NMTP Newsletter Volume 3, Number 1, May, 1999

Index

Suicide in African-American Adolescents: An Examination of Risk and Protective Factors - Terri A. Betts, Psy.D

Message from the President

If you are reading this column, you are either a member of the “network” which has sustained the Center for Multicultural Training in Psychology (CMTP) for more than 25 years, or you are a more recent member of our community as a subscriber to this newsletter of the Network for Multicultural Training in Psychology, Inc (NMTP). As President of NMTP and a founding member of the CMTP network, let me try to clarify the distinctions between, and relationships among, the network, CMTP and NMTP.

The“network” (hereafter without the quotation marks, with a lower-case “n”) was originally composed of psychologists, other mental health professionals, and community activists from the Boston area who, in the late 60's and early 70's, recognized the marginalization of people of color from the institutions and professions on which they depended for mental health services. Local members of the Association of Black Psychologists formed a critical nucleus for this network. Guy Seymour, then a Boston University graduate student, began to militate for culturally competent mental health services at Boston City Hospital, which hired him to make his vision real. Guy approached community-based human service agencies serving urban poor people of color, and asked them to specify how they felt they could make the best use of psychology trainees. Often, agency managers were already members of the network. Guy asked other professional members of the network for commitments to provide teaching and supervision. He acquired an NIMH training grant for a program with a small core staff based at Boston City Hospital. Interns trained at the hospital and in the community-based agencies, with supervision from core supervisors at the hospital, site supervisors at the agencies, and field supervisors from the network. This widely dispersed, loosely structured organization, the Minority Training Program (MTP, or “the Program”), was held together by the considerable force of Guy’s personality, and by biannual “network assembly program evaluations,” at which core staff, interns, site supervisors, field supervisors, and other members of the network would assemble to take a critical look at the Program, and to renew their commitments to the Program and its mission.

Conducted in the early years by Dr. Carolyn Attneave, a developer of the full-scale family network assembly, these network assemblies provided integration, revitalization, accountability, and community solidarity. They proved critical to Program survival in our most vulnerable formative years as we struggled with personal tragedies, threats to our survival from internal hospital political struggles, and the remarkably hostile racial atmosphere of the Boston area. We who labored for little or no pay were richly rewarded by the success of the Program, which trained many of today’s leaders in the field of culturally competent practice, and by the opportunity to participate in a community of like-minded colleagues, fortifying us in our daily personal and professional lives, where the idea of psychological practices adapted to specific circumstances of race and racism was either invisible, ignored, or treated as objectionable and unprofessional.

Now, more than 25 years later, MTP has grown up to become CMTP, the Center for Multicultural Training in Psychology, an APA-certified psychology internship program at Boston Medical Center (formed from the merger of Boston City Hospital and University Hospital). CMTP is a valued component of the Boston Medical Center/Boston University Medical School Psychiatry Department. Secure within our hospital setting, we are (like all health care enterprises) vulnerable to the uncertainties of the wider healthcare environment. The network now includes over 160 graduates of the internship program, 85% of whom are people of color. There are not as many opportunities now for network members to participate in the mature, more formalized CMTP; APA requirements, for example, do not permit the role of off-site field supervisor.

It is NMTP whose newsletter you are now reading. Responding to an idea conceived at the 1993 CMTP 20^th Reunion Conference, in 1995 a group of network members formally incorporated the Network for Multicultural Training in Psychology, Inc., as a vehicle to hold the network together, to strengthen external support for CMTP, and to promote more widely the culturally competent practice of psychology. Our purposes are “Education, training, research, consultation, dissemination of expert knowledge, public advocacy, raising funds and disbursing funds (e.g., scholarships, fellowships, and grants in aid) in furtherance of the competent practice of multicultural psychology.” We have established By-Laws, and achieved 501(c)(3) status with the IRS as a tax-exempt nonprofit corporation. With this spring election, all of the original incorporators will have been replaced by elected members of the Board of Directors. We have survived the early challenges of starting a nonprofit organization from scratch, the most obvious to the membership being our difficulty establishing an orderly process for collection of annual dues. Thanks to the labor of our current Membership Committee (Dyanne London, Alicia Lucksted, and Leon Nicks), we have our membership information organized in a database, and NTMP members should be receiving their dues notices on time. The active core is a small group of Board members and volunteers, who need to gather more activists to move forward.

The network remains central to the conception and prospects of NMTP. Our success depends on mobilizing the human resources of the network, and our survival depends on engaging network members in meaningful and productive activity. We began with the goal of signing on nearly every member of the network (over 300 culturally competent clinicians) as Fellows of NMTP, following this up by expanding to include other professionals from outside our network who are committed to culturally competent practice. With a large membership, annual dues would be sufficient to support our organizational activities and to provide substantial financial support to CMTP and other entities committed to cultural competence. This vision proved overly ambitious; we currently have 51 Fellows, 17 Students Members, 4 Organizational Members, and 2 Community Members. With a modest income from dues, we have been able to cover our operating costs (the largest being this newsletter) and to provide some financial support for activities supporting cultural competence, including Annual Conferences of the Boston-based Graduate Students for Multiculturalism in Mental Health, our November, 1996 gathering at which Dr. Kermit Crawford presented the work of the Multicultural Mental Health Research Center, and the 25^th Anniversary Reunion Conference of CMTP, “Racism Across the Life Cycle.” We will be helping to defray some travel costs for the NMTP presentation at this year’s APA Conference (described elsewhere in this issue).

NMTP Notes, conceived originally as an internal organ for the membership, has become a major vehicle for our promotion of the culturally competent practice of psychology, thanks to the efforts of the Newsletter Committee (Terri Betts, Merlin Langley, Alice LoCicero, and me). It is distributed free to over 350 subscribers, including members of the original network and others whom we have identified as supportive of our mission. From the very first issue, which included Victor De La Cancela’s column on the application of networking to collaborative community-based human service practice, we have offered substantial, thought-provoking columns challenging readers to grapple with issues in culturally competent teaching, training, and practice.

Whether or not you are an alumana/us or former staff member of CMTP, or a member of NMTP, you are as a reader of this publication a member of our informal network of colleagues committed to meaningful, culturally competent psychological practice. If you have not yet joined NMTP, please consider doing so. The benefit of membership is the opportunity to support a tradition which predates the current commodification of cultural competence in the psychological marketplace (see the conversation between Alice LoCicero and me in Volume I, Number 3). Your financial support will help fortify CMTP and other settings committed to training people of color and others to provide psychological services to people of color and other urban socially and economically marginalized populations. In time, the benefits of membership will include opportunities to participate in NMTP-sponsored activities, e.g., research projects, consultation and education, etc.

We need to plan carefully for our next phase of growth. After a couple of years working on the design of a consultation and education service, we realize that our current small group of overscheduled Board members and volunteers cannot move us forward alone. In addition to drawing in more volunteers, we will need to hire some people to do the work. Before embarking on serious fundraising, the Board plans to enlist the aid of a professional organizational consultant, familiar with and supportive of our community-based mission, to draw up a strategic plan. With the plan in hand, we hope to raise the money to establish the kinds of activities which both support our organizational purposes and engage members of the network in NMTP.

As we prepare for the strategic planning process, there are still plenty of activities for which you may want to volunteer. The Finance/Fundraising Committee is particularly interested in people experienced and enthusiastic about grant-writing and fundraising. The Membership Committee is seeking a Co-Chair, and for volunteers interested in drawing in members of the old network and recruiting new ones. The Newsletter Committee is always looking for new writers, particularly for each issue’s substantive column. The Newsletter Committee is also looking for a member who is knowledgeable about database management, to keep our address list up to date. We have also recently started an NMTP web site task force.

This column is a partial response to the program evaluation from our 1998 Annual Meeting, (published in the last NMTP Notes), which called for clear distinctions between CMTP, NMTP, and the network. I hope it helps you make sense of who we are, and who you, the reader, are in relation to the rest of us. We continue to welcome your participation, in whatever form.

NEWS FROM CMTP

Newsletter subscribers have already received a letter from Herbert Joseph announcing his departure from the position of CMTP Director. Herb's professionalism, reliability, and steadfast support served interns and Program well over the years. NMTP owes him a particular debt for his persistence in shepherding us toward incorporation.

NMTP is well‑represented on the committee searching for the new Director, who will welcome in September the following interns for the 1999‑2000 year: Aratha V. Franklin, M.S., from Florida Institute of Technology; Jason M. Luciano, B.S., from Gaulladet University; Danelle Reed‑Interblitzen, M.A., from University of South Dakota; Catherine Vuky, M.A., from California School of Professional Psychology; and Elvia Y. Valencia, B.A., from Chicago School of Professional Psychology.

Dr. Pedro Garrido has left the Core Faculty to devote time to fatherhood ‑the baby is expected in May, 1999. Dr. Don Elligan, former CMTP intern, has joined the Core faculty and will be assuming some of Dr. Garrido's supervisory responsibilities. Dr. Elligan co‑authored a recent article in Cultural Diversity and Ethnic Minority Psychology (5), "Utility of an African‑Centered Support Group for African American Men Confronting Societal Oppression and Racism."

Congratulations to former interns Drs. Catherine Louie, Don Elligan, and Terri Betts for recently achieving licensure in the Commonwealth of Massachusetts!

Mark your calendars: The annual CMTP Network Dinner will be held May 27, 1999.

NEWS FROM GUY SEYMOUR

MTP Founder Guy Seymour, who left his position with the City of Atlanta December 31, 1998, is now in full-time private practice in Atlanta and in Boston as Chief Psychologist of Psychologists In Public Safety {sm}, a collaborative of psychologists interested in consulting and clinical services to police, fire, emergency medical, and transportation agencies.

As the Department Psychologist for the Boston and M.B.T.A. police departments, he will be the primary host for the Police & Public Safety Section of Div. 18 at the 1999 APA convention in Boston. Dr. Seymour invites NMTP to join him and PIPS in recruiting more psychologists with interest in multiculturalism to address the needs of public safety agencies where culturally competent psychological expertise might be relevant, especially in the aftermath of recent highly charged and well-publicized events such as the shooting of an African man by the New York City police and the rousting of many youth of the African-American and Latino communities in major cities throughout the U.S.

NMTP LISTSERV

[Archives readers please note: this is out of date. As of March, 2002, we are in the process of establishing another Listserv – Ed]

Thanks to Larry Fieman of Boston University, NMTP now has a “listserv” email mailing list. Anything that you send to the listserv address is automatically sent to everyone else on the mailing list. Similarly, you receive everything that anyone mails to the listserv address. The listserv has been up an running for over a month now, with the original list made up of NMTP members whose email addresses we have. The list has been used to share information and concerns about culturally competent practice, to announce job openings, to solicit items for the newsletter, etc.

This is an open list; anyone can subscribe. Here’s how: Let us say that your email address is <<anyone@aol.com>>. To subscribe, send an email to <<majordomo@bu.edu>> (don’t include the <<>> punctuation). The subject line is unimportant; it is critical that the body of the message is as follows (again, without the <<>>punctuation): <<subscribe nmtp-list anyone@aol.com>>. To unsubscribe, email <<majordomo@bu.edu>>; in the body of the message write <<unsubscribe nmtp-list anyone@aol.com>>.

Once you have subscribed, you will start receiving messages addressed to the list. To post a message, send it to <<nmtp-list@bu.edu>>.

CMTP/NMTP AT APA

Save the cocktail hour (6 PM) on Saturday, August 21, to join CMTP and NMTP at a reception for all those grads and others who have been part of the network and are in Boston for the annual convention of the American Psychological Association, on August 20 through 24 (Friday through Tuesday). Undoubtedly many members of the Network will be participating in APA, and many will be making presentations a the conference. We list below those we have heard about by press time:

CMTP Family Therapy Team Symposium:

Culturally Competent Family Therapy Training: Situating Training in a Social Justice Framework (Sheraton Hotel, Fairfax Room A, Monday, August 23, 10-11:50 AM. Gonzalo Bacigalupe, Chair): Roxana Llerena-Quinn, How do assumptions about difference and power affect what and how we teach?; Jay King, Experiential or Didactic Educational Experiences: Dilemmas of Difference and Similarity; Jodie Kliman, Accountable Consultation: Situating Knowledge and Expertise in Cultural Experience; Gonzalo Bacigalupe, Supervising Clinicians Who Work with Latino Families: Reflexivity, Passion, and Voice; and Hugo Kamya, Listening to Spirituality in the Immigrant Experience.

NMTP Members Conversation Hour:

People of Color in Psychology: Teaching, Learning, Mentoring, Surviving (tentative title). (Westin Hotel, Hospitality Suite for Division 2, Teaching of Psychology, Saturday, August 21, 5 PM): Herb Joseph, Mabel Lam, Merlin Langley, Dyanne London and Alice LoCicero will facilitate an open discussion; hopefully, many network members will join in.

CMTP/NMTP Cocktail Hour:

The reception will follow this discussion immediately. The location was not definite as of press time. Look for announcements on the Iistserv , at APA, or call or email any of the newsletter staff if you need more details.

Other programs on cultural competence, featuring network members or supporters:

Cultural Competence and Managed Care (network member Jean Lau Chin, Chair). Friday August 20, from 12:00-12:50 PM. Clara Carr, Developing Cultural Competence Plans; network member Victor De La Cancela, Cultural Audits for Institutions, and Harriet McCombs, Cultural Competent Guidelines for Managed Care. Discussant: Nicolas Carballiera Parkhurst.

Advancements in Multicultural Competencies: Process-Outcome, Organizations, and Community Services. Gargi Roysircar Sodowsky, Chair (We did not have time and place by press time.) Gargi Roysircar Sodowsky, Studying Multicultural Competencies in Relation to Counseling Process and Outcome; Allen A Ivey, Multicultural Competencies in Counseling Psychology: Revisions for the New Millennium; Madonna G. Constantine & Nicolas Ladany, Addressing Multicultural Competence in Psychotherapy Supervision: Process and Outcome Implications; Margie Rogers -Cross-Cultural Competence in School Psychology: Present Status and Future Directions, and Jean Lau Chin, Quality of Care Guidelines for Conducting Cu1tura1ly Valid Service. Discussants: Clara Hill and Charles Ridley.

In the Public Interest: Psychology and Immigrant Children Youth, and Families, on Tuesday, August 24 at 11-12:50. Chair: Felicisima Serafica. Discussant: Jean Lau Chin

Suicide in African-American Adolescents: An Examination of Risk and Protective Factors

Terri A. Betts, Psy.D

Much empirical work needs to be done in the area of suicide in American-American adolescents. Understanding the psychosocial correlates of suicidality is a critical first step in planning intervention efforts. Many studies which look at suicide in adolescents compare the relative rates for Blacks and Whites. This practice is of questionable utility given the different cultural contexts the adolescents exist in. Models which have been tested only on White youth should be viewed skeptically. The alarming increase in the rate of suicide among African-American youth are a reminder that the answers we seek are more than an academic exercise. They are literally a matter of life and death.

Nationally, suicide is the 4th leading cause of death for 10 to 14 year olds, the 3rd leading killer of young people 15 to 24, and the 4th leading cause of death for young adults 25 to 34 (Massachusetts Department of Public Health, 1999). Girls are four times more likely to attempt suicide and boys are five times more likely to complete suicide (CDC, 1994). Suicide has historically been perceived as a White phenomenon. As a result relatively little attention has been paid to suicidal behavior in African- Americans (Guileyardo, Carmody, Lene, & Stone, 1994).

For African-Americans suicide is typically low in adolescence, increases in young adulthood and decreases with age, reaching a peak between the ages of 25-34 (Gibbs, 1997). The suicide rate for African Americans of all ages has historically been lower than that for Whites. However, from 1980-1995 the suicide rate for African -American youths aged 10-19 years old increased from 2.1 to 4.5 per 100,000 population (CDC, 1995). This is an increase of 146% and is primarily a result of an increase in African American male suicides. As of 1995 suicide was the third leading cause of death among African Americans aged 15-19. Suicide is not just a mental health concern but a public health crisis. It is critical for prevention and intervention efforts that there is a clear understanding of the risk and protective factors related to suicide in African- American adolescents. There is evidence that some risk factors differ according to race/ethnicity and/or socioeconomic status but this is not routinely taken into accuot by researchers.

Suicide and Socioeconomic Status

A number of reasons for the increase in suicide among African American youth have been hypothesized. The growth of the Black middle class has been posited as one reason. Black youth in upwardly mobile families may experience stress associated with their new social environments. Forms of racism may be subtler, thus requiring particular skill sets to offset the deleterious effects. It has been suggested that these youth may adopt the coping behaviors of the larger society in which suicide is more commonly used (CDC, 1995; King, 1982). The CDC has posited this theory but they do not routinely track socioeconomic data in suicide cases. Therefore this is no empirical support for this position. Marginality from both their own group and the dominant group has been posited as a reason for the increased rate. Kirk and Zucker (1979) found that African American suicide attempters, when compared with non-attempters, had a greater inter-generational social distance from their families of origin and tended to be struggling for acceptance in a predominantly European American society, while simultaneously turning away from less economically successful parental models. The authors posited that among African-Americans, suicide attempts are related to feelings of alienation and a lack of positive racial identity. This position has not been tested empirically. Some researchers have suggested that violence and suicide are two sides of the same coin, with lower income African-Americans being more likely to engage in violence while middle income African-Americans are more likely to turn to suicide. This position has not been empirically tested. Roberts, Chen & Roberts, (1997) found that suicidal ideation but not attempts were higher in lower class youth. The above theories, while intriguing, have not been empirically tested. It is therefore not possible to state with any degree of certainty whether and to what extent socioeconomic status acts as a risk or protective factor for suicidality in African American adolescents.

Risk and Protective Factors

Risk for suicide attempts in African Americans has been associated with a number of psycho-social risk factors. History of past attempts, current suicidal ideation. depression, recent attempt by a mend, low self esteem, family violence and dysfunction have all been implicated (Taylor Gibbs, 1997; Chance et al. 1998; Lewinsohn. Rohde & Seeley. 1994). Lewinsohn (1994) found a high correlation between being born to a teenage mother and later suicidality in African American adolescents. Nisbet (1996) found that seeking mental health support was a predictor for later attempts at suicide in African Americans. The author views seeking support from friendship and family resources as a protective factor. The author posited that given the historic underutilization of outpatient mental health services by African Americans, an African American who presents for mental health treatment is likely to have less social supports and thus report increased psychiatric distress.

One way to think about suicide is within cluster of risk behaviors. This avenue of inquiry views risk behaviors not as singular isolated events to be dealt with separately, but as an organized constellation of risk behaviors that are interrelated and co-vary (Jessor, 1991); (West Stevens, 1998); (Beauvais, Chavez, Oetting, Deffenbacher & Comell, 1996). This is an important approach for understanding and intervention purposes. It suggests that similar risk factors underlay many different risk behaviors. One example is the empirical support for the co-occurrence of substance abuse and interpersonal violence (APA, 1993).

In his study of attachment to parents and its relationship to social competence and emotional well being, Rice and his colleagues (Rice, Cunningham & Young, 1997) found that overall, attachment to father was the most important predictor of social competence for African American adolescents.

Some of the protective factors identified have been seeking friendship and family resources, attachment to father, orthodox religious beliefs of African Americans (Nisbet, 1996; Rice et al, 1997; Neeleman, 1998).

Racial identity attitudes have been found to be related to psychological functioning in a number of studies (Arroyo, Carmen & Zigler, 1995; Carter, 1991). Individuals who report lower levels of racial identity development tend to report increased incidences of psychiatric distress (commonly depression) and lower self-esteem; both of which are known risk factors for suicidality. These studies did not look at suicide per se. However, given the correlation of depression and low self-esteem with later suicidality I view the role of racial identity as an important area for further empirical examination.

A Model of Risk and Protective Factors

Jessor (1991) described adolescent risk behaviors as functional, purposive, instrumental and goal directed. He viewed many of them as related to normal adolescent strivings for increased autonomy from parents and increased acceptance from peers. It is a useful model for understanding the complicated interrelationship of risk and protective factors in African American adolescents. Jessor's model proposes five interrelated conceptual domains of risk and protective factors which encompass the adolescent's life and context. They are (1) Biology/Genetics, (2) Social Environment, (3) Perceived Environment, (4) Personality, and (5) Behavior. He viewed the five domains as influencing each other as well as risk behaviors/lifestyles which in turn can effect health/life compromising outcomes. Jessor based his conceptual model on research using Black and White adolescents. However, it is unclear what the number of subjects were in each of the total sample and in the racial groups. It is also not clear whether socioeconomic differences were taken into account in this model.

For African American adolescents we need to understand what particular aspects of their environment influence their risk behaviors and how. It would also be important to understand to what extent socioeconomic status and racial identity moderate the relationship. The implications of this relationship would be extremely useful in providing a fuller understanding of additional risk and protective factors for suicide in African American adolescents.

Incorporating Socioeeonomic Status and Racial Identity

I propose that socioeconomic status and racial identity be incorporated into a model of risk and protective factors for African American adolescents. Middle class status can bring with it additional pressures for the African American adolescent and his or her family. There is likely to be increased contact with and exposure to the dominant group and their methods of coping and images of African American people (many of which are negative). A positive racial identity can provide a buffer against the effects of this exposure and decrease feelings of isolation which could in turn leave the adolescent to view suicide as a viable alternative. The parents level of racial identity could also have an effect on the adolescents with parents who hold more positive racial identity being more likely to have children with the same. These parents are likely to provide a home environment which reinforces these attitudes. These are also parents who are more likely to engage in culturally relevant events and practices which engender racial pride. Parents who are more assimilated may be less attuned to some of the pressure their adolescent children are facing, such as feeling not quite in either world, African American or White. These parents may also be less able to teach their children the particular skill sets they will need to successfully navigate environments which are less than welcoming for African Americans. There is much empirical work which needs to be done in the area of suicide in African American adolescents. Understanding the psychosocial correlates of suicidality is a critical first step in planning intervention efforts. Given the different social contexts African Americans and Whites often live in, it is critical that any examination of this issue be culturally informed and relevant. Failure to do so can result in culturally uninformed interventions which might do more harm than good. I am currently examining the correlation of socioeconomic status and suicidality in African American adolescents from a longitudinal data set. It is my hope to contribute to and extend the model of risk and protective factors related to suicidality in African American adolescents. I am in the preliminary stages of data analysis and will be presenting the results at the AP A convention in August. I welcome readers' thoughts and input.

References

APA. (1993). Violence and youth: Psychology's Response (1): APA Commission on Violence and Youth.

Beauvais, F., Chavez, E. L., Oetting, E. R., Deffenbacher, J. L., & Comell, G. R. (1996). Drug Use, Violence, and Victimization Among White American, Mexican American, and American Indian Dropouts, Students With Academic Problems, and Students in Good Academic Standing. Journal of Counseling Psychology, 43(3), 292-299.

Jessor, R (1991). Risk Behavior in Adolescence: A Psychosocial Framework for Understanding and Action. Journal of Adolescent Health. 12. 597-605.

Lewinsohn, P. M., Rohde, P., & Seeley, J. R. (1994). Psychological Risk Factors for Future Adolescent Suicide Attempts. Journal of Consulting and Clinical Psychology. 62(2), 297-305.

Rice, K. G., Cunningham, T. J., & Young, M. B. (1997). Attachment to Parents, Social Competence, and Emotional Well-Being: A Comparison of Black and White Late Adolescents. Journal of Counseling Psychology, 44(1), 89-101.

Roberts, R E., Chen, R, & Roberts, C. R (1997). Ethnocultural Differences in Prevalence of Adolescent Suicidal Behaviors. Suicide and Life-Threatening Behaviors, 27(2), 208-217.

Taylor Gibbs, J. (1997). African American Suicide: A Cultural Paradox. Suicide and Life-Threatening Behavior. 27(1), 68-79.

West Stevens, J. (1998). Early Coital Behavior And Substance Use Among African American Female Adolescents. African American Research Perspectives, 4(1), 35-39.