Suicide stigma, grief, and John Henryism in African-American mothers

Suicide Grief among African-American Mothers

THE COLOR OF STIGMA

This research will explore the experience of representative African-American mothers who lost their sons to suicide. The biopsychosocial contextual model of stress, as specifically applied to suicide as stressor, by Clark, Anderson, Clark and Williams (1999) will guide the following research questions:

Does perceived stigma due to suicide, as measured by the Suicide Stigmatization Scale (Fiegelman et al., 2011) significantly predict severity of grief, as measured by the Inventory of Complicated Grief (Prigerson et al., 1995), in African-American mothers who have lost a son to suicide, controlling for maternal socioeconomic status, age, relationship status, depression, and history of suicide in the family?

Does the coping style of John Henryism, as measured by the John Henryism Active Coping Scale (James, 1983) increase perceived stigma due to suicide, as measured by the Suicide Stigmatization Scale (Fiegleman et al., 2011) and severity of grief, as measured by the Inventory of Complicated Grief (Prigerson et al., 1995), in African-American mothers who have lost a son to suicide, controlling for maternal socioeconomic status, age, relationship status, depression, and history of suicide in the family?

3. Does belief that suicide is due to societal causes, as measured by the societal causes subscale of the Attitudes Toward Suicide Scale (ATTS; Lester & Bean, 1992; Knight et al., 2000) significantly predict severity of grief, as measured by the Inventory of Complicated Grief (Prigerson et al., 1995), in African-American mothers who have lost a son to suicide, controlling for maternal socioeconomic status, age, relationship status, depression, and history of suicide in the family?

4. Does the coping style of John Henryism, as measured by the John Henryism Active Coping Scale (James, 1983) increase the belief that suicide is due to societal causes, as measured by the societal causes subscale of the Attitudes Toward Suicide Scale (ATTS; Lester & Bean, 1992; Knight et al., 2000) and severity of grief, as measured by the Inventory of Complicated Grief (Prigerson et al., 1995), in African-American mothers who have lost a son to suicide, controlling for maternal socioeconomic status, age, relationship status, depression, and history of suicide in the family?

Suicide Grief in African-American Mothers: the Roles of Suicide Stigmatization,

Attitudes toward Suicide, and John Henryism

Research Topic -- In 2010 an 2011, suicide was officially reported as the third suicides among African-Americans are male (CDC, 2011). The excruciating impact of a son's suicide on the severity of grief on his mother has scarcely been studied with any rigor despite the admitted sustained increase in the rates (CDC, 2011; Barnes, 2006; Day-Vines, 2007; Utsey, Hook & Stanard, 2007). The sordid picture is that it is reported as the leading cause of death among African-American males aged 15-24 and that 80% of all suicides in the black community are males. Societal and intrapersonal factors to these mothers' grief due to their son's suicide are believed to be influenced by societal and intrapersonal factors specific to the community (Barnes, 2006; Laurie & Niemeyer, 2008; Woods et al., 2013). One is stigma, which prevents affected African-Americans with mental illness and contemplating suicide (Walker, Lester, & Joe, 2006, p. 322). Another factor may be John Henryism, a cultural-based coping strategy, applied by African-Americans in dealing with chronic stress, which frequently leads to depression and psychological distress (Bronder, Speight, Witherspoon, & Thomas, 2013; Hunn & Craig, 2009). It consists of coping perceptions, attitudes, and behaviors, which comprise their belief in their capability to overcome any obstacle through intense hard work, perseverance and innate strength of character. (Hunn & Craig, 2009). While ideally admirable, they are practiced at the expense of their real physical and psychological health (Hunn & Craig, 2009). This concept is further exaggerated by Black feminist works, such as those of Simms-Brown (1982), Beauboeuf-LaFontant (2009), and Woods-Giscombe (2010), which enshrine the black female as "The Strong Black Woman" or SBW or a superwoman (Woods-Giscombe, 2010, p. 2). The cumulative ideal of superhuman strength of character in African-Americans is embodied by their women, specifically mothers, the normal human being can bear (Woods-Giscombe, 2010). But

Beauboeuf-LaFontant (2009) and Woods-Giscombe (2010) have persuasively argued against the stereotype as placing considerable or unbearable stress on black women rather than delighting or affirming their well-being. It is a ruthless expansion of John Henryism.

A third compelling contributing factor is the mother-son relationship among them. Scholars (Bush, 2004; Mandara et al., 2006, 2010; McLoyd, 1990; Randolph, 1995) observe and studies show that African-American mothers have different parenting approaches for sons and daughters. They love their sons but they raise their daughters (Randolph, 1995, p. 121; Lawson Bush, 2004; Mandara et al., 2006, 2010; McLoyd, 1990; Randolph, 1995). Mothers are generally more protective of their sons, specifically against a racist society (Bush, 2004). They are wary that their sons would not be capable of dealing with the pain of racism. They also perceive their men in general as enduring adversity while maintaining inherent dignity, strength and pride (Bush, 2004, p 382). African-American mothers ascribe these qualities and importance as part of John Henryism to both their sons and daughters. But Bush (2004) surmises that these mothers might feel more guilt if their sons failed the ideal than if their daughters did. Another explanation is that mothers raised and expected their daughters to be more independent and assertive, particularly in educational and career decisions and achievement (Bush, 2004; Wood, Kurtz-Costes, Okeke-Adeyanju, & Rowley, 2009). In contrast and in their over-protectiveness, mothers tend to make major life decisions for their sons more than their daughters (Gantt & Greif, 2009; Mandara et al., 2006, 2010; McLoyd, 1990; Wood et al., 2009). This overall valuing explains the extraordinarily painful impact of a son's suicide to African-American mothers. Their grief is thus uniquely different over the suicide of a son. As such, they require a highly specific cultural counseling approach, which must be handled only by culturally competent clinicians (Hunn & Craig, 2009; Neighbors, et al., 2007; Woods-Giscombe, 2010). This study recommends techniques, which ca prove valuable in structuring specifics programs adapted to this population and for the precise training of select mental health professionals.

The Need for the Study

Introduction of the Problem

The high and still increasing rates of suicide among young African-American males are now official record (CC, 2011). There is now some awareness of what factors lead to the phenomenon but not the consequences of suicide unique to this particular population. These consequences are the grief process and coping styles such as John Henryism that can ameliorate or exacerbate grief in African-American mothers who have lost a son to suicide. Grief is a very private event to them and inheres in them in a unique way (Kaslow, Ivey, Barry-Mitchell, & Franklin, 2009). That privacy is quite likely due the stigma attached to mental illness and suicide and the resultant lack of support for this particular population (Barnes, 2006; Crosby & Molock, 2006; Day-Vines, 2007; Perry, Pullen, & Oser, 2012). The purpose of this study is hence to examine how the factors of perceived stigma due to suicide and attitudes toward suicide directly influence African-American mothers' severity of grief, and if and how John Henryism plays a role in these processes.

The Gap in Research and the Need to Fill it

There is a dearth of literature on such mothers and their unique experience of sorrow. Demographics on this population on this specific phenomenon is non-existent. It is now widely knows that approximately 1,800 African-American males committed suicide in 2012 alone (American Association of Suicidology, 2012), no demographic data on the make-up of the mothers of these individuals are known or can be found. Existing research tends to fall into two categories: (a) parents' psychological response and grief due to the suicide of a child (e.g., Harper, O'Connor, Dickson, & O'Carroll, 2010; Maple, Edwards, Minichiello, & Plummer, 2013; Omerov, Steinbeck, Nyberg, Runeson, & Nyberg, 2013), and (b) children's psychological response and grief due to the suicide of a parent (e.g., Kuramoto et al., 2010; Wood, Byram, Gosling, & Stokes, 2012). And this existing literature primarily or almost exclusively -- focuses on White families.

The overwhelming impact of a male son's suicide on an African-American mothers and the severity of their grief over it have thus not been subjected to rigorous scholarly inquiry despite the already known dramatic and alarming rise in African-American suicide rates (CDC, 2011; Barnes, 2006; Day-Vines, 2007; Utsey, Hook & Stanard, 2007). These studies also do not report or assess the demographics. Studies conducted by Joe and Niedermeier (2008) provide additional support to the lack of study on this population in the subject of suicide. The authors themselves affirmed and recommended the need for further and deeper research on it.

II. Methodology

Purpose of the Study -- this is to determine which variables best explain African-American mother's grief, controlling for maternal socioeconomic status, age, relationship status, depression, and history of suicide in the family. Additionally, the study will seek to assess how the factors of perceived stigma of suicide and the attitudes toward suicide impact African-American mothers' grief. It shall also evaluate whether the coping style, John Henryism, increases such factors.

The research problem asks how does perceived stigma caused by stigma and the attitudes toward suicide affect African-American mothers' grief.

Research Design

This quantitative study uses a cross-sectional correlational research design. The sample was selected from current census data, death certificates and professional, educational and religious factors in the selected cities. The data were gathered from surveys and then numerically coded for statistical analyses (Creswell, 2012).

Answers to the four research questions were reached through the use of hierarchical multiple linear regression and hierarchical multiple linear regression for moderation (Baron & Kenny, 1986). A hierarchical multiple linear regression (HMLR) was selected because of the demographic covariates entered at the first step (or model) of the HMLR, with the study variables on the second and third steps and resulting in models two and three; and (b). HMLR is the type of regression analyses required for moderation, which was used in this study (Baron & Kenny, 1986).

Upon completion of data analysis and encoding of the findings, all materials collected during the entire research process were securely kept and stored for 5 to 7 years. After 5 years, these data, notes and other associated materials will be destroyed.

Population, Sample, Sampling Procedure and Instruments

Participants are mothers who have lost a son to suicide when he was aged 15-24. In selecting the participants, the five predictors and the five covariates were considered. The five predictors were the participants' perceived stigma of suicide, their beliefs about suicide, John Henryism, interaction terms of perceived stigma of suicide and John Henryism and beliefs about suicide and John Henryism). The five covariates are a mother's socioeconomic status, age, relationship status, depression, and history of suicide in family. I applied the formula recommended by Faul et al. (2007) and Judd and Kenny (2010), which uses multiple regression method in computing for the sample size of 92 volunteers.

This study also adopted the biopsychosocial contextual model of stress by Clark et al. (1999). It asserts that most individuals, no matter how strong, can be stressed to a breaking point that translates into a health problem. Beyond this point, they cease to function optimally. Values and beliefs dictate how a person shall decide what should stress them and define the meaning of these stressors in their lives (Boss, 2002). That meaning derived from the event is often dependent on their gender, age, race, ethnicity, as well as class (Boss, 2002). The stigma attached to suicide and depression can thus prevent these targeted women from actually seeking the mental health services that they need in order to hurdle through the experience (Kneeland, 2006).

Data Collection

Cities with urban populations, such as Raleigh or Durham, Greensboro and Charlotte in North Carolina; Atlanta in Georgia; Richmond and Hampton Roads in Virginia were selected as areas with high concentrations of African-American families. Census data were obtained from these cities through a targeted mailing list. Death certificates of African-American men who died by suicide were reviewed. Healthcare, social work, and community organizations, churches and other support groups linked to the care and/or treatment of African-American mothers who lost sons to suicide were contacted through email, phone calls and/or personal visits. Large AA churches and mental health professional groups, which specialize in grief, trauma or suicide, in these cities were also contacted. Local support groups of survivors were also contacted. The returned survey responses were coded two months after. The findings were analyzed and thank-you letters were sent to all participants.

Expected Findings

In answer to Research Question 1, the perceived stigma due to suicide, as measured, significantly predicts the severity of grief in African-American mothers who have lost a son to suicide, after controlling for maternal socioeconomic status, age, relationship status, depression, and history of suicide in the family. Increased feelings of perceived stigma will significantly and positively predict increased severity of grief, after controlling for maternal socioeconomic status, age, relationship status, depression, and history of suicide in the family. This finding is guided by Clark et al.'s (1999) biopsychosocial contextual model of stress, which is consistent with prior research (Barnes, 2006; Crosby & Molock, 2006; Day-Vines, 2007; Perry et al., 2012).

In answer to Research Question 2, the coping style of John Henryism increases the perceived stigma due to suicide and the severity of grief in African-American mothers who have lost a son to suicide. Under the condition of increased John Henryism, there will be an increase in perceived stigma due to suicide, which in turn will predict a corresponding increased severity of grief, after controlling for maternal socioeconomic status, age, relationship status, depression, and history of suicide in the family. This conclusion is again guided by Clark et al.'s (1999) biopsychosocial contextual model of stress. Although no studies to-date have examined the connection between perceived stigma due to suicide, John Henryism, and severity of grief in African-American mothers, John Henryism has been shown to exacerbate stress-related symptoms of grief in African-Americans, both male and female (James, 1994; Neighbors et al., 2007; Rosenfield & Mouzon, 2013; Subramanyam et al., 2013; Wang et al., 2005).

In answer to Research Question 3, the belief that suicide is due to societal causes significantly predicts the severity of grief in African-American mothers who have lost a son to suicide, after controlling for maternal socioeconomic status, age, relationship status, depression, and history of suicide in the family. This conclusion is guided by Clark et al.'s (1999) biopsychosocial contextual model of stress. Although no studies to date have examined this relationship with African-American mothers who have lost a son to suicide, existing research establishes the association between the belief that suicide is due to societal causes and grief (Chatard & Selimbegovi?, 2011; Fiegelman et al., 2011; Wagner, Keller, Knaevelsrud, & Maercker, 2012).

In answer to Research Question 4, the coping style of John Henryism increases the belief that suicide is due to societal causes and severity of grief in African-American mothers who have lost a son to suicide. It was found that under the condition of increased John Henryism, there tends to be increases in the belief that suicide is due to societal causes, which in turn will predict increased severity of grief, after controlling for maternal socioeconomic status, age, relationship status, depression, and history of suicide in the family. And again, this conclusion is guided by Clark et al.'s (1999) biopsychosocial contextual model of stress. And although no studies to-date have examined the connection between belief that suicide is due to societal causes, John Henryism, and severity of grief in African-American mothers, John Henryism has been shown to exacerbate stress-related symptoms, including symptoms in reaction to racism, in African-Americans, both male and female (James, 1994; Neighbors et al., 2007; Rosenfield & Mouzon, 2013; Subramanyam et al., 2013; Wang et al., 2005).

III. Advancing the Scientific Knowledge Base

Advancing Scientific Knowledge

Despite the fact that African-American mothers commit suicide after the suicide of their sons more often than do mothers from other ethnic groups with the same experience (Barnes, 2006; Taylor, 2010; Walker, et al., 2009), suicide grief in African-American mothers have been the subject of minimal research and clinical attention (CDC, 2011; Barnes, 2006; Day-Vines, 2007). Moreover, few studies exist that examine maternal perceptions to a son's suicide through the cultural lens (Day-Vines, 2007). African-American mothers' grief resulting from their son's suicide may be impacted by societal and intrapersonal factors specific to their particular community (Barnes, 2006; Clark et al., 1999).

The biopsychosocial contextual model (Clark et al., 1999) positsthat stress is influenced by culturally-based attitudes, which in this study, are perceived stigma and belief that suicide is due to societal causes. These causes, in turn, influence and are correspondingly influenced by culturally-based coping mechanisms. One such coping mechanism discussed in this study is John Henryism (James, 1983, 1994). John Henyrism is a "prolonged, high-effort" coping mechanism, involving persistence and steadfastness in the face of psychological stressors (James, 1983, p. 259).

The body of literature on suicide grief and psychological outcomes due to family member suicide is quite robust. Such literature generally falls below two categories: (a) parents' psychological response and grief due to the suicide of a child (e.g., Harper, O'Connor, Dickson, & O'Carroll, 2010; Maple, Edwards, Minichiello, & Plummer, 2013; Omerov, Steinbeck, Nyberg, Runeson, & Nyberg, 2013), and (b) children's psychological response and grief due to the suicide of a parent (e.g., Kuramoto et al., 2010; Wood, Byram, Gosling, & Stokes, 2012). Unfortunately, this body of research has primarily -- almost exclusively -- focused on White families.

There have been only a few studies that have examined suicide bereavement among African-American parents in response to their child's suicide. Barnes (2006) reported that mothers in the study did not receive much help from the broader community because of the stigma attached to suicide. They also lamented that church was unable to extend much help, and whatever help it extended did not ameliorate the grief of the family.. Finally, the mothers said that they had to experience the grieving process alone (Barnes, 2006). It may be safe to state that grieving African-American mothers of suicide victims are a unique category unto themselves who require culturally congruent counseling approaches and tools by culturally competent clinicians. This study also endeavors to provide techniques that can help structure programs that will benefit this specific target population as well as assist mental health professionals understand how to deal with this diverse population.

Theoretical Implications

African-American mothers' grief due to their son's suicide may be impacted by societal and intrapersonal factors uniquely specific to their community (Barnes, 2006; Clark et al., 1999). The biopsychosocial contextual model (Clark et al., 1999) provides an excellent framework for the study. This theory posits that stress is influenced by culturally-based attitudes, which in this study, are perceived stigma and belief that suicide is due to societal causes. These causes influence and, are in turn, influenced by culturally-based coping mechanisms. One such coping mechanism as used in this study is John Henryism (James, 1983, 1994). John Henyrism is a "prolonged, high-effort" coping mechanism involving persistence and steadfastness in the face of psychological stressors (James, 1983, p. 259).

This study has offers much value to many fields that have to do with helping and coping, particularly counseling, counselor education and supervision. It most certainly deserved to be more closely explored and elucidated on. Those pursuing counseling education can benefit from the grief and bereavement therapy training it provides through the culturally-based issues affecting African-American women in particular and the African-American community in general. The results of this study are likely to influence culturally-based factors, such as cultural sensitivity or cultural congruence issues in therapy, one's cultural "world view" and its impact on the consequences of bereavement, grief, coping and hope. Its results may also provide valuable information for pastoral counseling. This is because the African-American community is a religious community. As such, its members seek support from their minister at their time of grief and bereavement (Laurie & Neimeyer, 2008; Sharpe et al., 2012). But the stigma that goes with suicide may also influence the very response of the clergy and that of the community itself towards bereaved and grieving mothers (Sharpe et al., 2012). This study offers information, which may increase awareness on the uniqueness of these mothers' grieving process and what factors induce it. As a consequence, the religious community and other communities may extend the support needed by the affected mothers.

Findings of this study will also be an effective guide for future research. It examines the grief process in mothers who have lost a son to suicide, which is a unique situation in itself. One direction for future research is the grief process of the father, siblings, and other close relatives. Future research may also focus on family response to the suicide of a daughter, considering that suicides among daughters are comparative low. Still another area of profitable research is John Henryism and its effectiveness in dealing with stressors. Other coping styles may be explored, such as spiritual and religious modes and how they influence or interact with John Henryism in the area of suicide bereavement and grief. Finally, Finally, the development and evaluation of counseling interventions specific to African-Americans and suicide itself will certainly be a useful contribution to the body of existing literature.

Theoretical Foundations

African-American mothers' grief over their son's suicide appears to be impacted by societal and intrapersonal factors specific to the African-American community (Barnes, 2006; Clark et al., 1999). The biopsychosocial contextual model (Clark et al., 1999), as this study's selected framework, proposes that stress is influenced by culturally-based attitudes. These attitudes are perceived stigma and belief that suicide is due to societal causes. These causes both influence and are influenced by culturally-based coping mechanisms. One mechanism discussed by this study is John Henryism (James, 1983, 1994). John Henyrism is a "prolonged, high-effort" coping mechanism at persistence and steadfastness in the face of psychological stressors (James, 1983, p. 259). According to this model, psychological and social elements affect human functions and disease processes (Burg & Upchurch, 2007). In this condition, all the elements affect the individual holistically. The model stresses that when a particular aspect of a person's life is impacted, all others are affected. African-American mothers' grief over their son's suicide appears to be impacted by societal and intrapersonal factors in a specific way to the African-American community (Barnes, 2006; Laurie & Niemeyer, 2008; Woods et al., 2013). One factor is stigma, "a significant barrier to help seeking in troubled African-American people" (Walker, Lester, & Joe, 2006, p. 322). Srigma is associated with both mental illness and suicide in African-American communities Another is apparently John Henryism, a cultural-based coping strategy culturally practiced by this population when dealing with chronic stress and the resulting depression and psychological distress (Bronder, Speight, Witherspoon, & Thomas, 2013; Hunn & Craig, 2009). John Henyrism consists of coping cognitions, attitudes, and behaviors that exemplify the cultural belief that through intense hard work, perseverance, and strength of character, African-Americans are able to overcome any obstacle (Hunn & Craig, 2009). While these traits are viewed as admirable anywhere, they are, specifically in a suicide event, not attainable or suitable at the expense of the individual's physical and psychological health (Hunn & Craig, 2009). Neighbors, Njai and Jackson (2007) suggested that John Henryism may provide important cultural insight into how African-Americans perceive and manage various types of stressors.

Contributions to Research Theory

According to the Clark, et.al. (1999) biopsychosocial contextual model of stress leading to suicide as a stressor, an average individual, no matter how strong, can be pushed to an extreme and reach a health crisis. When he does, he fails to function optimally. Various values and beliefs influence a person's perception of stress and how they form or accept the meaning of an experience in their lives (Boss, 2002). The meaning that individuals derive on the event is usually based on or conditioned by their gender, age, race, ethnicity, as well as class (Boss, 2002).

Utsey et al. (2007) contributed some history behind African-American suicides. Incidents require the acknowledgment of the U.S. Surgeon General as a growing crisis. Yet it is an understudied phenomenon in this population. A journal article carries an overview of suicide among African-Americans and discusses the culture and worldwide view of African-Americans. Barnes (2006) research found that parents of suicide individuals felt that they did not receive appropriate or adequate help from religious communities at their time of bereavement and that mothers often had to undergo the grieving process alone. These findings are useful for mental health professionals to extend and direct help to bereaved families. Walker et al. (2009) also found that European-Americans were very less likely to bring God into the suicide phenomenon. Instead, they are likely to attribute the entire burden on the government and their interpersonal relations. The article connects the quality of interpersonal relations to the risk of suicide among young males and females (Andrews, 2006; Compton, Thompson, Kaslow, 2005; Grant & Grief, 2009; Prabhu, Molinari, Bowers & Lomax, 2010). In contrast, black men and women were more likely to attribute a person's death or self-destruction to God ordaining. They believe that a person who commits suicide is driven by God's plan for that person (Walker, et al., 2009). This is a clear and important difference in attitude between the blacks and European-Americans. Moreover, Gibson, Gallagher & Jenkins (2010), delves into the impact that suicide has on the parent / caregiver's ability to return to work and his or her quality of life following such a tragic event. Researchers interviewed bereaved working parents and thematically analyzed these responses. The three major areas of experience related by parents were social and emotional aspects of readjusting to the workplace; followed by changes in cognitive, emotional, and physical functioning; and their changed attitudes toward work and life. Limitations of the study include the transferability of findings to other populations and to less close-knit cultures.

African-American mothers often go through various levels and incidents of stress before, during, and even after their sons' suicide. Furthermore, as seen in Black feminist theoretical work by Simms-Brown (1982), Beauboeuf-LaFontant (2009), and Woods-Giscombe (2010), the black female has been recklessly, and maybe unfairly, catapulted into a permanently iconic role as "The Strong Black Woman (SBW)" or "Superwoman" (Woods-Giscombe, 2010, p. 2). The "SBW" is a culturally persistent and quite acceptable stereotype that black women are stronger and more enduring than a normal human being (Woods-Giscombe, 2010). Beauboeuf-LaFontant (2009) and Woods-Giscombe (2010) have persuasively objected to this concept. They argued that this stereotype can place considerable stress on black women, to the point of compromising their health and well-being. Woods-Giscombe (2010) commented that assuming a Superwoman's role has a price and can take a toll on them (p. 3). The same may be said about John Henryism. Extreme and unbearable stress can push the mothers to suicide as well (Boss, 2002). Mind and body are connected, and psychological stress can cause more than just physical disease. This process can then create consequences in the family system itself. While some are stronger and more resilient, the rest may not be (Boss, 2002).

It is, nonetheless, comforting that those mothers who receive culturally supported interventions have been less likely to yield to depression, according to Sharpe, Joe and Taylor (2012). The researchers emphasized the importance of such therapy in adjusting or correcting the mothers' coping mechanisms. It cannot be over-emphasized that grieving African-American mothers of suicide victims are a class on their own who require a specific counseling approach and tools unique to them. Lastly, the study may help evolve appropriate and effective techniques in structuring beneficial for the use of mental health professionals in their general dealings with this specific population.

Literature Review

Worldwide Prevalence, Incidence - Recent global statistics ascribes 800,000 yearly deaths to suicide or 1.4% (WHO, 2014). Records on attempters and millions of bereaved and others affected each year have yet to be updated. It occurs at any age in one's lifetime. In 2012, it was considered the second leading cause of death in the 15-29-year-old group. Suicide is a worldwide phenomenon, 75% of which occurred among low and middle-income countries in 2012 (WHO). Records also show that suicide rates are generally higher in industrialized countries than in non-industrialized countries (Reiss & Dombeck, 2007).

Third Biggest Killer in America. - Demographic Factors - Next to homicide and accidents, suicide is the cause of death of approximately 11 out of 100,000 persons in the United States (Reiss & Dombeck, 2007). Incidence is highest in the 15-19-year-old group, comparable to that of the WHO ranking. Risks have been associated with certain demographic factors, which tend to influence successful suicides. The 15-19-year-old age group is one demographic factor. Those in this age group also tend to use or abuse alcohol and restricted or prohibited drugs, use firearms and develop mental disorders, such as depression or schizophrenia. In addition, they tend to have greater fights with the law than those in older age groups. But these are not all (Reiss & Dombeck).

Traditionally, older Caucasian males account for the highest rate of suicide than older women and those of other age groups (Reiss & Dombeck, 2007). They use fatal means or methods, like firearms, in destroying themselves. They make fewer attempts and plan the act out more than any other age group. They also give subtle indications of their plan, such as completing or adjusting their wills or making remarks like there is nothing left for them to live for. They do not usually tell what they intend to do. Risk factors are serious, terminal or incurable illness; widowhood, a deep sense of failure and social isolation. More recently, suicide rates have been rising among young African-American young males (Reiss & Dombeck). This increase in rate among African-Americans has been noticeable in the last three decades yet not too well understood by them or those outside their community (Day-Vines 2007).

Suicide prevalence is higher in men than in women (Reiss & Dombeck, 2007). Men are less inclined to express or share depressed feelings and thus less likely to seek help for these feelings than women. They are also more driven to use alcohol and substance in dealing with depression, failure and loneliness. Aside from firearms, men use carbon monoxide, something for hanging or jumping from a high place. Women who commit suicide take an overdose of medicine or cut their wrists (Reiss & Dombeck).

Another risk is remaining unmarried or getting widowed (Reiss & Dombeck, 2007). Rates are lower among married persons. Suicide is also more common among divorced and widowed men than women. Parenthood decreases the risk of suicide. Those residing in the Rocky Mountains and in Western States have high suicide rates, which occur in spring. Isolation seems to be behind the phenomenon. Suicide rates are also higher in rural areas than in urban areas (Reiss & Dombeck). Studies are inconclusive about occupation and religiosity as risk factors. Recent investigations, however, indicate that suicide rates are higher in those without religious affiliations than those with some religious involvement. Findings attribute this to some form of social support system, increased capacity for coping directly with stresses, a level of hope, a strong reason for living and an awareness of the wrongness of self-destruction itself. Regular churchgoers and others with religious commitments are also less likely to indulge in alcohol, substance abuse or dissolve their marriage in divorce (Reiss & Dombeck).

Poverty and joblessness were also found to be significant risks to suicide (Reiss & Dombeck). It was theorized that poverty leads to depression, despair or shame and findings of studies support the assumption. The same findings support the other extreme in that suicide rates are high among the wealthy. And unemployment is logically associated with depression due to financial stress and distress. Many jobless people also resort to vice, such as alcohol and substance abuse, and experience marital disruption and divorce. These consequences are suicide risk factors (Reiss & Dombeck; Gibson, 2010).

Guns and Suicides, More Suicides than Homicides -- News21 analysis of 2012

firearm use revealed that at least 50 killed themselves with firearms as against 26 against others (Forman & Byk, 2014). Data listed 18,602 firearm suicides in 44 states and 9,655 firearm homicides in 49 states. Matthew Miller, an expert on suicide studies at the Harvard Injury Control Research Center, commented that suicide rates have always been higher than either homicide or murder. His statement and results of recent studies contravene the popular assumption that people tend to get killed by others than by their own hands. This is the consequence of the avoidance of the stigma of suicide and those who end their own lives. Most read about it or see it on television or the movies but do not have access to hard and concrete reality from objective research and reports (Forman & Byk).

Means Matter, a Harvard research group, concluded that unbearable depression or inner despair is the most common driving force of suicide (Forman & Byk, 2014). The group examined the means by which suicides are undertaken. It also found that those who resort to suicide devise several plans to carry it out or conduct attempts. Experts, however, contravene the conclusion. They instead observed a rise in the trend of impulsive suicide incidents as reflected by findings that 47% attempted to kill themselves within 10 minutes after deciding on it. Those with access to fatal weapons are largely successful. That suicide rates are higher among gun owners than non-owners support this finding. Whatever the means used, suicide is considered by experts a serious mental health issue that deserves greater awareness and treatment. While they recognized the difficulty or impossibility of preventing something that has not happened, prevention specialists have begun working at limiting gun stores and firing ranges. Nevada had the highest suicide rates in 1999, a trend, which likely led to the establishment of the Nevada Office of Suicide Prevention. This Office distributed pamphlets and posters on gun safety to gun stores, ranges and training centers. Their employees are trained to detect suicidal inclination in their customers. Classes and seminars have been held to encourage potential suicidal persons to express their feelings. Experts and other concerned sectors agree that suicide is preventable only to a certain extent. Some of those who will take their own lives will do so without warning and by any available means. Many of them are half-hearted about the act. While they are not sure if they want to go on living, they are neither too sure they want to die (Forman & Byk). This ambivalence is an encouragement to those behind all preventive measures.

Suicide and Black Americans - It is a common observation that African-Americans in general exhibit risky behavior, such as depression, which may prompt suicide (Young, 2014; Neighbors et al., 2007). Racial oppression and racism to which they are subjected exacerbate the risk. Yet the situation is either under-diagnosed or mis-diagnosed in their own community, according to Donald Grant a socio-cultural analyst. Grant elucidated that, despite the very high risk level among them, their suicide rates are comparably lower at 5.3% than those of Whites at 14.5%. The only significantly alarming element is the stigma of mental illness from which they suffer and which prevents them from seeking assistance. This stigma makes outsiders view Black people as "crazy," according to clinical psychologist Kevin Chapman of the OCD Institute of Louisville (Young, Neighbors et al.).

The Mental Health Picture - The 2013 U.S. Census Bureau reports that 42 million Americans, or 13.2% of the U.S. population, declare themselves as African-American (MHA, 2013). In 2010, 57% of them lived in the south and fewer spread out in the Midwest, the Northeast and in the West. They have been historically subjected to hardship and deprivation of rights. These adversities included slavery, sharecropping and denial of resources in health, education, social and economic rights and privileges. Their low socioeconomic status has been associated with poor mental health. The common view is that those who are poor, homeless, imprisoned or indulge in substance abuse are also mentally unhealthy. Their mental health remains neglected despite the election of the first African-American president. Racial stereotypes and rejection have decreased but persist along with their sore and concrete impact. This persistent bias developed mistrust in authorities whom African-Americans perceive as neglecting their best interests (MHA).

Prevalence -- The U.S. HHS Office of Minority Health reported that adult Blacks suffer from serious psychological pain at 20% more than adult Whites (MHA, 2014). Yet Blacks who live in poverty suffer twice or three times more than those living above poverty.. Adult blacks also experience grief, hopelessness and a sense of worthlessness than adult Whites. And while more White teenagers commit suicide than black teenagers, more black teenagers attempt to commit suicide than white counterparts at 8.2 and 6.3%, respectively. Over and above, African-Americans of all ages are more frequent victims of serious violent crimes than non-Hispanics. This raises their risk of developing Post-Traumatic Stress Disorder or PTSD (MHA).

Attitudes -- A recently conducted MHA-commissioned national survey found barriers, which prevent Americans from seeking treatment, such as their attitudes towards depression (MHA, 2014; Hill-Wagner, 2010)). Results of the survey showed that 63% of African-Americans consider depression a personal weakness at 63% and only 31% viewed it as a health problem. This majority also believed that depression was normal to them who are aging at 56%; to their women within two-week from childbirth at 45%; after the death of a spouse at 40% (MHA, Hill-Wagner).

The survey also identified the barriers to seeking treatment for depression as denial at 40%, embarrassment or shame at 38%, refusal at 31%, lack of money or insurance at 29%, fear at 17%, absence of knowledge about the problem or its treatment at 17%, and hopelessness at 12% (MHA, 2014; Cheng, 2014). They are also less likely to take antidepressants for depression unless ordered or prescribed by a physician at 34%. Dr. William Lawson of Howard University commented that many African-Americans harbor negative feelings about mental health provisions. Otherwise, they are not aware of the symptoms of mental disorders, which they commonly regard as a character fault (MHA, Cheng).

Treatment Situation and Issues - According to te 1999 U.S. Surgeon-General's report on mental health, African-American patients seeking assistance are five times more likely to be attended to by fellow African-American physicians than white physicians (MHA, 2014). The patients described their interaction with fellow African-American physicians as participatory. However, they find difficulty in locating African-American mental health practitioners. Public mental health programs and services of hospitals, community health centers, and local health departments are thus quite essential to many of them. Yet few of them receive treatment from private psychiatric hospitals. Publicly-financed residential treatment centers for emotionally troubled young people provide the treatment. Disparity in access is still another issue. The survey revealed that only 8.7% of them as against 16% of adult Whites were provided with treatment for mental health problems in 2007-2008. Only 6.2% of them as against 13.9% of adult whites were given medications for time. And in 2009, only 53.2% of adult blacks received treatment for major depression as against 68.7% of adult Whites. The Affordable Care Act was envisioned to close the gap in the provision of care among racial groups, in 211, 20.8% of blacks had no insurance as against only 11.7% of whites (MHA).

Joe Sean related how he discussed suicide and its stigma with Black American males (Singer, 2010). They talked about faith, the value of a child and the vision of a child as an adult, and healthy masculinity. He also shared with them some resources available for hem from social workers who could help them. He enjoined other social work clinicians and researchers to join him in the task of better understanding suicide and suicidal behavior in African-American males (Singer).

The Old Taboo against Suicide is Gone - In an interview, Dr. Alvin Poussaint of the Judge Baker Children's Center said that suicide was, in fact, taboo in the black community (Childeya, 2008; Wright, 2012). This taboo is now disappearing and no longer being talked about. This change is attributed by Dr. Poussaint to the increase in the types and levels of stress among young men in the community. The surge of single-parent homes at 70%, an overwhelming 50% school dropout rate, and 75% imprisonment rate are severe stressors. Imprisonment or incarceration alone is 9-10 times those of the 1950s. The Surgeon-General's office points to it as a risk factor in suicide. Besides these, violence that not infrequently occurs in the community triggers much stress and depression as well as PTSD. The most probable cause of suicide, Dr. Poussaint points out, is chronic depression or another major mental illness (Childeya, Wright).

Support Groups - Dr. Poussaint emphasized the importance of these groups during those extremely difficult times (Childeya, 2008; Wagner, 2012). One such group is NOPCAS, which was founded by Donna Barnes, who lost a son to suicide in 1990. Educational programs are also conducted to raise the level of awareness of the community to the dangerous symptoms of depression. In the absence of support groups, bereaved families should look for the support they need from those who have survived the loss. They tend to share an experience of deep guilt over it. They blame themselves for not preventing it. Their kind of grief is, therefore, unique and needs the precise emotional support at this particular time (Childeya, Wagner).

Donna Barnes joined the interview and shared valuable insider knowledge about suicide grief in an African-American mother (Childeya, 2008; Mayo Clinic Staff, 2014). Her son did not display detectable symptoms. He appeared happy and outgoing. He always wanted to please those around him. He wanted everyone to feel comfortable with him. He always joked. Mrs. Barnes described her son's behavior as laughing depression. He kept tight within him what really and deeply bothered him. He did not want to show or share it out of shame. If he did, they would not understand, anyway. They would not understand why her son perceived himself as not functioning or fitting. He could not participate in school because he could not get into it. He feared and felt that others would not understand how he was suffering from depression. They simply had no idea (Childeya, Mayo Clinic Staff).

Donna Barnes shared her own despair upon learning that her son committed suicide (Childeya, 2008; Lim-Gust, 2014). She was a total confusion and wreck. She had nowhere and no one to turn to. She did not know anyone who went through and survived the same tragedy. Those she asked said they did not know anyone who did. She had to go out of the community to find the support she desperately needed. And outside the community, she found herself more alone as she was the only black person. But instead of falling apart, she decided to do something about it. She wanted to know and understand more about suicide and why it happens. She found nothing about it in bookstores and the library. Information was nowhere, so she decided to set up her own support group. Things have changed in recent years. Information can now be found in bookstores. She learned that rates have greatly increased. What was more disturbing to her was that the black community was completely unaware of facts about suicide (Childeya, Lim-Gust).

Suicides in Tennessee - Something is quaintly unique about suicide occurrences in this State (TSPN, 2014). Official statistics reported 333 cases among the blacks between 2001 and 2006 or 5.55 for every 100,000 persons. The uniqueness is that these figures are slightly higher than the national average at half the overall national rate of 10.98 per 100,000. In those inclusive years, suicide was the 16th top killer in the Black community of the State and at a very young age group of 10-24. The means most commonly used were firearms at 68%. Rates have more than doubled in the 15-19 age group between 1980 and 1995. They increased three times in the 10-14 age group and exceeded those of whites in the age group. Although these rates have gone down in recent years, 5 deaths by suicide are still recorded today. This figure may be less than the actual, as medical examiners tend to conceal or camouflage the true causes of deaths on account of the stigma associated with suicide. African-American females tend to attempt self-destruction as compared with African-American males. A national survey found that 4% of black teen males and 7% of black females make the attempt at age 17. Ironically, young people from middle-class families are more likely to make the attempt than those from lower-income families (TSPN).

Although African-American teen males display depressed behavior than other racial groups, they do not express the intention to commit suicide or show depression before they actually commit suicide (TSPN, 2014). Moreover, they do not tend to take recourse in drugs. Major risk factors are under-30 age, substance abuse, firearms at home, and a personal history of aggressive threats. Some myths about suicide also thwart efforts at prevention. One is the belief that depression is a personal weakness instead of a medical condition. Another is the sinfulness of suicide. The black community tends to idolize and idealize their male members as too strong to crumble and take their own lives. They also esteem their women as too enduring to collapse under pressure. These beliefs prevent those who are severely depressed to express their feelings and to seek help. Suicide rates among African-American young males may be higher than reported by the Office of the Surgeon General if surveys include psychiatric hospitals, prisons and depressed areas. Lastly, results of a 2007 study, which appeared in the Archives of General Psychiatry, revealed that less than half of African-Americans with major depression receive treatment. That treatment was also of poorer quality than was extended to White Am

Americans (TSPN).

Perceived Racism as Stressor - Crocker (2007; Walker, 2009) discusses perceived racism as strongly influencing a person's well-being in a negative way. He presents racism-connected stress as causal basis for dysfunctional behavior, psychological distress, failure in coping, and psychosomatization. Non-Whites' exposure to racism can arouse, and has aroused, anxiety, paranoia, fury, a sense of helplessness or hopelessness, resentment and fear (Clark et al., 1999, as qtd in Crocker, 2007). These responses adversely influence a non-White's functioning in school, work, and social interaction. At the same time, they raise the level of violent outbursts and suicidal contemplation. Such perception can create adverse impact on the mind, behavior and overall psychological well-being of non-Whites, particularly African-Americans. They learn to adjust to the psychological distress by evolving coping strategies, which, ironically, do not shield or eliminate the problem. Instead, they enhance the distress. Examples of coping strategies are increased hostility and aggression, verbal aggression, substance abuse, tobacco addiction and poor dietary habits. They resort to these coping strategies precisely to reduce or mollify the psychological distress. But the strategies do not and cannot work because they do not address the true cause underneath. That true cause, racism, instead induces the stigmatization of the person who already suffers from psychological distress on its account. Substance abuse and poor eating habits also assert adverse physical impact on the sufferer. The sustained experience can encourage psychosomatization and serious physical illnesses. These include hypertension, cardiovascular conditions, and neuroendocrine response to severe and sustained psychological distress. Specifically in African-Americans, racism-related stress can adversely and severely affect resting blood pressure and compromise the immune system. The natural healing process slows down because of extreme and persisting stress. Their overall health is at a disadvantage as they continue to function in a society where stress is a regular fare (Clark et al., 1999 as qtd in Crocker, Walker).

The psychological distress that non-Whites, especially African-Americans, must confront day after day can be wearisome and weakening (Crocker, 2007). Substance abuse and poor eating habits negate one's physical and social well-being without eliminating the problem behind the coping. And prolonged psychological stress from perceived racism can lead to psychosomatization in the form of higher blood pressure, hypertension, compromised immunity, and slower healing (Crocker).

Stigmatization and Bereavement - The authors (Feigelman et al., 2009; Sharpe et al., 2012) investigated and compared the respective stigmatization responses of parents who lost children in different ways. Of the total sample population 463 lost their children to suicide, 54 were death survivors of other unnatural causes, and 24 to natural death. Those who registered harmful responses and experienced strained relationship with family, relatives and un-related persons said they suffered extensive guilt. Whether the loss or death of their children was traumatic or not, stigmatization remains linked to deep and protracted grief, depression and thoughts of suicide. Survivors of suicide attempts expressed slight deviation from survivors of other forms of traumatic loss. The two sample populations expressed comparable responses (Feigelman et al., Sharpe et al.).

Stigma of Mental Illness and Suicide Compared - Sudak and his research team (2013) used collected data from the experiences of survivors and relevant literature on the history and effects of suicide stigmatization to share with mental health practitioners and trainees in order to reduce the impact of the stigma. The output was aimed at a full range of populations, such as attempters, their families and those of completers, their friends, all therapists and others concerned as motivated by therapy or personal reasons. The team found that stigmatization of mental illness has somewhat diminished in the last decades. This, however, is not the case with the stigma attached to suicide, successful or failed (Sudak et al.).

Deep Roots of the Stigma - Calixte (2014; Peck, 2012) attributes the lack of forthright recognition and treatment of mental health issues to the deeply entrenched stigma associated with mental illness, especially in the black community. The community strongly believes that they, African-Americans, are a strong race capable of enduring and overcoming all adversities. This concept comes from their evident survival from slavery. It convinces them of their immunity from mental illness. They hold on or stand behind the active conviction of the "strong black man" and "strong black woman" as their image. This image is in each of them and makes them strong and capable enough to care for their family at the expense of his personal needs. The concept leads and empowers them to appear that nothing hurts them. But without family or community support, there is no way one who is severely suffering from the effects of the stigma can heal. Admitting and seeking treatment for mental illness would equate with vulnerability, the opposite of the "strong black man." Nobody wants to earn the stigma of mental illness or being described as weak or crazy (Calixte, Peck).

Whites are comfortable with talking about seeing a therapist for mental problems (Calixte, 2014; Joe et al., 2009). It is the opposite with the blacks who relish an image of mental and emotional strength. They consider only prayer the counseling and medication they need to surmount the tests they may be undergoing at the moment. The American Association of Suicidology or AAS reported that young African-Americans, especially male, are told to pray about their mental trouble or be man enough to stand on it. Looking for treatment and a support group is not an option. What makes the situation worse is that those who are afflicted with mental illness, predominantly depression, believe or feel that they are capable of handling it themselves. Moreover, they also believe that sharing their emotional problems with others with outsiders is taboo. These attitudes prevent those in trouble to seek the treatment (Calixte, Joe et al.).

Blacks are also subjected to extra stresses from the outside world, which render them more vulnerable to mental illness (Calixte, 2014). These include racism, poverty and ethnic prejudice more than other minorities. Even those who are aware of their mental problem and its risks do not have the capabilities and resources to cope as compared with Whites. The overall consequence equates to much lower levels of satisfaction with life, personal happiness, self-image and overwhelming psychological distress. And because the situation is not addressed, it leads to deterioration of overall health (Calixte).

Those who have the courage to consult with a therapist confide that they do so only secretly (Calixte, 2014). Shame prevents them from letting any member of their family to know. This prevailing shame compels them to endure their condition in silence. Shame is invincible because of the fear of getting disconnected from the rest. Hence, it was not only shameful but also frightening to be known as a mental health patient (Calixte).

The stigma can be confronted headlong only through education (Calixte, 2014). Those afflicted by mental illness not only need treatment but also a support group to see them through recovery. This group should be composed of treated survivors who can share their experiences and coping skills with the new patient. The support group will encourage and enable the patient to express himself and talk about his mental problem. A likely consequence of this disclosure is their willingness to seek help (Calixte).

Recent mental health statistics likewise show that African-Americans who suffer from mental illness do not receive adequate treatment (Calixte, 2014). Untreated mental illnesses can progress into worse conditions, such as psychosis, depression, bipolar disorder, and a worse kind of anxiety disorder. Therapists and support groups should have the capability and willingness to listen to patients. They will be very helpful to him in changing his deeply-rooted values, inclinations and habits. They should train him to disregard stereotype beliefs of risky behavior, worthlessness and weakness. They should promote public education through family target groups and a network community and by advocating group society consciousness (Calixte).

Un-addressed Factors - At least five factors, which drive Blacks to suicide, remain chronic and un-addressed (Monroe, 2014). These are untreated mental illness, homophobic bullying, religion, "cop-assisted" suicide, and the so-called strong-black-woman syndrome (Monroe).

Untreated Mental Illness - Not only the stigma itself but also the barriers to treatment are responsible for suicide (Monroe, 2014). Disparities and the lack of mental health practitioners account for the situation. These practitioners are therapists, counselors, psychologists, and psychiatrists. The 2010 AAS report revealed that only 4% of the country's psychiatrists, 3% of psychologists, and 7% of social workers are African-American (Monroe).

Homophobic Bullying - The most frequent targets of this activity are young gay African-Americans, who may eventually self-destruct by suicide or gang violence (Monroe, 2014). One such youth killed himself by hanging after suffering unbearable homophobic bullying by classmates. He was ironically never known to be gay. Massachusetts Governor Deval Patrick signed a landmark anti-bullying legislation in 2010 to signal a stronger commitment against bullying in schools. Supporters and defenders of the gays and lesbian movement participated in the drafting and legislative process from start to finish (Monroe).

Religion - A survey conducted by the Washington Post-Kaiser Family Foundation found that 74% of African-American women professed to live a religious life (Monroe, 2014). It is ironic that religious commitment itself may contribute to cult suicide, as in the case of the Peoples Temple Agricultural Project in November 1978 in Jamestown. The project induced the mass suicide of more than 900 members. Approximately 75% of the members were African-American who were the very backbone of the organization. The members are deeply committed to the philosophy, mission and culture of the church. Yet suicide is something not discussed or even thought about in the black community. These will explain how limited the knowledge exists on how religion actually harms not only the gay community but also female relatives (Monroe).

"Cop-assisted Suicide - This is a situation wherein a young African-American male performs an unlawful act, which impels a police officer to shoot and kill the youth (Monroe, 2014). The victim is typically subjected to intolerable and persistent social stressors, which lead him to choose self-destruction. These stressors are police profiling, visual suggestions of cops shooting defenseless young black males, high unemployment, imprisonment, and dropout rates, domestic and community violence. Dr. Poussaint described the situation as victim-precipitated suicide in a radio interview. It may also be called victim-precipitated homicide, often committed by cops (Monroe).

":Strong Black Woman Syndrome" - The July2010 study called "Black Lesbian Matter" investigated the distinct experiences, beliefs and priorities of this sector yet the findings are hardly known (Monroe, 2014). The study revealed that gay African women are the most vulnerable in society and most in need of advocacy in financial independence, health care, education and marital equality. The study was conducted on 1,596 gay women from different regional, states and local organizations via the internet. The survey touched on health, family and parenting, identity, aging, and invisibility. Results revealed a trend of higher suicide rates among the volunteers. Researchers previously ascribed the trend to the person's inability to deal with their faith. Yet what succeeding occurrence imply is that racism and gender stereotypes are really behind it but hiding it from view (Monroe).

A Reason for Living - A study explored the sample population's self-reported reasons for living and its effect on suicidal ideation (Flowers et al., 2014). The surveyed 150 African-American female suicide attempters said that their respective reasons for living opposed or negated their suicidal intention. The results revealed that their reasons for giving value to life can protect them or prevent them from undertaking suicide. The capacity to see the importance of life more than spirituality and religiosity can be a protective factor to attempters and those experiencing extreme racism-related depression. At the same time, these findings can direct future research into interventions, which will fortify these and other reasons for living. Researchers can conduct randomized controlled trials in assessing the motives behind suicide attempts. Moreover, research should add knowledge to existing literature on suicidal behavior, particularly among black Americans. More studies focusing on this will be most valuable in addressing this chronic public health and mental health burden of both deaths and attempts nationwide and worldwide. They can also improve the capability of health care providers in detecting or predicting suicidal behavior and preventing suicides (Flowers et al.).

Parental Duty or Stressor - Motherhood was one examined protective role against suicide, particularly among low-income African-American attempters (Woods, 2013; Maple, 2013). Earlier findings provide inconsistent evidence in the connection between the value of family and the risk of suicide in this sample population. This study revealed that the sample population identified family and concerns with children as their reason for living. This reason or value, thus, reduced the risk of suicide in this sample group. The study was conducted on 146 African-American female attempters, aged 18-64, who were inpatients at a big city public hospitals at the time of the study. Researchers used the bootstrapping mediation model on motherhood, the Reasons for Living scales, and the Beck Suicidal Ideation Scale in testing responses. The model reflected the statistically significant effect of this reason for living in 41% of the participants. Incorporating this factor in clinical intervention measures for this high-risk group should be seriously considered in improving preventive treatment (Woods; Maple).

The Family as a Precipitating or Deterring Factor - While motherhood can discourage or reduce suicide ideation, family relationships and interactions can lead to it (Prabhu et al., 2010). The authors gathered related and updated data from a wide range of online databases on the role of the family in preventing suicide. Data yielded information on the role of attachment and family system perspective in preventing self-destruction through family support. The data pointed to suicide as an act of despair, wrath or escape from unbearable agony from disrupted family bonds, interpersonal loss or perceived lack of support and supportiveness from one's family. The authors drew new family concepts in suicide prevention from their data. These are family cohesion, family adhesion, and the formation of a new family (Prabhu et al.).

The authors (Prabhu et al., 2010; Walker, 2008) believe that therapists should first consider all available family resource in avoiding untimely closure of unpleasant family events. They should first build on the current perception of support among all family members. The authors also suggest that therapists involve all the members of the family in preventing suicide according to an appropriate conceptual framework. The authors also recommend that therapists first conduct adequate research in determining the validity of their approach in addressing the family situation as a deterrent or precipitating factor to suicide (Prabhu et al., Walker).

Gendered Racism - Applying theories of social inequality, medical sociology, and the process of stress, the authors surveyed a sample population of 204 African-American female volunteers from low socioeconomic levels (Perry et al., 2012). They found that African-American women's risk in contemplating suicide was gender-based in their socioeconomic levels. On the other hand, gendered racism does not induce suicide in women in higher states of well-being, stronger self-esteem and more active or effective coping capabilities. However, it adversely influences those with high or low psychosocial capabilities and resources (Perry et al.).

Moderating Effects of Color - The authors (Perry et al., 2013) utilized the stress process framework in investigating on the moderating effects of ethnicity and color of the skin on suicidal ideation and behavior. They drew data from a sample of 204 African-American women enrolled in the B-WISE project. The results showed that the perception of gendered racism strongly raised their risk for suicidal ideation or behavior. The difference was that it was true only for women with medium or dark skin color. The authors also found that a strong ethnic identity was a protective factor against suicide. It functioned as an effective form of affirmation through psychosocial ways, which interfered with the internalization of belittling stereotypes. The affirmation thus lowered the level of distress resulting from the response to an experience of gendered racism (Perry et al.).

Social, not Financial - Dr. Sean Joe, social work researcher on suicidal behavior among African-Americans, stressed that the risk factors for the phenomenon are social rather than financial or linked to success (Issa, 2010). Higher suicide rates among African-Americans in the Midwest than those in the South provide strong ground to his contention. The rates are also 9 times higher in those born after 1975 than those earlier. Joe explained that the younger generation has a different social experience than its older counterparts. That difference in the type of experience probably accounts for the difference in attitudes between them. The younger generation is more accepting or open about suicide. Today's young African-Americans, unlike older ones, are more inclined to attribute life events to their own actions more than to outside forces beyond their control. While this attitude allows them credit for their own accomplishments, it also assigns them greater responsibility for their failures and negative life events. They feel subjected to a different set of pressures and social stressors, like needing to "act tough and look cool." Their concept of their masculinity both enhances their person and prevents them from seeking help when they need it. The concept makes them feel that seeking help is a sign of weakness. This is not the case with young females who have no problems with seeking help. Young African-American women and girls are also more religious and thus more resilient and accepting of their limits (Issa).

Joe also presented and explained the two traditions of race theory (Issa, 2010). The biologically based theory defines race according to genetic factors. The socially-based theory extends to people's self-view in relation to others, their interaction with them and how they feel for themselves. An understanding of these discoveries is very important in interpreting the rise of suicide rates among young African-American males and the increase in rates in the United States in general (Issa).

Unique Grief - A recent study examined the African-American experience of grief, focusing on identity change, interpersonal aspects of loss, and persisting attachment with a deceased family member (Laurie & Neimeyer, 2008; Crawford, 2010; Jordan, 2012). Results showed a different kind of bereavement experienced more frequently from homicide, sustained and strong bond with the deceased family member and by relatives beyond the immediate family, and an unusual sense of support drawn from them in spite of their lack of tendency to share their grief or secure professional support to contain their grief. They felt higher and deeper levels of grief symptoms than Caucasians experience, especially as a result of their unwillingness to share their grief over the bereavement. The study sample consisted of 940 Caucasians and 641 African-Americans from a large southern university. The participants filled out the Inventory of Complicated Grief-Revised, the Continuing Bonds Scale, and interview questions on circumstances surrounding the death (Laurie & Neimeyer, Crawford, Jordan).

While grief is universal and a necessary experience over the death of someone loved, it normally goes through stages, which eventually end in acceptance in the majority of people (Craig, 2010; Kubler-Ross, 1969 as qtd in Craig). Some studies, however, found that 10-20% of the population goes through prolonged and ineffective pattern of grieving (Shear et al., 2005 as qtd in Craig). This prolonged grief disorder or PGD often starts 6 to 12 months after the death of the deceased. PGD is the inability of the bereaved or survivors to accept the reality of that loss (Maciejewski, Zhang, Block, & Prigerson, 2007 as qtd in Craig). This condition has been reported to afflict approximately 1 million persons (Kissane et al., 2006; Shear et al., 2005 as qtd in Craig). The strong denial aspect of PGD reduces self-worth, makes adaption to life difficult due to the loss, and disables the formation of new relationships (Prigerson et al., 2009 as qtd in Craig). Risk factors of PGD already pre-exist the loss or trauma. These include childhood separation anxiety, insecure attachment condition, parental abuse or death, extreme parental control and frustrated reunion with a loved one (Prigerson et al., 2009 as qtd in Craig). Additional risks to PGD are the bereaved dependence of any kind on the deceased, the deceased closeness to the survivors, and the unexpected or complicated death of the loved one (Prigerson et al., 2009 as qtd in Craig).

Intervention measures, prevention or amelioration of PGD hangs on the identification of risk factors and the specific criteria, and the evaluation of the most vulnerable family member or members for prolonged grief (Craig, 2010). Existing research provides evidence that African-Americans are 2.5 times more likely to develop PGD than the general population at bereavement. This situation appears to be the result of multiple societal stressors Goldsmith, Morrison, Vanderwerker, & Prigerson, 2008 as qtd in Craig). Other individuals at risk for PGD are those with previous bouts of depression, anxiety and bipolar disorder (Redfield Jamison, 2009; Simon, Pollack, Fischmann, Perlman, & Muriel, 2005 as qtd in Craig).

John Henryism - John Henry is a character in American folklore who worked to extreme in order to outdo a steam engine (Duke Medicine, 2014). Experts coined the term "John Henryism" to represent or symbolize the medical reality of African-Americans in the current age (Duke Medicine, 2014). That medical reality consists of extraordinary effort at coping with an extreme or hopeless situation, which leads to adverse physical health conditions. A recent study explored the relationship between this coping mechanism and psychological distress and the effect on the well-being of |African-American women (Bronder et al., 2013). Findings revealed a negative connection between John Henryism and the symptoms of depression in the Black volunteers to the study. These findings refuted those of previous studies and instead suggested that John Henryism inflicts adverse effects on physical health but not mental health (Bronder et al.).

Other recent studies placed a clear genetic connection between John Henryism or JH and African-Americans' personality traits (Duke Medicine, 2014). The effects are both clinically and non-clinically apparent to the professional eye. And these effects are likely to influence African-Americans' emotional reactions and everyday functioning. These four studies evaluated JH and its health consequences among African-American volunteers who participated in a March 3, 2006 symposium conducted by researchers of the American Psychosomatic Society (Duke Medicine).

Psychologists formally acknowledge JH as the strong coping method applied by African-Americans in tackling psychosocial and environmental sources of stress (Duke Medicine, 2014). These include career, health problem and racism. JH is detected most distinctively in African-Americans who are most ambitious, especially in environments or areas, where they have little exposure to or experience in. While exceedingly goal or success-oriented, they also often lack the means to achieve that goal, such as finances and emotional support. Individuals in this situation and with this behavior pattern are most prone to health disorders, which compel them to over-reach their goal at the expense of their health. And, worse, they are often unaware that this is what they do. Dr. Christopher L. Edwards, a lead psychiatrist at the Duke University, commented that JH is a most promising model in explaining the coping behavior and health consequences of present-day African-Americans. He believed that a better understanding of the coping mechanism and how it induces harmful health behaviors will help in developing new methods and modes of reducing health disparities and improving the overall health of African-Americans (Duke Medicine).

Researchers at the Cleveland State University, Harvard and Duke concluded that JH influences individuals' emotional reactions within their environment (Duke Medicine, 2014). Their study surveyed 58 healthy black males, aged 23-47, on various activities, including public speaking on a racial issue, and reading a material and an anger recall assignment. Results showed that respondents with lower educational achievement exhibited more JH traits and were happier than those with higher educational levels and JH traits. Dr. Edwards stated that the use of the JH model increased overall understanding of how African-Americans cope with loss and tragedy as well as the health issues they confront. He concluded that a better understanding of this coping mechanism would assist experts in devising a clearer and better concept of how it contributes to the sample population's health problems. As a consequence, it provides health professionals with the means to reduce the sample population's stress in bereavement and help improve their overall health picture (Duke Medicine).

Postvention Program: HUGSS - The Healing and Understanding Grieving Suicide Survivors or HUGSS is one culturally suitable family intervention program aimed at preventing suicide (Kaslow et al., 2009). Multiple studies used the symbolic interaction approach in evaluating African-American families who participated. This concept guided the conceptualization of this intervention program. It has three themes. One, human behavior has important meaning. Two, every person's unique self develops from social interactions. And three, social processes and the individual's recognition of the connection between him and freedom and constraints to it affect how he interprets his dealing with experiences or events he encounters (Kaslow et al.).

The first theme deals with the meaning of suicide in an African-American family (Kaslow et al., 2009). Historically, it was not considered inherent in the black race. The expected reaction of conflict the sample population to their racial identity can aggravate the grief process. The second and ninth sessions of this program will reject the myths about the occurrence of suicide. Religious conviction, coping, and spirituality are used in the 8th session as major resources. The individual's level of religious commitment and spirituality influence the meaning of suicide to them (Kaslow et al.).

The second theme emphasizes the collective approach among their families (Kaslow et al., 2009). The kinship network consists of extended families and even non-blood-related families. HUGSS therapists work with each member of the extended family network in gaining his or her perspective on his or her idea of family for incorporation into the model (Kaslow et al.).

And the third theme deals with black history (Kaslow et al., 2009). They face the situation of cultural adaptation as Americans and as Blacks in America. One response they developed in the course of historical events consists of cultural mistrust and powerlessness. This leads them to feel skeptical about mental health treatment and health providers. They are unsure about being accepted by them. HUGSS deals with this problem by making both African-American and white therapists. Black therapists can palliate the cultural mistrust and raise the level of intervention effectiveness. Therapists, on the other hand, must be well aware of establishing and maintaining common communication patterns between them. They should use common gestures, dialect, tone and tempo; share non-verbal expressions; respect privacy; communicate indirectly; and speak in general but positively, realistically, assertively and animatedly (Kaslow et al.).