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Weaving Culture into Suicide Prevention Strategies
Four Recommendations for Tribal Suicide Prevention
Honoring Culture and Building Partnerships
Adapting Evidence Based Practices in Tribal Communities


Working with Native Communities
Information Hub: Adverse Childhood Experiences (ACEs) in Indian Country
Toolkit for Modifying Evidence-Based Practices to Increase Cultural Competence (55 page PDF)
Guidance for Culturally Adapting Gatekeeper Trainings


Working with Native Communities

To effectively prevent suicide among American Indians and Alaska Natives (AI/AN), we must learn to appreciate the uniqueness and build upon the strengths of each tribe, nation, and community. Evidence-based suicide prevention practices need to be tailored for the community and context in which they will be used. There are important differences in the scope and patterns of suicidal behaviors in individual AI/AN communities as well as in the cultural contexts in which prevention programs take place. My experiences growing up in and working with tribal communities and pueblos in the Southwest is different from those of someone living and working with Native communities in other parts of the country. Communities can also have important experiential differences. For example, working with an AI/AN community that has experienced a suicide cluster among its young people will present challenges—and opportunities—that are different from those in a community that has not faced this specific type of trauma.

One way to learn about a community’s culture and the strengths it can bring to suicide prevention activities is to engage in “community-based participatory prevention.” This approach brings community members into the process of developing a suicide prevention program that reflects their culture and beliefs. Community members can help us understand what our own experience and the scientific literature cannot teach us. There are three points that we as suicide prevention practitioners need to remember when we begin this conversation.

First, it is essential to understand a community’s taboos—what community members feel is inappropriate to talk about—and how a prevention program can address issues that are not traditionally discussed. For example, some tribal cultures believe talking about people who have died can impede their path to moving on. And people from many cultures, including some AI/AN traditions, believe that talking about death or other unwanted events can cause them to happen. I once worked with a community that created a protocol for responding to suicide. When a community member then died by suicide, some people felt that we caused a suicide by preparing for one. A reluctance to talk about suicide and death is neither universal among AI/AN cultures nor unique to these cultures. It is essential to understand what cannot be discussed openly in a community and how our suicide prevention messages can be reframed to be effective in the context of that culture. Some tribal communities have addressed this problem by engaging in suicide prevention activities that emphasize life instead of death. For example, on World Suicide Prevention Day, the GLS program in San Felipe Pueblo in New Mexico held a “We Are Resilient” walk rather than a suicide prevention walk. This simple name change helped attract many people in support of an event that highlighted the strengths and resilience of their community.

The second important point we need to remember when working with AI/AN communities is to understand why some communities and families may be reluctant to collect and share data on death and suicide. Many AI/AN communities have seen information about problems in their communities used to perpetuate stereotypes rather than solve problems. Yet some AI/AN communities have come to understand how the use of data can benefit them. The White Mountain Apache Tribe has developed and implemented a suicide surveillance system that is saving lives in their community and has become a model of how data can be used to prevent suicide.

The third point is the importance of talking about community strengths and resilience in every conversation. We often spend too much time talking about suicide rates and risk factors in a community, while ignoring its strengths, abilities, and assets. Books, media reports, and the scientific literature on AI/AN people are far too often filled with negative stereotypes about poverty, substance abuse, and rates of chronic illness such as diabetes. Native people can internalize these negative stereotypes. It is essential to remember that there are strengths in AI/AN communities, peoples, and cultures. These could include family and community connections, respect for elders and traditional knowledge, and a concern for future generations. Working with a community to discover and use its unique strengths and assets is an essential part of helping AI/AN communities create suicide prevention programs that can help their members to sustain their communities.

Information Hub: Adverse Childhood Experiences (ACEs) in Indian Country

Adverse Childhood Experiences (ACEs) are common. Many Tribal individuals, families, and communities have been impacted by childhood experiences causing physical and mental health adversities throughout the lifespan. This Information Hub includes brief education and resources to increase awareness and knowledge of ACEs and will increase Indian Country's capacity to address these adversities.

Introduction and Contents

This Information Hub is the result of a partnership between the Centers for Disease Control and Prevention (CDC) and the National Indian Health Board (NIHB). This Hub includes a "resource basket" designed for AI/AN individuals, families, communities, professionals, and leaders to rummage through, harvesting resources. This Hub can assist Tribes to learn more about ACEs, research, tools, and interventions. Additionally, NIHB plans to continue weaving into the basket, adding more resources and building on this resource in the future.

The Hub contains the following sections:

  • Background Information on ACEs
  • A Word on the Content, Hope, and Healing
  • How are ACEs Relevant to Me?
  • ACE Assessments
  • Success Story
  • Resource Basket for American Indian and Alaska Native Communities
    • Peer-Reviewed Articles about ACEs and AI/ANs
    • How Communities are Adapting and Integrating Research Findings
    • General ACE Resources
    • Accessible Tools used in Peer-Reviewed AI/AN Research
  • ACE Trainings

This resource was developed through the support from a cooperative agreement between the Centers for Disease Control and Prevention and the National Indian Health Board (CDCOT18-1802, Grant #NU38OT000302). The findings and conclusions presented in this resource are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention, the Department of Health and Human Services, or the U.S. government.

For more information about the ACES Information Hub, contact Courtney Wheeler,, 202-507-4081.

Background Information on ACEs

Mary grew up one of three children. Her father was an alcoholic and her mother suffered from depression. They lived in a remote area on a reservation and where there were few opportunities. Both parents struggled with finding and keeping employment and the family was very poor. Sometimes, there was not enough money to buy food or heat their home. Because her parents were sick, they sometimes did not take adequate care of the children, leaving Mary with no attention, care, or support. Mary and her siblings were often bullied by classmates. Because of all these issues, Mary had trouble paying attention in school so she often earned poor grades and got into fights. When she got in trouble at school, her father sometimes hit her. When Mary was in middle school, her mother attempted suicide. Fortunately, she recovered, but Mary's family was deeply affected and her dad left. This story is a fictional example, but reflects realities that many American Indian/Alaskan Natives experience.

How many of us have been affected by suicide? Divorce? Violence at home? Substance abuse? Poverty? Lack of opportunities? In Western society, these experiences are commonly described as ACEs, or Adverse Childhood Experiences.

The health impacts of ACEs first came to light during a groundbreaking study conducted by the CDC and Kaiser Permanente between 1995 and 1997. This study identified relationships between the breadth of the exposure to abuse or household challenges during childhood and multiple risk factors for several of the leading causes of death in adults (Felitti, Anda, & Nordenberg, 1998). This study is known as the Adverse Childhood Experiences study.

ACEs are potentially traumatic events occurring during childhood (from the ages of 0 to 17) such as experiencing violence, abuse, or neglect; witnessing violence in the home; and having a family member attempt or die by suicide. ACEs also include aspects of a child's environment that can undermine their sense of safety, stability, and bonding such as growing up in a household with substance misuse, mental health problems, or instability due to parental separation or incarceration of a parent, sibling, or other member of the household. Some of the research or resources below also consider other types of ACEs, including historical trauma, bullying, and discrimination. Many AI/AN people have experienced these impacts, even though they are not considered in most traditional, mainstream ACE questionnaires. Adverse Childhood Experiences have been linked to risky health behaviors, chronic health conditions, low life potential, mental health and poor behavioral health outcomes, and early death. As the number of ACEs increases, so does the risk for these outcomes (Centers for Disease Control and Prevention, 2019).

The graphic below shows some of the health consequences of ACEs.

Early Adversity Has Long Lasting Impacts

In addition to experiencing a greater burden of health disparities compared to other Americans, AI/AN people also experience ACEs disproportionately. These health disparities may result from social determinants of health including inadequate education, poverty, and lack of healthcare, but ACEs are implicated as well. ACEs have been shown to affect health and wellbeing in the general population and have likely impacted AI/AN of all ages in ways researchers are only now beginning to understand. The image below shows the general mechanism for how ACEs impact health and wellbeing during an individual's life

Mechanism by which Adverse Childhood Experiences Influences Health and Well-being Throughout the Lifespan

A similar pyramid was published as part of the original ACEs study and there have been several different adaptations, including the one shown above designed by the RYSE Center.

Since 1998, many researchers have used the ACE survey to explore the influence and impact of these experiences on a range of health conditions and populations; however, few of these studies have focused on effects of ACEs within AI/AN populations.

The information hub compiles/organizes known resources about ACEs and AI/AN to share information about the work done to date and making findings, instruments, and recommendations easily available for use.

Indigenizing ACEs

Most research on ACEs has come from outside of indigenous communities using mainstream American values, standards, definitions, and lenses. Therefore, ACEs and ACE interventions in Tribal communities may be different. This Hub contains information on how Tribes are using and implementing work with ACEs. In the future, there may be opportunities to indigenize the framework itself-including the pyramid above, the ACE assessment, and other ACE information to better fit AI/AN populations. This ACE information can be considered foundational and adapted as appropriate to different groups; for example, traditional studies may not have yet shown the impact of inadequate housing as an ACE, but it may still have similar impacts and be relevant to your community.

Below are 2 examples of indigenizing ACEs for Tribal communities . See the Peer-Reviewed Articles about ACEs and AI/ANs section for more examples.

A Word on the Content, Hope, and Healing

This Information Hub and the resources below use candid language to discuss the important topics with the hope that addressing these issues frankly will benefit AI/AN communities. However, this content may be disturbing to people, especially (but not only) those who have directly experienced ACEs.

It is important to understand that the consequences of ACEs are not inevitable-experiencing ACEs does not destine someone for a life of pain or illness. It is not fate that someone will suffer or will not heal from the effects of ACEs. Although ACEs can be used to highlight health risks for individuals and populations overall, many happy, healthy, and successful people have experienced ACEs. Additionally, seeking treatment can combat ACEs' effects on individuals and break the cycle for themselves and their children. It is never too late to get help. It is also worth noting that ACE questionnaires do not typically consider positive factors such as resilience and support or the overall impact of ACEs on any one individual. In other words, an ACE score is an indicator of what happened to a person, not an absolute indicator of how someone functions now or even how ACEs affected or might affect him or her. Understanding this can turn an ACE score into something productive-a way to better understand oneself, one's health, and one's health risks in order to lead a healthy life.

If you find the content here upsetting, please consider seeking help. Primary care providers are able to provide treatment or referrals for trauma and other mental/behavioral health problems related to ACEs. Local resources such as counseling, substance misuse support, and psychiatry may also be available.

The following helplines may be useful. Most are available 24 hours a day and many offer phone, text, and online chat options.

  • National Suicide 800-273-8255
  • StrongHearts Native Helpline (AI/AN specific helpline for domestic/dating violence): 844-762-8483
  • Domestic Violence Hotline: 800-799-7233
  • National Sexual Assault Hotline: 800-656-HOPE (800-656-4673)
  • The Substance Abuse and Mental Health Services Administration (SAMHSA) National Helpline (for mental health/substance abuse treatment referral and information) 800-662-HELP (800-662-4357)
  • Crisis Text Line: Text SOS to 741-741
  • Veterans Crisis Line (for veterans and their friends and family members) call 800-273-8255 and press 1, or text 838255
  • SAFE Alternatives: Self Abuse Finally Ends (for non-suicidal self-harming; not a crisis line): 800-DONTCUT (800-366-8288)
  • (dating concerns, advice, and abuse for teens and young adults): 866-331-8453 or text loveis to 22522
  • In most of the United States, dialing 211 on a phone will reach a referral service connecting individuals to resources addressing a variety of different needs. This service is not available in all areas.
  • As always, call 911 or your local emergency number if you are in immediate danger.

How are ACEs Relevant to Me?

ACEs are relevant to individuals, family and community members, and people in a variety of different occupations and roles.

People Who Have Experienced ACEs

People who have experienced ACEs should be aware of their effects so they can seek appropriate health care when needed. They can also get professional and social support to improve their lives and avoid allowing ACEs to impact their children, families, and futures. Some ACE survivors find they understand themselves better after learning about ACEs and considering their own experiences.

Healthcare Providers

Healthcare providers of all types including traditional practitioners, physicians, nurse practitioners, midwives, nurses, and others-should understand ACEs and their impacts on physical and mental health. This information can help them understand and help their patients efficiently and make appropriate referrals and screenings.

Social Workers and Community Health Workers

Social workers and community health workers can use ACE knowledge to better help their clients, screening for ACEs when appropriate and providing support and referrals. ACEs can also help explain ongoing client challenges, trauma, behavioral challenges, and repeating cycles of violence.

Teachers and Others Working with Children

Teachers and others who work with children are sometimes the first and only individuals outside of a family to recognize when children are currently experiencing ACEs. They can provide initial support and referrals to help the children and their families. Understanding ACEs can also help teachers and others better understand their children's challenges, behaviors, and needs.

Family and Community Members

People who have family members, friends, community members, or coworkers who have experienced ACEs can offer support and help address needs. Sometimes, they can be the first to identify that someone is having problems or needs help. Understanding ACEs can also help people become more patient, offer support and assistance, and prevent further damage.

Tribal Leaders

Tribal leaders should know about ACEs to help understand and support their communities and include ACEs in decision making.

Policy Makers

Policy makers and related experts should understand ACEs to allocate funding to address these needs.

Law Enforcement

Law enforcement staff and others in related roles can use ACE knowledge to efficiently serve their communities. Understanding challenges can help them recognize and address special needs and prioritize support to physical and mental health care services and rehabilitation.


Everyone should know about ACEs! Their impact on individuals and on our communities is important.

Who can ask about ACEs?

No credentials are needed to administer an ACE's questionnaire. Any provider can use ACEs and ACE tools to make a difference for clients. However, it IS important to know how to respond and have the appropriate skills and resources to follow up. It can be emotional, difficult, or painful for clients to disclose their ACE scores, especially if also sharing details of lived trauma, and clients may feel there is risk involved. Disclosing clients deserve appropriate follow-up and should never feel their issues or calls for help were ignored, left unaddressed, or mishandled. For example, ignoring a disclosure on an intake form, responding in a way that could seem judgmental (such as asking probing questions), or not providing appropriate resources and support in follow-up, could make the client feel worse. It is important for any staff to have appropriate training and a clear response plan in place. Many of the resources below provide support on responding to ACE disclosures.

ACE Assessments

There are different assessments used to screen for ACEs. Below, you can see the original ACE questions used in the first study and the Behavioral Risk Factor Surveillance System (BRFSS) questions currently used by the CDC. These questionnaires are most standardly used.

Obtained the questions from a table developed by Coordinated Core Services, Inc.,

I'd like to ask you some questions about events that happened during your childhood. This information will allow us to better understand problems that may occur early in life, and may help others in the future. This is a sensitive topic and some people may feel uncomfortable with these questions. At the end of this section, I will give you a phone number for an organization that can provide information and referral for these issues. Please keep in mind that you can ask me to skip any question you do not want to answer. All questions refer to the time period before you were 18 years of age. Now, looking back before you were 18 years of age--,

Lifetime prevalence of emotional abuse

Did a parent or other adult in the household often or often swear at you, insult you, put you down or humiliate you? Or ever act in any way that made you afraid that they might physically hurt you? [yes/no]

How often did a parent or adult in your home ever swear at you, insult you, or put you down? Was it…

  • Never
  • Once
  • More than once
  • Don't Know

Lifetime prevalence of physical abuse

Did a parent or other adult in the household often or very often push, grab, slap or throw something at you? Or ever hit you so hard that you had marks or were injured? [yes/ no]

Not including spanking, (before age 18), how often did a parent or adult in your home ever hit, beat, kick, or physically hurt you in any way? Was it-

  • Never
  • Once
  • More than once
  • Don't Know

Lifetime prevalence of sexual abuse

Did an adult or person at least 5 years older than you ever touch or fondle you or have you touch their body in a sexual way or attempt to, or have sex with you? [yes/ no]

How often did anyone at least 5 years older than you or an adult, ever touch you sexually? Was it…

  • Never
  • Once
  • More than once
  • Don't Know

How often did anyone at least 5 years older than you or an adult, try to make you touch them sexually? Was it…

  • Never
  • Once
  • More than once
  • Don't Know

How often did anyone at least 5 years older than you or an adult, force you to have sex? Was it…

  • Never
  • Once
  • More than once
  • Don't Know

Lifetime prevalence of physical neglect

  • Never
  • Once
  • More than once
  • Don't Know

5. Did you often or very often feel that you didn't have enough to eat, had to wear dirty clothes, or had no one to protect you or your parents were too drunk or high to take care of you or take you to the doctor if needed? [yes/no]

For how much of your childhood was there an adult in your household who tried hard to make sure your basic needs were met? Would you say never, a little of the time, some of the time, most of the time, or all of the time?

  • Never
  • A little of the time
  • Some of the time
  • Most of the time
  • All of the time
  • Don't Know

Lifetime prevalence of emotional neglect

4. Did you often or very often feel that no one in your family loved you or thought you were special, or your family didn't look out for each other, feel close to each other or support each other? [yes/no]

For how much of your childhood was there an adult in your household who made you feel safe and protected? Would you say never, a little of the time, some of the time, most of the time, or all of the time?

  • Never
  • A little of the time
  • Some of the time
  • Most of the time
  • All of the time
  • Don't Know

Lifetime prevalence of witnessed intimate partner violence

Was your mother or stepmother often or very often pushed, grabbed, slapped or had something thrown at her? Or sometimes, often, or very often kicked, bitten hit with a fist, or hit with something hard, or ever repeatedly hit for at least a few minutes, or threatened with a gun or a knife? [yes/no]

Why is this question only asked about mother or step mother? According to annual WOmen abuse children more than men in all levels of Child Maltratment except sexual abuse and they represent 40% in that category. U.S. Department of Health & Human Services Annual Report

How often did your parents or adults in your home ever slap, hit, kick, punch or beat each other up?

Was it…

  • Never
  • Once
  • More than once
  • Don't Know

Lifetime prevalence of household substance abuse

Did you ever live with someone who was a problem drinker or alcoholic or used street drugs? [yes/no]

Did you live with anyone who was a problem drinker or alcoholic?

  • Yes
  • No
  • Not sure

Did you live with anyone who used illegal street drugs or who abused prescription medications?

  • Yes
  • No
  • Not sure

Lifetime prevalence of household mental illness

Was a member of your household depressed, mentally ill or did a household member attempt suicide? [yes/ no]

Did you live with anyone who was depressed, mentally ill, or suicidal?

  • Yes
  • No
  • Don't Know

Lifetime prevalence of incarcerated relative

Did a household member ever go to jail or prison? [yes/no]

Did you live with anyone who served time or was sentenced to serve time in a prison, jail, or other correctional facility?

  • Yes
  • No
  • Don't Know

Lifetime prevalence of parental divorce/separation

Were your parents ever divorced or separated? [yes/ no]

Before you were 18 years of age, were your parents married, never married, separated, or divorced?

  • Married
  • Never Married
  • Separated
  • Divorced
  • Don't Know



Here are links to important wellness resources for our Tribal community.

Crisis lines:

Tribal members services

  • Elk Valley Clinic, 2298 Norris Ave, Cresent City, CA 707-464-2919
  • Tolowa Dee-ni' Nation, Dept of Community & Family Service, 140 Rowdy Creek Rd., Smith River, CA 707-487-9255x1192
  • United Indian Health Services, 1675 Northcrest Dr., Crescent City, CA 707-464-2750
  • Yurok Youth At-Risk Program, 190 Klamath Blvd., Klamath, CA 95548

Counseling and mental health:

Tribal youth:

Sobriety support:

Domestic, Dating and Sexual Violence

  • a 24/7 safe, confidential and anonymous domestic, dating and sexual violence helpline for American Indians and Alaska Natives, offering culturally-appropriate support and advocacy. SAFETY ALERT Computer use can be monitored and is impossible to completely clear. If you are afraid your internet usage might be monitored, call StrongHearts Native Helpline at 1-844-7NATIVE (762-8483).
  • Note: The StrongHearts Native Helpline above went 24/7 mid February, 2021. This web site says "This is a free, safe, anonymous, and confidential service for Native Americans affected by domestic violence and dating violence. Advocates are available at no contact Monday through Friday from 9am to 5:30pm CST when you are ready to reach out.1-844-7NATIVE (762-8483)'" I have notified both organizations of this error.
  • National Domestic Violence Hotline 24/7 hotline for survivors, friends/family of survivors, and professionals looking for resources. Services include referrals to local DV agencies as well as peer support and advocacy. 1-800-799-SAFE (7233) or TTY 800-787-3224.

Daily meditation:

Podcasts for wellness:

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