A Path Toward Hope

On her arms, she has more than 50 cuts, elbows to wrists. She knows the times and dates for each one.

The girl lives in turmoil. Last year, her father and a grandfather died. Then a friend died by suicide. Her home life is upended by alcoholism. She finds temporary refuge in school. After her classes end, she walks … anywhere but home. Late in the evening, she slips into her house to go to sleep, says Melanie Alchesay, a community mental health specialist for an innovative suicide prevention program developed by the tribe and the Bloomberg School’s Center for American Indian Health (CAIH).

Alchesay once asked the girl why she engages in cutting, a risk factor for suicide. “It’s because of my home situation, because of my family,” the girl replied. “Woman, I’m so stressed out!”

She is 14 years old.

“I wish I had a house to provide her,” says Alchesay. “I wish I could hug her and tell her you’ll be okay. I wish I had a big house. I’d take them all in.”

The suicide rate among young people ages 15 to 24 on the White Mountain Apache Reservation is among the highest in the U.S.—13 times the U.S. average, according to a 2009 American Journal of Public Health article by CAIH authors, including Apaches and Baltimore-based researchers. From 2001 through 2006, 25 people on the reservation under the age of 25 died by suicide—a devastating toll for a community of 15,500. And for every suicide, there were 36 attempts. More than 200 attempts were recorded annually in 2005 and 2006; two-thirds of the attempts were by young people under 25. (In the U.S population, suicide peaks much later in life.)

“There are certain ills, certain challenges out there that we thought we would never see,” says Lupe. “But we know how to saddle up and ride and see what it looks like in that challenge.”

Even a single youth suicide is ineffably sad, but the issue requires perspective, says David Yost, MD, clinical director at the Indian Health Service hospital who has worked on the reservation for 22 years. “We always have to remember the overwhelming majority of our young people are healthy,” Yost says. “It is important not to judge the community by what shows up in our emergency room.”

At the same time, many in the community have been touched by suicide in one way or another.

The tribe and CAIH confronted the issue by creating the Celebrating Life program that works to reduce the suicides one youth, one family, one community at a time. Every day, the program’s staff—all Apaches—help young people overwhelmed by daunting economic, historical, social and interpersonal issues.

"They just found him. I don't know if they have a pulse. They are working on him right now."

Novalene Goklish talks urgently on her cell phone to a colleague on a March afternoon, in Apache and English. A young man on the reservation has attempted suicide. Goklish stands on the porch of CAIH’s headquarters. It is in a portable building behind the Indian Health Service hospital in the town of Whiteriver, near the center of the 1.6-million-acre reservation. Behind her, a bright noon sun casts short shadows on the Ponderosa pines of Gold Butte.

Usually quick to joke or share an ironic aside, the senior field program coordinator for Celebrating Life has gone quiet. Her face is stilled with concern. Between calls, she confides, “Right now you’re hoping for the best. They’re doing everything they can to save him.”

As Goklish leaves to take another call, Francene Larzelere-Hinton sits pensively. The director for the White Mountain Apache site of the Native American Research Centers for Health, Larzelere-Hinton had expected a joyous day; she is going to a traditional ceremony in the evening, part of the multi-day “sunrise dance ceremony” that marks an Apache girl’s transition to womanhood.

“You can feel heaviness,” she says. “I don’t know if you can tell, but you can feel the heaviness.”

Concern for the young man weighs on them. So does worry that the suicide attempt may lead to others. Suicides can erupt like contagions, as happened here in the early 1990s when 11 young people died by suicide in less than a year. In response, some tribal elders were mobilized to visit people who were suicidal. The elders would talk and pray with them, staying at their homes for days, if need be, to guide them out of danger. The group was formally known as Apaches Helping Apaches, but people called them the “ghostbusters.”

Tribal leaders knew more was needed so they turned to a friend they could trust.

Back in 1980, a young pediatrician and researcher named Mathuram Santosham had arrived in the dry, manzanita-dotted valley surrounding Whiteriver. Lupe and the tribe were wary; they had been burned before by researchers who took grant money, gathered data and then just left.

Santosham earned the tribe’s trust by confronting a lethal epidemic of diarrheal disease. “Truly, kids were dying of diarrhea just like in developing countries,” says Santosham, MD, MPH ’75, and now a professor of International Health. The tribe embraced his recommendations for widespread use of oral rehydration solution. Diarrheal deaths soon fell almost to zero.

Next, with the Apaches’ help, he proved the effectiveness of vaccines against Haemophilus influenzae type b (a leading cause of meningitis) and later, rotavirus (a cause of diarrhea), quelling epidemics and saving more young lives. Data from these efforts helped transform health care standards in the U.S. and the world. Along the way, Apaches received public health training to help their neighbors.

So when the suicides erupted in the 1990s, the tribe drew on Santosham and the CAIH. Apache leaders came to Baltimore to meet with researchers, and together they devised a public health answer to prevent more young deaths. They would train Apaches as paraprofessionals who would specialize in community mental health and preventing suicide.

Tribal leaders and the CAIH team (including Santosham, John Walkup, MD, Raymond Reid, MD, MPH ’81, Larry Wissow, MD, MPH ’84, Allison Barlow, MPH ’97, and others) knew they needed data and an understanding of the problem’s root causes. So the tribe mandated in 2001 that all suicide attempts, completions and even ideation be reported by first responders. Later, the reports were collected in a central registry. It is the first community-based suicide surveillance system in the U.S. “The tribe is very innovative in their thinking. They say, we are not going to stand for this suicide epidemic,” says Barlow, now a CAIH associate director. “They treat suicide as an infectious agent that is foreign to their community and have directed their collective will around containing it and getting rid of it.”

In 2004, the tribe and CAIH researchers began to regularly analyze data from the suicide registry, helping them uncover valuable information: The suicide rate is highest among the 15- to 24-year-olds, with 128.5 suicides per 100,000. (The all-ages U.S. suicide rate is 10.7.) Although Apache males and females attempt suicide at roughly the same rate, males are five times more likely to die. Hanging is the primary method of suicide, followed by firearm and overdose. Saturday is the most common day for suicide deaths.

“Suicide seems scary, a mystery, an unapproachable topic to many people, but we know it is a preventable public health problem,” says Barlow. “No one in the U.S. is addressing it with more courage and science than the White Mountain Apache people.”

In 2010, the Celebrating Life team collected 543 surveillance reports. Each yellow report triggers a visit to the young person by an Apache community mental health specialist trained by CAIH, who verifies what happened, begins a dialogue and refers the youth to Apache Behavioral Health Services for counseling. The specialist also gets young people to recognize what upsets them and to create a “safety plan” of actions to take when they are upset. Together, they also brainstorm ways to overcome barriers to counseling like transportation or privacy concerns. The specialists try to stay in touch with the young people, sharing advice and lending a sympathetic ear.

“We have taken an important leap to train native community mental health specialists to do diagnostic screening and crisis management,” says Barlow. “Local people are more credible and more compassionate to the youth and their families.”

With NIH and Substance Abuse and Mental Health Services Administration support, the Apache-Hopkins research team is assessing Celebrating Life by following more than 30 Apache adolescents who attempted suicide and then enrolled in the program. Initial results are encouraging. Youth in the program have reported fewer depressive symptoms, a reduced negative outlook and an increase in peer social support.

During the first or second visit, a specialist will try to help the youth understand the seriousness of a suicide attempt by playing a short, gender-specific video. In the video for young men, a teenage boy responds to a break-up with his girlfriend by hanging himself, but is saved by his mother. Tribal elders, speaking in Apache with English subtitles, share the tribe’s beliefs about the sacredness of life and each individual’s responsibility to the Apache web of life.

The team also offers a nine-session program for youth that helps them with conflict resolution and problem-solving and coping skills. In addition, more than 120 teachers, coaches, parents and others have taken two-day workshops that train them to recognize those at risk and help them effectively. An outreach program called Family Spirit gives teen mothers and fathers skills to help them raise healthy, emotionally resilient children. Another program called NativeVision enrolls third to fifth graders in afterschool classes in fitness, healthy lifestyles and tribal culture. The team also has led eight prayer walks with spiritual leaders to call attention to the suicide problem.

Lupe recalls addressing a sea of young faces in a school gymnasium after a recent prayer walk in his home community of Cibecue. He told them the ancient story of a young White Mountain Apache boy. Guided by a voice and helped by a spider and a gopher, the boy gathered an eagle feather, sinew from an elk, a stick, obsidian and other materials and made the first bow and arrow. “I want them to understand that we depend on the young generation,” Lupe says. “I want them to know that they have a responsibility. They can create a weapon for us. They can create motivation where the White Mountain Apache tribe can be so strong and so powerful.”

For their innovative approach, the Apache’s suicide prevention team was honored in October by the American Psychiatric Association with a bronze Psychiatric Services Achievement Award.

Despite their remarkable efforts, however, sometimes they still must deal with the sorrow of a suicide death. A little while after the first flurry of phone calls about the suicide attempt on that March afternoon, Goklish gets bad news. The young man has died.

Goklish and Larzelere-Hinton get in a blue Ford Escape and pull away from the hospital complex and head south on Arizona 73. They are driving to the family’s home to offer what comfort and counsel they can—and hopefully prevent any spark spreading from the first suicide of 2012.

For Alida Antonio, suicide is a spirit. The spirit has stalked her family since January 14, 2005. That day her 14-year-old niece took her own life.

Grieving, Antonio retrieved her niece’s pictures, books, knickknacks and souvenirs. Some possessions, in the Apache tradition, went into the grave with her; the rest were stored in her daughter’s room. “We didn’t have an elder to tell us to not keep it in the house,” she recalls.

Nine days later, Antonio’s daughter, distraught by her cousin’s suicide, started drinking and, later, throwing her cousin’s pictures in her room. Antonio called the police. When they arrived and peered in the bedroom window, they saw her hanging. She was alive but would never regain consciousness. She died in a Phoenix nursing home three years later.

Then late in 2011, Antonio’s 13-year-old son attempted suicide. He survived and later said he did it because he “just got so mad” at his brother. Suicides by young people are often precipitated by emotional conflicts.

Meeting with a Celebrating Life team member and watching the video had a strong impact on her son, says Antonio. He also has been getting counseling. “It’s opened up his eyes to a lot of things,” she says. He says he will never again try to kill himself. But she still checks on him when he goes to his room. “I always have to worry,” she says.

Antonio has shared her experience with others in hopes of preventing future suicides. She urges parents to talk more with their children and reminds young people how suicide hurts families and the whole community. “The ones who are here afterwards … we are the ones who suffer,” Antonio says. “I just pray it doesn’t happen to anyone again.”

At some point Antonio realized her niece’s books and pictures had been moved into her son’s room. She worried they carried the spirit. “The books, I burned, but the pictures I saved are not in my house. They are outside,” she says.

A spirit, a dark figure, a dark force … the idea of a malignant being behind the youth suicides comes up frequently in conversations here. Outsiders may be tempted to label it a manifestation of depression or a reflection of emotional disturbance, but that assumption is wrong, says Goklish, who has led the suicide prevention team for eight years.

“You tend to expect certain things when you live in an area where there was bloodshed a long time ago,” she says. She recalls a fourth-grade girl who told her a nightmarish story. The girl said that while she was walking near her home, a dark figure in a black jacket appeared beside her and told her to walk to a nearby mountain where she would find a playground that she had never seen before. There, the figure told her, she would always be able to play and would never have to worry or be sad ever again. But first, the figure said, she would have to kill herself. The girl bolted, ran home and later told her teacher. The school nurse alerted the Celebrating Life team.

Johns Hopkins researchers take such reports very seriously. “In the communities we serve, the spiritual realm is important,” says Mary Cwik, PhD, a child clinical psychologist and a CAIH assistant scientist. “Maybe that dark force has always been around but in past times, the Apache people and other Native Americans were much closer to their original way of life. And built into that were things that discourage the [bad] spirit.”

Goklish says her Apache ancestors had many ceremonies and prayers that were woven into daily life. “You were told to get up in the morning and do prayers. If you are not feeling right, or out of balance, you were told to pray,” she says.

Some believe a return to traditional beliefs and ways is the answer. Others think suicide prevention starts with listening. Novalene Goklish’s son Warren, 14, may have saved a friend’s life. A target for bullies, the friend talked about feeling worthless and contemplating suicide. Warren broke up one bullying incident and counseled his friend against even thinking of suicide.

Sitting in his aunt’s house in Whiteriver, Warren stares at his hands, his fingers interlocked as if in prayer. “I told him there are always people who will be there for you. I told him suicide is not the answer,” Warren says quietly. “I guess I helped him. I guess it turned around for him.”

His older cousin, Julian Goklish, helps his own friends and has warned them about cutting: “You know what happens if you hit the main vein? You’re going to go black. You’re not going to see your family no more. You’re not going to have a joyful life with friends. You’re not going to see them all no more. You’re just going to see yourself in hell.”

Julian, 20 years old and taking online classes in computer technology, says he lives by his grandparents’ admonition to “keep our heart clean and live life.” He goes on “sweats” and participates in Apache ceremonies but also chooses not to emphasize differences between his tribe and other peoples. “We are all brothers and sisters,” he says. “Apaches, Navajos, Mexicans, blacks, whites—we’re all the same. We all bleed the same blood. That’s the way I look at everybody on the whole world. We’re all one.”

This message is not lost on the Celebrating Life staff. Novalene Goklish and Francene Larzelere-Hinton have already made presentations about the program to other tribes interested in preventing suicides among their young people.

The model would be most applicable in other limited-resource settings, such as inner cities, rural areas and international locations, notes Cwik.

Men beat on drums and sing. They lead a procession late Friday afternoon at the old fairgrounds on Whiteriver’s outskirts. “The dressing,” a key event in a girl’s sunrise ceremony, is about to begin. People from the godparents’ camp are dancing and walking to the camp of the young girl. Cars, trucks and dancing raise a powdery dust that envelops the ceremony in a cloud, made orange by the late afternoon light.

The men sing in waves of rising volume and shifting pitch as they file into the girl’s camp. A cell phone ringtone suddenly erupts but is quickly drowned out by the music. Some people stand on dusty white benches to get a better view.

The singing stops as medicine man Harris Burnette explains the ceremony’s journey in Apache. Before him lies a blue tarp covered with an elaborately beaded buckskin top, eagle feathers and traditional jewelry. A young girl in a white dress stands in front of him.

Her godmother dresses her in the buckskin top, patiently attaches the traditional jewelry, ties an abalone shell on the girl’s forehead and affixes a single white eagle feather to the back of her head as children play in the dirt and people snap cell phone pictures.

The sun starts to sink below the mountains. The people dance and sing with the young girl’s family, wishing her hope for a pure and untroubled future.

At the ceremony’s end, everyone in the crowd turns around once in a clockwise direction, a rapid sweep of the four sacred directions of the Apache and an implicit acknowledgment of their sacred mountains and the beautiful land around them.

Francene Larzelere-Hinton makes her revolution and explains, “It’s our way of saying Amen.”