Relationship between family history of mandatory boarding school experiences and suicide risk in US reservation-based Native American youth: a cross-sectional analysis.

INTRODUCTION: Suicide is a leading cause of death among Native American youth and adolescents in the USA. A myriad of factors have been correlated with risk for suicide ideation (SI)/suicide attempt (SA), including historical trauma; however, accurate measurement of historical trauma has been inconsistent. OBJECTIVE: To examine the association of family history of a negative mandatory boarding school experience with SI and SAs. METHODS: An anonymous online survey was conducted with 288 Native youth aged 15-24 years from the Fort Peck Reservation in Montana. Multinomial regression was applied adjusting for other known risk and protective factors of SI and SAs. RESULTS: Thirty-five percent reported past SAs and 15% reported ideation without prior attempt. Of the 129 (45%) reporting a family history of mandatory boarding school experiences, 28% perceived the experience as positive while 22% as negative. After adjusting for risk and protective factors, both SI and SAs were associated with a family history of negative mandatory boarding school experiences (adjusted OR (AOR)=4.8 and 4.3, respectively) and polydrug use (AOR=3.6 and 2.3). SAs were also associated with post-traumatic stress disorder (AOR=2.6) and depressive symptoms (AOR=3.6). CONCLUSION: The association between family history of negative mandatory boarding school experiences and SI and SAs implies that culturally responsive interventions are needed to reduce the intergenerational impacts of historical trauma.

Tribal Reservation Adolescent Connections Study: A study protocol using mixed methods for examining social networks and associated outcomes among American Indian youth on a Northern Plains reservation.

BACKGROUND: Rich cultural and traditional practices make interpersonal relationships vital for American Indian (AI) youth. Social relations and multigenerational networks (i.e., peer, family, kinship, and community) remain a salient fixture of AI culture, survival and thriving in reservation communities. Research in other populations has demonstrated how social networks impact youth risk and resilience, but data are lacking on AI adolescent networks. Intergenerational trauma from settler colonialism leads some AI youth to early initiation of substance use and subsequent substance misuse, along with disproportionately high risk for suicide and vulnerability to witnessing and experiencing violence. Using network data to develop prevention strategies among this population is a promising new avenue of research. In this study protocol paper, we describe the rationale and methodology of an exploratory study to be conducted with American Indian 9th and 10th graders at three schools on a Northern Plains reservation. METHODS: This mixed methods study will collect quantitative social network surveys (N = 300) and qualitative interviews (n = 30). The study will examine the extent to which existing social network theories and data metrics adequately characterize AI youth networks or how they may need to be expanded for this population. Associations of network characteristics with risk and protective factors for substance use, exposure to violence, and suicide will also be examined. DISCUSSION: This innovative methodological approach holds promise for informing the development of effective preventive approaches to address co-occurring risks for substance use, violence and suicide among AI adolescents. Understanding processes that impact social networks among AI adolescents can promote culturally resonant social relationships that may support better outcomes for youth.

Unsettling Settler Colonialism in Research: Strategies Centering Native American Experience and Expertise in Responding to Substance Misuse and Co-occurring Sexual Risk-Taking, Alcohol-Exposed Pregnancy, and Suicide Prevention Among Young People.

Native American (NA) populations in the USA (i.e., those native to the USA which include Alaska Natives, American Indians, and Native Hawaiians) have confronted unique historical, sociopolitical, and environmental stressors born of settler colonialism. Contexts with persistent social and economic disadvantage are critical determinants of substance misuse and co-occurring sexual risk-taking and suicide outcomes, as well as alcohol exposed pregnancy among NA young people (i.e., adolescents and young adults). Despite intergenerational transmission of resistance and resiliencies, NA young people face continued disparities in substance misuse and co-occurring outcomes when compared to other racial and ethnic groups in the USA. The failure in progress to address these inequities is the result of a complex set of factors; many of which are structural and rooted in settler colonialism. One of these structural factors includes barriers evident in health equity research intended to guide solutions to address these disparities yet involving maintenance of a research status quo that has proven ineffective to developing these solutions. Explicitly or implicitly biased values, perspectives, and practices are deeply rooted in current research design, methodology, analysis, and dissemination and implementation efforts. This status quo has been supported, intentionally and unintentionally, by researchers and research institutions with limited experience or knowledge in the historical, social, and cultural contexts of NA communities. We present a conceptual framework illustrating the impact of settler colonialism on current research methods and opportunities to unsettle its influence. Moreover, our framework illustrates opportunities to resist settler colonialism in research. We then focus on case examples of studies from the Intervention Research to Improve Native American Health program, funded by the NIH, that impact substance use and co-occurring health conditions among NA young people.

Grounding evidence-based prevention within cultural context: promising effects of substance use prevention adapted for American Indian families.

Background: Effective substance use prevention strategies are needed for American Indian (AI) youth, who face disproportionate risk for early substance use and consequently bear a disproportionate burden of health and developmental disparities related to early use. With few exceptions, significant advances in prevention science have largely excluded this population, leaving gaps in the evidence of effective practice. This paper builds on emerging efforts to address this gap, reporting first outcome findings from an evidence-based early substance use prevention program culturally adapted for young adolescents on a Northern Plains reservation. Methods: Using a community-based participatory approach, the Thiwáhe Gluwás'akapi Program (TG, sacred home in which family is made strong) was developed by embedding cultural kinship teachings within the Strengthening Families Program for Parents and Youth 10-14 and aligning other elements of program content with local culture and context. Results: Results of pre and post comparisons of proximal program outcomes showed that youth reported significant improvements in parental communication about substance use, substance use resistance skills, stress management, family cohesion, and overall well-being. Adults reported improvements in a wide array of parenting behaviors and indicators of family dynamics. Conclusions: These findings provide an initial glimpse into the potential effects of the TG program and suggest that it holds promise for helping AI families address risks for youth substance use through positive impacts on modifiable risk and protective factors documented to influence early substance use.

Conceptualizing Indigenous strengths-based health and wellness research using group concept mapping.

BACKGROUND: In recent years public health research has shifted to more strengths or asset-based approaches to health research but there is little understanding of what this concept means to Indigenous researchers. Therefore our purpose was to define an Indigenous strengths-based approach to health and well-being research. METHODS: Using Group Concept Mapping, Indigenous health researchers (N = 27) participated in three-phases. Phase 1: Participants provided 218 unique responses to the focus prompt "Indigenous Strengths-Based Health and Wellness Research…" Redundancies and irrelevant statements were removed using content analysis, resulting in a final set of 94 statements. Phase 2: Participants sorted statements into groupings and named these groupings. Participants rated each statement based on importance using a 4-point scale. Hierarchical cluster analysis was used to create clusters based on how statements were grouped by participants. Phase 3: Two virtual meetings were held to share and invite researchers to collaboratively interpret results. RESULTS: A six-cluster map representing the meaning of Indigenous strengths-based health and wellness research was created. Results of mean rating analysis showed all six clusters were rated on average as moderately important. CONCLUSIONS: The definition of Indigenous strengths-based health research, created through collaboration with leading AI/AN health researchers, centers Indigenous knowledges and cultures while shifting the research narrative from one of illness to one of flourishing and relationality. This framework offers actionable steps to researchers, public health practitioners, funders, and institutions to promote relational, strengths-based research that has the potential to promote Indigenous health and wellness at individual, family, community, and population levels.

Understanding opioid use within a Southwestern American Indian Reservation Community: A qualitative study.

PURPOSE: Morbidity and mortality due to nonprescription use of opioids has been well documented following the significant increase in the availability of prescription opioids in the early 2000s. The aim of this paper is to explore community beliefs about correlates of opioid risk, protective factors, and behavioral functions of opioid misuse among American Indian youth and young adults living on or near a reservation. METHODS: Qualitative in-depth interviews were conducted with N = 18 youth and young adults who were enrolled in a parent research trial focused on American Indian youth suicide prevention. Participants were eligible if they endorsed the use of opioids themselves or by close friends or family members at any point during their trial participation. FINDINGS: Major themes discussed include: (1) description of opioid use and those who use opioids; (2) acquisition; (3) initiation; (4) motivation to continue using; (5) consequences; and (6) possibilities for intervention. Family played an important role in the initiation of use, but was also highlighted as an important factor in treatment and recovery. A need for upstream prevention methods, including increased employment and after-school activities, was described. CONCLUSIONS: The insights gained through this work could help to inform treatment and prevention programs in the community. This work is timely due to the pressing urgency of the opioid epidemic nationally, and community capacity to address opioid use locally.

Measure of Socialization of American Indian Children (MOSAIC): Understanding the roots of ethnic-racial identity.

OBJECTIVES: The Measure of Socialization of American Indian Children (MOSAIC) was created as part of a larger study developing a family-based and culturally grounded substance use prevention program for young American Indian (AI) adolescents. The MOSAIC was designed to measure ethnic-racial socialization (ERS) for use with AI families to support better understanding of the roots of ethnic-racial identity among AI youth and their relationship to risk for substance use in early adolescence. METHOD: This study was conducted in partnership with a Lakota reservation community. Community partners and advisors provided guidance on the creation of an item pool, which also drew extensively from the existing literature on ERS in other populations. The MOSAIC was pilot tested with a small sample of parents (N = 19) and then tested with a development sample of participants (N = 197) taking part in the larger study. A series of factor analyses were conducted with data from this development sample to explore associations among items and alignment with proposed dimensions. RESULTS: Four dimensions emerged, related to socialization practices to support spirituality, language, pride, and preparation for bias. The original MOSIAC measure was refined based on these analyses and prepared for testing in an independent sample. CONCLUSIONS: Dimensions of ERS common to measures developed for other populations emerged as relevant for AI families, with adaptations to reflect the unique context of this population. Further work is needed to confirm the structure of the MOSAIC in both this AI community and with other diverse indigenous populations. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Empowering American Indian and Alaska Native youth to lead measurement development of an indigenous adolescent wellbeing measure: A protocol paper.

Background: American Indian and Alaska Native youth research has rarely included young people from within these populations as co-designers. In addition to the lack of youth involvement, most findings focus on presenting statistics around disparity vs. focusing on this population's unique strengths and resiliency. The research design of this protocol aims to fill this gap in the current literature. Methods: To address this discrepancy, a multipronged approach to youth and young adult participatory research was implemented. These prongs included a virtual gathering where the Nominal Group Technique was conducted and an assembly of a Youth Research Design Team. Lastly, the research team will implement a protocol developed by the Research Design Team. The Research Design Team plans to conduct qualitative interviews and distribute a web-based quantitative survey with a raffle as respondent compensation. This protocol is a preliminary phase to developing a wellbeing measure for AIAN youth. Discussion: Having an operationalized definition of wellness from AIAN youth will fill a gap in the current body of research with optimism that this will lead to additional studies exploring the AIAN youth voice.

Development of "CULTURE FORWARD: A strengths and culture-based tool to protect our native youth from suicide".

OBJECTIVE: Indigenous knowledge and practices promote American Indian/Alaska Native (AI/AN; Native) communities' health and well-being. Historical losses and continued oppression have resulted in disproportionately higher AI/AN youth suicide rates. This article describes the development of a new national resource guide titled "CULTURE FORWARD" for tribal leaders and stakeholders to support youth suicide prevention efforts through cultural strengths. METHOD: The CULTURE FORWARD guide was developed over 6 months through a community-engaged process. We conducted nine roundtables and eight interviews with a wide variety of community members, leaders, and providers representing 36 diverse tribal communities and geographic regions. Participants discussed AI/AN youth risk and protective factors, successful community efforts to prevent suicide, and content and dissemination ideas. A comprehensive literature review complemented qualitative findings. A diverse and representative National Advisory Editorial Board guided content and design throughout development. RESULTS: Qualitative data were analyzed iteratively and thematically. Across all listening sessions, culture was identified as a key protective factor against AI/AN youth suicide. Five themes related to cultural strengths informed guide chapters. Each chapter includes an introduction; how that theme helps prevent Native youth suicide; a review of academic literature, community stories and programs; action steps; and additional resources. CONCLUSIONS: CULTURE FORWARD honors and empowers communities by weaving strands of knowledge, stories, and practical resources highlighting Native communities' strengths to protect against Native youth suicide. The guide is free online and print copies are being distributed nationally. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Cultural Protection from Polysubstance Use Among Native American Adolescents and Young Adults.

Reservation-based Native American youth are at disproportionate risk for high-risk substance use. The culture-as-treatment hypothesis suggests aspects of tribal culture can support prevention and healing in this context; however, the protective role of communal mastery and tribal identity have yet to be fully explored. The objectives of this study were to investigate (1) the relationship between cultural factors and high-risk substance use, which includes polysubstance use, early initiation of alcohol and illicit drugs, and binge drinking, and (2) substance use frequency and prevalence of various substances via cross-sectional design. Multiple logistic regression modeling was used to analyze data from 288 tribal members (15-24 years of age) residing on/near the Fort Peck Reservation in the Northern Plains. When controlling for childhood trauma and school attendance, having at least a high school education (OR = 0.434, p = 0.028), increased communal mastery (OR = 0.931, p = 0.007), and higher levels of tribal identity (OR = 0.579, p = 0.009) were significantly associated with lower odds of polysubstance use. Overall prevalence of polysubstance use was 50%, and binge drinking had the highest single substance prevalence (66%). Prevalence of early initiation of substances (≤ 14 years) was inhalants (70%), alcohol (61%), marijuana (74%), methamphetamine (23%), and prescription drug misuse (23%). Hydrocodone, an opioid, was the most frequently misused prescription drug. Findings indicate programs focused on promoting education engagement, communal mastery, and tribal identity may mitigate substance use for Native American adolescents living in high-risk, reservation-based settings.

Increasing Native Research Leadership Through an Early Career Development Program.

Inequities impact American Indian, Alaska Native, and Native Hawaiian populations across various health conditions; in particular, many Native communities bear a disproportionate burden of substance use disorder. Such inequities persist despite concerted efforts of communities and significant research directed toward prevention and intervention. One factor hampering these efforts is the underrepresentation of researchers who are themselves Native and uniquely equipped to respond to the needs of their communities. This paper describes the innovative Native Children's Research Exchange (NCRE) Scholars program, now entering its ninth year of successful career development support for emerging Native scholars. We summarize the history of NCRE Scholars, outline the mentoring and training approaches taken to meet the unique needs of early-career Native scholars, and present key progress of program alumni. The current cohort of Scholars provide first-person perspectives on how four key program elements have supported their career development to date. NCRE Scholars has been an effective approach for supporting the next generation of Native research leaders and for helping to build an essential mass of Native researchers prepared to respond to Native community health priority needs.

Social Network Differences Between American Indian Youth Who have Attempted Suicide and Have Suicide Ideation.

Suicide is a crucial public health concern for American Indian and Alaska native (AIAN) communities. AIANs have the highest suicide rate compared to all other ethnic groups in the United States. Social relations are a salient fixture of AIAN culture. The primary aims of this study were to describe the personal networks of AI youth that have recently had a suicide attempt or suicidal ideation and to identify key network differences between the two groups. This study uses personal networks collected among AIs living on a reservation in the Southwest. Our sample included 46 American Indians that have recently attempted suicide or had suicidal ideation. We explored social network characteristics of the two groups descriptively as well as comparatively (t-tests). Our findings suggest that AI youth that have attempted suicide nominate more friends in their networks that have used alcohol and drugs compared to the networks of AI youth that have recent suicide ideation. Additionally, AI youth that recently attempted suicide have used alcohol and drugs with their network peers at a higher rate than youth that have had recent suicide ideation. Lastly, AI youth that have attempted suicide recently were significantly more likely to have more nominated friends in their networks that they had reached out to when they were struggling with suicide compared to their peers that have experienced recent suicide ideation. These results indicate a promising method moving forward to identify unique intervention strategies that extend beyond the individual.

Crisis-Resilient and Antiracist Approaches to Community-Based Participatory Research During COVID-19 and Beyond.

Social and health inequities among communities of color are deeply embedded in the United States and were exacerbated by the COVID-19 pandemic. Community-based participatory research (CBPR) is a powerful approach to advance health equity. However, emergencies both as global as a pandemic or as local as a forest fire have the power to interrupt research programs and weaken community relationships. Drawing from Public Health Critical Race Praxis (PHCRP), as well as our research experience during the pandemic, this article proposes an expansion of prior CBPR principles with an emphasis on advocacy and storytelling, community investment, and flexibility. The article summarizes key principles of CBPR and PHCRP, contextualizes their relevance in COVID-19, and outlines a practical vision for crisis-resilient research through deeper engagement with antiracism scholarship. Structural barriers remain an issue, so policy changes to funding and research institutions are recommended, as well, to truly advance health equity.

Community Perspectives on Social Influences on Suicide Within a Native American Reservation.

Relative to the general population, Native Americans (NA) bear a disproportionate burden of suicide-related mortality rates. NA males and females aged 15 to 24 years experience suicide rates nearly 3 times than the U.S. all races rates in this age group. Although efforts have been made to understand and reduce suicide in tribal communities, a large portion has focused on individual characteristics with less attention given to social factors that may also inform suicide. This article aims to build on a local conceptual model of NA youth suicide by examining additional potential social factors through qualitative interviews. Findings from the thematic analysis resulted in the identification of seven perceived social influences: contagion, violence and abuse, discrimination and bullying, negative expectations, spirituality, social support, and cultural strengths. Public health approaches to reduce suicide should consider local social factors that resonate with tribal communities to build resilience.

Balancing cultural specificity and generalizability: Brief qualitative methods for selecting, adapting, and developing measures for research with American Indian communities.

Culturally appropriate, valid and reliable measures are critical to assessing how interventions impact health. There is a tension between measures for specific cultural settings versus more general measures that permit comparisons across samples. We illustrate a feasible approach to measurement selection, adaptation and testing for a study of brief interventions to prevent suicide among American Indian youth ages 10-24. We used a modified Nominal Group Technique (NGT) with N = 7 Apache Community Mental Health Specialists (CMHS') to elicit priority impacts of interventions under study. We then tested the reliability and validity in N = 93 youth at baseline. The NGT results included selection of alternative measures, item removal and addition, and creation of a local well-being index. Measurement testing indicated excellent to good internal consistency (α: 0.82-0.96) and strong construct validity. Study results demonstrate a feasible approach to balancing cultural specificity and generalizability while producing valid and reliable measures to use in an intervention trial. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Suicide and the opioid overdose crisis among American Indian and Alaska Natives: a storm on two fronts demanding swift action.

The opioid crisis in the United States has received national attention and critical resources in the past decade. However, what has been overlooked is the effect the opioid crisis may be having on a three-decade suicide crisis among American Indian and Alaska Native (AIAN) communities that already have too few resources to address behavioral and mental health issues. This paper describes recent epidemiological trends associated with both opioid overdose and suicide at a national level for AIANs and the rest of the United States. We used data reported by the Centers for Disease Control and Prevention to report historical trends of opioid overdose and suicide for AIAN and non-AIAN populations. We found alarming and potentially correlated trends of opioid use and suicidality among AIAN populations. We highlight both current and future research that will be essential to understanding and addressing the unique intersection between opioid and suicide risk and protective factors to inform dual prevention and intervention efforts among AIAN populations with potential relevance to public health response among other at-risk populations.

From "Fast Friends" to True Friends: Can a Contact Intervention Promote Friendships in Middle School?

The protective role of friendships in middle school is well established, yet no research to date has examined how to build friendships among middle school peers. In the present research, we adapted the Fast Friends procedure for inducing interpersonal closeness to promote friendships among students (n = 301) in middle school. Given the growing diversity in the K-12 population and the benefits of cross-ethnic friendships for ethnic majority and minority youth, we examined whether the intervention was equally effective at fostering same- and cross-ethnic friendships. Results indicated that the intervention successfully increased interpersonal closeness and friendships for participants in both same- and cross-ethnic conditions. Implications for using Fast Friends to promote the healthy social development of adolescent youth are discussed.

Pathways of Adaptation: Two Case Studies with One Evidence-Based Substance Use Prevention Program Tailored for Indigenous Youth.

Indigenous communities often face disproportionate challenges across a variety of health domains, and effective prevention strategies are sorely needed. Unfortunately, evidence is scant regarding what approaches are effective for these communities. A common approach is to take an evidence-based practice or program with documented effectiveness in other populations and implement it with Indigenous populations. While a science of intervention adaptation is emerging, there remains little guidance on processes for adaptation that strategically leverage both existing scientific evidence and Indigenous prevention strategies. In this paper, two case studies illustrate promising practices for adaptation, documenting the approaches of two research teams funded under the National Institutes of Health's initiative to support Intervention Research to Improve Native American Health (IRINAH). These teams worked with distinct Indigenous populations in the USA and Canada to culturally adapt the same prevention program, the Iowa Strengthening Families Program for Parents and Youth 10-14. The approaches of these two teams and the programs that resulted are compared and contrasted, and critical elements of adaptation in partnership with Indigenous communities are discussed.

Employing a sequential multiple assignment randomized trial (SMART) to evaluate the impact of brief risk and protective factor prevention interventions for American Indian Youth Suicide.

BACKGROUND: This study is built on a long-standing research partnership between the Johns Hopkins Center for American Indian Health and the White Mountain Apache Tribe to identify effective interventions to prevent suicide and promote resilience among American Indian (AI) youth. The work is founded on a tribally-mandated, community-based suicide surveillance system with case management by local community mental health specialists (CMHSs) who strive to connect at-risk youth to treatment and brief, adjunctive interventions piloted in past research. METHODS: Our primary aim is to evaluate which brief interventions, alone or in combination, have the greater effect on suicide ideation (primary outcome) and resilience (secondary outcome) among AI youth ages 10-24 ascertained for suicide-related behaviors by the tribal surveillance system. We are using a Sequential Multiple Assignment Randomized Trial with stratified assignment based on age and suicidal-behavior type, and randomizing N = 304 youth. Brief interventions are delivered by AI CMHSs, or by Elders with CMHS support, and include: 1) New Hope, an evidence-based intervention to reduce immediate suicide risk through safety planning, emotion regulation skills, and facilitated care connections; and 2) Elders' Resilience, a culturally-grounded intervention to promote resilience through connectedness, self-esteem and cultural identity/values. The control condition is Optimized Case Management, which all study participants receive. We hypothesize that youth who receive: a) New Hope vs. Optimized Case Management will have significant reductions in suicide ideation; b) Elders' Resilience vs. Optimized Case Management will have significant gains in resilience; c) New Hope followed by Elders' Resilience will have the largest improvements on suicide ideation and resilience; and d) Optimized Case Management will have the weakest effects of all groups. Our secondary aim will examine mediators and moderators of treatment effectiveness and sequencing. DISCUSSION: Due to heterogeneity of suicide risk/protective factors among AI youth, not all youth require the same types of interventions. Generating evidence for what works, when it works, and for whom is paramount to AI youth suicide prevention efforts, where rates are currently high and resources are limited. Employing Native paraprofessionals is a means of task-shifting psychoeducation, culturally competent patient support and continuity of care. TRIAL REGISTRATION: Clinical Trials NCT03543865, June 1, 2018.

Community mobilization for rural suicide prevention: Process, learning and behavioral outcomes from Promoting Community Conversations About Research to End Suicide (PC CARES) in Northwest Alaska.

RATIONALE: This study evaluates the process and preliminary outcomes of Promoting Community Conversations About Research to End Suicide (PC CARES), an intervention that brings key stakeholders together so they can discuss suicide prevention research and find ways to put it into practice. Originally piloted in remote and rural Alaskan communities, the approach shows promise. METHOD: Using a multi-method design, the study describes a series of locally-facilitated "learning circles" over 15 months and their preliminary results. Sign-in sheets documented participation. Transcriptions of audio-recorded sessions captured facilitator fidelity, accuracy, and the dominant themes of community discussions. Linked participant surveys (n=83) compared attendees' perceived knowledge, skills, attitudes, and their 'community of practice' at baseline and follow-up. A cross-sectional design compared 112 participants' with 335 non-participants' scores on knowledge and prevention behaviors, and considered the social impact with social network analyses. RESULTS: Demonstrating feasibility in small rural communities, local PC CARES facilitators hosted 59 two to three hour learning circles with 535 participants (376 unique). Local facilitators achieved acceptable fidelity to the model (80%), and interpreted the research accurately 81% of the time. Discussions reflected participants' understanding of the research content and its use in their lives. Participants showed positive changes in perceived knowledge, skills, and attitudes and strengthened their 'community of practice' from baseline to follow-up. Social network analyses indicate PC CARES had social impact, sustaining and enhancing prevention activities of non-participants who were 'close to' participants. These close associates were more likely take preventive actions than other non-participants after the intervention. CONCLUSION: PC CARES offers a practical, scalable method for community-based translation of research evidence into selfdetermined, culturally-responsive suicide prevention practice.