Adapting a Zero Suicide Approach to Native Communities

Jordan Anderson and Dhivya Sridar

May 03, 2022

Edwina Valdo found herself on the receiving end of a desperate phone call last year on the suicide crisis line at Acoma Pueblo Behavioral Health Services in New Mexico. Valdo, whose regular job is as a grant manager, was filling in because the pandemic had left the facility short-staffed.

"I did my best to keep her on the phone, to try to find out where she was and who she was," says Valdo, a member of New Mexico's Pueblo of Acoma Tribe.

The caller told Valdo she was being verbally abused at home and having thoughts of suicide. Because the woman didn't want to involve law enforcement or emergency services, Valdo drove her to a local shelter herself.

"I was really glad I could be there for her," Valdo says. "This was one of my people, so I was more than happy to support her in that time of crisis."

Acoma is one of eight sites supported by the Indian Health Service working to adapt a long-established suicide prevention program known as the Zero Suicide Initiative to their communities. The facilities are trailblazing a culturally competent approach to suicide care that combines research-backed practices with traditional healing, even in the face of funding challenges and enduring stigmas about suicide.

Customizing Zero Suicide for Native Populations

Native Americans have the highest rates of suicide of any racial or ethnic group in the United States. During the first year of the COVID-19 pandemic, a National Council for Mental Wellbeing survey found that 45% of Native American adults said they'd had more stress and mental health challenges, while only 24% had received treatment for mental health.

While Native Americans have high suicide rates and unique cultural challenges, programs aimed at prevention have seldom been designed for their specific needs.

Zero Suicide is a generalized suicide program that first launched in 2012, promoting the adoption of "zero suicide" as a goal across U.S. health care systems. It has since mobilized the field of suicide care worldwide.

The program uses seven elements, including assessment of suicide risk, collaboration with patients on safety plans, suicide-specific treatment, and follow-up care. It also expands suicide prevention training for health care workers and engages the broader community, including family members of those receiving care.

This model has been shown to work in the general population but has not been validated for Native communities. Research about effective suicide prevention in Native communities is sparse, says Sadé Heart of the Hawk Ali, tribal lead and senior project associate for the Zero Suicide Institute in Waltham, MA.

One reason is that federal funding is rarely available to support ideas like traditional healing, says William Hartmann, PhD, an assistant professor of clinical psychology at the University of Washington.

"That's one of the core challenges that I've heard community health organization administrators grapple with," he says. "How to balance local visions for health and wellness with what's realistically fundable by the federal government."

Zero Suicide has since developed a companion toolkit that recommends how to use the program in Native communities. The toolkit offers steps to adapt the program to Native-serving health systems that are tribally owned or managed by the Indian Health Service (IHS).

IHS, a U.S. government agency that provides medical and public health resources to Native communities, started its Zero Suicide Initiative in 10 Native health sites in 2016. This past November, IHS announced $46.4 million in funding to help expand behavioral health programs. About $2 million will directly support the Zero Suicide Initiative in IHS facilities that applied for the extra funding.

Ali says suicide prevention programs must be adapted to Native communities' individual cultures.

"Each one has different ways, different stories, different dances, different ways of articulating what is health and what is wellness in our communities," she says.

With decades of experience in behavioral health, Ali says the program provides a chance to customize care to each tribe's needs. Some tribes don't have a word for suicide, she says. For others, talking about the issue can be taboo. To combat the taboo, some have changed the program's name. At the Chinle Comprehensive Health Care Facility in Chinle, AZ, the program is known as "Iiná Ayóó'oo'nii: Embrace Life Project."

Native health providers have also adapted Zero Suicide's screening tool and risk assessment process in a culturally sensitive way. Instead of directly asking about thoughts of suicide, health care providers reframe the question: Rather than, "Do you feel like killing yourself?" they may pose the question as, "Do you feel like ending your life?"

"The idea is that everyone feels comfortable and confident in their cultural perspective," Ali says.

According to Ali, effective, culturally informed suicide care not only focuses on those at risk, but rather the entire community, involving elders, tribal leaders, and other community members in order to create a safety net.

At Chickasaw Nation, Native patients stay with their families during their crisis, use community and cultural support, and are more likely to check back in with health care providers sooner, according to a report by Chickasaw Nation Departments of Health and Family Services.

Legitimizing Traditional Medicine

Zero Suicide began in Detroit's Henry Ford Health System as a way for the hospital system to better provide suicide-specific care, rather than address suicide as a part of other mental health conditions such as depression, says Brian Ahmedani, PhD, director of the Center for Health Policy & Health Services Research at Henry Ford.

"We recognize that Native communities have very important cultural ways and medical approaches," he says. "It's really important to work to adapt this kind of a model to integrate those cultural approaches."

The Zero Suicide framework involves clinical practices that focus on care for people at risk, including screening, assessment, safety planning, and follow-up. The effort also works to expand suicide prevention training for health care workers and engages the broader community.

The framework's approach has consistently reduced suicide rates by 65% to 75%, according to the Zero Suicide Institute website. But research into Zero Suicide is still developing. Published research on its impact remains limited.

Now, Ali's work focuses on creating that sense of validation by merging Native traditional health practices with Zero Suicide's research-based framework.

Ali also believes using traditional medicine and practices along with the Zero Suicide structure can make the healing process even more effective, even for Native Americans who may not feel as connected with their culture.

These practices can include prayer, talking circles, and the use of sacred herbs, according to Native American Connections, an organization that provides health services for Native communities in central Phoenix.

The adapted Zero Suicide toolkit emphasizes that combining Western ways of medicine and the use of traditional healers and medicine may prove to be more effective in Native communities.

"Our people believe that our culture is our cure, and so just being able to teach some of these things and to return to some of those ways has been so healing for the nations that we work with," Ali says.

It's about legitimizing approaches to suicide care not found in research literature, she says.

"I can trace my people back 30,000 years," Ali says. "Our ways are ancient. You're not going to find them in peer-reviewed journals. You're not going to find research on them, but we know they've worked."

Specific Challenges Adapting Zero Suicide at Acoma

Valdo, the director of health and wellness programs at Acoma, has worked with its Zero Suicide Initiative since the facility first received Indian Health Service funding in 2017. Along with research-based suicide prevention techniques, Acoma offers language classes, sewing, and other cultural activities.

While the purpose of Zero Suicide is to treat suicide directly, she says many community members opt for treatment focusing on another condition, such as substance abuse. Others refuse services altogether.

Due to the stigma, some tribal leaders are hesitant to confront issues surrounding suicide. Valdo says Acoma's recent leadership has openly addressed mental health and supports Zero Suicide's goals in the community.

"Sometimes it takes that position of leadership to help drive change," Valdo says. "In a small community, people feel very stigmatized. If their vehicle is just parked outside [the facility], most people know, right?"

She says Acoma has also seen success in breaking the stigma around suicide through community outreach. The organization can attract 500 or more people for spirit week, suicide prevention week, and other events.

"It's always been considered a taboo subject," Valdo says. "We let the community know, anytime of the year, any day, there's resources available and we're here if they need to reach out."

Acoma's program still confronts issues with staff recruitment with regards to Zero Suicide, as the nearest metropolitan area is about 60 miles away. Representation is another challenge. Out of nine health care providers, two are Native. This highlights a larger problem with the shortage of Native American doctors nationwide.

More recently, Acoma has focused on preparing for a future without financial support from IHS, as its Zero Suicide grant expired in April. Valdo said the staff is actively planning how they intend to keep programming going and applied for a second round of funding.

Despite the challenges, Valdo says the program has improved since it began in 2017, pioneering new suicide-specific care for the community in the process.

"It's not only putting this beautiful framework into these communities, but the creation of this way to bring those two worlds together, those schools of thought together," Ali says. "We know that those things work."

Sources

Edwina Valdo, grant manager, Acoma Pueblo Behavioral Health Services, Arizona.

Suicide Prevention Resource Center: "Racial and Ethnic Disparities."

National Council for Mental Wellbeing: "Minority Mental Health Worsened During the COVID-19 Pandemic."

Zero Suicide International.

Psychiatric Services: "The Relationship Between Suicidal Behaviors and Zero Suicide Organizational Best Practices in Outpatient Mental Health Clinics."

Zero Suicide: "Best and Promising Practices for the Implementation of Zero Suicide in Indian Country," "Chickasaw Nation Departments of Health and Family Services," "Expert researchers share questions and findings about the effectiveness of the Zero Suicide approach."

Sadé Heart of the Hawk Ali, tribal lead, senior project associate, Zero Suicide Institute, Waltham, MA.

William Hartmann, PhD, assistant professor of clinical psychology, University of Washington.

Department of Health and Human Services: "IHS announces $46.4 million to fund behavioral health programs that serve American Indians and Alaska Natives."

Brian Ahmedani, PhD, director, Center for Health Policy & Health Services Research, Henry Ford Health System.

Native American Connections: "Traditional Healing."

American Medical Association: "Native Americans work to grow their own physician workforce."

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