Advancing prevention research on the role of culture in suicide prevention

Despite evidence of considerable racial/ethnic variation in adolescent suicidal behavior in the United States, research on youth of European American descent accounts for much of what is know about preventing adolescent suicide. In response to the need to advance research on the phenomenology and prevention of suicidal behavior among ethnic minority populations, NIMH co-sponsored the "Pragmatic Considerations of Culture in Preventing Suicide" workshop to elicit through interdisciplinary dialogue how culture can be considered in the design, development, and implementation of suicidal behavior prevention programs. In this discussion paper we consider the three ethnic minority suicide prevention efforts described in the articles appearing in this issue, along with workshop participants' comments, and propose six major areas where issues of culture need to be better integrated into suicidal behavior research.     

Substance-abuse prevention: Beyond the schoolyard

Substance-abuse prevention in children and youth has had limited success, possibly because the scope of traditional interventions, usually school based, is too narrow. Children who live in poverty and/or whose homes are dysfunctional need environmental changes beyond what traditional school-based programs can offer. Community psychologists need to expand their work in this area. School-based and community-based interventions are addressed. Ideas for broadening interventions to include elements such as family, media, and community collaboration are evaluated and discussed, along with successful examples of such interventions. Suggestions are made for further innovative work in this area.     

Suicide prevention in the psychiatric hospital

It is currently impossible to distinguish between patients with depression who will make a suicide attempt and those who will not. Prevention, therefore, must be based on the assumption that any patient with more than mild symptoms of depression is at risk of suicide, and can only be effective if it is applicable to all patients with moderate to severe depression. A treatment strategy that differentiated between regressive and progressive therapeutic measures was developed for patients admitted to a psychiatric hospital. Regressive, as opposed to progressive, treatment meant that the patient was temporarily relieved of virtually all responsibilities for self and others. Progressive measures were strictly avoided for all patients with symptoms of depression, regardless of the primary diagnosis. This strategy was tested on 5,149 inpatients and day patients over a period of 6.25 years and compared with 6,891 patients over the 15.75 years prior to this period. The suicide rate was 97 (per 100,000 admissions) compared with 319 in the previous period. The treatment method appears to be able to reduce the suicide rate. Although this result was achieved with hospital patients, it suggests that a regressive treatment method could be promising if developed for outpatient treatment as well.     

Using drugs to modify the effect of response prevention on avoidance extinction

Amobarbital and chlordiazepoxide were administered during avoidance response prevention and the effect evaluated in the nondrugged state in a subsequent test for avoidance extinction. It was found that Ss administered 15 mg/kg and 30 mg/kg amobarbital, and 30 mg/kg chlordiazepoxide during response prevention differed significantly from the control Ss in extinction performance. Rather than showing either reduced avoidance performance or no difference with the nondrugged Ss, the Ss drugged during response prevention showed increased avoidance performance in the subsequent test of avoidance extinction. That is, preventing avoidance responding under a drugged (versus nondrugged) state produced increased resistance to extinction of the avoidance response.     

A contextual approach to research on AIDS prevention

The acquired immune deficiency syndrome (AIDS) is a disease that is transmitted almost entirely through behavioral factors. In the absence of a cure or vaccine, the modification of AIDS-risk behavior presents a unique challenge to behavioral scientists and should be taken as a clear imperative by behavior analysts. This paper discusses the currently dominant social-cognitive theories (the health belief model, the theory of reasoned action, and self-efficacy theory) that have been widely used to predict and understand AIDS-risk behavior. Although these theories have generated a voluminous literature on the cognitive, attitudinal, and demographic correlates of AIDS-risk behavior, they have not resulted in specific intervention strategies to influence risky behavior, most likely because they fail to specify manipulable variables. As an alternative to social-cognitive theories, this paper evaluates the usefulness of a behavior-analytic approach to stem the spread of HIV infection. It examines some of the philosophical differences underlying cognitive and behavioral approaches that are embedded in mechanistic versus functional contextualistic principles. It explores the theoretical and practical implications of adopting either predicting and explaining behavior or predicting and influencing behavior as the goals of science. To illustrate the value of adopting the goal of prediction and influence, behavior-analytic research on the social context of risky sexual behavior in adolescents is described. The paper argues that in order to alter the future course of the AIDS epidemic, the behavioral sciences must move beyond describing cognitive and attitudinal correlates of risky behavior and focus on the social context of the behavior of individuals. In addition, population-wide changes in AIDS-risk behavior can be accomplished only if research focuses on how to influence larger social systems, including the media, school systems, and community organizations.     

Perspectives on relapse prevention: An exploratory study

This article explores the hypothesis that factors associated with relapse early in a quit attempt may lose their predictive power over time. Participants were 195 recent ex-smokers calling a telephone Quitline. Quitters were interviewed, then re-interviewed three weeks later to determine outcome (relapse or maintenance of attempt). There was strong evidence for a discontinuity in prediction of outcome between those who quit for less than one week, or who reported at least daily strong urges to smoke and those who quit for more than a week who reported less than daily strong urges to smoke. Several variables, including self-efficacy and scales of positive social and negative affect temptations, reversed predictive value. This study provides evidence of a perspective or stage within the Action stage of the TTM. More work is required to confirm both the findings and the exact nature of the discontinuity point.     

Suicide prevention in the genetic counseling context

Utilizing a case report, this paper explores psychosocial aspects of suicidal intent in a woman seeking prenatal diagnosis. Using knowledge and practice of appropriate assessment, referral, and intervention procedures, the therapy team of genetic counselor and psychotherapist facilitated successful identification and management of this potentially suicidal client. The main counseling goals for the genetic counselor are to assess the situation adequately, decrease the immediate danger, and, with supervision and/or consultation, stabilize the seriously suicidal person until that individual can be triaged to mental health or medical professionals for treatment. The prevalence of suicide issues in genetic counseling contexts is unknown and reports mentioning suicidal ideation unusual in the genetic counseling literature. Is this reported case a rarity among genetic counseling referrals? Systematically collected information on the prevalence and resolution of suicidal issues in genetic counseling contexts would be helpful for those setting curricula for genetic counseling training programs, standards for professional certification exams, and policy and procedures manuals for clinical units.     

Outcome interdependence shapes the effects of prevention focus on team processes and performance

Although the effects of regulatory focus on individual-level performance have often been studied, relatively little is yet known about team-level effects. Filling this void, we integrate the notion that promotion-focused individuals are concerned with progress and achievement, whereas prevention-focused individuals are concerned with security and vigilance, with the insight that team processes and performance depend on outcome interdependence (individual versus team rewards). The hypothesis that prevention-focused teams react more strongly than promotion-focused teams to differences in outcome interdependence was tested among 50 teams performing an interactive command-and-control simulation. Regulatory focus and outcome interdependence were both manipulated. The results showed that prevention-focused teams working for team rather than individual rewards reported higher work engagement and less error intolerance, coordinated more effectively, and performed better. Promotion-focused teams were not influenced by outcome interdependence. We discuss the implications of our results for theory and effective team management.     

What works in prevention. Principles of effective prevention programs

The high prevalence of drug abuse, delinquency, youth violence, and other youth problems creates a need to identify and disseminate effective prevention strategies. General principles gleaned from effective interventions may help prevention practitioners select, modify, or create more effective programs. Using a review-of-reviews approach across 4 areas (substance abuse, risky sexual behavior, school failure, and juvenile delinquency and violence), the authors identified 9 characteristics that were consistently associated with effective prevention programs: Programs were comprehensive, included varied teaching methods, provided sufficient dosage, were theory driven, provided opportunities for positive relationships, were appropriately timed, were socioculturally relevant, included outcome evaluation, and involved well-trained staff. This synthesis can inform the planning and implementation of problem-specific prevention interventions, provide a rationale for multi-problem prevention programs, and serve as a basis for further research.     

Physical violence at the workplace: Consequences on health and measures of prevention

Based on definitions and theoretical models of physical violence at the workplace, this paper presents scientific knowledge and working hypotheses regarding both, the causes and effects of physical violence on health, and pertinent preventive measures of intervention to be taken by enterprises. Four groups of determinants of violence are presented and discussed: determinants relative to the structure and the culture of the enterprise; the aggressor; the victim; and the socio-cultural environment. The theoretical model by Baron and Neumann [Public Admin Q 21 (1998) 446–64] is used to explain the complex origin of violent behavior at work based on these determinants. Moreover, the various and multiple consequences of a violent act are examined. In addition to the direct effects of such an act on the social, organizational and individual level, the indirect effects are also taken into consideration. In this analytical context, health problems are more particularly underlined, such as the psychological trauma suffered by victims of a violent act. Finally, two different areas of intervention will be distinguished: interventions on the physical environment and interventions on the level of company management or an organizational group which aims at changing the behavior of the members of the organization. Different scientific evaluations of action programs to reduce violent acts are presented. In conclusion, this paper calls for further research on physical violence in the workplace.     

Praise and prevention

I argue that it is possible to prevent (and to be praiseworthy for preventing) an unwelcome outcome that had no chance of occurring. I motivate this position by constructing examples in which it makes sense to explain the non-occurrence of a certain outcome by referring to a particular agent's intentional and willing behavior, and yet the non-occurrence of the outcome in question was ensured by factors external to the agent. I conclude that even if the non-occurrence of an unwelcome outcome is ensured, the agent whose action explains this non-occurrence is praiseworthy for preventing the outcome. My examples are similar in important respects to Frankfurt-type cases. In the second half of the paper, I discuss the relationship between my examples and Frankfurt-type cases involving both actions and omissions. I conclude that while I may be responsible for the consequences of an action even if those consequences are unavoidable, this is not necessarily so for the consequences of omissions.