10107_Interpersonal suicide risk for Latino-a Americans – Investigating thwarted belongingness, perceived burdensomeness, and cultural factors of relevance

Graduate Theses and Dissertations
Iowa State University Capstones, Theses and
Dissertations
2018
Interpersonal suicide risk for Latino/a Americans:
Investigating thwarted belongingness, perceived
burdensomeness, and cultural factors of relevance
Kelsey E. Engel
Iowa State University
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Recommended Citation
Engel, Kelsey E., “Interpersonal suicide risk for Latino/a Americans: Investigating thwarted belongingness, perceived
burdensomeness, and cultural factors of relevance” (2018). Graduate Theses and Dissertations. 16348.
https://lib.dr.iastate.edu/etd/16348

Interpersonal suicide risk for Latino/a Americans: Investigating thwarted belongingness,
perceived burdensomeness, and cultural factors of relevance

by

Kelsey E. Engel

A thesis submitted to the graduate faculty

in partial fulfillment of the requirements for the degree of

MASTER OF SCIENCE

Major: Psychology

Program of Study Committee:
Loreto Prieto, Major Professor
Karen Scheel
Carolyn Cutrona

The student author, whose presentation of the scholarship herein was approved by the program
of study committee, is solely responsible for the content of this thesis. The Graduate College
will ensure this thesis is globally accessible and will not permit alterations after a degree is
conferred.

Iowa State University

Ames, Iowa

2018
ii
TABLE OF CONTENTS

Page

LIST OF TABLES………………………………………………………………….

iv
ACKNOWLEDGMENTS…………………………………………………………. v
ABSTRACT……………………………….
…………………………………………………….. vi
CHAPTER 1
INTRODUCTION ………………………………………………………………..
1
CHAPTER 2
LITERATURE REVIEW ……………………………………………………… 13

Definition of Suicidal Risk and Associated Constructs
…………………………………
13

General Incidence and Prevalence of Suicide in the US
………………………………..
14

The Interpersonal-Psychological Theory of Suicide
……………………………………..
20

The Present Study ……………………………………………………………………………………
39
CHAPTER 3
METHOD ……………………………………………………………………………
41

Procedure ……………………………………………………………………………………………….
41

Participants ……………………………………………………………………………………………
42

Measures ………………………………………………………………………………………………..
43

Research Questions
………………………………………………………………………………….
50

CHAPTER 4 RESULTS …………………………………………………………………………… 53

CHAPTER 5 DISCUSSION
……………………………………………………………………… 68

Brief Summary of Findings ……………………………………………………………………… 68

The Interpersonal-Psychological Theory of Suicide
…………………………………….. 70

Cultural Factors of Relevance
…………………………………………………………………… 72

Limitations …………………………………………………………………………………………….. 75

Implications for Future Research
………………………………………………………………. 77

Implications for Clinical Practice ……………………………………………………………… 79

Conclusions
……………………………………………………………………………………………. 80

REFERENCES …………………………………………………………………………………………….
81
APPENDIX A. EMAIL INVITATION TO PARTICIPATE ………………………………
98
APPENDIX B. FOLLOW UP EMAIL INVITATION TO PARTICIPATE …………
99
APPENDIX C. INFORMED CONSENT.
……………………………………………………….. 101
iii
APPENDIX D. DEMOGRAPHIC QUESTIONNAIRE ……………………………………. 104
APPENDIX E. INTEPERSONAL NEEDS QUESTIONNAIRE (INQ-15) …………. 105
APPENDIX F. SUICIDAL RISK QUESTIONNAIRE …………………………………….. 106
APPENDIX G. BIDIMENSIONAL ACCULTURATION SCALE ……………………. 107
APPENDIX H. SAFE-R ACCULTURATIVE STRESS SCALE
……………………….. 108
APPENDIX I. IRB APPROVAL
……………………………………………………………………. 110

iv
LIST OF TABLES

Page
Table 1. Sample Means, Standard Deviations, and Ranges of Study Measures
……..55

Table 2. Inter-correlations and Alpha Coefficients of Study Measures
…………………57

Table 3. Summary of Hierarchical Regression for IPTS Variables Predicting Suicidal

Risk……. ……………………………………………………………………………………………..60

Table 4. Moderation Effects …………………………………………………………………………..62

Table 5. Mediation Effects
……………………………………………………………………………..65

v
ACKNOWLEDGMENTS

I would like to express my gratitude to Dr. Loreto Prieto, my graduate advisor and committee
chair, for his continual guidance and patience throughout this research project. I would also like
to thank Dr. Karen Scheel and Dr. Carolyn Cutrona, my committee members, for their excellent
advice and willingness to answer questions and generate solutions. My committee’s continual
encouragement and belief in my ability to complete my thesis was so appreciated.

I would also like to communicate appreciation for the support and guidance of several
colleagues in my graduate cohort, research lab, and counseling practice, whose compassion and
wisdom throughout my graduate career have been essential to the completion of this research
project. Thank you, Meredith, Mary, Julio, Patrick, Rachel, and Kaitlyn. I am so grateful for
Iowa State University’s Department of Psychology, as a whole.

Most importantly, I would like to express my endless gratitude to my family. To my mother, for
her boundless love, modeling of strength, and for always communicating her confidence in me,
even when I failed to see it in myself. To my partner, whose patience, love, and humor brought
laughter and warmth to many long days of research, and supported my self-care and positivity
throughout this process. Lastly, to Hemingway, my loyal shadow, I give my love and care.

vi
ABSTRACT

There is evidence that different racial groups not only complete suicide at different
rates, but conceptualize suicidal behavior differently (American Association of Suicidology
[AAS], 2016; Brownson, Becker, Shadick, Jaggers, & Nitkin-Kaner, 2014; Maris, Berma, &
Silverman, 2000; Shadick, Backus, & Babot, 2015). Evidence also exists indicating that key
culture-based variables such as acculturation, enculturation, and acculturative stress are
important variables to explore in research using Latino/a samples (Bernal, 1990; Del Pilar,
2009; Padilla & Lindholm, 1984), and may be related to the suicidal behavior of Latino/as
(Fortuna, Perez, Canino, Sribney, & Alegria, 2007; Perez-Rodriguez, Baca-Garcia, Oquendo,
Wang, Wall, et al., 2014), especially Latino/a college students (Gomez, Miranda, & Polanco,
2011; Hovey & King, 1996; Saldana, 1994; Walker, Wingate, Obasi, & Joiner, 2008).
The Interpersonal-Psychological Theory of Suicide (IPTS; Joiner, 2005; Van Orden,
Cukrowicz, Witte, & Joiner, 2012; Van Orden, Witte, Gordon, Bender, & Joiner, 2008; Van
Orden, Witte, Cukrowicz, Braithwaite, Selby, & Joiner, 2010), a recent theory in suicidology
that has generated a significant amount of research, does not include culture-based factors
within its model, and has not been shown to fit well when used to explain the suicidal behavior
of racially diverse people (Davidson, Wingate, Slish, & Rasmussen, 2010; O’Keefe, Wingate,
Tucker, Thoades-Kerswill, Slish, & Davidson, 2014; Wong, Koo, Tran, Chiu, & Mok, 2011;
Garza & Pettit, 2010).
In my study, I tested and expanded upon IPTS, by applying Joiner’s construct of
suicidal desire (as measured by the sub-constructs of thwarted belongingness and perceived
burdensomeness) to Latino/a American college students, to examine the ways in which the
IPTS theory can predict their past, current, and future suicidal behavior. In addition, I gave
vii
consideration to Latino/a cultural factors by examining the moderating effects of acculturation
and enculturation, as well as the potential mediation effects of acculturative stress, on the
relation between primary IPTS constructs and past, present, and future suicidal risk. In a sample
of 147 Latino/a American college students, results indicate that the IPTS, and perceived
burdensomeness in particular, is useful in predicting suicidal risk. Acculturation, enculturation,
and acculturative stress were not found to significantly moderate or mediate the relations of the
IPTS model. However, enculturation was found to be a particularly salient cultural variable in
the explanation of Latino/a American college student’s experience of perceived
burdensomeness and its relation to their suicidal risk. Implications for continued examination of
the role that relevant cultural factors play in the context of thwarted belongingness, perceived
burdensomeness, and Latino/a American college student suicidal risk, as well as implications
for utilizing the IPTS in future research and clinical work, are discussed.

Keywords: Suicidal behavior; Latino/a Americans; college students; acculturation;
enculturation; acculturative stress

1
CHAPTER 1
INTRODUCTION

In the United States, suicide continues to be among the top ten leading causes of death
(American Association of Suicidology [AAS], 2016). More specifically, in the United States, in
2015, more than 40,000 people committed suicide (AAS, 2016), translating to an incidence of
approximately 1 person committing suicide every 11.9 minutes and a prevalence ratio of 13.8:
100,000 suicides every year in the general population. For college-aged persons (aged 18 – 24),
suicide is the second leading cause of death, only behind deaths categorized as a result of
unintentional injury (Centers for Disease Control [CDC], 2015).
Suicide base rates have remained proportionately constant for over the past hundred years
(Maris, in press), yet the field of suicidology and the working theories used to understand suicide
have remained stagnant. Investigators still strive to understand who commits suicide and why
(Rogers & Lester, 2010). The overwhelming majority of completed suicides in the US are
committed by European Americans (AAS, 2016), and the majority of extant knowledge
surrounding suicide is representative of that same racial group. This reality means that the field
of suicidology continues to fail to comprehensively advance theoretically our understanding
regarding racial group differences in suicide behavior for non-European Americans. Further,
modern suicidologists have acknowledged an existing paradox of racial group differences in
suicide; that is, most US cultures of color evince lower incidence and prevalence rates for suicide
than European Americans, despite the fact that persons of color face far more social, economic,
and psychological adversity on average than do European Americans. Despite working theories
in the area of suicidology, which largely adopt a diathesis-stress perspective (cf. Lester & Gunn,
2
2016), the overwhelming body of empirical research in suicidology has been atheoretical and has
not paid due attention to specific culture-based factors that can increase the risk for suicide. This
is problematic as when theory does not drive empirical investigations, it becomes difficult (if not
impossible) to reconcile inconsistent and non-integrative findings that emerge among various
studies. This, in turn, hampers investigators’ efforts to achieve clarity concerning what data truly
indicate across studies. In the next section, I will briefly lay out the theory that guided my
research.
The Interpersonal-Psychological Theory of Suicide
A recent theory that has emerged in the field of suicidology is Joiner’s Interpersonal-
Psychological Theory of Suicide (IPTS; 2005). The IPTS has gained widespread attention and
use among researchers since its development as a way to investigate suicide in a theory-driven
manner. Assertions in the IPTS suggest that individuals who attempt suicide must have the
desire to do so, and the model lays out primary constructs and associated variables suspected of
contributing to individuals’ desire to take their own lives. To date, the IPTS theory has been
largely tested using the fifteen-question Interpersonal Needs Questionnaire (INQ-15), a measure
that captures the IPTS theoretical constructs of thwarted belongingness and perceived
burdensomeness, which are seen as the primary variables directly influencing suicidal behavior.
This measure was created by Joiner and colleagues to directly assess constructs in the IPTS and
has been validated on primarily European American samples (Van Orden et al., 2008; Hill, Rey,
Marin, Sharp, Green, & Pettit, 2015). However, neither the IPTS theory nor the INQ-15 measure
have been validated using samples of people of color, neither does the theory or measure
consider ways in which culture-based variables can affect suicidal behavior.
3

Van Orden et al. (2008a) highlighted the need for theory driven research on the proximal,
causal, and interactive factors involved with suicidal behavior, so that clinicians and researchers
may more accurately and comprehensively detect and intervene in cases of suicidal behavior to
prevent suicide. Joiner’s theory has spurred significant research efforts in the field, and is often
cited within current research in suicide for its operationalization of suicidal desire, specifically
through combining a wide array of empirically supported suicide risk factors into the measurable
constructs of thwarted belongingness and perceived burdensomeness. Joiner (2005) devised
these constructs based on the fundamental psychological need for humans to avoid a sense of
social isolation; social isolation has been found to be one of the most reliable predictors of
suicide attempts (Trout, 1980). As described by Van Orden et al., thwarted belongingness
represents a lack of reciprocal care, social withdrawal, neglect, abuse, or loss felt by individuals,
and spans both personal and public dimensions (Joiner, 2005; Van Orden et al., 2010). Van
Orden et al. found relations of this construct to negative physical and mental health outcomes,
biological stress responses, and elevations of negative affect.
The second component of ‘suicidal desire’ is the belief, held by people contemplating
suicide, that others would be better off without them. Past research has found family conflict,
unemployment, and physical illness to be strong predictors of suicidal ideation (Van Orden et al.,
2010; Waern, Rubenowitz, Wilhelmson, 2003; Bastia & Kar, 2009), which underscores the idea
that those contemplating suicide may perceive themselves as a burden upon others. Joiner argues
that perceiving oneself as a burden, to others as well as society, is a common thread of several
interpersonal risk factors and includes elements of self-hate and feelings of being a liability for
others (Joiner, 2005; Van Orden et al., 2010, p. 584). Studies have shown that perceived
4
burdensomeness is strongly related to suicidal ideation (e.g., Filiberti, Ripamonti, Totis,
Ventafridda, De Conno, et al., 2001; Joiner, Pettit, Walker, Voelz, Cruz, Rudd, & Lester, 2002).
Joiner argues that both thwarted belongingness and perceived burdensomeness are
proximal and causal factors in individuals’ desire to commit suicide. He maintains that each
construct is a significant independent predictor of suicidal ideation, and that the interactive effect
of thwarted belongingness and perceived burdensomeness is more strongly determinant of
suicidal ideation (Van Orden et al., 2010). In the IPTS model, both thwarted belongingness and
perceived burdensomeness must be present for individuals to ‘desire’ to commit suicide.
However, these two constructs and the IPTS model have found only mixed empirical support,
especially in samples of racially diverse populations, an issue that I will discuss further in the
next section.
Race and the Interpersonal-Psychological Theory of Suicide
The primary support for the IPTS and its associated measure, the INQ-15, rests on a five
sample, 2000 participant, series of studies (Van Orden et al., 2012) conducted by the developers
of the theory. Although these authors found that both thwarted belongingness and perceived
burdensomeness, independently and interactively, statistically significantly predicted suicidal
ideation in all five samples, the racial demography of each sample was identified largely as
European American (some as high as 90%). Other studies testing the IPTS have found that the
constructs of belongingness and burdensomeness statistically significantly predicted suicidal
ideation (Cero, Zuromski, Witte, Ribeiro, & Joiner, 2015; Christianson, Batterham, Soubelet,
Mackinnon, Donker, & Soubelet, 2014), but either failed to report, or account for, any racial
diversity in their samples.
5
Studies indicate that people from different racial backgrounds have different rates of
suicide, and generally that cultures of color have lower incidence and prevalence rates of suicide
as compared with European Americans (AAS, 2016). In many ways, these facts seemingly do
not align with the general assumptions of Joiner’s IPTS, as people of color would appear to
experience, on a regular basis, significant experiences of thwarted belongingness and to receive
ubiquitous messages that, as a people, they are burdensome to society. Given that extant suicide
research holds as its ‘gold standard’ the case of European males as the prototypical victim of
suicide, we would expect, according to Joiner’s theory, that people of color would attempt and
complete more acts of suicide than European Americans due to these relatively constant societal
messages and stressors of thwarted belongingness and burdensomeness.
A few non-replicated studies (Davidson et al., 2010; O’Keefe et al., 2014; Wong, Koo,
Tran, Chiu, & Mok, 2011; Garza & Pettit, 2010), either using predominantly racially diverse
samples, or that have examined culture-based factors on the endorsement of belongingness and
burdensomeness, show only partial support for the IPTS. In these investigations, thwarted
belongingness has consistently been found to be a much weaker predictive construct than
perceived burdensomeness for suicidal behavior, and the two constructs interactively do not
predict suicidal behavior consistently or more strongly as theorized by Joiner. In addition,
investigators have directly asserted that cultural factors are an important element to include when
studying the suicidal behavior of racially diverse groups, and that the absence of such factors
from the IPTS and INQ-15 are possible explanations for the theory finding inconsistent support
among racially diverse populations (Davidson et al., 2010; O’Keefe et al., 2014; Wong et al.,
2011; Garza & Pettit, 2010). Clearly, accounting for the different ways in which different
cultures may endorse and succumb to suicide is essential to advancing our general understanding
6
regarding individual and racial group differences in suicidality (AAS, 2016; Brownson et al.,
2014).
Latino/a Americans and suicide
I dealt specifically with Latino/a Americans in my study; as such, it is pertinent to
address known findings specifically concerning this racially diverse group. Generally, Latino/a
Americans are an understudied group in suicide research, despite the fact that, for over 15 years,
Latino/as have been the largest racial minority group in the United States (US Census Bureau,
2016). The Latino/a population currently comprises 17.6% of the US population, and
approximately half of the 2.5 million people added to the US population between the 2014 and
2015 census. Estimates indicate that the US Latino/a population will reach a quarter of the US
total population by the year 2060.
Regardless, suicidologists continually reference the lack of data and research regarding
suicidal behavior among Latino/a Americans (Baca-Garcia, Perez-Rodriguez, Oquendo, Keyes,
Hasin, et al., 2011; Zayas, Lester, Cabassa, & Fortuna, 2005). In the United States, in 2015,
3,303 Latino/a Americans completed suicides as compared with 39,796 completed by European
Americans (AAS, 2016). The rate of completed Latino/a suicide (5.8/100,000 base rate) is lower
than that for European Americans (15.8/100,000 base rate). However, important to note is that
Latino/a Americans have a higher suicide attempt rate than non-Latino/a Americans, especially
among adolescents and young adults (CDC, 2014; Substance Abuse and Mental Health Services
Administration [SAMHSA], 2014). Studies report that the prevalence of plan formation and
suicide attempts are consistently higher among Latino/a teens than their European American and
African American peers (CDC, 2014; Locke & Newcomb, 2005; Tortolero & Roberts, 2001).
7
Given these facts, examining suicidal behavior among Latino/as can provide insight into
general and specific risk factors surrounding suicide for this group of people. In the next section,
I will briefly identify cultural factors of relevance for Latino/as that I considered in my study as I
examined the applicability of the IPTS to this racial group.
Cultural factors of relevance for Latino/as
With approximately 40% of Latino/a Americans identifying as foreign born (U.S. Census
Bureau, 2016), scholars have emphasized that cultural factors such as acculturation,
enculturation, and acculturative stress are critical to consider (Del Pilar, 2009) in research
concerning this racial group. Acculturation has been defined as the extent to which people
incorporate and adjust to the norms and values of a dominant culture (cf. Marin, Sabogal, Marin,
Otero-Sabogal, & Perez-Stable, 1987), while enculturation is defined as the extent to which
people adhere to their own indigenous culture (Garcia & Lega, 1979; Rogler, Cortes, &
Malgady, 1991).
The extent to which Latino/as identify with indigenous culture and the extent to which
they identify with majority culture may have effects on not only the amount of belongingness
they feel, but also their level of perceived burdensomeness in relation to society. Some past
research relating to Latino/a culture (cf. Marin et al., 1987; Rogler et al., 1991) indicated
acculturative and enculturative forces can increase or decrease feelings of belongingness and
perceived burdensomeness in Latino/as. For example, higher levels of enculturation can offer
greater social support opportunities within individuals’ indigenous culture. However, Latino/as’
perceptions of burdensomeness may also increase, given their stronger connection to their
indigenous culture, if they fall short in meeting family or Latino/a community cultural
expectations. Conversely, higher levels of acculturation to the majority culture may also have
8
effects on belongingness and perceived burdensomeness in Latino/as. When racially diverse
individuals more closely align with the majority culture, they may internally feel a greater degree
of belongingness due to a relative decrease in observable difference from the majority culture
(e.g., speaking English, preferring majority culture mannerisms and outward appearances). Yet,
despite these efforts to ‘fit in’ with European American culture, they may simultaneously receive
social and personal messages from European Americans that they inherently do not belong to,
and will never be truly considered a part of, the US majority culture (cf. Perez, Fortuna, &
Alegria, 2008; Helms, 1995). Last, they may receive messages from their indigenous Latino/a
culture that they are ‘selling out’ and do not help present an image of cultural pride or value their
home culture (Sue & Sue, 2016).
Although specific research has not been conducted to test the relations between
acculturation, enculturation, and acculturative stress with the specific constructs of IPTS,
previous research findings do generally suggest that acculturation and enculturation may play a
role in the declining mental health status of Latino/as, especially concerning depression and other
mental health difficulties associated with suicide (García & Zea, 1997). More specifically,
general trends suggest that as Latino/a acculturation to the majority culture increases, so does
their suicidal risk (Perez-Rodriguez, Baca-Garcia, Oquendo, Wang, Wall, et al., 2014; Fortuna,
Perez, Canino, Sribney, & Alegria, 2007). These findings suggest that acculturation and
enculturation can both directly and indirectly affect the suicidal behaviors of Latino/as.
A third culture-based factor, acculturative stress, related to both acculturation and
enculturation, may also play a key part in the suicidal behavior of Latino/as. The difficulties
associated with increasing acculturation (or decreased enculturation) are commonly referred to as
acculturative stress. Specifically, acculturative stress is the psychological stress that comes from
9
the daily conflicts individuals experience as they try to reduce or minimize their cultural
differences with the prevailing majority culture (Mena, Padilla, & Maldonado, 1987).
Acculturative stress encompasses many experiences that could affect the level of belongingness
or burdensomeness an individual may feel, such as perceived discrimination, role and value
conflicts, and cultural awareness related to generational status and time spent in the country
(Padilla & Lindholm, 1984; Mena et al., 1987).
My research concerns not only Latino/as and the applicability of the IPTS to this racial
group, but most specifically Latino/a college students and the degree to which the IPTS can be
used to understand suicidal behavior in this specific population, as well as how the
aforementioned culture-based variables of acculturation, enculturation, and acculturative stress
may play a part in Latino/a college students’ suicidal behavior. Research (cf. Saldana, 1994) has
suggested that acculturation, enculturation and acculturative stress can play a strong part in
Latino/a college students’ general mental health, lending support to the need to examine these
constructs in my study. In the next section, I will briefly discuss issues concerning college
students generally, as well as Latino/a college student suicide, specifically.
Suicide and College-Aged Populations
Although common practice in research on suicide is to utilize college students as
convenience samples, it is important to acknowledge that this age group and population present
unique concerns regarding suicide prevalence and behavior, to be understood in its own right.
Recent reports indicate that suicide is the second leading cause of death among individuals aged
15 to 34 (CDC, 2014). Therefore, college students, in particular, likely exhibit both specific risks
for, and protective factors against, completing suicide.
10
A recent review of college student suicide by Schwartz (2011) found that, although
college students are less likely to complete suicide than their non-student, same-aged peers, the
percentage of full-time college students who have seriously considered suicide has been
gradually increasing each year (SAMHSA, 2014). Arria, O’Grady, Caldeira, Vincent, Wilcox, et
al. (2009) highlighted the ways in which suicidal behavior among college students may be
unique to this population, given the developmental transitions that occur in college and young
adulthood. With approximately 1000 college students completing suicide each year (Schwartz,
2011; Emory University, 2017), researchers must utilize theory-driven approaches to study
suicide, relevant to college students, that can validly capture the unique circumstances and
cultural factors surrounding the college student experience.
Suicide and college students of color
College populations are becoming more racially diverse (U.S. Census Bureau, 2015) and
college students of color, have been particularly overlooked in suicide research and theory. This
group deserves further attention from investigators given that the unique stressors of emerging
adulthood, as well as stressors in the campus climate, may be more salient for someone from a
diverse culture (Gomez et al., 2011).
Most suicide research regarding college-aged students draws from general campus
samples, with little focus on reporting or analyzing data for differences among racial group
statuses. However, some studies have begun to establish that college students of color may be at
higher risk for suicidal ideation than their European American peers, and that college students of
color may not receive proper referrals or obtain help for their concerns surrounding suicide
(Kisch, Leino, & Silverman, 2005; Otero, Rivas, & Rivera, 2007; Muehlenkamp, Marrone, Gray,
& Brown, 2009; Brownson et al., 2014). These studies have brought attention to the complexity
11
of understanding risk factors for suicide among diverse racial groups and the questionable utility
of using universal assessments or general theory bases with racially diverse groups of college
students.
Suicide among Latino/a college students
In a review highlighting the need for more research on the suicidal behavior of Latino/as,
Zayas et al. (2005) reported that one in five Latina adolescent girls can be expected to attempt
suicide. Studies have also reported that the prevalence of suicide attempts and creating a plan to
commit suicide are consistently higher for Latino/a youth than their European American and
African American peers (CDC, 2014; Locke & Newcomb, 2005). In fact, college-aged Latinas
were twice as likely as their non-Latina peers to have engaged in suicidal ideation (Tortolero &
Roberts, 2001). To add concern, replicated findings indicate that young adult Latino/as also
report lower rates of help-seeking than their European American peers (De Luca, Schmeelk-
Cone, & Wyman, 2015; Brownson et al., 2014). Clearly, further theory-driven examination into
the suicidal behavior of Latino/a college students is needed to provide insight into both general
and culture-based risk factors surrounding their suicidal behavior.
Importance of the Present Study
There is clear evidence that various racial groups in the US complete suicide at different
rates and likely conceptualize their suicidal behavior differently (AAS, 2016; Brownson et al.,
2014). Evidence also exists that key culture-based variables such as acculturation, enculturation,
and acculturative stress are important variables to explore in research using Latino/a samples
(Del Pilar, 2009; García & Zea, 1997; Rogler et al., 1991; Saldana, 1994), and may be related to
the suicidal behavior of Latino/as, especially Latino/a college students (Brownson et al., 2014;
De Luca et al., 2015; CDC, 2014; Locke & Newcomb, 2005; Tortolero & Roberts, 2001; Zayas
12
et al., 2005). Finally, scrutiny of empirical findings concerning the IPTS suggest clearly that key
culture-based variables that may affect the suicidal behavior of racially diverse groups are not
present in the IPTS and the theory may not apply well to racially diverse people (Davidson et al.,
2010; O’Keefe et al., 2014; Wong et al., 2011), particularly Latino/as (Garza & Pettit, 2010).
Therefore, in my study, I tested and expanded upon the IPTS, by applying the tenets of
the theory to a sample of Latino/a American college students, to examine if the IPTS can predict
suicidal risk for this group. In addition, I gave consideration to how the specific cultural factors
of acculturation, enculturation, and acculturative stress may affect the suicidal behavior of
Latino/a college students, and their endorsed relations of the constructs in the IPTS model.
Specifically, I examined the moderating effects of acculturation and enculturation, and
the mediation effects of acculturative stress, on the relation between thwarted belongingness,
perceived burdensomeness, and suicidal risk. I sought to test both the applicability of Joiner’s
theory to a Latino/a college student sample and to clarify the generalizability of IPTS to Latino/a
college students.

13
CHAPTER 2
LITERATURE REVIEW

In this literature review, I define various aspects of suicidal behavior and present the
prevalence of suicide in the United States, specifically as these pertain to Latino/a college
students. I also review research published in support of Thomas Joiner’s Interpersonal-
Psychological Theory of Suicide (IPTS). Finally, I specifically examine how the IPTS constructs
apply to Latino/a college students, and assess the direct and indirect effects that culturally
relevant constructs for Latino/as (acculturation, enculturation, and acculturative stress) have on
the relation between IPTS constructs and Latino/a college students’ reported past, present, and
future suicidal risk.
Definition of Suicidal Behavior and Associated Constructs

Beginning in the mid-1990s (O’Carroll. Berman, Maris, Moscicki, Ranney, & Silverman,
1996) and continuing through today (Rogers & Lester, 2010; Silverman, Berman, Sanddal,
O’Carroll, & Joiner, 2007), there has been a call for a more explicit, standardized, and
generalizable definition of suicidal behavior. Suicidology is defined as the scientific study and
control of self-destructive behavior (Maris, in press), but in the discipline of psychology, the
understanding of what constitutes self-destructive or suicidal behavior has been dependent on
varying nomenclature, and inconsistently defined by clinicians, researchers, policy makers, and
epidemiologists (Silverman et al., 2007).

De Leo, Burgis, Bertolote, Kerkhof, & Bille-Brahe (2006) provided historical definitions
of suicide that included four common and focused themes: 1) the outcome of the behavior; 2) the
agency of the act; 3) the intention to die; and, 4) an awareness of the outcomes of the behavior.
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These four criteria guide the proposed nomenclature that I believed should be used in suicide
research, and are how I differentiate, in my study, among suicidal ideation, suicide attempts, and
completed suicide. My definition of suicidal ideation will be based in Joiner’s (2005) and
Silverman et al.’s (2007) shared conceptualization; suicidal ideation includes passive (e.g. “I
would be better off dead.”) or active (“I want to kill myself.”) thoughts of suicide. Within my
study, suicidal ideation will be defined as any communications, threats, or plans which verbally
or nonverbally impart, convey, or transmit a desire or intent for future suicidal behavior, but
with no direct self-injurious act or component (Silverman et al., 2007, p. 268).

Suicidal behavior includes both non-lethal and lethal suicide attempts and differs from
the idea of ‘self-harm’ (e.g., controlled cutting of the self or other injurious behaviors), in that the
victim has an intent to die and an awareness of the lethal consequences of their behavior. Suicide
attempts can result in no injuries, injuries, or death. Within my study, I will define a non-lethal
suicide attempt as: a self-inflicted, potentially injurious act with an intent to die, but that has a
non-fatal outcome (Silverman et al., 2007, p. 273). A lethal suicide attempt is synonymous with
completed suicide in that it is: a self-inflicted, potentially injurious act with an intent to die that
had a fatal outcome, resulting in death (Silverman et al., 2007, p. 273). In my study, lethal
suicide attempts resulting in completed suicide will be referenced, generally, as suicide. Non-
lethal attempts and suicidal ideation will be always be specified as such, but will be understood
to be pre-intention acts, possibly preceding, and emphasizing the risk for, a possible completed
suicide in the future.
General Incidence and Prevalence of Suicide in the US
In the United States, across all racial and ethnic groups, suicide continues to be among
the top 10 leading causes of death (AAS, 2016). Specifically, in 2015, 44,193 people committed
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suicide (AAS, 2016). This translates to approximately 1 person committing suicide every 11.9
minutes and an annual prevalence ratio of 13.8: 100,000 in the general U.S. population. For
college-aged persons (18 – 24) in the U.S., suicide is the second leading cause of death, behind
deaths categorized as the result of unintentional injury (CDC, 2014).
Although suicide base rates have remained constant for over the past hundred years, the
theoretical understanding of suicide within the field has remained stagnant, with researchers still
striving to understand who commits suicide and why (Maris, in press; Rogers & Lester, 2010). In
his most recent review of the history of suicide, Maris (in press) highlights the fact that the
absolute number of suicides completed each year has increased as the U.S. population has
increased (32,533 suicides in 2005, 38,364 in 2010, and 41,148 in 2013), but that the overall base
ratio of prevalence has remained steady at approximately 11 to 12 completed suicides per
100,000 people annually. Ninety percent of these suicides were committed by European
Americans (AAS, 2016), and the majority of our data and knowledge surrounding suicide is
representative of this same racial group, which fails to advance our understanding regarding
individual and racial group differences in suicidality for people of color. Traditionally, suicide
research holds the case of the middle aged, European American male as the prototypical victim
of suicide, yet modern suicidologists have simultaneously acknowledged the less understood
racial group differences in suicide, with some cultures of color evincing lower incidence rates
and prevalence ratios (Maris, Berman, & Silverman, 2000).
Suicide and people of color
The suicide rate of African American men is one-third of that of European American men
(AAS, 2016). This fact is surprising in that people of color have suffered (and still experience)
significant discrimination and oppression (Davidson et al., 2010). Generally, although people of
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color face more social, economic, and psychological adversity on average than European
Americans, statistics reflect that they are committing suicide at a fraction of the rate that
European Americans are (Maris, Berman, & Silverman, 2000). One explanation for this disparity
of suicide rates among different races could be that outcome statistics reflect a lower completion
of suicide, but not necessarily a lower rate of attempts or risk for suicide amongst people of color
and students of color (Shadick, Backus, & Babot, 2015). This observation is demonstrated in
research regarding the Latino/a population. In 2015, 3,303 Latino/a Americans completed suicide
as compared to 39,796 completed by European Americans (AAS, 2016). Although the ratio of
completed Latino/a suicide (5.8/100,000 base rate) is comparably lower than that for European
Americans (15.8/100,000), Latino/a Americans have a higher attempt rate than other racial
groups, especially among adolescents and young adults (CDC, 2014; SAMHSA, 2014). This
higher attempt rate by young Latino/as suggests the need for greater sensitivity to cultural
differences within suicide research, and also the need for investigators to better account for
multivariate cultural identities and the possible interactions of age, culture, and sex in suicide
risk assessment.
Suicide and college-aged populations
One group often sampled in suicide research due to convenience, but seldom
acknowledged directly as an intended focus sample, is that of college-aged young adults. A
common practice in research on suicide is to sample college students at a university setting as to
their suicidal behavior, and attempt to generalize these findings across other populations of
interest. However, it is important to acknowledge that this age group and population presents its
own unique concerns regarding suicide prevalence and behavior.
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There are no federal requirements that require higher education institutions to report the
number of attempted or completed suicides on college campuses, and as a result, researchers
argue that knowledge of college student suicide prevalence is incomplete and often estimated by
data obtained within a few select studies, from a comparatively small sample of campuses
(Christensen, 2011). Therefore, college students, in particular, may exhibit unique risks for, and
protective factors against, completing suicide.
A recent review of college student suicide by Schwartz (2011) found that college
students are less likely to complete suicide than their non-student, same-aged peers (7/100,000
vs. 12.1/100,000). However, the percentage of full-time college students who have seriously
considered suicide has been gradually increasing each year, with 6.6 % reporting suicidal
ideation in 2012, and 8.0 % reporting suicidal ideation in 2013 (SAMHSA, 2014). Researchers
have indicated that college students often have more low or no-cost mental health treatment
services available to them, possibly leading to their lower rate of suicide completion (Hass,
Hendin, & Mann, 2003). As well, although the campus environment can allow for more direct
and proximal ways to serve those in need of counseling, the college experience itself can be a
stressor that potentially increases suicidal risk among students. Arria et al. (2009) highlighted the
ways in which suicidal behavior among college students may be unique to this population given
the developmental transitions that occur in college and young adulthood. Changes in family
relationships, peer contexts and social support, as well as increased opportunities for alcohol and
drug use typically take place during this developmental phase of life. Various environmental
issues on campus, such as the high incidence of sexual assault within college environments
(Krebs, Lindquist, Warner, Fisher, & Martin, 2009), may affect suicidal behavior (Bryan,
McNaughton, Cassill, Osma, & Hernandez, 2013; Tomasula, Anderson, Littleton, & Riley-