Working with suicidal adolescents and adolescents who self-harm
Working with suicidal adolescents and adolescents who self-harm
When reviewing the literature regarding adolescence, it is clear that it is a very difficult term to define. There seems to be no strict age at which adolescence begins or ends, and many authors who write on the subject of adolescence fail to provide a succinct definition of adolescence. This is perhaps because no clear definition can be given, as the transition from childhood to adulthood is such an individual, diverse phenomenon that to even begin to define it is futile. Most people would probably think of adolescence as the teenage years, from thirteen through to nineteen, but every individual develops, both physically, psychologically and emotionally, at different rates. As Steinberg states, "it is obvious that generalising about the nature of adolescence is no easy task" (p. 3, Steinberg, 1993). He goes on to describe adolescence as a time of transitions, both biological, psychological, social and economic, and comments that it is an exciting period of life, where adolescents are allowed to start work, get married, and to vote, and at some stage are expected to become financially independent. Steinberg also correctly remarks that establishing the beginning and end of adolescence comes down to a matter of opinion, rather than fact. For these reasons, this essay will not attempt to offer a definitive explanation of adolescence, but rather will point out that it can be one of the most difficult times of change in a person's life, and that this is important to bear in mind when working with this group.
During this period in life of huge change and transition, it is not surprising that many individuals experience some level of suicidal ideation at some point during adolescence (Geldard & Geldard, 1999). According to many recent studies, the levels of stress, anxiety and depression are increasing in young people in Western culture, and this is leading to an increase in suicidal ideation, attempted suicide and completed suicide (Dacey & Kenny, 1997). Levels of self-harm are also thought to be increasing, and have been referred to as reaching epidemic proportions (Hawton, 1986). In 1990, the suicide rates per million for 15-19 year olds in England and Wales for males and females were 57 and 14 respectively. This is almost definitely an under-estimate due to the reluctance of Coroner's to give a verdict of suicide, unless they are one hundred per cent certain. The steep rise in the number of male adolescent suicides is even more concerning as, between 1980 and 1990, they rose by 78%. The rates for females and for all other age groups, however, are declining (Flisher, 1999).
Rutter (1991) defines suicide as, "self-chosen behaviour intended to bring about one's death on the short(est) term" (p.214). It is important to recognise, however, that suicidal behaviour is not always carried out by people with the intention of ending their own life, but that often it is meant only to express or communicate feelings of despair, hopelessness or anger. For this reason, suicidal behaviour can be divided into three categories. Suicidal ideation, that can range from fleeting thoughts that life is not worth living anymore, to a very certain well-planned strategy for killing oneself, to a very intense delusional preoccupation with ending ones life (Godney et al., 1989). Parasuicide refers to behaviour that can vary from manipulative attempts and suicidal gestures, to serious but unsuccessful attempts to kill oneself. This can also be referred to as self-harm ( Kreitman, 1977). The third category is suicide, which Maris (1991) refers to as, "any death that is the direct or indirect result of a positive or negative act accomplished by the victim, knowing or believing the act will produce this result" (p.215). Little is known about the factors that precipitate or protect against transformations from suicide ideation to parasuicide, and from parasuicide to actual suicide. This is a very important area, and one that needs to be researched more. If these factors could be identified, then counsellors would have specific material to work with and to look for when working with adolescents who present as being in one of the stages of suicide mentioned above.
So what are the risk factors that make one adolescent more likely to commit or attempt suicide or self-harm than another? An adolescents coping strategies and resources will determine whether or not they see suicide as an option, and whether or not they actually choose to take this option. It is thought that adolescents are particularly vulnerable to self-harm and suicide if they are already suffering from depression (Geldard & Geldard, 1999; Rutter, 1995; Steinberg, 1993). Obviously, adolescents who choose suicide as their coping strategy are experiencing severe psychological distress, possibly as a result of stress, anxiety or ...
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So what are the risk factors that make one adolescent more likely to commit or attempt suicide or self-harm than another? An adolescents coping strategies and resources will determine whether or not they see suicide as an option, and whether or not they actually choose to take this option. It is thought that adolescents are particularly vulnerable to self-harm and suicide if they are already suffering from depression (Geldard & Geldard, 1999; Rutter, 1995; Steinberg, 1993). Obviously, adolescents who choose suicide as their coping strategy are experiencing severe psychological distress, possibly as a result of stress, anxiety or depression, or alternatively due to a psychotic illness or substance abuse. A depressed mood, which is one of the main characteristics distinguishing adolescents who are referred for clinical help from those who are not, is generally not associated with frequent suicidal wishes or thoughts. Depressive syndrome and major depressive disorder, however, both tend to include frequent thoughts about death and/or suicide, suicide plans, or suicidal acts (Achenbach, 1991).
According to Geldard & Geldard (1999), adolescents who attempt suicide share some common characteristics. They tend to have very intense interpersonal relationships with only a few people, and to express their feelings by acting out rather than by communicating them verbally. It is also likely that they have an external locus of control regarding their situation, and that they express high levels of hopelessness, thinking that things are unlikely to ever improve. This is also suggested by research that has shown that the cognitive characteristic of hopelessness is the single best predictor of eventual suicide (Freeman & Dattilio, 1992). Additionally, adolescents who are more likely to commit suicide are inclined to overreact to things, and can be hypersensitive. Dacey & Kenny (1997) also point out that adolescents who attempt and complete suicide frequently have more stressful lives, less coping strategies and poor school performance.
Suicide can be related to any number of problems that that person is experiencing at that time in their life, but specific problems that are often experienced by adolescents who attempt or commit suicide or self-harm are family problems, especially those which threaten the stability of the family, such as parental separation; a serious lack of communication between the adolescent and their parents or care givers; problems within peer relationships; not belonging to a group or having any friends; and what they perceive to be a failure to live up to expectation of others, such as parents (Geldard & Geldard, 1999). Hawton et al. (1982) reported that over four fifths of adolescents who had attempted suicide reported being unable to discuss their problems with their parents. Bhugra et al.'s (2002) findings also support Geldard & Geldard's comments. They found, in their study of Asian and white adolescents who had self-harmed over a three year period, that one of the major risk factors for the adolescents in this study was an unfavourable family environment, including issues such as parental separation, especially in the white groups. Abuse of alcohol by a parent or sibling was another risk factor, and physical or sexual abuse at home another precipitating factor of self-harm. These problems seemed to be exacerbated by trouble with peers and problems at school, with over half of the whites and one third of the Asians reporting it. The problems at school varied, from academic problems to bullying, but whatever kind of problem it was, was a large precipitating factor. It is not surprising then, if adolescents are experiencing problems at home as well as problems at school, that they need "time out". Taking an overdose was reported by the participants in the study as a way of getting "time out" from all these pressures, even if it was only for a short time (Bhugra et al., 2002).
Only two of the ninety-nine cases in Bhugra et al.'s study, however, mentioned racial harassment as a triggering factor, so it would appear in this case that racism is not a major issue. This contradicts results of former studies that have implied racial issues can be a risk factor. When examining the prevalence of suicide among differing ethnic groups, the findings are apparently contradictory. MIND (1995) published statistics that suggest suicide rates are much higher among ethnic minority groups, stating for example, that immigrant status increases the risk of suicide and attempted suicide, and that Asian females have a suicidal rate three times higher for the 15-24 year age group than the national average. However, Bhugra et al. (2002), in the study cited above, found that Asian adolescents are no more likely to take overdoses. This implies that figures may have changed over the last few years. Obviously, there are bound to be discrepancies between different studies, and Bhugra et al.'s study did have a relatively small participant sample, and was based purely on case notes. It would be interesting to see the results of a similar study carried out with a larger sample size, and using a more qualitative approach, to try and understand the reasons for the differences between ethnic groups, if any are found at all. This could lead to important discoveries regarding risk factors and triggers for suicide and self-harm within different cultural settings in today's society.
The rate of suicide attempts in adolescents is also increased in those who have been abused during childhood, another risk factor identified in Bhugra et al.'s research. Adolescents who have been physically abused can experience feelings of powerlessness and helplessness (Kaplan et al., 1997), and are therefore more at risk of developing other risk factors associated with suicide, such as depression, substance abuse and disruptive behaviour. Sexual abuse during childhood and adolescence has also been documented as contributing to suicidal gestures and attempts (VanderMay & Meff, 1982; Bagley et al., 1997). Boys who are sexually abused have significantly more behavioural and emotional problems, including suicidal thoughts and behaviour, than do girls, according to research by Garnefski & Diekstra (1996). Another risk factor associated with adolescent suicide is the loss of a loved one. This risk is increased when that person committed suicide themselves, and it has been noticed that bereavement after suicide is more complicated when compared to that of losing someone through natural causes, as there can be more guilt involved (Peters & Weller, 1994). For these reasons, counsellors need to be aware of the nature of the loss suffered by their client.
Bhugra et al. (2002) also found a marked increase in the prevalence of suicide in adolescents over the age of 14, highlighting the impact of puberty, and also suggesting that this is the age where individuation begins, causing further stresses at home. The favoured method for the adolescents involved in this study was overdosing on paracetamol, which has preventative implications. If access to drugs is restricted, then the rate of impulsive suicides may be reduced.
When working with adolescents who may be at risk of self-harm or suicide, special attention needs to be paid to this subject in the confidentiality contract, discussed and signed at the beginning of therapy. The counsellor needs to explain to their client that in the event of them disclosing plans of suicide, then other people, such as the clients' GP or a professional emergency team, will need to be informed. It is best, however, whilst always taking into account legal, ethical and professional requirements, to try and give the client as much control over the disclosure of their intentions as possible (Geldard & Geldard, 1999).
Once the risk factors of suicide in adolescents have been identified, it is important for counsellors to be familiar with the best ways of working with them. Baumeister (1990) considers that helping adolescents who have attempted suicide, or threatened to commit suicide, to find goals is vital. His 'escape theory' holds that suicidal adolescents deliberately ignore broader goals and values that usually provide meaning to people's feelings, thoughts and actions. Transitions in personal beliefs, goals and emotions are often fundamental to suicide, and therefore when working with this client group, short-term and long-term goals can be useful. This point of view is also shared by Greenberger (1992) who believes that, "the cognitive therapy approach to treating suicidal patients is to focus on the thoughts, assumptions, and beliefs that accompany the suicidal intent. Understanding the cognitive component of the suicidal patient can be instrumental in treatment planning and eventual therapeutic success" (p.139).
Anderson (2000), however, would argue that psychodynamic therapy is more helpful, especially during the assessment process. He believes that psychodynamic factors can be used to broaden and advance the quality of assessment of adolescents at risk of self-harm, and that a consideration of the internal and external factors and their interaction, as manifested in the transference between client and therapist, and also considering the clients history and present circumstances, allows form and intensity to be added to the assessment. Anderson (2000) recommends that an assessment of risk consist of being aware of the known risk factors, and putting these into context with that young persons situation at the time of the assessment, their history, and their personality characteristics. The more information that can be gathered the better the chance of receiving an explanation of that person's behaviour. A calming effect on the client's mind, and on those carrying the responsibility and anxiety, can be achieved by them perceiving that they are understood. Therefore, a good assessment can already reduce the risk of suicide before the therapy has even begun.
Orbach (1988) comments that assessment of the familial dynamics and external events and situations is vital when evaluating risk of suicide or self-harm, as these are the major risk factors and determinants associated with this type of behaviour. Orbach suggests when working with suicidal adolescents, to try and obtain an idea of what death means to them. Do they see death as an improved life, for example? An analysis of the adolescent's specific fantasies about death is in itself useful, as it can give a way of understanding the distress in their life. He suggests also that identifying the "unresolvable problem" (p.232) is important, and that the therapist must constantly ask what processes, situations, relations or facts bring this client to feel that there is no other way of coping than to take their own life. Family therapy is recommended by Orbach as a way to deal with difficulties between an adolescent and their parents, or one parent. This may involve in-depth work with one or both of the parents exclusively. Suicidal behaviour is often an attempt to solve the unresolvable problem, and if the problem can be resolved in therapy, then this will hopefully avoid the tragedy of a suicide. According to Orbach, therapeutic treatment for suicidal children and adolescents should focus on bringing about change in destructive behavioural patterns, unravelling the unresolvable problem, providing corrective experiences, and satisfying basic needs. Distinguishing principles include, " the examination of the death fantasy, empathetic participation in considering suicide, splitting of the self-image, and alliance with sources of strength" (p.244).
In conclusion, it is clear that there are a number of risk factors that occur during the period of adolescence that can, and will, in some cases, lead to suicide. Every individual will have a different experience of these problems - some will experience all of them intensely, others will experience them all to a lesser degree, and maybe others will experience only one of these risk factors, or triggers, and just find it too much to bear. Rutter (1991) compares developmental stress to a model of work stress, commenting that the number, nature, and patterning of the developmental task demands is one factor, and how well someone copes with these is dependent on four other factors, namely social support, external resources for meeting those demands, personal coping skills, and the socioecological context in which the demands must be met. He argues that the developmental tasks need not cause adverse emotional consequences if the four other factors measure up to the demands of those tasks. He suggests that future priorities for public health and research agendas, regarding adolescents, should be to accurately identify the developmental tasks for adolescents in today's society; a description of the conditions, both material and physical, psychological and social, for their successful achievement in adolescents; and a clear description of who is responsible for ensuring these conditions are met.
Obviously counsellors can be involved in helping to ensure these conditions are available, by providing emotional and psychological support to adolescents who need some help in achieving their developmental tasks. Whilst it is vital that counsellors have the ability to identify and correctly deal with suicidal thoughts and behaviour to avoid the occurrence of tragedy, it is also paramount that they know their own limits: counsellors who are working with suicidal clients need to work under close supervision and seek help from other specialist helpers when they need it (Geldard & Geldard, 1999).
When looked at as a statistic, seventy-one per million seems a very small percentage, which of course it is. However, one life that is wasted through the act of suicide is one too many, and usually it is the case that when one life is taken, several more lives are ruined. The devastation suffered by family members and friends cannot be under-estimated, and the effect on communities and schools is severely detrimental. Therefore, by researching, understanding and learning more about all the processes, risk factors and fundamental causes that are associated with suicide, many more lives than that small percentage can be saved.
Experiential Workshop Essay Carolyn Liddell
