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This course focuses on cultural diversity issues as they relate to suicidal behavior.    We have other courses on suicide prevention, but those are more focused on actual techniques and interventions.  In contrast, this course focuses on the relationship between cultural issues and suicide behavior.  The course begins with a discussion of suicide and a discussion of diversity.  The course then discusses the relationships between the two. The course content includes the following along with three articles (links to these public domain articles are provided).      

COURSE OUTLINE

Introduction

Learning Objectives

Suicide in the United States

     Terms and Definitions

Diversity in the American Population

     Definitions and Concepts

Diverse Population and Suicide

     Ethnic and Race Diversity

     Sexual Orientation Diversity

     Religious Diversity

     The Elderly as a Diverse Population

References

INTRODUCTION

Most therapists receive very little formal training on the assessment and management of the suicidal patient and essentially no training on diversity and suicide behavior.  It has been estimated that less than 40% of graduate programs provide curriculum-based education in these areas (Oordt et al., 2009).  This means that most practitioners must learn about this important aspect of practice from during a supervised experience, continuing education, or self-taught when the need arises.  This is certainly not an ideal situation for equipping professionals with managing one of the most important issues in practice.  The lack of attention to formal education in this area is likely due to its low base rate.  But even with the low base rate, suicide does not occur on a continuum; if completed, it is “all or nothing”, underscoring the importance of having expertise in this area. This course will specifically review cultural and diversity issues related to suicidal behavior.  Many suicide risk assessment guidelines and tools do not include information on how to take into account diversity as it might relate to the suicide behavior (including risk assessment, prevention, management, etc.).  This course will review the important association between diversity and suicide behavior.

Seeing a patient with suicidal ideation or behavior is probably one of the most challenging and emotionally-charged areas in mental health practice.  It is also highly likely to occur on one or more occasions in a professional’s career.  In fact, the possibility of confronting a situation involving a suicide or suicide attempt is ever-present in practice.  Consider the following statistics presented in the Table (See Schwartz & Rogers, 2004; Tsao & Layde, 2007 and references for a review):

Suicide in the United States

The following Table presents an overview of US statistics related to suicide.  This is general data and more detailed and updated information can be found on the NIMH and CDC web sites.  As will be seen, this information is important since it provides data that enters into the suicide risk assessment process.  Those in these static higher risk groups might be assessed more carefully and more frequently as part of mental health treatment.  For instance, according to this demographic data, an 85-year-old white male already has increased risk regardless of any other factors.

The following Table present statistics related to diverse groups including the elderly, ethnicity/race, and sexual orientation (In suicide statistics and risk assessment, adolescents also represent a special group for increased risk and those statistics are presented in the previous Table).

Suicide Behavior: Agreeing on Terms and Definitions

When discussing suicide behavior, it is important to be able to agree on terms and definitions to insure accurate communication (Rudd, 2008; Rudd et al., 2006).  In some cases, patients with different characteristics will need to be assessed and managed very differently (e.g. history of suicide attempts versus instrumental suicide-related behavior versus self-harm).  Current terminology can be found in the following Table.

When discussing suicide behavior, it is important to distinguish between some other key concepts beyond defining terms.  For instance, some risk factors are associated with suicide (potentiating risk factors and/or chronic risk factors) and some are known to actually increase the risk of suicide (acute or warning signs).  Potentiating or chronic risk factors tend to be static and do not change much over time.  These risk factors do not necessarily indicate that a person is at increased risk for an imminent attempt. On the other hand, acute or warning signs are dynamic and include those factors that suggest suicidal behavior may be set in motion in the very near future. Warning signs may suggest the heightened risk of suicide in the short term even in the absence of potentiating/chronic risk factors.  Alternatively, potentiating/chronic risk factors may predispose a person to a chronic heightened risk of suicide in which warning signs may not be present (but when they emerge, may represent an emergent situation).  The interplay between potentiating risk factors and warning signs is discussed in the other suicide courses and is beyond the focus of this course.  Related to diversity, various diversity and cultural issues might represent potentiating risk factors (for example, alienation from one’s culture of origin, culture conflict with the dominant culture, and experience of discrimination related to sexual preferences, a lack of social connectedness) or protective factors (e.g. self-perceived importance of religion, social connectedness, etc.).

In addition, it is important to distinguish between chronic suicidality and acute suicidality, since these patients must be managed differently.  Chronic suicidality presents differently from acute suicidality, and the treatment approach is different.  For instance, hospitalization of the chronically suicidal person (absent significant warning signs) has little value in preventing suicide and may have a negative effect (repeated admission, destruction of therapeutic alliance).  The chronically suicidal patient may present symptoms over the long term (e.g. months or years) but still must be assessed and monitored for emergence of acute suicidality (warning signs).  Treatment of the chronically suicidal patient often includes addressing the underlying reasons for the symptoms (e.g. personality disorder, as a means to express distress). In these cases, the clinician must often tolerate the suicidality over extended periods and provide treatment in the least restrictive setting (e.g. outpatient) even when there is a slightly elevated risk.  If diversity issues are significant in the suicide behavior, the clinician may be faced with managing the suicide behavior over the long term while the diversity issues are addressed.

Diversity in the United States

This section includes a review of American diversity based on the results of the 2010 census and more recent findings (Kaiser Family Foundation, 2018). Of course, the 2020 Census information is not yet available.  An examination of the diversity trends relating to the composition of the American population will provide a context for a discussion of issues related to diversity and suicide behavior. The section then discusses concepts and definitions related to cultural diversity and cross-cultural mental health treatment. The 2010 census revealed that the country’s population is growing rapidly and its racial and ethnic composition are ever-changing.  Minority groups of the past and present continue to expand and have grown considerably.  The following is a brief summary of some of the 2010 census data taken directly from the government website.  Data from the census underscores the importance of multiculturalism in mental health services.

The examination of racial and ethnic group distributions nationally shows that while the non-Hispanic white only population is still numerically and proportionally the largest major race and ethnic group in the United States, it is also growing at the slowest rate. As of 2018, This continues to be the case at 60% (KFF, 2018). Conversely, the Hispanic and Asian populations have grown considerably, in part because of relatively higher levels of immigration. The overwhelming majority (97 percent) of the total U.S. population reported only one race in 2010. This group totaled 299.7 million. Of these, the largest group reported white-alone (223.6 million), accounting for 72 percent of all people living in the United States. The black or African-American population totaled 38.9 million and represented 13 percent of the total population. Approximately 14.7 million people (about 5 percent of all respondents) identified their race as Asian alone. There were 2.9 million respondents who indicated American Indian and Alaska Native alone (0.9 percent). The smallest major race group was Native Hawaiian and Other Pacific Islander alone (0.5 million), which represented 0.2 percent of the total population. The remainder of respondents who reported only one race, 19.1 million people (6 percent of all respondents), were classified as "some other race" alone.

Nine million people reported more than one race in the 2010 Census and made up about 3 percent of the total population. Ninety-two percent of people who reported multiple races provided exactly two races in 2010; white and black was the largest multiple-race combination. An additional 8 percent of the two-or-more-races population reported three races and less than 1 percent reported four or more races. The Census showed that interracial or interethnic opposite-sex married couple households grew by 28 percent over the decade from 7 percent in 2000 to 10 percent in 2010. A higher percentage of unmarried partners were interracial or interethnic than married couples. Nationally, 10 percent of opposite-sex married couples had partners of a different race or Hispanic origin, compared with 18 percent of opposite-sex unmarried partners and 21 percent of same-sex unmarried partners.

One can also look at the racial composition stratified by generation to see how diversity in the population is increasing. The following Figure displays these results.  As can be seen, for those in the GI Generation, the multicultural rate is about 17%.  This gradually increases generation by generation to its current level of almost 51%. The Milliennials and Gen-Next are the most racially and ethnically diverse in American history and this trend is likely to continue.  

culture: Definitions and Concepts

There is considerable controversy and overlap in definition and concepts related to race, culture, and ethnicity (APA, 2003; Helms & Talleyrand, 1997; Phinney, 1996). In this section, we define important terms and concepts related to diversity.  

Culture

According to Matsumoto and Jones (2009), culture can be defined as a unique meaning and information system that is shared by a group and transmitted across generations, and that allows the group to meet basic needs of survival, pursue happiness and well-being, and derive meaning from life (p. 327). According to the Multicultural Guidelines, culture can also be defined as the belief systems and value orientations that influence customs, norms, practices, and social institutions, including psychological processes (language, caretaking practices, media, educational systems) and organizations such as media and educational systems (APA, 2003; Fiske, Kitayama, Markus, & Nisbett, 1998). Inherent in this definition is the acknowledgement that all individuals are cultural beings and have a cultural, ethnic, and racial heritage. Culture has been described as the embodiment of a worldview through learned and transmitted beliefs, values, and practices, including religious and spiritual traditions. It also encompasses a way of living informed by the historical, economic, ecological, and political forces on a group. These definitions suggest that culture is fluid and dynamic, and that there are both culturally universal phenomena as well as culturally specific or relative constructs.

Race

Definitions of the terms “race” and “ethnicity” are varied and these terms are often used interchangeably whether appropriate or not. Historical definitions of race often refer to physical and biological characteristics.  In a more precise definition, the term “race” refers to groups of people who have differences and similarities in biological traits deemed by society to be socially significant, meaning that people treat other people differently because of them. For instance, while differences and similarities in eye color have not been treated as socially significant, differences and similarities in skin color have.

Dictionary definitions of race are as follows: (1) A group of people identified as distinct from other groups because of supposed physical or genetic traits shared by the group. Most biologists and anthropologists do not recognize race as a biologically valid classification, in part because there is more genetic variation within groups than between them. (2) A group of people united or classified together on the basis of common history, nationality, or geographic distribution: the Celtic race. (3) A genealogical line; a lineage. (4) Humans considered as a group.

The biological basis of race has, at times, been the source of fairly heated debates in psychology (See the Multicultural Guidelines for a literature review). Helms and Cook (1999) note that “race” has no consensual definition and that, in fact, biological racial categories and phenotypic characteristics have more within-group variation than between-group variation. The definition of race is often considered to be socially constructed, rather than biologically determined. Within this definition, race is the category to which others assign individuals on the basis of physical characteristics, such as skin color or hair type, and the generalizations and stereotypes made as a result. Thus, “People are treated or studied as though they belong to biologically defined racial groups on the basis of such characteristics” (Helms & Talleyrand, 1997).

Ethnicity

Similar to the concepts of race and culture, the term “ethnicity” does not have a commonly agreed upon definition. In general, ethnicity refers to shared cultural practices, perspectives, and distinctions that set apart one group of people from another. That is, ethnicity is a shared cultural heritage (rather than biologically and physically based characteristics). The most common characteristics distinguishing various ethnic groups are ancestry, a sense of history, language, religion, and forms of dress. Ethnic differences are not inherited, they are learned.

Another definition is as follows: Ethnicity is the acceptance of the group mores and practices of one’s culture of origin and the concomitant sense of belonging. However, individuals may have multiple ethnic identities that operate with different salience at different times (Sedikides and Brewer, 2001; Hornsey and Hogg, 2000).

Multiculturalism and Diversity

According to the APA Multicultural Guidelines, the terms “multiculturalism” and “diversity” have been used interchangeably to include aspects of identity stemming from gender, sexual orientation, disability, socioeconomic status, or age. All of these are critical aspects of an individual’s ethnic/racial and personal identity. The term “multicultural” can also be defined more narrowly as meaning interactions between racial/ethnic groups in the U.S. and the implications for education, training, research, practice, and organizational change.

The concept of diversity has been widely used in employment settings. The application of the term began with reference to women and Persons of Color, underrepresented in the workplace, particularly in decision-making roles. It has since evolved to be more encompassing in its intent and application by referring to individuals’ social identities including age, sexual orientation, physical disability, socioeconomic status, race/ethnicity, workplace role/position, religious and spiritual orientation, and work/family concerns.

Culture-centered

In the Multicultural Guidelines, the term “culture-centered” is used to encourage the mental health professional to use a “cultural lens” as a central focus of professional behavior. In culture-centered practices, mental health professionals recognize that all individuals including themselves are influenced by different contexts, including the historical, ecological, sociopolitical, and disciplinary. According to Pedersen, “If culture is part of the environment, and all behavior is shaped by culture, then culture-centered counseling is responsive to all culturally learned patterns” (Pedersen, 1997, p. 256). For example, a culture-centered focus suggests to the mental health practitioner to consider that behavior may be shaped by culture, the groups to which one belongs, and cultural stereotypes including those about stigmatized group members. According to Pedersen (2008), “A culture centered approach to counseling recognizes culture as central and not marginal, fundamental and not exotic, for all appropriate counseling interventions” (page 5). 

Acculturation

Acculturation refers to the gradual physical, biological, cultural, and psychological changes that take place in individuals and groups when contact between two cultural groups takes place (Cardemil & Battle, 2003; Chun, Organista, & Marin, 2003).  When an individual or group moves to an area dominated by an existing cultural group, there is pressure on the newcomers to conform and accommodate to the dominant culture’s way of life and to devalue or abandon their own cultural roots.  Concepts of acculturation have been applied to racial/ethnic minority groups interacting with the larger American Caucasian culture, as well as the usual conceptualization of immigrant groups adjusting to novel environmental situations. 

Diversity Issues and Suicidal Behavior

As part of this course, please read the article “Suicide and Culture” (Lester, 2008) which can be found in the public domain here. (If you have trouble with the link, the article can also be found here). In reading the article, please pay close attention to the following highlights:

Diversity in Sexual Orientation, Race/Ethnicity, and Religion

As part of this course, please read Diversity & Suicidal Behavior: Fact Sheet. This is a fact sheet prepared by Section VII of APA Division 12 (2012) which is in the public domain here (if you have trouble with the link, the fact sheet can also be found here).

A recent survey of transgender and gender non-conforming adults (TGNA) yielded important information about suicide behavior in these groups. The specific aims of the analysis were to identify the key characteristics and experiences associated with lifetime suicide attempts in the NTDS sample as a whole, and to examine how lifetime suicide attempts vary among different groups of transgender and gender nonconforming people. The survey also looked at associated variables in the groups including race, disability, etc.  The report is titled, “Suicide Attempts among Transgender and Gender Non-Conforming Adults: Findings of the National Transgender Discrimination Survey” (Haas, Rodgers and Herman, 2014) and can found in the public domain here.  If you have trouble with the link, it can also be found here. Review the article as part of this course.  The following are highlights of the findings as presented in the report.

The prevalence of suicide attempts among respondents to the National Transgender Discrimination Survey (NTDS), conducted by the National Gay and Lesbian Task Force and National Center for Transgender Equality, is 41%, which vastly exceeds the 4.6% of the overall U.S. population who report a lifetime suicide attempt, and is also higher than the 10-20% of lesbian, gay and bisexual adults who report ever attempting suicide. Much remains to be learned about underlying factors and which groups within the diverse population of transgender and gender non-conforming people are most at risk.

Overall, the most striking finding of our analysis was the exceptionally high prevalence of lifetime suicide attempts reported by NTDS respondents across all demographics and experiences. Based on prior research and the findings of this report, we find that mental health factors and experiences of harassment, discrimination, violence and rejection may interact to produce a marked vulnerability to suicidal behavior in transgender and gender non-conforming individuals. More research on suicidal behavior among transgender and gender non-conforming people is needed.

The elderly

Although all of the risk factors and management guides apply to the geriatric population, this does represent a special group.  The data demonstrate that there is a bimodal distribution to the suicide curve.  The elderly and adolescents are at the highest risk.  About 20% of all successful suicides are completed by men over 65 years old with the greatest risk among those over 69 years old. An interesting but as yet unexplained trend beginning in the 1990’s when managed care became prevalent is the increase in the number of successful suicides in men over 80 years old. 

About 75% of the elderly who successfully commit suicide had been recently diagnosed with a first episode of major depression which was rated to be only “moderately severe” and a similar number (about 75%) had seen their family doctor within one month of the completed suicide. 

Among the elderly, detecting suicidality and preventing suicide is more challenging since they may tend to be more reserved about the symptoms (e.g. sharing emotional distress), making a cry for help (e.g.  instrumental suicide-related behavior) and being more serious in their attempts (gunshot, hanging, lethal overdose with no chance of discovery). When suicidality in an elderly individual is suspected, the special risk factors should be assessed carefully.  Talking with the patient’s family is also important since 60% of individuals who commit suicide have discussed suicidal ideations with family members within the past year. In stark contrast, only 18% discuss their intentions with a healthcare professional. 

One of the most important factors is the accurate identification of depression in the elderly. Many healthcare professionals will miss the telltale signs of depression in the elderly (or disregard them), believing they are “normal” signs of aging.  Depression presents differently in the elderly than in other populations.  The elderly individual with depression often presents with fewer mood-related symptoms and instead complains of fatigue, concentration difficulties, diminished memory, and lack of initiative.  In at least one study, depressed patients were more likely to deny sadness and/or lack of pleasure in activities formerly enjoyed. This is referred to as “masked depression” or “non-dysphoric depression” (See Table). 

Assessment of the elderly person with depression (and suicidality) should determine whether it is more lifelong (most major depression begins with a first episode in the person’s 30’s) or whether it is late onset.  If the first episode of major depression occurs after age 65 then it is referred to as late-onset or geriatric-onset depression.  This category of depression is well-known in the literature, but is not specifically identified in the DSM.  Late-onset depression has different characteristics than a lifelong pattern and these can be found in the Table.

Suicide in the Person without Depression

The euthanasia program in Oregon provides data relative to a unique population, mostly elderly: those patients who want to die and are not depressed. Part of the physician-assisted suicide program screening is that the patient be free of depression.  Given the unique characteristics of this euthanasia population, the following are reasons given for desiring suicide (See the Table):

Some of this information may be useful in assessing the depressed elderly person.  In the research, psychiatric nurses listed the following issues as important reasons for patients deciding on euthanasia:  lack of control, loss of independence, pain relief, concern about becoming a burden to one’s family.  Thus, in patients without identified depression, overriding issues of loss of physical function and declining health seemed to be related to suicidality.  Importantly, the patient’s perception of being a burden (and the other issues) were rated as more severe than those of the significant others’ ratings of the same issues. This data is important since it can alert the clinician to other suicidality issues even in patients who do not present with the classic depression symptoms.

References

Diversity and Suicidal Behavior

APA Division 12 (2012). Diversity & Suicidal Behavior: Fact Sheet. Compiled by Section VII of APA Division 12. This document is in the public domain and can be found here. (If you have trouble with the link, it can be found here).

Center for Disease Control.  Promoting Individual, Family and Community Connectedness to Prevent Suicidal Behavior.  Author: Atlanta, GA.  This article can be found in the public domain here. (If you have trouble with the link, the article can also be found here).

Haas, A.P., Rodgers, P.L. & Herman, J.L. (2014). Suicide Attempts among Transgender and Gender Non-Conforming Adults: Findings of the National Transgender Discrimination Survey. American Foundation for Suicide Prevention and the Williams Institute.  This report can found in the public domain here.  If you have trouble with the link, it can also be found here.

James, S. E., Herman, J. L., Rankin, S., Keisling, M., Mottet, L., & Anafi, M. (2016). The Report of the 2015 U.S. Transgender Survey. Washington, DC: National Center for Transgender Equality.

Lester, D. (2008). Suicide and Culture. World Cultural Psychiatry Research Review, 3, 51-68.  This document can be found in the public domain here. (If you have trouble with the link, the article can also be found here).

Suicidal Behavior

American Psychiatric Association (2003). Practice Guideline for the Assessment and Treatment of Patients with Suicidal Behaviors. Washington, D.C.  (123 pages).

Antony, M. M., & Barlow, D. H. (Eds.). (2002). Handbook of assessment and treatment planning for psychological disorders.  New York: The Guilford Press.

Bryan, C.J. and Rudd, M.D. (2006).  Advances in the assessment of suicide risk.  Journal of Clinical Psychology: In Session, 62, 185-200.

Chambless, D. L., & Ollendick, T. H. (2001). Empirically supported psychological interventions: controversies and evidence.  Annual Review of Psychology, 52, 685-716.

Ellis, T.E. (2004). Collaboration and a self-help orientation in therapy with suicidal clients. Journal of Contemporary Psychotherapy, 34, 41-57.

Hall, RCW, Hall, RCW, & Chapman, MJ. (2003). Identifying geriatric patients at risk for suicide and depression.  Clinical Geriatrics, 11, 36-44.

Hendin, et al. (2006). Problems in Psychotherapy with Suicidal Patients. American Journal of Psychiatry, 163, 67-72.

Kroll, J. (2000). Use of no-suicide contracts by psychiatrists in Minnesota.  American Journal of Psychiatry, 157, 1684-1686.

Lee, J.B. and Bartlett, M.L. (2005). Suicide prevention: Critical elements for managing suicidal clients and counselor liability without the use of a no-suicide contract.  Death Studies, 29, 847-865.   

Nathan, P. E., & Gorman, J. M.  (Eds.). (2002). A guide to treatments that work, 2nd ed.  New York: Oxford University Press.

Oordt, M.S. et al. (2009). Training mental health professionals to assess and manage suicidal behavior: Can provider confidence and practice behaviors be altered? Suicide and Life-Threatening Behavior, 39, 21-32.

Page, S.A. and King, M.C. (2008). No-suicide agreements: current practices and opinions in a Canadian urban health region. Canadian Journal of Psychiatry, 53, 169-176.

Perlman et al. (2011). Suicide Risk Assessment Inventory: A Resource Guide for Canandian Health Care Organizations.  Toronto, ON: Ontario Hospital Association and Canadian Patient Safety Institute.

Rudd, M.D. (2008). Suicide warning signs in clinical practice.  Current Psychiatry Reports, 10, 87-90.

Rudd, et al. (2006).  Warning signs for suicide: Theory, research, and clinical applications.  Suicide and Life Threatening Behavior, 36, 255-262.

Shea, C.S. (1998).  Psychiatric Interviewing: The Art of Understanding.  Philadelphia, PA: W.B. Saunders.

Simon, R.I. (2006).  Suicide risk assessment: Is clinical experience enough?  The Journal of the American Academy of Psychiatry and the Law, 34, 276-278.

Smith, A.R. et al. (2008).  Revisiting impulsivity in suicide: Implications for civil liability of third parties.  Behavioral Sciences and the Law, 26, 779-797.

Thyer, B.A., & Wodarski, J.S.  (2007).  Social work in mental health: An evidence based approach.  New York: Wiley.

Diversity

American Psychological Association (2003). Guidelines on multicultural education, training, research, practice, and organizational change for Psychologists. American Psychologist, 58, 377-402.

Atkinson, D.R., Morten, G., & Sue, D.W. (1998). Counseling American Minorities (5th Edition). Boston: McGraw-Hill. 

Bennett, M.J. (2004). From ethnocentrism to ethnorelativism. In JS Wurzel (Ed). Toward multiculturalism: A reader in multicultural education (pp. 62-77). Newton, MA: Intercultural Resource Corporation.

Betancourt, JR, Green, AR, et al. (2003). Defining cultural competence: A practical framework for addressing racial/ethnic disparities in health and health care. Public Health Reports, 118, 293-302.

Cardemil, E.V. & Battle, C.L. (2003). Guess who’s coming to therapy? Getting comfortable with conversations about race and ethnicity in psychotherapy.  Professional Psychological, Research and Practice, 34, 278-286.

Chun, K.M., Organista, P.B. & Marin, G. (2003). Acculturation: Advances in Theory, Measurement, and Applied Research. Washington, DC: American Psychological Association.

Comas-Diaz, L. (2001). Building a multicultural private practice. The Independent Practitioner, 21, 220-223.

Cross, T., Bazron, B., Dennis, K., & Issacs, M. (1989). Towards a culturally competent system of care: A monograph on effective services for minority  children who are severely emotionally disturbed (pp. 13-17). Washington, DC: CASSP Technical Assistance Center, Georgetown University Child Development Center.

Finlay, K. A., & Stephan, W. G. (2000). Improving intergroup relations: The effects of empathy on racial attitudes. Journal of Applied Social Psychology, 30, 1720–1737.

Fiske, A. P., Kitayama, S., Markus, H. R., & Nisbett, R. E. (1998). The cultural matrix of social psychology. In D. T. Gilbert & S. T. Fiske (Eds.), The handbook of social psychology, Vol. 2 (4th ed., pp. 915–981). New York: McGraw-Hill.

Galinsky, A. D., & Moskowitz, G. B. (2000). Perspective-taking: Decreasing stereotype expression, stereotype accessibility, and in-group favoritism. Journal of Personality & Social Psychology, 78, 708–724.

Griner, D., & Smith, T. (2006). Culturally adapted mental health interventions: A meta-analytic review. Psychotherapy: Theory, Research, Practice, 43, 531-548.

Helms, J. E., & Cook, D. A. (1999). Using race and culture in counseling and

psychotherapy: Theory and process. Boston: Allyn & Bacon.

Helms, J. E., & Talleyrand, R. M. (1997). Race is not ethnicity. American Psychologist, 52, 1246–1247.

Hornsey, M. J., & Hogg, M. A. (2000). Assimilation and diversity: An integrative model of subgroup relations. Personality & Social Psychology Review, 4, 143–156.

Knapp, S. (2007, January). Implicit prejudice: The bad news and the good news. Pennsylvania Psychologist, 6-7.

Matsumoto, D. & Jones, C.A. (2009). Ethical Issues in Cross-Cultural Psychology.  In D.M. Mertens and P.E. Ginsberg (Eds.), The Handbook of Social Research Ethics (pp. 323-336). Thousand Oaks: Sage Publications.

Pedersen, P.B. (2008). Ethics, competence, and professional issues in cross-cultural counseling. In P.B. Pedersen, JG Draguns, WJ Lonner & JE Trimble (Eds.), Counseling Across Cultures, 6th Edition (pp. 5-20).  Thousand Oaks: Sage Publications

Phinney, J. S. (1996). When we talk about American ethnic groups, what do we mean? American Psychologist, 51, 918–927.

Sedikides, C., & Brewer, M. B. (2001). Individual self, relational self, collective self. Philadelphia: Brunner-Routledge.

Sue, D.W. (1990). Culture-specific strategies in counseling: A conceptual framework. Professional Psychology: Research and Practice, 21, 424-433.

Sue, D.W. & Sue, D. (1990).  Counseling the Culturally Different: Theory and Practice (2nd Edition). New York: Wiley.

Sue, D. W., Bernier, J., Durran, M., Feinberg, L., Pedersen, P., Smith, E., & Vasquez-Nuttall, E. (1982). Position paper: Multicultural counseling competencies. The Counseling Psychologist, 10, 45–52.

U.S. Department of Health and Human Services. (2000; 2001). Mental health: Culture, race and ethnicity—A supplement to Mental Health: A report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Public Health Office, Office of the Surgeon General.