On our journey of enlightenment and understanding the mechanisms of Black suicidality, we have explored the socio-historical context, current literature, and treatments available towards mental health care. By utilizing an intersectional lens, we began to unravel the complexities of systemic racism and how those processes influence and trigger suicidal behavior among Black Americans. It illustrates the erasure of methodology and treatment centered towards the Black experience within the U.S. Like a worn-out washing machine, it continues to perpetrate the cycle of institutionalized violence.

Now what? It is important to articulate the discourse around Black suicidology, but discourse by itself is an empty vessel. Even more relevant is the ability to apply knowledge to practice. In this final part of this series, we will conceptualize the implementation of effective treatment on suicidal Black youth, which has been alarmingly on the rise these past few years. Although we have been taken a macro analysis of Black suicide, I think it is important to center our lens towards the current crises: Black adolescents.¹

Internal & External Risk Factors

As we have discussed in the previous parts of this series, there is a magnitude of risk factors that influence Black youth suicidality. I have compiled a list of internal and external risk factors that possibly influence suicidal behavior among Black adolescents:

• A history of mental health disorders.
  Research suggests that Black children with a history of mental health disorders (i.e., depression, anxiety, ADHD, etc.) are at higher risk to die by suicide.² Factoring the prevalence of misdiagnosis and underdiagnosis of Black mental disorders, these suggestions are alarming.
• Bullying victimization.
  Black children raised in predominately White neighborhoods experience increased peer bullying, institutionalized racism, lower academic performance, and higher suspensions than their White counterparts.³ Trends show these children (ranging from school age to adolescence) use more lethal means such as suicide by hanging.
• Lack of family/community cohesion.
  Within marginalized groups, family and community are important components of social survival. Family/community cohesion is the perception and inclusion of an individual within their identity groups, enabling a feeling of inclusion and the action of support. Sometimes these cohesive structures maybe broken due to social, economic, and other structural stressors. An individual that does not have family/community cohesion may exhibit feelings of isolation, burdensomeness, and hopelessness.
• Inaccessibility to mental health services.
  Mental health services are often inaccessible to individuals who reside in low-income communities. Without the means to affordable and accessible care, suicidal behavior is not addressed or left unchecked.
• Mental health stigma.
  The average person is not fully versed on the scientific and psychological understandings of mental health. There are numerous taboos and perceptions about suicide that may hinder treatment. Some religious, cultural, and social backgrounds may perceive suicidal behavior as a manifestation of “weakness” or “crazy-behavior”. These views help to stigmatize suicidal individuals.
• Racial biases among mental health providers.
  As we have previously discussed, there has been a racialized bias, and even intentional mistreatment, of Black patients within the mental health field. This can be presented as the perception that Black people are so mentally and physically “strong” that suicide might not be a problem, or they have a higher threshold for the stressors that lead to suicidal behavior. This may lead to dismissal of an individual’s mental health needs.

Treating Black Youth Suicidality

While working with Black clients, I have established three main goals that I think are essential to the therapeutic process. These objectives can be implemented across your therapeutic style, whether CBT, psychoanalyses, or a mix-treatment. The aim is to build a foundation of trust between the client and the provider. The initial process of therapy should include the following steps:

1. Identify Risk Factors.
   Address the core issues presented by your client. Suicidal behavior among Black youth is not isolated. In my opinion, it is a residual effect of environmental, social, genetic, and psychological stressors. It is like a puzzle piece, a small component of a larger picture. It is influenced by many other factors, and to effectively address suicidal behavior you must identify and acknowledge the risk factors that influence the client’s suicidality.
2. Affirm Their Experiences.
   Affirming the client’s experiences is crucial because it provides it provides a safe space in the context of solidarity and helps to re-distribute the power dynamics in the relationship. Affirmation of the individual allows them to feel and experience a sense of control, while allowing the therapist to embrace empathy.
3. Speak Truth to Power.
   There is power in words. In expression. Vocalization is the act of giving voice what is voiceless. It is providing the tools necessary for an individual’s enlightenment of self and the support system. This can be presented in the form of education through family/community engagement, client narrative writing (journaling), or a tool such as the CAMS the suicidal status form (SSF), which allows the therapist and client to note suicidal behavior through a collaborative exercise.

I try to implement these objectives in both my academic and clinical work. They can be generalized to every patient; however, I find that keeping these three objectives in mind helps me to provide a more holistic approach when working with Black adolescents.

Case Studies:  Practicing the Identify-Affirm-Speak Method

Tiffany

Tiffany is six years old. She lives in the suburbs of Northern Virginia with her parents. She attends a predominately White primary school and is the only Black student in her classroom. Tiffany is often bullied by her peers due to her physical appearance. She is beginning to feel isolated from her classmates. Tiffany informs her teacher about the bullying. The teacher assures her that if she ignores the bullies, the bullying will stop.

The bullying does not stop. It continues and begins to affect her academic performance. Tiffany, a recently high achiever, has not been completing her assignments and is not engaged in class discussions. Her teacher remarks to her parents that Tiffany’s behavior has become detached and rude towards others. Tiffany’s mother has also noticed negative changes in her behavior. She labels Tiffany’s behavior as lazy and disrespectful.

Tiffany attempts to avoid school by stating she feels sick during the weekdays, and on the weekends, she sleeps the whole day. Tiffany also spends a lot of time on the computer. Her mother has discovered her recent search history includes “how to kill yourself” and “how to hang a rope”. Her parents have found a Black, female therapist in the region because they are worried about her wellbeing.

When providing therapy for Tiffany, the therapist might find it helpful to:

1. Identify risk factors: Tiffany’s risk factors include a history of victimization/bullying by her peers. It is important for the therapist to recognize the racialized/gendered aspect of the discrimination. Tiffany is constantly being dismissed or negatively perceived by authority figures (her teacher and mother). This increases her feelings of isolation and withdrawal. She displays symptoms of depression and her exposure to the internet has provided her with information to make death by suicide a reality.
2. Affirm her experience. Tiffany’s emotions and experiences are valid. It is important to affirm her experiences because she has been de-valued by her peers, authority figures, and parents. Providing affirmation will build the foundation to work together to create a plan to deal with the factors that influence her suicidality.
3. Speak truth to her power. The therapist should work with Tiffany and her parents to establish a solid support system and establish health boundaries between the parent-child relationship and provide educational understanding of suicidal behavior. Increasing the parents’ comprehension may address the academic challenges as a cohesive unit. Finding positive outlets of expression may increase Tiffany’s vocalization of her emotions and experiences.

Omar

Omar is a thirteen-year-old who lives in the Bronx with his parents, who are working class and sometimes struggle with finances. Omar has always been perceived as “troubled”. Since a toddler, he has displayed emotional outburst whenever he is frustrated or annoyed. He struggles with academics and continues to display a lack of emotional regulation. When confronted by an authority figure, Omar erupts into explosive outbursts. His teachers classify his behavior as disruptive and aggressive, however he is viewed as a class clown by his classmates. Omar has an extensive history of suspensions and has recently been expelled from his current school due to a physical altercation with a teacher.

At the age of nine, Omar was diagnosed with Oppositional Defiant Disorder (ODD). Omar is very active on social media and follows a politically motivated group that shares information about police brutality and systemic racism in the NYC area. Omar shares with the group his negative experiences with “the system”. On these sites, Omar has been increasingly exposed to visual media of images of Black people being brutalized on camera. These images have psychologically impacted Omar and influence his feelings of isolation and trauma.

Omar has a history of hospitalization due to self-mutilation and suicide attempts. Recently, Omar has been hospitalized after threatening suicide with his father’s handgun. He has been referred by his social worker to a White, male therapist who specializes in suicidal behavior and multicultural therapy.

When providing therapy for Omar, the therapist might find it helpful to:

1. Identify risk factors: Omar’s history with a mental disorder is something to considered. However, it is important to be mindful of the delicate balance between providing treatment and safe space for the client. Analyze what you observe from the behavior and confront assumptions that may contribute to systematic biases. Omar’s history of self-mutilation and past suicide attempts are huge red flags. His increased exposure to social media and political engagement may increase his suicidal behavior if not moderated. His proximity to lethal means is also a consideration.
2. Affirm his experiences. Omar’s therapist should internalize the complexities of Omar’s mental disorder and his subjective experience with racism, classism, and other oppressive categorizations. Individuals who experience mental disorders are not a monolith, so in treating Omar’s suicidal behavior, the therapist should affirm his subjective experiences. What might be presented as symptoms of a mental disorder could be symptoms of discrimination, and vice versa. These things can also be mutually inclusive. It is a complex and delicate balance that a professional needs to navigate. I think that to be effective, all possibilities must be affirmed with the client. The therapist might want to be mindful that while social media and political engagement can be therapeutic, past a certain threshold it can turn counterproductive and unhealthy. Omar’s methods of engagement and the possibility of social media burnout should also be discussed with him. Omar’s complicated history with authority figures should warn the therapist that this relationship must be more mutually inclusive and collaborative to function.
3. Speak truth to his power. The therapist should work with Omar and his parents to better understand and discuss his mental health including his suicidal behavior. Omar is at a critical stage where he needs a cohesive support system. At this step, a focus is Omar’s emotional regulation and ability of expression. A plan should be created to implement safe spaces where Omar can freely acknowledge his emotional triggers and build confidence in expressing himself. Room should be provided to address the suicidal behavior. As the therapist continues to validate Omar’s experience, discussion can begin on self-care and de-escalation of engagement for Omar’s personal growth.

Tiffany and Omar are examples of the complexities of treating Black youth and express the importance of encompassing a critical theory lens when addressing suicidal behavior among minority groups. To address their suicidality a mental health provider should contextualize the social, cultural, and historical oppositions that they endure. This is their positionality within society. Identify their risk factors. Affirm their experiences. Speak truth to their power.

In Conclusion

There are numerous risk factors impacting the phenomena of suicidal behavior among Black adolescents in the U.S. These internal and external factors possibly underscore the undercurrent of institutionalized racism. Addressing the context of this marginalization may help build the therapeutic relationship between mental health providers and Black clients—extending to the larger Black community.

I appreciate your willingness to journey with me in this series through the complex dynamics of systemic racism and its impact on the suicidality of Black youth. These things are messy and uncomfortable. Yet we must sit with our discomfort and acknowledge the social-historical context of medical biases, racial civil unrest, and political engagement. If we can ask our clients to enter our spaces and share their personal experiences, then it is our responsibility to reciprocate, we can make a difference in this vulnerable population. The mental health of Black children depends on it.

Footnotes:

1. https://www.apa.org/news/apa/2020/01/black-youth-suicide
2. https://watsoncoleman.house.gov/uploadedfiles/full_taskforce_report.pdf
3. https://www.usatoday.com/story/news/education/2019/02/04/black-history-month-february-schools-ap-racism-civil-rights/2748790002/