationguideastowhattypeoflocaleffortsisneededinwhicharea(Jumper-Thurmanetal.,2003).ThefivedimensionsareCommunityKnowledgeofEfforts,CommunityClimate,CommunityKnowledgeofIssue,Leadership,andResources.Eachdimensionreceivesacommunityreadinessscoreandeachcanbeatadifferentreadinesslevel.Thedimensionsarecorrelatedthereforeoneaspectofcommunityreadinessisnotusuallymorethantwostagesapartfromtheotherdimensions(Jumper-Thurmanetal.,2003).Thedimensionsarenotspecifictoculture;howevertheycanbeinterpretedwithinthecontextofthecultureofeachcommunity(Jumper-Thurmanetal.,2003).

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