BETHEL — For a week in November, people from remote Alaska villages holed up at an Oregon retreat to reset their thinking on the crushing problem of suicide.
Now they are gearing up to try a new way of stopping people from killing themselves. This method is infused in research and structured so that village residents — not outsiders — decide what to do next.
The approach follows others that have shown promise in strengthening people and communities suffering from old and deep wounds, the "historical trauma" rooted in the collision of traditional Alaska Native life and Western ways.
The act of suicide can be impulsive. Destructive behavior can erupt — even spread — fast. A project using culture for healing was in place in the Southwest Alaska village of Hooper Bay for three years, a period with no suicides. Then, in less than three weeks this fall, a village that felt like it had found a healthy path was hit with four suicides of young residents.
Organizers of the latest strategy, coming from the Kotzebue region in Northwest Alaska, say it's designed to create conditions for change that work alongside long-term approaches. Its success will come from the ideas and efforts of village residents themselves.
"I do think it is kind of revolutionary in that it gives communities information and control," said Lisa Wexler, a University of Massachusetts associate professor who has spent 15 years developing the strategy.
What her team calls Promoting Community Conversations About Research to End Suicide is simple: Give people easy-to-understand data at monthly meetings. Provide a structure to figure out what it means. Talk about what to do.
"They can decide how to use their resources to make things better, to use the research for the good," Wexler said. "It gives people really practical ways to make a difference."
Answers to a problem that is both personal and patterned have long challenged the public health system. Despite tens of millions of dollars in spending and years of attention on suicide in Alaska, the overall rate has held steady since 1990, and since 2005, even is up slightly — meaning more suicides.
"We always say the community has the answers," Wexler said. But many programs, including state-backed training to identify young people at risk, arrive already packaged, she said. A village may just need help finding its own way. "This one is different," she said.
Experts say that a multitude of factors usually contribute to a decision to take one's own life, not a single bad thing like a lost job or broken relationship, but also mental illness, a lack of jobs and opportunity, alcohol abuse and among Native people, cultural loss.
In Western society, suicide is seen as a psychological issue that needs "an acute, crisis-oriented response of mental health services," Wexler wrote in a survey of research about Alaska Native mental health published in April for the National Institutes of Health. "In Indigenous communities, however, suicide can be understood as a way of expressing social and spiritual distress and despair."
On the surface, Alaska Native culture in many villages appears to be thriving with art and dance, hunting and gathering for subsistence, Yup'ik language taught in schools. But generations were shattered by disease, forced placement in boarding schools and the smothering of Native ways by missionaries. Deeper values of how to relate to other people, the understanding and connections developed in the times everyone had to work together just to survive, are harder to rebuild, said Rose Domnick, head of prevention services for the Yukon-Kuskokwim Health Corp. and leader of a program called Calricaraq ("way of healthy living"). Her team is trying to reteach a different way of thinking and being.
"This is the part that if we don't learn, we start to turn to alcohol and violence and suicide," she said recently. Targeting a bad behavior isn't enough, she said. Something else will replace it.
She told her own family's story at a December conference, of grandparents separated by a priest because they were too closely related, of little boys who died trying to escape an orphanage, of sexual abuse and alcohol abuse, of broken trust and unresolved grief.
Wexler landed in Kotzebue 20 years ago as a young counselor. She found the depth of despair and perpetual tragedy overwhelming. She responded by immersing herself in a study of youth suicide in Northwest Alaska, earning her doctorate. Now the professor based in Massachusetts has a national reputation for expertise in Native American suicide prevention, especially in Northwest Alaska.
Almost any meeting on suicide will quickly turn to historical trauma, she said. The kind of work that Yukon-Kuskokwim Health Corp. is doing through Calricaraq to examine those deep issues and resurrect lost ways is important, she said. But it's a long process and people are in crisis now.
Alaska's suicide rate of 23 for every 100,000 people in 2013 was the second highest in the nation, behind Montana, according to data reported to the U.S. Centers for Disease Control and Prevention. The highest reported count in Alaska was 172 in 2013.
Young Alaska Native men are particularly vulnerable. For those between the ages of 15 and 24, the rate is 169 suicides per 100,000 – almost six times the national rate for young Native American males and almost 14 times the U.S. rate for everyone, according to a five-year average of the most recent CDC data. For these Alaskans, suicide is the No. 1 killer.
Yet among Alaska Native elders, often revered as culture bearers, suicide is so rare that the CDC doesn't even calculate a rate.
In villages, residents have become accustomed to waiting for troopers, courts or some other Western institution to solve problems, a "learned hopelessness" from living under state and federal laws, said Roberta Moto, wellness program manager for the Maniilaq Association in Kotzebue.
The Maniilaq Association was part of the development team for the new research-based approach. It is starting to test the model in Kotzebue and 10 Inupiaq villages.
Too often outside researchers come in, do their work and leave behind nothing of use, Moto said. This new way relies on ideas from people in villages, for villages.
"People are sort of wary of the idea of research," she said. "We want to put that control back into the village's hands."
Diane McEachern, an assistant professor at the University of Alaska Fairbanks campus in Bethel, worked with Wexler to design the curriculum. The content isn't based in culture, but the carefully packaged lessons are framed around it, she said. Meetings open with prayer, elders are always present, and communities are urged to add talking circles if members need time to work through emotions, said McEachern.
"We see these learning circles every month as a community organizing opportunity," she said.
The sessions will bring together people in villages from key institutions: health aides and law enforcement officers, school counselors and pastors, wellness workers and tribal workers.
Maniilaq has decades of data from the Northwest Arctic region. They show there was not a single documented instance of youth suicide until the 1960s.
That piece of research helps begin the conversation, Wexler said.
Some 45 people gathered at the recent training retreat in Portland, including one from Hooper Bay.
Some places and groups are particularly susceptible to suicide, while others seem almost immune. The four recent deaths in Hooper Bay focused new attention there, but five years ago, there was a cluster of nine suicides in Yukon-Kuskokwim Delta villages including Hooper Bay. And before that, a rash of suicides in the area that began in 1998.
After the 2010 wave, Sen. Lisa Murkowski held a hearing in Bethel. Young people who came from around the region struggled to speak but wanted to be part of the solution, the senator remembered.
One said suicide had become almost normal to young people.
"It rattled me to the core that that would be considered normal," Murkowski said recently.
Yet dozens of Alaska villages have gone a decade or longer with no suicides.
In indigenous cultures around the world, young men are most at risk, and they die by hanging or gunshot, Wexler said. In China, it's rural young women, who drink the poison used on the fields, she said.
"That is a not an accident. That is a pattern. And there are conditions that create that pattern. And that's what we are trying to teach people, to see some of those patterns," Wexler said.
In the remote Canadian territory of Nunavut, one village went from having the highest suicide rate to zero suicides in four years. What did they do there? They talked about suicide and agreed to look out for each other. They also took out the clothing rod in every closet, eliminating the place where young people could most easily hang themselves.
Just ensuring that guns are stored unloaded is a simple thing that has been shown to lower the number of suicides, Wexler said. Already, Yukon-Kuskokwim Health Corp. sends gun safes to villages at cost with free shipping.
One of the monthly learning circles is framed around that theme: how reducing access to places, guns, pills and even snowmachines can save lives.
"Sometimes you just have to buy 15 minutes," McEachern said.
The new approach includes research on factors that may make a person or a community more resistant to destructive behavior. Wexler led a survey in 2006 of 355 young people and adults from the Northwest Arctic asking what would help prevent Inupiaq youth suicides. Almost no children picked teaching culture and only a few thought more programs, activities or community involvement would help.
What kids wanted, the survey showed, was for adults to talk to them.
There was everything
In the Yukon-Kuskokwim Delta, a culture-rich approach that began almost 15 years ago seems to make a difference. It started in the village of Alakanuk after a rash of 11 suicides of young people in 18 months. A young mental health clinician, Stacy Rasmus, came to the same realization that Wexler had in Kotzebue. She didn't have the tools to deal with what she was seeing. So, like Wexler, she created them.
UAF's Center for Alaska Native Health Research worked with Alakanuk and other Yup'ik communities to build a framework for reaching kids, she said. They call it Qungasvik, Yup'ik for toolbox, and it involves 36 activities that a community can pick from.
Alakanuk was already mobilizing and asked researchers to study what makes people sober and successful. Qungasvik is intended to promote sobriety and reasons for living — residents didn't want the suicide prevention label.
One activity is reestablishing a qasgiq, the Yup'ik men's house, as a place to teach how to live. Another is holding a community meeting and creating a timeline that shows what everyone can remember about life at age 15. Or maybe carving walking sticks for the ice. Elders could teach about the dangers of rotting ice, but also about risks next door from pot or alcohol.
With its toolbox, Alakanuk went a long stretch with no suicides until one this fall. Hooper Bay seemed to be on the same course. Then in May 2014, the federal grant that paid for three people to run the program ended. A youth and elder building shut down for a time. Grants through other agencies ran out too.
"There was everything and then there was nothing," Rasmus said.
In all, six Yup'ik villages have tried Qungasvik, two with documented success and four others still being studied, she said. The work has been supported with federal and state grants.
The long run
This year, the state is spending $8.3 million for suicide prevention programs, including about $6 million in federal grants. Some of it backs Alaska Careline, a 24-hour hotline. Most of the federal dollars go to tribal organizations.
The state's strategy is to give information about mental health and suicide to large numbers of people. The goal is to give them confidence to ask questions and make referrals if they encounter a young person who might be in crisis. More than 6,000 people have been trained so far, said James Gallanos of the state Division of Behavioral Health.
Research elsewhere has found a reduction in suicides the year after people were trained in the gatekeeper approach but not evidence of a lasting impact.
In schools, a multitiered approach that educates all students on suicide, trains older students to talk to younger ones and provides intensive help to those in crisis can reduce the numbers, as was found by the Miami-Dade County Public Schools. It created its program after 18 students took their own lives in 1988.
Last school year, according to Miami district crisis team member Frank Zenere, there was only one suicide among 350,000 students.
"The bottom line is a community coming together and working on this," McEachern of UAF's campus in Bethel said. "That in the long run is what is going to stop suicide."
Here are a few resources, including some that offer instant help, for people who are depressed or in emotional crisis:
* Alaska Careline, for people depressed, thinking of suicide or just lonely: 1-877-266-4357 or carelinealaska.com.
* National Suicide Prevention lifeline, also for people in crisis over a range of issues, from illness to family problems to substance abuse: 1-800-273-8255 or text GO to 741741.
* Suicide prevention app, for health care providers: store.samhsa.gov.
* Trevor Project, for gay, lesbian, bisexual and transgender youth: 1-866-488-7386 or thetrevorproject.org.
* State coalition against suicide: stopsuicidealaska.org.
* Warning signs compiled by the American Foundation for Suicide Prevention: afsp.org.