Edition 20 – Dying in the Shadows: Suicide Among the Homeless
Dying in the Shadows:
Suicide Among the Homeless
By Lori Holleran and Gabrielle Poon
Holleran L, Poon G. Dying in the shadows: suicide among the homeless. Harvard Public Health Review. Fall 2018;20.
Dying in the Shadows: Suicide Among the Homeless
According to the 2017 Annual Homeless Assessment Report to Congress, conducted by the U.S. Department of Housing and Urban Development (HUD), nearly 554,000 individuals, or 17 per 10,000 people, are homeless within the U.S. on any particular night (HUD, 2017). Homeless individuals represent some of society’s most marginalized and unsupported populations. One particularly alarming outcome amongst those experiencing homelessness is the prevalence of suicides. Suicide rates among homeless populations are estimated at nine times that of the US general population (112.5 suicide deaths per 100,000 versus the U.S. national average of 12.5 per 100,000; Centers for Disease Control and Prevention [CDC], 2014; Peate, 2013). Unfortunately, little is known—much less being done—about alleviating this risk because empirical knowledge and evidence-based prevention efforts regarding suicide in these marginalized populations are lacking, particularly among diverse ethnic minority and LGBTQ individuals.
Among those experiencing homelessness, transitional age youth (TAY) ages 18-24, LGBTQ individuals, and ethnic minorities represent groups of elevated need. For example, in the midst of growing rates of homelessness among TAY, sexual minorities become homeless at rates that are nearly double that of heterosexual peers, often due to social and family conflict (Cochran, Stewart, Ginzler, & Cauce, 2002). Among homeless TAY, sexual minorities are over eight times more likely to attempt suicide than their heterosexual counterparts (LAFYS, 2014). Further, suicide rates and risk factors vary across cultural groups – among youth, those identifying as Latino or African American demonstrate particularly elevated risk (CDC, 2015; Chu, Goldblum, Floyd, & Bongar, 2010). Moreover, individuals with multiple minority identities (e.g., ethnic and LGBTQ) have higher suicide rates than those with single minority status (Hughes, Matthews, Razzano, & Aranda, 2002). Yet, while homelessness is increasingly reaching individuals at particularly high risk for suicide, the environment remains absent of a response.
Inadequate Prevention Services
Despite the fairly recent increase in commitment to suicide prevention efforts nationally, strategies focused on identifying clear and definitive approaches to preventing suicide amongst the homeless have remained largely overlooked. A number of interventions and screening tools have demonstrated effectiveness in reducing suicide in the general population (van der Feltz-Cornelis et al., 2011), and some have demonstrated efficacy among specific populations such as veterans, elderly adults in primary care, Native Americans or Alaskan Natives, and youth in high schools (Suicide Prevention Resource Center, n.d.). However, few of these programs have been tested with the homeless, and no program broadly targeting culturally diverse homeless individuals at risk for suicide exists under the Substance Abuse and Mental Health Services Administration’s (SAMHSA) National Registry of Evidence-based Programs and Practices (SAMHSA, 2015).
A crucial part of managing risk for suicidal patients is restricting an individual’s access to lethal means. Having the means to complete suicide greatly increases the risk of fatal results (Brent & Bridge, 2003; McNeil, 2009). Yet, despite this knowledge, there is a paucity of research examining standards of care for restricting access to these lethal means amongst the homeless. Current lethal means restriction approaches primarily focus on firearms, the most common method of suicide among Caucasian males and the leading cause of completed suicide in the United States, which accounts for 51% of completed suicide attempts (Bryan, Stone, & Rudd, 2011; CDC, 2012). Unfortunately, these efforts predominantly benefit individuals utilizing typical means, which may fail to address the needs of marginalized and/or minority populations.
When examining the chosen means of suicide among groups other than Caucasian males, one sees tremendous variability. Rather than firearms, hanging among Asian American individuals and drug overdose among LGBTQ youth, for example, are the most common methods of suicide (D’Augelli & Hershberger, 1993; Shiang et al., 1997). These methods, hanging and intentional overdose, are also used more commonly than firearms by those experiencing homelessness (Barak, Cohen, & Aizenberg, 2004). As the accessibility of means greatly influences the acceptability of a particular suicide method within cultural and geographic groups (Ajdacic-Gross et al., 2008), easily accessible means should be assessed among diverse homeless populations to appropriately tailor means-restriction interventions to the cultural sanctions of the population.
Lack of Cultural Competence
Compounding the problem of a lack of best practice efforts and programs designed and tested specifically for the homeless is a dearth of clear guidelines for culturally competent suicide prevention efforts (American Psychiatric Association, 2003; Granello, 2010). With ethnic minority and LGBTQ individuals overrepresented in homeless populations compared to the general U.S. population (Durso & Gates, 2012), it is imperative that any suicide prevention practice incorporates cultural competency.
In recent years, cultural competence has emerged as a focus in suicide risk and prevention (Leong & Leach, 2010), as different cultural groups experience culturally variant suicide risk factors (Chu et al., 2010). For example, though psychiatric disorders such as depression, schizophrenia, and bipolar disorder are present among 90% of suicidal individuals in the general population, approximately half of suicidal Asian Americans exhibit a non-psychiatric subtype of suicide marked by cultural, medical, and functional factors rather than mental health symptoms (Chu, Chi, Chen, & Leino, 2014) – a finding suggesting that mental illness may be a poor indicator for suicide prevention strategies among some ethnic minorities. Additionally, research shows that LGBTQ individuals often turn to community supports in the face of rejection from family members, making high family rejection and alienation from one’s social community particularly important suicide risk factors for LGBTQ populations (D’Augelli, 2002; McBee-Strayer & Rogers, 2002; Ryan, Huebner, Diaz, & Sanchez, 2009). Understanding social isolation from a supportive LGBTQ community may be a better indicator of suicide risk than social isolation from family for an LGBTQ client struggling with the coming out process.
Suicide prevention practices also typically target the dominant culture and neglect minority populations. Homeless agency gatekeepers often apply existing prevention strategies such as QPR (question, persuade, and refer; QPR Institute, n.d.) for the management of suicide risk. However, interventions such as QPR do not address cultural differences in early warning signs, expressions of distress, communication differences, and help-seeking preferences that are often found across minority groups. On the flip side, several culturally sensitive efforts exist, but suicide prevention targeting homeless populations have largely been neglected within such efforts (Christensen & Garces, 2006).
Ultimately, we are currently failing to reduce lives lost during a time when individuals are facing acute and extremely challenging cultural stressors. As a result, there is a clear need for primary prevention suicide efforts targeted at a culturally diverse homeless population. If, as President Carter noted, the measure of a society is found in how they treat their weakest and most helpless citizens, we undoubtedly have room to grow.
Ajdacic-Gross, V., Weiss, W. G., Ring, M., Hepp, U., Bopp, M., Gutzwiller, F., & Rössler, W. (2008). Methods of suicide: International suicide patterns derived from the WHO mortality database. Bulletin of the World Health Organization, 86(9), 726-732.
American Psychiatric Association. (2003). Practice guideline for the assessment and treatment of patients with suicidal behaviors. American Psychiatric Publishing. Arlington: VA. Retrieved from http://psychiatryonline.org/pb/assets/raw/sitewide/practice_ guidelines/guidelines/suicide.pdf
Barak, Y., Cohen, A., & Aizenberg, D. (2004). Suicide among the homeless: A 9-year case-series analysis. Crisis, 25(2), 51-53.
Brent, D. A., & Bridge, J. (2003). Firearms availability and suicide: Evidence, interventions, and future directions. American Behavioral Scientist, 46, 1192–1210.
Bryan, C. J., Stone, S. L., & Rudd, M. (2011). A practical, evidence-based approach for means-restriction counseling with suicidal patients. Professional Psychology: Research And Practice, 42(5), 339-346.
Centers for Disease Control and Prevention. (2012). Leading causes of death 1999-2012, for national, regional, and states (restricted)*. Retrieved January 14, 2018 from http://webappa.cdc.gov/cgi-bin/broker.exe
Centers for Disease Control and Prevention (CDC). (2014). Mortality in the United States, 2012. NCHS data brief, no 168. Hyattsville, MD: National Center for Health Statistics.
Centers for Disease Control and Prevention (CDC). (2015). Web-based injury statistics query and reporting system (WISQARS). Fatal injury reports. Atlanta, GA: National Center for Injury Prevention and Control. Retrieved from: https://webappa.cdc.gov/sasweb/ncipc/ mortrate.html
Christensen, R. C., & Garces, L. K. (2006). Where is the research on homeless persons and suicide? Psychiatric Services, 57(4), 447.
Chu, J., Chi, K., Chen, K., & Leino, A. (2014). Ethnic variations in suicidal ideation and behaviors: A prominent subtype marked by nonpsychiatric factors among Asian Americans. Journal of Clinical Psychology, 70(12), 1211-1226.
Chu, J.P., Goldblum, P., Floyd, R., & Bongar, B. (2010). A cultural theory and model of suicide. Applied and Preventive Psychology, 14, 25-40. Dunne, E., Duggan, M., & O’Mahony, J. (2012). Mental health services for homeless: patient profile and factors associated with suicide and homicide. Irish Medical Journal, 105(3), 71.
Cochran, B. N., Stewart, A. J., Ginzler, J. A., & Cauce, A. M. (2002). Challenges faced by homeless sexual minorities: Comparison of gay, lesbian, bisexual, and transgender homeless adolescents with their heterosexual counterparts. American Journal of Public Health, 92(5), 773-777.
D’Augelli, A. R. (2002). Mental health problems among lesbian, gay, and bisexual youths ages 14 to 21. Clinical Child Psychology and Psychiatry, 7, 433-456.
D’Augelli, A. R., & Hershberger, S. L. (1993). Lesbian, gay, and bisexual youth in community settings: Personal challenges and mental health problems. American Journal of Community Psychology, 21(4), 421-448.
Durso, L. E., & Gates, G. J. (2012). Serving Our Youth: Findings from a National Survey of Service Providers Working with Lesbian, Gay, Bisexual, and Transgender Youth who are Homeless or At Risk of Becoming Homeless. Los Angeles: The Williams Institute with True Colors Fund and The Palette Fund.
Granello, D. H. (2010). The process of suicide risk assessment: Twelve core principles. Journal of Counseling and Development, 88(3), 363-371.
Hughes, T. L., Matthews, A. K., Razzano, L., & Aranda, F. (2002). Psychological distress in African American lesbian and heterosexual women. Journal of Lesbian Studies, 7(1), 51–68.
LAFYS. (2014). Sexual and gender minority youth in foster care. Retrieved from: http://williamsinstitute.law.ucla.edu/wp-content/uploads/LAFYS_report_final-aug-2014.pdf
Leong, F. T., & Leach, M. M. (2010). Suicide among racial and ethnic minority groups: Theory, research, and practice. New York, NY: Taylor & Francis.
McBee-Strayer, S. M., & Rogers, J. R. (2002). Lesbian, gay, and bisexual suicidal behavior: Testing a constructivist model. Suicide and Life-Threatening Behavior, 32, 272-283.
McNeil, D. E. (2009). Assessment and management of acute risk of violence. In P. M. Kleespies (Ed.) Behavioral Emergencies: An evidence-based resource for evaluating and managing risk of suicide, violence, and victimization (125-145). Washington, DC: American Psychological Association.
Peate, I. (2013). The other silent killer: homelessness. British Journal of Nursing (Mark Allen Publishing), 22(11), 607.
QPR Institute. (n.d.) What is QPR? Retrieved from: http://www.qprinstitute.com/about.html
Ryan, C., Huebner, D., Diaz, R., & Sanchez, J. (2009). Family rejection as a predictor of negative health outcomes in White and Latino lesbian, gay, and bisexual young adults. Pediatrics, 123, 346-352.
Shiang, J., Blinn, R., Bongar, B., Stephens, B., Allison, D., & Schatzberg, A. (1997). Suicide in San Francisco, CA: A comparison of Caucasian and Asian groups, 1987–1994. Suicide and Life-Threatening Behavior, 27(1), 80–91.
Substance Abuse and Mental Health Services Administration (SAMHSA). (2015). Behavioral health services for people who are homeless. Treatment Improvement Protocol (TIP), Series 55. Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved from http://store.samhsa.gov/shin/content//SMA13-4734/SMA13-4734.pdf
Suicide Prevention Resource Center. (n.d.). Best practices registry section I: Evidence-based programs. Retrieved from http://www.sprc.org/bpr/section-i-evidence-based-programs
The 2017 Annual Homeless Assessment Report to Congress. Retrieved from: https://www.hudexchange .info/resources/documents/2017-AHAR-Part-1.pdf
Van der Feltz-Cornelis, C. M., Sarchiaphone, M., Postuvan, V., Volker, D., Roskar, S., Grum, A.T., …Hegerl, U. (2011). Best practice elements of multilevel suicide prevention strategies: A review of systematic reviews. Crisis, 32(6), 319-333.
About the Authors
Lori Holleran, PhD, MPH
Lori Holleran, PhD, MPH obtained her MPH in health policy from the Harvard T.H. Chan School of Public Heath, and her Ph.D. in clinical psychology from Palo Alto University. She currently manages special programs for Arizona Housing Inc., where she is focused on addressing chronic health issues, behavioral health concerns, and social determinants of health among extremely low-income Arizonans, She recently concluded her two-year service as a VA Quality Scholars Fellow, where she focused on national healthcare improvement efforts within the VA. Prior to her work with the VA, she was the recipient of a Philanthropy Advisory Fellowship within the Effective Altruism Center at Harvard College, where she served on a cross-disciplinary team advising large foundations on how to maximize the impact of their charitable giving. She also completed an Interdisciplinary Concentration Certification in Humanitarian Studies, Ethics and Human Rights through the Humanitarian Academy at Harvard University, focused on sector-based assistance and aid coordination.
During her academic tenure she participated in research within the Harvard Injury Control Research Center and Research Program on Children and Global Adversity, the Clinical Crises and Emergencies Research laboratory, the Palo Alto VA’s National Center for Posttraumatic Stress Disorder and Substance Abuse and Anxiety Laboratory, Stanford’s Psychophysiology Laboratory, and the University of California, Los Angeles’s Alzheimer’s Disease Research Center. Her previous research and publications have broadly focused on policies and programs aimed at improving health care among structurally marginalized and high-risk groups in a culturally competent manner. Lori is passionate about initiatives that integrate technology, environment, and collaborative partnerships with healthcare in order to offer more comprehensive and accessible care to a broader group of individuals.
Gabrielle Poon, PhD
Gabrielle Poon, PhD, of British Columbia, Canada, completed her predoctoral and post-doctoral residency training in Anchorage, Alaska, and earned her Doctor of Philosophy in clinical psychology from Palo Alto University. Since then, she has worked in treatment settings in British Columbia, California, and Washington, and is a Registered Psychologist in BC.
Dr. Poon emphasizes transparency and collaboration in her clinical work. She leverages a culturally-responsive, patient-centered lens as a practitioner, and works primarily with adults and adolescents (age 19 to seniors/elders).