Melatonin Improves Sleep in Patients With Circadian Disruption Taking melatonin about an hour before turning in for the night improved sleep dis- turbances and sleep-related impairments in patients who had trouble falling asleep at their chosen bedtime and difficulty wak- ing the next day, investigators reported in PLOS Medicine.

The 116 participants in the study were di- agnosed with delayed melatonin secretion in dim light, an indicator of abnormal circa- dian timing related to sleep. They were randomly assigned to take 0.5 mg of fast- release melatonin or a placebo 1 hour be- fore bedtime for at least 5 consecutive nights per week for 4 weeks. All patients were scheduled to try to fall asleep at their de- sired, rather than habitual, bedtime.

Relative to baseline and compared with placebo, sleep onset occurred 34 minutes earlier in the melatonin group. The melato- nin group also had improved sleep quality and fewer sleep-related impairments.

The authors cautioned that melatonin may be less effective for sleep disorders that are not caused by a circadian delay.

No Benefit for Women From Sigmoidoscopy Screening Offering sigmoidoscopy screening to adults reduced colorectal cancer incidence and mortality in men, but had little or no effect in women, researchers reported in the Annals of Internal Medicine.

Investigators randomly assigned 98 678 study participants aged 50 to 64 years who lived in Norway to a single screening with flexible sigmoidoscopy, with or without ad- ditional fecal blood testing, or to no screen- ing. Participants with positive screening re- sults were offered colonoscopy. After 17 years of follow-up, colorectal cancer inci- dence decreased by 34% and mortality de- clined 37% among men in the sigmoidos- c o p y g r o u p c o m p a r e d w i t h m e n w h o weren’t screened. Little or no reduction in colorectal cancer risk or mortality occurred among women screened with sigmoidos- copy compared with those not screened.

An accompanying editorial suggested that the findings might support revising the

5- or 10-year intervals in current recommen- dations to help prevent potential harm from screening. However, the editorial’s authors said the study also raises the question of w h e t h e r s c r e e n i ng r e c o m m e n d a t i o n s should be sex-specific.

Automated Device Improves Glucose Control in Hospitalized Patients Recent research has shown that a closed- loop insulin delivery system—also known as an artificial pancreas—controls glucose more effectively than standard subcutaneous in- sulin therapy during hospitalization.

The investigators randomly assigned 136 adults with type 2 diabetes who needed in- sulin to receive it with the automated sys- tem or via standard subcutaneous therapy for 15 days or until they were discharged.

Glucose control was significantly better among patients who received insulin with the automated system than among those re- ceiving standard subcutaneous therapy. In addition, the groups didn’t differ signifi- cantly in duration of hypoglycemia or in the amount of insulin delivered. No patient in either group had an episode of severe hy- poglycemia or clinically significant hypergly- cemia with ketonemia. Patients in the closed-loop group also said they were very satisfied with results from the system.

Behavior Therapy May Help Prevent Teen Suicide A form of behavioral therapy that helps pa- tients control their emotions and tolerate distress may prevent adolescents who are at high risk of suicide from harming them- selves or attempting suicide again.

In a JAMA Psychiatry study, 173 youths who had attempted suicide were ran- domly assigned to participate in either dia- lectical behavior therapy (DBT) or in indi- vidual and group therapy. Both groups had weekly individual and group psychotherapy as needed.

At 6 months, 9.7% of youths in the DBT group said they had attempted suicide com- pared with 21.5% who had individual and group therapy. In addition, 46.5% of those in the DBT group and 27.6% in the other therapy group hadn’t attempted suicide or

tried to harm themselves. During a 6-month follow-up period after treatment ended, self- harm rates declined in both groups; DBT had a more pronounced clinical effect but the dif- ference wasn’t statistically significant. Be- cause study participants were predomi- nantly female, the investigators said the findings may not generalize to males.

Drug Improves Glucose Levels and Drives Weight Loss Treatment with a balanced glucagon-like peptide 1 and glucagon receptor dual ago- nist, MEDIO382, significantly improved gly- cemic control, bodyweight, and liver fat in patients with type 2 diabetes who were over- weight or obese, according to a Lancet study.

The 61 patients were randomly assigned to once-daily injections of MEDIO382 or to placebo in the multiple-ascending dose por- tion of the study, and 51 patients were ran- domly assigned to the study drug or to pla- cebo in the phase 2a portion.

Fr o m b a s e l i n e t o d a y 41 , c l i n i c a l l y a s s e s s e d p o s t p r a n d i a l g l u c o s e d e - c r e a s e d s i g n i f i c a n t l y w i t h M E D I 03 82 ( – 3 2 . 7 8 % ) c o m p a r e d w i t h p l a c e b o (–10.16%). In the intention-to-treat popula- tion, the MEDI0382 group lost 8.5 pounds compared with a 3.7-pound weight loss in the placebo group. The phase 2b trial is ongoing. − Anita Slomski, MA

Note: Source references are available online through hyperlinks embedded in the article text.

Melatonin improved sleep in patients with circadian disruption.

Clinical Trials Update

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YOUTH SUICIDE INTERVENTION USING THE SATIR MODEL*

Wendy Lum Jim Smith Judy Ferris

ABSTRACT: Youth suicide is a social issue that needs serious consider- ation among families, therapists and helping professionals. This article presents an actual case of a youth who completed suicide, and discus- sion of the hypothetical Satir model treatment of this youth while alive. The Satir model has numerous interventions that have current applications toward dealing with suicidal youth in a humanist and hopeful way, fostering youths’ desire to live and to become more posi- tively involved in their lives. In the past, Satir focused on coping stances in communication, and now the coping stances give a deeper under- standing into the internal world.

KEY WORDS: adolescence; family therapy; Satir model; suicide; treatment; youth.

This article is intended to share how the Satir model (Satir, Ban- men, Gerber, & Gomori, 1991) can be used to understand and treat youth who are suicidal. Youth suicide is a major concern in Western society, and measures need to be explored to reduce suicide among the adolescent population. In the United States the suicide rate among adolescents and young adults tripled between 1950 and 1980. The rate for people 15–34 years old during that time and throughout the 1990s

Wendy Lum, MA, is a Child, Youth, and Family Therapist, Kelowna, British Colum- bia, Canada (e-mail: [email protected]). Jim Smith, BPE, RSW, is Director of Langley Youth & Family Services, 5569-204th Street, Langley, British Columbia, Canada V3A 1Z4. Judy Ferris, MA, MEd, is a Youth and Family Therapist, Langley Youth & Family Services, Langley, British Columbia. Canada.

*Portions of this paper were presented at the Canadian Association for Suicide Prevention (CASP) Conference, Vancouver, BC, October 2000.

*The authors wish to acknowledge the inspiration received from their involvement with the Suicide Intervention & Treatment Task Force, Satir Institute of the Pacific.

Contemporary Family Therapy 24(1), March 2002  2002 Human Sciences Press, Inc. 139

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remained at approximately 15 per 100,000 population. By 1996, suicide was the third leading cause of death for adolescents and young adults (Maris, Berman, & Silverman, 2000). The suicide rate for 15–24 year olds is 12 per 100,000. The rate for 5–14 year olds is 0.8 per 100,000. Approximately 10,200 people ages 15–34 years old kill themselves each year and 4,700 from ages 15–24. These numbers show the tragedy of despair amongst young people.

Everall (2000) highlighted the fact that in Canada, suicide is the second leading cause of death for young people aged 15–24 years. Banmen (2000) suggested that youth suicide is a significant concern for mental health professionals. Youth struggle with internal coping in relationship to their external factors (e.g., family violence, disruption during key transitional periods at school, teasing/bullying, loss of signif- icant family member) and this factor may contribute to increased sui- cide rates. Clearly youth suicide is a societal issue that needs more effective education and intervention for prevention of suicide among adolescents.

COMMON THERAPIES FOR SUICIDAL ADOLESCENTS

The Satir model (Satir, Banmen, Gerber, & Gomori, 1991) is a unique therapeutic system that offers hope for therapists who wish to connect with and to positively affect suicidal youth in making a choice to live. Satir’s model will be discussed in relationship to an actual case study. There are other therapeutic frameworks that are used to deal with youth suicide prevention and intervention. The methods, which are currently used to understand and intervene with suicidal youth, will now be reviewed.

The preferred treatment for working with the suicidal adolescent is individual therapy on an outpatient basis. Richman and Eyman (1990), examine the three major types of therapy used with suicidal patients—individual, group, and family. Issues such as fragile identity, conflicted self-expectations, and difficulty expressing emotions are dis- cussed. Hoover (1987) looks at the self in regard to suicidal behavior, stating that the distinguishing factor in suicide is the invalidation of the sense of self. Hoover and Paulson (1999) describe the journey away from self as a disconnection from self and others. The return to self occurs through reconnection through feeling, self-awareness, and hon- ouring the self.

Initially, crisis intervention is the treatment used to deal with the suicidal crisis. The immediate therapeutic task is to prevent self-harm.

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The work of therapy can focus on broadening the adolescent’s linkages to a wider network of resources and on the predisposing conditions that make the adolescent vulnerable. Suggested interventions are so- cial skills training, treatment of loneliness, cognitive-behavioral ther- apy and other behavioral approaches, problem-solving skills, training in anger, and aggression management. Solution-focused brief therapy uses the client’s strengths, competencies, resources, and successes (abil- ity to be resilient) to bring about change (Fiske, 1998). This approach emphasizes co-operation between client and therapist and offers tools in the form of questions when working with suicidal children and ado- lescents to help divert their attention from problems to possible solu- tions.

Ellis and Newman (1996) link cognition and suicidality. They state that hopelessness, problem-solving deficits, and perfectionism as well as dysfunctional attitudes and irrational beliefs are characteristic of individuals contemplating suicide. Cognitive-behavioral therapy is used with both adults and adolescents. This is a collaborative model in which client, therapist, and the family identify the client’s problems, strengths, and previous attempts at problem-solving. Problem-solving skills are further developed, and the client learns to develop alternative interpre- tations and beliefs so that suicide no longer seems the only viable option. Freeman and Reinecke (1993) refer to the techniques of activity scheduling, mastery and pleasure ratings, graded task assignments, behavioral rehearsal, social skills and assertiveness training, biblio- therapy, in vivo exposure, and relaxation, meditation, and breathing exercises. Cognitive techniques useful in developing adaptive responses to dysfunctional thinking are described. These include understanding of idiosyncratic meaning; decatastrophizing, guided association discov- ery, cognitive rehearsal, and development of cognitive dissonance.

Dialectical Behavior Therapy (Linehan, 1993; Linehan, MacLeod, & Williams, 1992) also uses a problem-solving strategy. However, it differs from cognitive behavioral therapy in that it tries to make the techniques more compatible with psychodynamic models. Fiske (1998) suggests DBT be modified for use with children and adolescents. Con- structive goals and reasons for living are the basis for this model.

The goal of psychoanalytic/psychodynamic approaches is to gain insight into the unconscious conflict of the client. In summarizing these approaches, Maris, Berman, and Silverman (2000) refer to object rela- tions theory, which states that suicidality represents a failure in the task of separation-individuation. Research on attachment styles among suicidal youth supports this aloneness.

Goals of family therapy are modifying communication patterns,

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increasing support for the adolescent’s attempts at self-care, and im- proving the family’s problem-solving behavior. A central goal is to de- velop an understanding within the family of the meaning of the adoles- cent’s suicidal behavior and to improve family functioning (Berman & Jobes, 1997; Maris et al., 2000). Group therapy provides a social support network for suicidal clients and provides a milieu where social skill development can take place (Maris et al., 2000). Themes emerging from group psychotherapy are family relationships, peer relationships, and the control of potentially overwhelming feelings and impulses (Rich- man & Eyman, 1990).

SATIR MODEL THERAPY

Virginia Satir initially developed a model of intervention that fo- cused on personal growth and accessing life energy for healing. Since then it has been developed further for use with suicidal clients to choose life. The Satir model (Satir et al., 1991) has many applications for therapists to learn in strengthening connection with suicidal youth. This model recognizes that all human beings strive to survive and to grow. Satir had great faith in people’s ability to grow, as long as there is breath (Satir & Banmen, 1983). Satir believed in the life force that all humans have access to, and her therapeutic work was aimed at releasing this life force from within the person (Banmen & Banmen, 1991). When youth are suicidal, there is less energy for living, although they may summon up the energy to commit their final act. This model encompasses many aspects of theory and enables therapists to gain insight into the inner world of youth and their ways of coping. The Satir model recognizes the impact of family of origin disappointments, rules, expectations, and relationships. By working through and healing past unresolved hurts and resentments, youth may be better able to move in a positive direction toward future growth.

Within the Satir model, the Personal Iceberg Metaphor (Banmen, 1997; Satir et al., 1991) is a conceptual framework of the inner experi- ence, which can be used to assess, understand, reflect, interact, change, and transform youth. This concept is an intrapsychic psychological map of the inner world. There are seven components within the Personal Iceberg Metaphor (Self: I am/Spiritual Core, Yearnings, Expectations, Perceptions, Feelings about Feelings/Feelings, Coping Stances, and Behavior). The metaphor concept allows therapists to understand their own as well as another’s intrapsychic experience. The Personal Iceberg

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Metaphor enables therapists to process youths’ internal world, while at the same time acknowledging their external world.

INNER EXPERIENCE

Behavior of the Suicidal Youth

The acting out behavior and verbal communication of suicidal youth is an expression of his or her internal experience. The Satir model looks at behavior and verbal communication as the result of the inner world of youth. Through using the Satir model and by focusing on changing adolescents’ internal world, destructive external behavior has the stronger possibility of being positively changed. Satir’s Personal Iceberg Metaphor (Satir et al., 1991) acknowledges behavior as only being a one-eighth part of the whole person, and that seven-eighths is hidden from external view, thus the iceberg metaphor.

In dealing with suicidal youth, therapy has often been focused more on identified behaviors. Some of these behaviors are displayed such as running away, disruptive behavior, challenging comments and actions, resistance to others, chronic nonattendance at school, notice- able mood changes, body movements, nonverbal responses, substance abuse (drugs and/or alcohol), sexual acting out, giving away posses- sions, and verbal comments (Banmen, 2000). Suicidal teenagers have a higher possibility of experiencing disruption and unpredictability within their family environment (Everall, 2000). Suicidal actions or intentions can be seen as a sign that within youth’s internal worlds, there may be a sense of hopelessness, helplessness, despair, and discon- nection.

Coping Stances of the Suicidal Youth

Satir (1972) suggested that in order to survive, people cope in different ways under stress. The four coping stances are referred to as the placating stance, the blaming stance, the super reasonable stance, and the irrelevant stance (Satir, 1972; Satir et al., 1991). Satir also viewed relationships as involving three crucial components: self, other, and context. This is how a person acts and feels in relationship to oneself, in relationship to another, and depending on the situation or environment in which the relationship is taking place.

Suicidal youth who use the placating stance under stress may not

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highly value themselves, but will value the other person and be aware of the context. These teenagers live in their feelings about themselves, others, and the world. The placating suicidal youth may experience a deep sense of worthlessness, unworthiness, hopelessness, and helpless- ness. There may be behaviors that indicate depression, and a deep unhappiness about themselves and their life. Suicidal adolescents may reject themselves, while expecting that others have given up on them. The rejection could manifest as a giving up on themselves, which will inhibit their own life energy, hence possible depression. Suicidal youth may be very unhappy and disappointed that their needs are not being met by others (Banmen, 2000).

Suicidal youth who use the blaming stance under stress value themselves and are aware of the context, but will not value the other person with whom they are in a relationship. These adolescents have high expectations of others and the world. When their expectations are not met, a blaming stance will occur. The blaming suicidal youth may feel a deep sense of inner isolation and loneliness. Outwardly they may display verbal and/or non-verbal anger towards others through acting out, bullying others, drug abuse, and delinquent behavior. These teen- agers may also feel aggressive, revengeful, and indignant.

Suicidal youth who use the super reasonable stance under stress will be focused on the context, information, and details of situations. The super reasonable suicidal youth may feel very fragile, and have a deep sense of isolation from others and within themselves. These youth may create distance from others by isolating themselves with books, games, and computers. Their behaviors may manifest outwardly through perfectionistic, obsessive, and/or compulsive behaviors.

Suicidal youth who use the irrelevant stance under stress, have no sense of belonging or sense of connection. Disconnection from self can be a constant state of being. The irrelevant suicidal youth may feel extreme pain and sensitivity. They may experience turmoil and chaos externally and internally. They can be very impulsive, spontaneous, and make poor choices due to their impulsive actions. These adolescents may not be focused on tasks or not be present within their own selves. These youth may appear to be funny, joking, and class clowns, but internally the disconnection is extremely and deeply painful. These teenagers may struggle with creating a sense of self or have an inability to create a sense of self.

Adolescents are less able to access their strengths and resources while under stressful circumstances. Suicidal youth could use any of these coping stances, however one stance may be more prominent. Suicide

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results from a decision that comes from young peoples’ inability to transpose stresses in their daily life.

Feelings of the Suicidal Youth

Feelings are our emotional response to ourselves, others, and the context (situations and events). Satir and associates (1991) believed that we have a right to feel our feelings, however we may have family rules that deny the display of these feelings or emotions. Often placating youth may be very aware of this feeling component in their lived experi- ence. Suicidal youth may be flooded with feelings of their emotions, or they can be numbed from feeling their emotions. Teenagers who are suicidal may feel hurt, sadness, depression, loss, abandonment, fear, anxiety, remorse, guilt, self punishment, disillusionment, confusion, and a sensitivity to being criticized by others (Banmen, 2000). The experience of loss can be accumulated over a period of time in childhood (Everall, 2000). Suicidal youth can also feel anger, rage, revenge, and retaliation and be critical of others. There may be a deep sense of rejection and betrayal that can create a helpless feeling. In summary, how suicidal youth cope will influence the kind of feelings that will be internally experienced.

Feelings about the Feelings for the Suicidal Youth

Satir and colleagues (1991) acknowledged the impact that feelings have on oneself, and attributed this to our feelings about having feel- ings. This is a component that deepens and displays the intricacy of the feeling experience. The feelings about the feelings component have an impact on suicidal teenagers with their sense of self-esteem, self- worth, and adequacy. Suicidal youth may experience feelings of shame, guilt, and worthlessness in relation to their initial feelings. Adolescents who are suicidal may also experience a sense of vulnerability, hopeless- ness, helplessness, and deep despair.

Beliefs of the Suicidal Youth

Suicidal youth will have perceptions and beliefs that influence their suicidal intentions and behaviors. Adolescents who use the super reasonable stance are likely to be highly aware of and focused on their intellectual perceptions in order to make sense of their world. How suicidal youth view themselves, others, and the world, will affect their

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decisions about life and death. Chandler and Lalonde (1998) found that four out of five youth (84%) who were actively suicidal did not believe that they had any connection to their past, present, or future. There may be a sense that they have lost control, or have never had any control over their world, and they may feel unable to change their circumstances. Suicidal youth may believe that they have no choice, or that committing suicide is the only choice that is left for them to make. Some suicidal youth may believe that they are emotionally invisi- ble to others and that no one will listen to them. Adolescents who are suicidal may have had numerous losses and believe that such losses will continue in their lives. A sense of being abandoned by others or the world can be predominant. Suicidal youth see rejection as an acknowledgment of their sense of being contaminated or flawed (Ever- all, 2000). These teenagers may believe that they are losers, and they could be on a downward spiral in relationship to their self-esteem. Some suicidal adolescents may believe that they are unlovable, unac- ceptable, or incompetent. If these teenagers or their family members have high expectations of them, there can be a sense of failure for not living up to being perfect or successful.

Expectations of the Suicidal Youth

Unmet yearnings will manifest in expectations of others to meet their yearnings, and this can interfere with teenagers’ taking responsi- bility for their lives. Suicidal youth who use the placating coping stance may be self-punishing and self-victimizing and expect that they cannot affect their world. There can be expectations which are negatively focused. Suicidal youth who use the blaming coping stance can be blaming, accusatory and controlling, especially if they expect others to meet their needs. Their expectations can be unrealistic, imagined, and contribute to disappointments. Often expectations are formed from family rules that involve “shoulds, musts, and oughts.” Suicidal adolescents may judge themselves for having failed their own expectations. High expec- tations that are realistic can help as a protective factor in preventing suicide.

Yearnings of the Suicidal Youth

Satir and colleagues (1991) believed that all humans have univer- sal yearnings for love, validation, belonging, connection, acceptance,

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acknowledgment, meaning, growth, and freedom. So no matter what age a person is, these yearnings are common, even for the adolescent population. When youths’ yearnings are met, then a sense of fulfillment, wholeness, and harmony will be experienced. When unfulfilled yearn- ings are not met, there is a negative impact on the internal worlds of these youth, and often these can turn into expectations of self or others, which lead into negative behaviors. If youth yearn to be loved and do not feel loved, then they may conclude that they are unlovable. If there is a yearning to feel a sense of worthiness and these yearnings are not met, they may think that they are worthless. When adolescents yearn for connection and these yearnings are not met, there is a disconnection from self. If youth yearn for attachment and these yearnings are not met, they may become detached and this detachment can be from Self: I am and/or God. If there is yearning for belonging, but these yearnings are not met, they may experience social isolation or an isolation from self. When youth yearn to feel acknowledgment and these yearnings are not met, they may feel rejected. If youth yearn for growth and these yearnings are not met, then they may experience a sense of failure and stagnation. Yearnings are a significant component of the inner world that gives meaning to life.

Self of the Suicidal Youth

The Self: I am is one’s connection to his or her soul, essence, core, or life force. It is through this life force that life’s energy is manifest. When youth are fully connected with the life force of the Self: I am, then they will experience peace, inner calm, hope, faith, wisdom, harmony, a desire to live, high self esteem, and a willingness to take responsibility. This deep connection with Self: I am can be a spiritual source for youth, which can also help to provide a sense of meaning in their lives.

When youth are disconnected from the Self: I am, there will be disruptions or blockages in their life force energy (Satir et al., 1991). This disconnected energy may occur as a result of the impact of their family of origin experiences between family members (Everall, 2000; Satir et al., 1991). As a result of this disconnection, youth will experi- ence low self-esteem and self worth. This inner experience of self will affect youths’ intrapsychic world, which will in turn have an impact on their relationships with others. Suicide may be a rejection of the Self: I am, a punishment of Self: I am, a violence toward the Self: I am, or an abandonment of Self: I am.

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WHAT SUICIDE INVESTIGATIONS TEACH US

“Wars come and go; epidemics come and go; but suicide, thus far has stayed. Why is this and what can be done about it?” (Jamison, 1999, p. 24).

The experiences of an individual youth suicide will be analyzed in the context of the Satir model. The information of the inner experience of the deceased individual has been gathered from the testimony of significant others in the youth’s life through an extensive investigative process. This collaborative view is derived from the case file taken from one of the authors (Smith) from his work as a Behavioral Investigator for the British Columbia Coroner’s Service, Canada, where he performs child, youth, and adult suicide investigations. Between 50 and 75 per- cent of approximately 500 child and youth suicides examined through the behavioral investigation program were not predicted by the parents, service providers, or gatekeepers. This was a surprising number of unpredicted suicides suggesting that precursors to child and youth suicide needed to be understood differently.

Looking at suicide through the theory of the Satir model brings forth new learning applicable to the living. In his work as director and therapist for a youth and family services agency, Smith has also had the opportunity to apply this new learning with suicidal youth.

Many reasons for suicide and attempted suicide have been put forth. We hear a lot about the external factors that are major contributors to the cause of suicide. These factors, including drugs and alcohol, loss and grief, divorce, peer pressure, re- duced job opportunities, economic competition, and world ten- sion have all been used to explain the suicidal scenario. The external, contextual, environmental, interactive factors are probably stronger stressors now than in previous decades. Yet, most teenagers seem to handle these stressors well. All of life is within a context. How we handle the impact of various stressors might be a more important consideration than the stressors themselves. . . . The Satir model (Satir et al., 1991) has some basic premises that might fit in our exploration of suicide. Satir believed that human beings have the internal resources they need to survive and grow. She also believed that internal change is always possible, even if we do not have control of our external world. She taught that the problem is not the problem, but how we cope with the problem is usually

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the problem. She found that most people choose familiarity over the discomfort of change, especially during times of stress. She also advocated that therapy needs to focus on health and growth possibilities instead of pathology (Ban- men, 2000, pp. 1–2).

The work of the behavioral investigation program is intended to illuminate the human factor in death investigations. Specifically, the program serves to assist the coroner in determining the classification of death and why certain deaths may have occurred and how they may have been prevented.

A behavioral investigation is a voluntary inquiry into the inner experience of the deceased. The information gathered includes: back- ground history of the parents and a multi-generational family history, information about the pregnancy, pre,-peri,-and post-natal history, de- velopmental milestones, marital and family history, significant events in the family and life of the deceased, and school information. In addi- tion, the behavioral investigator gathers testimonial descriptions of the deceased from significant others in the life of the deceased. This process adds important dimensions to understanding how the deceased experienced life. Those interviewed include parents, siblings, relatives, friends, employers, lovers, fellow students, coaches, leaders, teachers, therapists, psychiatrists, social workers, and medical doctors. The col- lective view of the possible experience of the deceased is gathered through a careful and sensitive interviewing process frequently lasting between three to four hours per interview. With these interviews the investigator gathers a body of information that when viewed through the Satir model (Satir et al., 1991) provides a means to understand behavior as coping.

Behavior patterns are analyzed and reported to the coroner. In addition, the behavioral investigators are required to speculate how each suicide death may have been prevented. This speculation has become the art of understanding the experience of the deceased. Consid- ering behavior as coping as seen through the Satir model shifts focus from the individual act of self death to the story behind the struggle to live and the meaning the individual may have attached to this struggle. For some, suicide appears not to be so much about wanting to die, but more about believing they can no longer endure the pain of living. This suggests that explanations for suicide might lie within himself or herself in relation to the world in which he or she exists.

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CASE STUDY

Satir model theory regards behavior as the external manifestation of the internal experience. Understanding behavior in this way provides opportunity for earlier intervention into suicidal ideation. While invest- igating the suicide death of Paul, a pseudonym for a 16-year-old male, Smith was initially puzzled by the lack of information to explain the reasons for his suicide.

The information from the coroner’s office that Smith reviewed, included:

1. The suicide note left by the deceased. 2. Interview narratives with the principal of the high school that

Paul last attended. 3. Attendance and disciplinary files profiles for grades kindergar-

ten through to and including grade nine. 4. School records 1998 to January 1999. 5. Eulogy given by high school principal. 6. Interview narrative and psychological summary report of school

district psychologist. 7. Interview narratives with Paul’s parents. 8. Interview narrative with teaching staff of the elementary school. 9. Psychological research questionnaire completed and provided

by the coroner’s agent.

In addition to the information provided by the coroner’s agent, Smith conducted a telephone interview with Paul’s mother to gather birth and family system history. The suicide note contained messages of hopelessness and helplessness. It did not explain why or how Paul arrived at the state he was in at the time of his death. Smith wondered what indications he may have given that might have been seen as a precursor if not to his suicide, at least to his apparent suffering.

Through information taken from his school records (Table 1), Paul appeared to be quiet, compliant, and academically successful. When he reached high school he had become uncooperative, oppositional, and bullying in his behavior with absenteeism and suspensions. He appears to have coped with his feelings by withdrawing into himself. Adopting a compliant coping style, as Smith suspects Paul did, prevented others from understanding his personal internal experience.

Paul was unable to externalize his feelings of pain and/or fear. This inability to externalize feelings, in Smith’s experience, is likely the meaning of his statement in his suicide note “There is no way I can explain what I did but it was done. I just couldn’t go on living.” Smith believes that Paul lacked a deeper understanding of who he

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TABLE 1 Paul’s School Records

Days Grade Absent Comments

Kindergarten 13 Nervous, high-strung, low self-esteem. Grade 1 13 Grade 2 25.5 Grade 3 27 Hesitates to ask for help in class. Grade 4 Unknown With learning assistance support

achieved a B average. Grade 5 05 A/B average Grade 6 8.5 A/C average Grade 7 35.5 Marks dropped. Achieved one B, other

(middle marks were C, P and F. Lack of effort, school) disciplinary problems, missed

assignments, disrupting others. Grade 8 Unknown Several suspensions, spitting,

intimidation, fighting, using drugs at school, extortion.

Grade 9 (3 Marks continue to fall, indefinite years in suspension, absenteeism, was repeating grade 9) grade nine for third time with marks

ranging from B to F with an average of C−.

already was; that in a sense Paul felt he had yet to become a person. This expression from Paul’s suicide note gives a feeling his life was not working out and that he lacked connection with his self. This expression from Paul’s suicide note also indicates the state of despair he was in at the time of the writing of the suicide note.

Paul succeeded academically in elementary school and appears to have done so with the external support of his teachers. In middle-school and high school, records show he struggled to succeed academically, indicating he may have continued to require external support and likely expected this support to continue as he progressed through his school years. Without this support, his performance dropped off, as did his compliance.

The attendance and comment profiles for grades Kindergarten through Grade 9 as recorded by the school, are a clear indication Paul could succeed academically when sufficiently motivated.

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School records for kindergarten indicate Paul presented at school as lacking self-esteem. These perceptions on the part of the school system resulted in academic support. In retrospect his low self-esteem presentation might more accurately have been seen as the external expression of his coping. Understanding externalized behavior as cop- ing with an internal state, nervous and tense behavior for Paul might have been about a deeper level state of fear. Interpreting Paul’s nervous and tense behavior as a deep level fear could have initiated an earlier referral for therapeutic intervention in elementary school. By Grade 3, Paul is experienced at school as withdrawn. His withdrawn behavior withholds his true feelings from the external world, and in Smith’s experience this withdrawn behavior might be the first sign that Paul is experiencing feelings of both helplessness and hopelessness.

With continued support at school he achieved a reasonably high standard of academic success through Grade 7. In his Grade 7 year Paul moved into middle-school at a different geographical location from his elementary school and with different teachers. His marks and the behavior comments from Grade 7 through to the end of his life reflect lack of effort, missed assignments, suspensions from school, fighting, intimidation of others, and drug use. Paul at this time is experienced as uncooperative, manipulative, and passive-aggressive, inviting reactive disciplinary action on the part of the school district. Smith suspects that he was possibly experiencing the combined painful feelings of fear of failure, disappointment, helplessness, hopelessness, and frustration. Smith believes Paul may have been acting these feelings out through lack of effort, missed assignments, fighting, intimidation, and drug use. Had the school district understood these externalized behaviors as coping, they likely would have referred Paul for psychological therapy, rather than only reacting to his behavior through disciplinary mea- sures.

Smith believes Paul was in a desperate emotional state through the later part of middle-school into high school and that this state is reflected in his angry acting out behavior. This was the last attempt Paul was able to make in order to have his life come out right. Smith believes he was likely in deep emotional pain of despair, and that he likely harbored expectations of himself, family, and teachers that had not been met at the time of his death. Without external support Paul was unable to succeed and eventually gave up trying. Smith believes the non-compliant behavior of Paul may have had the purpose of asking for support. By shutting down, he may have carried the hope he would receive the same support in middle-school and high school that he received in elementary school. Smith believes Paul likely experienced this absence of support as painful feelings of loneliness and abandon- ment, and that his drug use may have served to ease this pain.

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Smith discovered that Paul had at times performed acts of self- mutilation by digging into his hand, and exposed skin on his arms with a pencil or sharp instrument. Smith also discovered Paul drew pictures depicting violence and scenes containing blood. This self-mutilation behavior and graphic sadistic art provided another obvious opportunity for therapeutic intervention.

The ability to understand behavior differently may be the key to early intervention and prevention of suicide. Understanding behavior as the external expression of an internal state sees behavior as a dy- namic purposeful activity with attached expectations of self and others, and views expectations as linked to deeper unmet universal yearnings. These universal yearnings are directly linked to the individual’s need to evolve and, when these yearnings remain unmet, can be the experi- ence of their life not working out.

SUICIDE TREATMENT USING THE SATIR MODEL

This section will share how a therapist using the Satir model (Banmen, 1997; Satir et al., 1991) might have engaged in treatment with Paul while he was still alive. From the identified case study, Paul could have been referred to a therapist to deal with his sense of inadequacy at an earlier age; unfortunately his referral for therapy in Grade 9 was not initiated soon enough. Therapy could have been initi- ated at an earlier time when it was evident that Paul struggled with his school involvement. The behaviors he exhibited in Grades 7 and 8 could have alerted friends, family, teachers, school counselors, or principals that Paul was in need of therapy.

In the Satir model (Banmen, 1997) there are four main goals for therapy; to raise self esteem, encourage better choice-making, increase responsibility, and facilitate congruence. The Satir model recognizes the universal yearnings of all humans to be connected with themselves and with others. By facilitating a sense of connection, the therapist would be able to better explore Paul’s commitment to live. First of all, using the Satir model (Banmen, 1997) the therapist would intentionally connect and attempt to maintain connection with Paul throughout the treatment period. The therapist would share an attitude of acceptance, genuineness, and caring. Initially the therapist would assess Paul’s energy and willingness to engage in therapy throughout the first ses- sion and within each subsequent session. The therapist would use process questions throughout sessions, such as, “What would you hope

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would happen from our time together?” By listening closely to how Paul had perceived himself, others, and his situation, the therapist would gain valuable information into how to approach the therapy process. The therapist could ask, “Is there anything you would like to change in your life?”

The therapist would listen for a possible goal and help Paul to define a goal for therapy. The therapist would check to see if he were committed to working with the therapist on attaining his goal. Once a commitment had been made, the therapist would remain conscious of his specific goal throughout the therapy period. If there were resistance from Paul, then the therapist might have to recheck the goal to see if he was still committed to this goal, otherwise there would be further exploration and a re-clarification regarding the goal of therapy. “Are you sure that this is what you really want for yourself?”

With regard to self-esteem, the therapist would wonder about Paul’s self esteem, and ask questions such as, “What do you know about yourself? and “Who do you believe you really are?” As noted, it appeared that Paul had low self-esteem and was not well connected to himself. The therapist would explore his relationship to himself, and foster a stronger inner connection to self. “When do you feel most alive?” “When do you experience inner calm?” The therapist would find ways to strengthen Paul’s self esteem, by increasing self-awareness, fostering self-acceptance, and self-validation. One way to get a sense about how Paul saw himself, would be to ask, “What are your hopes and wishes for yourself?” His answer could enable the therapist to understand which yearnings could motivate him to live. In the case of Paul, his dreams of becoming a rock star suggest a desire for acceptance and recognition. The therapist would find out how he could have found an acceptable way to express himself either through singing, playing an instrument, or possibly creating poetry. The therapist might be able to help him to realize his dream, or change his dream for one that could have been attainable.

The Satir model supports the idea of resilience within all people and the belief that each person has strengths and resources to deal with their lives. The therapist would listen to the problem, and reframe the problem into more positive possibilities. As the therapist listened to and continued to be engaged with Paul, there would be exploration on finding out how Paul experienced himself, others, and his world. The therapist could ask, “How do you handle your loneliness?” “How do others see you?” “When have you felt supported and seen by others?” The therapist would use process questions throughout the therapy

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process, in order to find out if there were strengths or resources that had been developed by Paul as a result of his situation(s) and relation- ship(s). For example, “When do you feel good about yourself?” and “What do you do well?” The therapist would be creative in reframing negative perceptions into more positive resources. “Can you appreciate that you have deep, deep feelings, like the depths of a passionate song- writer?” Once the strengths and resources had been identified, the therapist would help Paul to take ownership for his strengths and resources, in spite of any perceived obstacles. “Right in this moment, can you be aware of your love of music? How does it make you feel inside?” Awareness of his strengths and resources could foster increased self-esteem.

One of the four goals of the Satir model is to help the client to make better choices. The choice to live is a crucial goal for the therapist to explore with suicidal youth. “Are you willing to live for yourself and not for others?” “Do you deserve to live in peace?” “Can you make a decision today to live and not to die inside?” Another important aspect of the Satir model is to create experiential moments for the client in therapy. During these moments when Paul was becoming aware of and experiencing his inner world, the therapist would gently challenge him to make some choices about his life. “Close you eyes and as you become aware of the pain, can you send compassion to that painful place, so it can begin to breathe?”

If the therapist sensed that Paul had suicidal thoughts, it would have been important to explore whether he was willing to live for himself. The therapist would ask Paul to make a decision to live at the level of self while he was immersed in an experiential moment. “In this vulnerable place, can you find the inner strength to live and grow?” If Paul did not feel hopeful, then the therapist would suggest, “Will you accept my hope for you, so that we can work together until you gain your own hope?” The therapist would ask, “Are you willing to make a decision not to hurt yourself, while we are working together to change things?” If Paul felt suicidal when he was away from the therapy ses- sion, then the therapist would help him co-create a plan for coping that Paul could agree to.

Increasing responsibility is another one of the four goals of the Satir model. Working with and changing expectations is also a fundamental concept in the Satir model. Helping a client to either accept his or her expectations or to change those expectations can facilitate a client to take on responsibility for his or her life and to make different choices. If the therapist heard any regret(s), then exploration could occur with

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having Paul accept that these were his expectations. The therapist would suggest that if Paul accepted and owned his expectations, then he could have been more willing to fulfill his expectations and let go of his expectations of others. “Are you willing to make a decision to stop hurting yourself, and to ease your pain?” “How can you let go of expecting that they should know about your painful hurt, when you hurt yourself?” If Paul would not let go of his expectations, then the therapist would explore the costs for him in keeping these expectations. The therapist would suggest that he meet his own yearnings for accep- tance and validation, instead of waiting for others to meet his yearn- ings. Together they could make a concrete plan on how Paul could meet his yearnings. “How can you extend a caring, helping hand to yourself ?” “Are you willing to give yourself the gift of life, instead of waiting for someone else to give your life to you?” “Is it time to let love inside?”

The facilitation of congruence, the last of the goals in the Satir model, involves helping with the ability to be honest and truthful in actions and words coming from one’s internal experience. As clients become more aware of interactions with self, other, and the context, there can be the opportunity to develop congruence. Gaining an under- standing of the impact of Paul’s past experiences in the family and within the school system would be very useful. “What happened for you when no one seemed to pay attention to you anymore?” The thera- pist could also include Paul’s family in family therapy, and involve his parents or siblings in the therapeutic process. The therapist would explore his past family experiences and past social experiences, and then work on reducing any negative impacts in the present. “Are you still waiting for your parents to really see you?” By changing how he experienced his memories of the past, Paul could have been freer to live his present life. “Your parents gave you the gift of life, are you now ready to accept their gift into your heart?” “Are you willing to forgive your parents for not understanding you in the way that you needed?” “Can you now forgive yourself for not taking better care of yourself in the past?” When Paul was not burdened by negative percep- tions of himself or others, then he would have been more able to become congruent. “Can you allow yourself to live with your mistakes, without having to punish yourself for having the courage to live?”

Another important aspect of the Satir model would be reflected in the therapist’s listening closely to how Paul verbalized his world and any meaningful metaphorical words or concepts. The therapist would closely listen to and respond with specific and intentional conscious

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responses. “Are you willing to shine a warm, bright light on the part of you that feels isolated and invisible?” The pace and the tone of the therapist would match Paul’s energy level and pace in order to have created a close therapeutic relationship and shared language.

The Satir model also encourages therapists to strengthen their own abilities for observation of self, the client, and the context of the session. Throughout the session, the therapist would be observing in these three different ways. The therapist would pay close attention to Paul’s language, connection, and responses; pay attention to the responses that he or she shared with him; and would watch his or her own inner responses to Paul’s comments and interactions.

The therapist would notice Paul’s inner experience through using the framework of the Personal Iceberg Metaphor. The therapist would listen to, watch for and pay attention to Paul’s inner experience by using the components of the Iceberg metaphor. The therapist would be using his or her intuition to comprehend what kind of intentional responses might have been most effective with him. The therapist would be watchful of his behaviors, coping, feelings, feelings about having his initial feelings, perceptions, expectations of himself, expecta- tions of others, expectations of his world, yearnings, and Self: I am. The therapist could ask questions that speak to the inner components of Paul’s world. For example: (behavior) “When you cut yourself, what is the wound saying?”; (coping) “How do you cope with the rejection?”; (feeling) “How do you feel right now as we explore this?”; (feelings about the feelings) “What is the feeling that lies beneath your anger?”; (perceptions) “What do you think would stop the pain?”; (expectations) “What do you expect they should have done when they saw your wounds?”; (yearnings) “If you were to live in that way you had hoped, what would be happening for you instead?”; (Self: I am) “Can you allow your favorite music to soothe your soul?”

The therapist would look beyond Paul’s initially withdrawn behav- iors or his later external acting out behaviors. The transformational experience would be more likely to occur after the therapist was able to facilitate Paul’s acceptance, acknowledgment, forgiveness, honoring, loving, and commitment to his Self: I am. By helping to change Paul’s inner experience of himself, this would create the space for healing and growth. The Satir model would give the therapist a map into understanding Paul’s inner experience. It can also help the therapist to support him, to make new decisions to live, to increase his self- esteem, and support Paul to become more responsible for his life and to encourage congruence within.

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CONCLUSION

Current treatment modalities often may address only separate components of youths’ inner experience. The Satir model gives a frame- work that encompasses an integrative and holistic view of their inner experience. This model can be effectively applied to the prevention, intervention, and treatment of suicidal youth. We can now begin to understand suicidal behavior differently by exploring and changing the inner world of youth. Seeing suicide through new lenses allows the focus of treatment to be internally based and transformationally focused. The Satir model offers hope for therapists in facilitation of deep inner transformation in youth. We need to instill hope in youth, so that they can look forward to having a positive impact toward their future. As more of our young people find meaning and reason in living, there will be great hope for this and the next generation of youth.

REFERENCES

Banmen, A., & Banmen, J. (Eds.). (1991). Meditations of Virginia Satir: Peace within, peace between, peace among. Palo Alto, CA: Science and Behavior Books.

Banmen, J. (1997). Invitational training: Satir’s systemic brief therapy. Bellingham, WA: Unpublished video.

Banmen, J. (2000). Suicide prevention: A treatment alternative. Suicide Interven- tion & Treatment Task Force: Satir Institute of the Pacific, Vancouver, BC: Unpublished paper.

Berman, A. L., & Jobes, D. A. (1991). Adolescent suicide: Assessment and intervention. Washington, DC: American Psychological Association.

Berman, A. L., & Jobes, D. A. (1997). The treatment of the suicidal adolescent. Washington, DC: American Psychological Association.

Chandler, M. J., & Lalonde, C. (1998). Cultural continuity as a hedge against suicide in Canada’s First Nations. Transcultural Psychiatry Research Review, 35(2) 191–219.

Ellis, T.E., & Newman, C.F. (1996). Choosing to live: How to defeat suicidal behavior through cognitive therapy. Oakland, CA: New Harbinger.

Everall, R. (2000). The meaning of suicide attempts by young adults. Canadian Journal of Counselling. 34 (2), 111–125.

Fiske, H. (1998). Applicatios of solution-focused therapy in suicide prevention. In D. Deleo, A. Schmidtke, and R.F.W. Diekstra (Eds.), Suicide prevention: A holistic ap- proach (pp. 185–197). Dordecht, the Netherlands: Kluwer.

Freeman, A., & Reinecke, M. A. (1993). Cognitive therapy of suicidal behavior: a manual for treatment. New York: Springer Publishing Co.

Hoover, M. (1987). Suicide and the self as process: Self validation-invalidation. Unpublished master’s thesis, University of Alberta, Canada.

Hoover, M.A., & Paulson, B.L. (1999). Suicidal no longer. Canadian Journal of Counselling. 33 (3), 227–244.

Jamison, K.R. (1999). Night falls fast. New York: Vintage Books. Linehan, M.M. (1993). Cognitive- behavioural therapy of borderline personality disor-

der. New York: Guilford Press.

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Linehan, M. M., MacLeod, A. K., & Williams, J. M. G. (1992). New developments in the understanding and treatment of suicidal behavior. Behavioral Psychotherapy, 20 (3), 193–218.

Maris, R.W., Berman, A.L., & Silverman, M.M. (2000). Comprehensive textbook of suicidology. New York: Guilford Press.

Richman, J., & Eyman, Jr. (1990). Psychotherapy of suicide: individual, group, and family approaches in current concepts of suicide. In Lester, D. (Ed.), Current concepts of suicide (pp 139–158). Philadelphia, PA: The Charles Press.

Satir, V. (1972). Peoplemaking. Mountain View, CA: Science and Behavior Books. Satir, V., & Banmen, J. (1983). Virginia Satir verbatim 1984. North Delta, BC: Delta

Psychological Associates, Inc. Satir, V., Banmen, J., Gerber, J., & Gomori, M. (1991). The Satir model: Family

therapy and beyond. Palo Alto, CA: Science and Behavior Books.

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G. R. Cox et al.: Suicide Clusters in Youn g PeopleCrisis 20 12; Vol. 33(4):208–214© 2012 Hogrefe Publishing

Research Trends

Suicide Clusters in Young People Evidence for the Effectiveness of Postvention Strategies

Georgina R. Cox1, Jo Robinson1, Michelle Williamson2, Anne Lockley2, Yee Tak Derek Cheung2, and Jane Pirkis2

1Orygen Youth Health Research Centre, Centre for Youth Mental Health, University of Melbourne, Australia, 2Centre for Health Policy, Programs & Economics, Melbourne School of Population Health,

University of Melbourne, Australia

Abstract. Background: Suicide clusters have commonly been documented in adolescents and young people. Aims: The current review conducts a literature search in order to identify and evaluate postvention strategies that have been employed in response to suicide clusters in young people. Methods: Online databases, gray literature, and Google were searched for relevant articles relating to postvention interventions following a suicide cluster in young people. Results: Few studies have formally documented response strategies to a suicide cluster in young people, and at present only one has been longitudinally evaluated. However, a number of strategies show promise, including: developing a community response plan; educational/psychological debriefings; providing both individual and group counseling to affected peers; screening high risk individuals; responsible media reporting of suicide clusters; and promotion of health recovery within the community to prevent further suicides. Conclusions: There is a gap in formal evidence-based guidelines detailing appropriate post- vention response strategies to suicide clusters in young people. The low-frequency nature of suicide clusters means that long-term systematic evaluation of response strategies is problematic. However, some broader suicide prevention strategies could help to inform future suicide cluster postvention responses.

Keywords: suicide clusters, young people, postvention response

A suicide cluster can be defined as “a group of suicides or suicide attempts, or both, that occur closer together in time and space than would normally be expected on the basis of statistical prediction/or community expectation” (Centers for Disease Control [CDC], 1988). Clusters can be split into two distinct groups: point clusters and mass clusters. Point clusters are close in both space and time, occur in small communities, and involve an increase in suicides above a baseline rate observed in the community and surrounding area. Mass clusters involve a temporary increase in suicides across a whole population (Mesoudi, 2009), and have been documented following suicides by high-profile celebrities or political figures which have received considerable media attention (Chen et al., 2010). This literature review outlines the evidence relating to the containment and future preven- tion of clusters and focuses solely on point clusters.

The mechanisms underlying suicide clusters are unclear, although it has been proposed that they may result from a process of “contagion,” whereby one person’s suicide in- fluences another person to either attempt or to complete suicide (O’Carroll & Potter, 1994). Suicide clusters have been most commonly observed in adolescents and young people under the age of 25 years (Hazell, 1993); this pop- ulation is the main focus of this review. However, it should

be noted that suicide clusters have also been observed in other high-risk groups, including indigenous communities (Hanssens & Hanssens, 2007; Wilkie, Macdonald, & Hil- dahl, 1998), prisoners (McKenzie & Keane, 2007), and people with mental illness (McKenzie et al., 2005), partic- ularly within inpatient settings (Haw, 1994).

Youth suicide rates have gradually increased, and this age group is now at the highest risk of suicide in one third of all countries (World Health Organization [WHO], 2010). At least 100,000 adolescents complete suicide every year (WHO, 2002); worldwide suicide ranks in the top five causes of mortality among 15- to 19-year-olds (WHO, 2000). In adolescents and young people, it has been esti- mated that between 1% and 5% of all suicides are part of a cluster (Gould, Wallenstein, & Kleinman, 1987). Further- more, contagion is thought to be a key factor in 60% of all suicides in this population (Davidson, Rosenberg, Mercy, Franklin, & Simmons, 1989). The death of a peer can be a traumatic experience for a young person, and it is estimated that for every suicide, three friends are strongly affected (Mauk & Gibson, 1994). Although the exact process by which suicide contagion operates is still unclear, suicidal behavior in peers may act as a risk factor to exacerbate underlying psychiatric disturbances in young people. For

DOI: 10.1027/0227-5910/a000144 Crisis 2012; Vol. 33(4):208–214 © 2012 Hogrefe Publishing

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example, the presence of suicidal ideation in young people has been estimated to lie between 20% and 30% (Evans, Hawton, Rodham, & Deeks, 2005; Nock et al., 2008), which may act as an additional risk factor for contagion to occur. Furthermore, adolescent peers of suicide attempters and completers report significantly more suicidal behavior compared to those who have not been exposed to the sui- cidal act of a peer (Ho, Leung, Hung, Lee, & Tang, 2000). Young people also appear to be particularly susceptible to contagion effects brought about by certain types of media reporting of suicide (Gould, Jamieson, & Romer, 2003).

It is difficult to predict exactly when and where a suicide cluster will occur, and as a result, there is a need to develop a set of postvention strategies that can be implemented fol- lowing the identification of such a suicide cluster. One of the most widely quoted documents concerning the manage- ment of suicide clusters is the CDC community plan for the prevention and containment of suicide clusters (CDC, 1988). The report was originally developed to assist com- munity leaders from a variety of backgrounds, including public health, mental health, and education, implement pre- vention, and containment strategies to manage a suicide cluster. The community plan focuses strongly on commu- nities developing a response plan that can be implemented before the onset of a suicide cluster, and on postvention responses once a cluster has occurred.

The current literature review conducts a search of the academic and gray literature on suicide clusters that have been documented in young people. Key postvention strat- egies implemented in response to a suicide cluster in this population were identified, and evidence for their effective- ness is discussed.

Method

Medline, Psychinfo, and Embase were searched using search strings including the following keywords; “suicid*” AND (“cluster” OR “epidemic” or “copycat” OR “conta- gion” OR “multiple” OR “postvention”). Hand searching of references and specialist journals was also conducted. The above search terms were also used in the search engine “Google” in order to identify gray literature.

Results

A total of 155 articles were retrieved in the database search, the majority of which related either to the identification of clusters in high-risk groups or to the mechanisms underly- ing why suicide clusters occur.

The literature search identified two publications that have formally documented postvention strategies em- ployed following a suicide cluster in young people within a community setting (Askland, Sonnenfeld, & Crosby, 2003; Hacker, Collins, Gross-Young, Almeida, & Burke, 2008). An additional three publications detailed more lim- ited and specific strategies that have been employed in a school setting either following a suicide cluster, or where individuals were identified as being at risk of imitative sui- cidal behavior (Brent et al., 1993; Hazell, 1991; Poijula, Wahlberg, & Dyregrov, 2001).

There was consistency in the type of postvention strate- gies adopted by the wider community and in schools, in order to “contain a cluster” once it had begun to evolve. These strategies tended to involve six main approaches: development of a community response plan; education- al/psychological debriefings; providing both individual and group counseling to affected peers; screening of high- risk individuals; responsible media reporting of the suicide cluster; and promotion of health recovery within the com- munity to prevent future suicides (see Table 1).

Development of a Community Response Plan

A response plan has tended to involve members of commu- nity-based trauma teams or networks, and, ultimately, a “re- sponse team” has been formed. The role of this team has been to investigate the events that have affected the com- munity, be on the frontline to respond to young people who show signs of distress as a result of a suicide, and imple- ment postvention strategies such as improving media rela- tionships or setting up focus groups for survival victims. Teams have commonly consisted of teachers, mental health professionals, parents, representatives from a local crisis center, law enforcement, and liaison members from the lo- cal media and community (Hacker et al., 2008). Training

Table 1. Common postvention strategies employed following a suicide cluster in young people

Study Development of a community response plan

Educational/psy- chological debriefings

Counseling for high-risk individuals

Screening of high-risk individuals

Promotion of health recovery and prevention

Responsible media reporting

Brent et al. (1989) ×

Hazell (1991) ×

Poijula et al. (2001) ×

Askland et al. (2003) × × × ×

Hacker et al. (2008) × × × × ×

G. R. Cox et al.: Suicide Clusters in Young People 209

© 2012 Hogrefe Publishing Crisis 2012; Vol. 33(4):208–214

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for team members (such as posttraumatic stress manage- ment) is often required in order for individuals to deal with the crisis in an appropriate manner (Hacker et al., 2008). A collaborative approach, using existing partnerships within the community, has been highlighted as essential in imple- menting an effective trauma team and network (Hacker et al., 2008).

Evidence for the effectiveness of response plans was predominantly descriptive in nature and lacking in long- term follow-up. Askland et al. (2003) developed a “real- time” community response plan following a suicide cluster involving adolescents in a rural community of Maine, USA. Key strategies included educational debriefings giv- ing young people information about suicide; suicide pre- vention and coping strategies; individual screening of young people identified as being at-risk for suicide (by their parents, other students, or school staff); and crisis evalua- tion, whereby young people who were felt to be at imme- diate high risk of self-harm or suicide were referred to the appropriate mental health service (which included outpa- tient services, crisis stabilization services, or psychiatric hospitalization). The collaboration that occurred between law enforcement, school staff, and health services (both public and private) allowed the community to gather infor- mation about potential high-risk individuals, carry out screening in schools in order to facilitate referral to mental health services, and offer suicide awareness and prevention training to key stakeholders. Overall, 39 individuals were identified as needing intervention for potential suicidal be- havior and were referred in a streamlined manner to the relevant services.

Hacker et al. (2008) reported on the implementation of a community response to a suicide cluster primarily via drug overdose in young people in 2002; this was the only study to include a long-term follow-up on the effectiveness of their response plan. After implementing their response plan, they recorded only one death by suicide which was unrelated to the previous cases of suicide contagion. In ad- dition, since 2004, hospital discharges for nonfatal self- harm and nonfatal opiate related discharges have steadily decreased.

The CDC guidelines recommend developing a response plan before a cluster occurs, but timely implementation of a response plan following a suicide cluster in a school set- ting has been associated with fewer students showing symptoms of PTSD (Poijula et al., 2001). This underscores the importance in making a response plan a possible strat- egy to consider when managing an evolving suicide cluster.

Educational/Psychological Debriefings

The death of a young person can have a deep and far-reach- ing effect on individuals close to the deceased, other young people in their school, and the community in general. After a suicide cluster has been identified, schools have raised the awareness of the issue in a sensitive and timely manner.

Information regarding suicide and suicide risk has been de- livered either to a whole school, in order to raise awareness universally, or to high-risk individuals there. Askland et al. (2003) disseminated information about suicide, suicide prevention, and coping strategies to school students over 3 days, in 1.5 h small group educational debriefing sessions, led by trained clinicians. No evaluation, however, was car- ried out regarding the effectiveness of the sessions.

Individual and Group Counseling for Affected Peers

Friends of a young person who dies by suicide experience a range of emotions, including guilt for “missing the signs” of their friend’s distress, or anger with themselves or others for not having prevented it. It has been suggested that adolescent suicide is closely related to posttraumatic stress (PTSD), major depression, and suicidal ideation in peers following exposure to a suicide (Brent et al., 1993; Poijula et al., 2001). Crisis counseling sessions have been highlighted as important in addressing the needs of these high-risk individuals, and they have been employed in a postvention strategy following suicide clusters. Group counseling sessions for young people affected by the sui- cide of a peer have centered around four themes: addressing guilt and responsibility following the death of a friend; dif- ficulties in interpreting the signs of suicidal behavior; rec- ognizing reactions to grief; and directing adolescents to- ward appropriate services for help should they feel suicidal themselves (Hazell, 1991). Counseling sessions have also been delivered in schools to both students and parents, in collaboration with local mental health services, and com- munity-based trauma teams (Hacker et al., 2008). Howev- er, the effectiveness of these sessions was not evaluated.

Screening High-Risk Individuals

The CDC recommended, and Hazell (1993) highlighted, the fact that risk assessment and screening of high-risk in- dividuals is an important postvention response strategy to a suicide cluster. A number of young people can be classi- fied as high risk following the suicide of someone in their community including friends or acquaintances of the suicide victim, individuals with an existing psychiatric dis- order, and/or young people who have recently attempted suicide themselves. Screening has taken place following a suicide cluster for a number of risk factors, most notably suicidal behavior including recent attempt or ideation (Brent et al., 1989) and symptoms of PTSD (Poijula et al., 2001).

Schools play an important role in the response to suicide clusters in young people and have the potential to play a pivotal role in implementing screening programs for high- risk individuals. Following a suicide cluster among teenag-

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ers, 33% of the school population screened were identified as “at risk.” Furthermore, 28% of this screened population reported current or recent suicidal ideation – and of these individuals, 17% reported a suicide attempt occurring with- in the previous 4 weeks. Furthermore, following screening for PTSD symptoms in three secondary schools where teenage suicides had occurred revealed that friends of the suicide victims were more likely to be in the high-risk group showing PTSD symptoms compared with those who were not friends with the victims (Poijula et al., 2001).

Individuals at high risk of suicidal behavior have also been identified through a number of other sources. Parents play a role in recognizing signs of distress in their offspring, especially after the death of someone close, and trauma response teams have acted to increase awareness of suicide “warning signs” in the community. Professionals that come into contact with young people such as school staff – in- cluding teachers, school guidance counselors, or school nurses – and health professionals are also key individuals in identifying young people at risk of suicidal behavior. Although GPs have been identified as playing a key role in helping families, friends, and those close to the deceased after a teenage suicide, and as having the potential to iden- tify high-risk individuals (Johansson, Lindqvist, & Eriks- son, 2006), no formal evaluation regarding the effective- ness of GPs in identifying young people at risk of suicide following a suicide cluster has been reported.

Responsible Media Reporting of Suicide Clusters

Literature retrieved from the database search highlighted that suicide clusters often receive a large volume of media attention. Young people are thought to be particularly sus- ceptible to suicide contagion effects as a product of certain types of media reporting (Gould, Jamieson et al., 2003), so that inappropriate media attention may contribute to the cluster continuing.

Previous postvention strategies included the media as part of the development of a community response. This al- lowed information to be disseminated and reported on in a sensitive and responsible manner. For example, members of community trauma teams met with the local newspaper editor to clarify CDC recommendations on reporting sui- cide clusters (Hacker et al., 2008). As a result, the deaths of the young people who were part of the suicide cluster were reported in a nonsensational manner.

It has also been suggested that media reporting of suicide clusters should be kept to a minimum, due to the risk of imitative suicide in the community. A body of evidence suggests that irresponsible reporting of suicide in the media can potentially lead to “copycat” suicides and could thus act as a tipping point upon which a cluster could begin or be exacerbated. (Pirkis & Blood, 2001).

Promotion of Health Recovery Within the Community to Prevent Further Suicides

Although crisis management of a suicide cluster appears to be imperative, communities in which suicide clusters have occurred highlight a number of long-term steps that must also be taken in order to promote the recovery of the com- munity. Poijula et al. (2001) found that, 6 months after a suicide cluster had occurred in a school, 30% of the class- mates of the suicide victim still continued to show signs of PTSD, and 9.8% showed a high level of grief reaction. This highlights the need to implement long-term programs to prevent suicide in the population within which the suicide cluster occurred.

Whole school screening and ongoing surveillance of sui- cidal behavior has contributed to the development of a community response plan and has aided the recovery of a community by identifying risk factors and risk behaviors that may have contributed to the suicide cluster. For exam- ple, Hacker et al. (2008) identified poor social functioning and school adjustment as risk factors for suicide attempts in the community. They also reported that surveillance of suicidal behavior in the community had been collected via surveys, death certificates, hospital discharge data, and 911 calls.

Prevention training for community stakeholders and gatekeepers has been given in order to increase awareness of the warning signs of suicide and to aid early intervention (Hacker et al., 2008). For example, teachers, parents, and mental health professionals were trained in posttraumatic stress management, which acted not only to provide key community members skills essential to deal with the cur- rent suicide cluster, but also equipped them with the knowl- edge and strategies to be implemented in the future.

The anniversaries of suicide deaths can also unearth a range of difficult emotions for the family and peers. In the long term, suicide prevention articles could be published in the local media around the anniversary of a youth death to promote timely help-seeking and awareness (Hacker et al., 2008).

Discussion

Despite young people being a high-risk population in which suicide clusters occur, the current review highlighted the limited number of studies published on postvention strategies in response to suicide clusters in this group. At present, two community case studies have been published illustrating that the CDC guidelines are helpful in allowing a community to contain, manage, and curtail a suicide clus- ter specifically among young people (Askland et al., 2003; Hacker et al., 2008). However, only one evaluated the long- term gain from postvention strategies (over the period 2002 to 2006; Hacker et al., 2008), while the other reported on

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immediate “crisis management” of a cluster, without long- term evaluation of its effectiveness (Askland et al., 2003). These publications, while rich in information concerning the nature of interventions implemented following a sui- cide cluster, did not evaluate the overall effectiveness of such steps in preventing future clusters. Furthermore, many papers identified in the search were epidemiological stud- ies assessing risk factors and previously observed clusters, lacking in information regarding the response to such situ- ations. This finding mirrors the general suicidology litera- ture, which has a disproportionately strong focus on epide- miology rather than intervention (Robinson et al., 2008).

A number of limitations need to be considered about the nature of the review. First, many communities that have experienced a suicide cluster may have developed, or al- ready implemented, postvention strategies that are not in the academic or public domain, where documents are cir- culated only at a local level. As the suicide cluster abates, resources are directed into community recovery, rather than to a formal and scientific evaluation of their experience. Indeed, the lack of opportunity to evaluate postvention strategies using randomized controlled trials (RCTs) means that formal evaluation of such approaches is problematic. Second, because of the guidelines surrounding media re- porting of suicide (Commonwealth of Australia, 2010), and the potential negative effects that inappropriate media cov- erage can cause following a suicide cluster, many clusters may not have been identified by our search, as they were not reported in the media in the first place. In addition, because suicide is a rare event – and suicide clusters even more so – the availability of information regarding such experiences is likely to be limited in nature. The CDC rec- ommendations on how to contain and manage a suicide cluster were initially developed in 1989 and have, to the authors’ best knowledge, not been updated. Given the ways in which young people now communicate, such as through email, social networking sites, and mobile phones, it may be advantageous to update these guidelines with these com- munication methods in mind. Mobilizing resources and dis- seminating information following a suicide cluster may be helped by exploiting these methods of communication. Re- cent reviews on the prevention and treatment of mental ill- ness in young people using internet delivered programs suggest that they are an effective means of intervention (Calear & Christensen, 2010; Richardson, Stallard, & Vel- leman, 2010). With the advent of newer media, which al- lows for more rapid and more widespread communication between young people, it will become even more important to investigate and understand how clusters operate within these communication methods.

As discussed, there are a handful of published articles on postvention strategies that appear to show promise in managing and containing suicide clusters in young people. We need to develop a better evidence base to confirm the effectiveness of these strategies, but as alluded to above, this can be challenging given the nature of suicide clusters and suicide prevention in general. However, evidence of

effective interventions from the broader suicide-prevention literature could be adopted and applied to the notion of suicide clusters. For example, screening high-risk individ- uals has been shown to be effective in identifying young people at risk of suicidal behavior (Gould, Greenberg, Vel- ting, & Shaffer, 2003; Shaffer et al., 2004) and may in- crease the likelihood of such individuals subsequently ac- cessing services (Gould et al., 2003, 2009). Providing gate- keeper training to school staff also has the potential to prevent a suicide cluster, by aiding professionals in identi- fying individuals at risk of suicidal behavior. Gatekeeper training programs such as the Sources of Strength Program (Wyman et al., 2008) and Question, Persuade, and Refer (Reis & Cornell, 2008), delivered to school staff, have been shown to increase knowledge of suicide risk factors and self-efficacy in performing help-seeking behaviors. Fur- thermore, universal prevention programs delivered to school students, such as the Signs of Strength (SOS) pro- gram (Aseltine & DeMartino, 2004) and Surviving the Teens (King, Strunk, & Sorter, 2011), have been shown to increase knowledge of suicide warning signs in oneself and others. However, concerns have been expressed previously regarding potentially negative effects such programs may have (Shaffer & Gould, 2000). In the absence of evidence indicating otherwise, solid recommendations for their use cannot therefore be made. Given that these types of pro- grams are preventive in nature, providing intervention op- tions to schools affected by a suicide cluster can assist them in developing a long-term suicide prevention program.

In addition, providing young people with information following a suicide may be a useful postvention strategy that could be applied following a suicide cluster. In Aus- tralia, the “Toughin’ It Out” pamphlet was first designed to help young people talk about their own suicide risk after the suicide of a loved one. Bridge, Hanssens, and Santha- nam report that, since 1999, this pamphlet has been used extensively as a brief intervention and educational resource in the Northern Territory and Queensland (Bridge, Hans- sens, & Santhanam, 2007) where a number of suicide clus- ters have occurred. However, no formal evaluation of its effectiveness in relation to dealing with suicide clusters could be located.

In summary, there is limited evidence regarding the effectiveness of postvention strategies in response to sui- cide clusters. The most commonly implemented strate- gies are developing a community response plan; educa- tional/psychological debriefings; providing both individ- ual and group counseling to affected peers; screening high-risk individuals; responsible media reporting of sui- cide clusters; and promotion of health recovery within the community to prevent further suicides. However, adopting a broader perspective on the interventions that have been shown to be effective in preventing suicide in youth and identifying young people at risk of suicidal be- havior may be beneficial in helping communities to de- velop effective evidence-based response strategies to a potential suicide cluster.

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Received April 19, 2011 Revision received October 18, 2011 Accepted November 29, 2011 Published online June 20, 2012

About the authors

Dr. Georgina Cox is a postdoctoral research fellow specializing in suicide prevention at Orygen Youth Health, University of Mel- bourne, Australia. She has undertaken work in the area of depres- sion in children and adolescents and is currently involved in im- plementing a web-based intervention for at-risk youths.

Jo Robinson is a research fellow at Orygen Youth Health Research Centre, University of Melbourne, Australia, where she leads a research program specializing in youth suicide prevention. She is also undertaking her PhD study with the University of Melbourne examining the effects of a web-based intervention on at-risk youths.

Michelle Williamson is a research fellow at the Centre for Health Policy, Programs, and Economics at the University of Melbourne, Australia. She has worked predominantly in the areas of suicide prevention and mental health research and has worked on a num- ber of large-scale government program evaluations.

Anne Lockley is a freelance consultant specializing in program design, evaluation, and community-based research. She has de- signed and managed multiagency programs in sectors such as HIV, youth development, initiate partner violence, and public health.

Yee Tak Derek Cheung is currently completing a PhD on suicide clusters under the supervision of Professor Jane Pirkis. He has practical experience in suicide surveillance and monitoring and has published a number of academic articles and evaluation re- ports related to suicide.

Jane Pirkis is Professor and Director of the Centre for Health Pol- icy, Programs, and Economics at the University of Melbourne, Australia. She has undertaken a broad program of work on the epidemiology of suicide and has conducted a number of large- scale evaluations of suicide prevention initiatives.

Georgina Cox

Orygen Youth Health Research Centre Centre for Youth Mental Health University of Melbourne Parkville, Victoria 3052 Australia Tel. +61 4 0-630-0558 Fax +61 3 9-342-2941 E-mail [email protected]

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ANTIDEPRESSANTS AND SUICIDE

Further evidence of increased suicide risk with antidepressants in children

ccording to a new case-control study, antidepressant treatment may increase

the risk of suicide in severely depressed chil- dren and adolescents, but not in adults. Sui- cide attempt risk among young people hospi- talized for depression and treated with antide- pressants was 1.5 times greater than among comparable groups of children who received no antidepressant treatment.

No significant associations were found between adults who received antidepressant treatment and suicide attempt or suicide death following hospital discharge.

The study, led by Mark Olfson, M.D., and published in the August issue of Archives of General Psychiatry, is unique in being the first large-scale analysis comparing suicide attempts and suicide deaths in adults and chil-

linicians face a particular challenge when treating pregnant women with

mood and anxiety disorders, write Shaila Misri, M.D., clinical professor of psychiatry and OB/GYN, University of British Colum- bia, and colleagues in a study appearing in the American Journal of Psychiatry. They have to balance the consequences of exposure to unstable maternal mood and anxiety with the risks of prenatal exposure to psychotropic medications.

The authors followed children who were exposed prenatally to psychotropic medica- tions for four years and found no association with increased reports of internalizing behav- iors at age 4. The authors did find, however, that impaired maternal mood had an identifi-

able impact on child behavior. Children with internalizing behaviors often go unrecognized and receive inadequate treatment. After a

PRENATAL DRUG EXPOSURE: SPECIAL REPORT

No link between prenatal drug exposure and internalizing behaviors in young children

PRENATAL EXPOSURE, continued on page 6

VOLUME 8, NUMBER 10 OCTOBER 2006 ISSN 1527-8395 ONLINE ISSN 1556-7567

Editor: Henrietta L. Leonard, M.D.

Highlights… This month we bring you an update on the latest data regarding whether antidepressant use is linked to suicide in children and adolescents. Mark Olfson, M.D., talked with us about the results of his study.

For special coverage of neonatal drug exposure, see pages 1, 3, 4, 5, and 8.

Inside WHAT’S NEW IN RESEARCH . 3 • Prenatal exposure to SSRIs and/or

maternal depression • Prenatal exposure to mirtazapine

and birth outcomes

NEWS NOTES. . . . . . . . . . . . 7

CASE REPORT . . . . . . . . . . . 8 • Elevated neonatal gamma-

glutamyl transpeptidase with maternal lamotrigine use

FROM THE FDA . . . . . . . . . 8

A

C

précis • New findings suggest antidepressant treat-

ment may increase suicidality in children and adolescents, but not in adults

• Case-control study comparing suicide attempts and suicide deaths among 878 Medicaid inpatients (ages 6 to 64 years) with severe depression, treated or not treated with antidepressants, and matched to 4,070 controls

• Nearly two thirds of all suicide attempts or suicide deaths occurred within 4 months of hospital discharge; nearly 75% occurred within the first 6 months following dis- charge

• Results are consistent with recommenda- tions for close monitoring for clinical wors- ening during acute phase of antidepressant treatment in pediatric patients

précis • Prospective analyses find little variation in

internalizing behaviors between 4-year- olds with and without in-utero exposure to an SSRI

• Increased parental reports of child internal- izing behaviors associated with maternal symptoms of depression and anxiety

• Researchers emphasize importance of monitoring long-term behavioral outcomes of children exposed in utero to psychotrop- ic medications and born to mothers with chronic mental illness.

• FREE PATIENT HANDOUT: MIRTAZAPINE (GENERIC) – REMERON (BRAND) •

SUICIDE RISK, continued on page 2

Published online in Wiley InterScience (www.interscience.wiley.com)

DOI: 10.1002/cpu.20029

2 THE BROWN UNIVERSITY CHILD & ADOLESCENT PSYCHOPHARMACOLOGY UPDATE OCTOBER 2006

Editor: Henrietta L. Leonard, M.D., Professor of Psychiatry, Brown Uni- versity; Director of Training, Child and Adolescent Psychiatry, Rhode Island Hospital, Providence, RI.

Guest Editor....Christopher Kratochvil, M.D.

Executive Editor..................Karienne Stovell

Associate Editor .......................Sarah Merrill

Associate Editor......................Diana Steimle

Contributing Writer.......................Gary Enos

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dren treated or not treated with antidepres- sants. While the findings provide addition- al data supporting an association between antidepressant treatment and suicide risk in young people, the reasons for the associa- tion are less clear. Olfson is Professor of Clinical Psychiatry, New York State Psy- chiatric Institute/Department of Psychiatry, College of Physicians and Surgeons of Columbia University, New York, NY.

The results are consistent with an FDA meta-analysis1 of 24 clinical trials which found a higher risk of suicidal thinking and behavior among children treated with antidepressants compared with children not treated with antidepressants. In Octo- ber 2004, the FDA directed pharmaceuti- cal manufacturers of all antidepressant medications to include a “black box” warning of increased suicidality in chil- dren and adolescents treated with antide- pressants. Fluoxetine (Prozac) is currently the only antidepressant approved for treat- ment of depression in pediatric patients.

The findings also support current rec- ommendations2-3 for close monitoring of clinical worsening, including irritability, agitation, suicidality, and unusual behav- ioral changes during antidepressant treat- ment.

Study details Olfson and his team designed the two-

year matched-control study based on a rel- atively homogenous population. “By lim- iting the analysis to patients after inpatient treatment of depression, we sought to ensure that cases (suicide attempt and sui- cide death) and controls (no suicide attempt and no suicide death) who did or did not receive antidepressant treatment had a high and comparable level of illness severity,” write Olfson and colleagues.

The study was based on an analysis of 878 cases of Medicaid beneficiaries (ages 6 to 64 years) throughout the United States who received inpatient treatment for a depressive disorder and subsequently attempted or completed suicide, matched to 4,070 controls. The reference period was from January 1, 1999 through December 31, 2000. Patients with claims for pregnan- cy, bipolar disorder, schizophrenia or other psychoses, mental retardation, or demen- tia/ delirium were excluded from the study cohort. The date of a suicide attempt or sui-

cide death was defined as the event date. Cases were excluded for patients who received 15 days or more of inpatient treat- ment within 60 days before the event date.

Among patients who attempted suicide, 784 cases were matched to 3,635 controls. For completed suicides, 94 cases were matched to 435 controls. Criteria for match- ing cases and controls were the same for sui- cide attempts and completed suicides. Each case was individually matched to up to 5 controls by age, sex, race/ethnicity, date of hospital discharge, and state providing Med- icaid services. Controls were also matched to cases based on claims of substance abuse disorder, recent suicide attempt and use of antipsychotics, anxiolytic/hypnotics, mood stabilizers and stimulants.

Cases and controls were classified ac- cording to whether they received antide- pressant medication treatment or not, with treatment defined as a prescription for an antidepressant drug covering the days that included or exceeded the event date.

The antidepressant drug groups includ- ed selective serotonin reuptake inhibitors (SSRIs), including citalopram, fluoxetine, fluvoxamine, paroxetine, and sertraline; or other antidepressants (including bupropi- on, mirtazapine, nefazodone, trazodone, venlafaxine, and tricyclic antidepressants). The tricyclic antidepressants included sec- ondary and tertiary tricyclic antidepres- sants, as well as the tetracyclic antidepres- sants amoxapine and maprotiline. During the two-year reference period no cases or controls used monoamine oxidase inhi- bitors.

The main outcome measures were sui- cide attempt or completed suicide with patient antidepressant medication prescrip- tion as the independent or predictor variable.

Three conditional logistic regressions

SUICIDE RISK continued from page 1 “Child psychiatrists must

grapple with the clinical challenge of balancing safety concerns against the risks of not treating

young people at high risk.” Mark Olfson, M.D.

OCTOBER 2006 THE BROWN UNIVERSITY CHILD & ADOLESCENT PSYCHOPHARMACOLOGY UPDATE 3

were used for analysis, with no antidepres- sant treatment as the reference group: (a) comparison of any antidepressant treat- ment with no antidepressant treatment; (b) comparison of SSRIs, venlafaxine, mir- tazapine, bupropion, trazodone, nefa- zodone, and tricyclic antidepressants with no antidepressant treatment; and (c) com- parison of each SSRI with no antidepres- sant treatment.

Results Among children and adolescents (mean

age 15.4 ± 1.8 years), there were 263 cases of attempted suicide, and 8 cases (mean age 16.1 ± 1.5 years) of completed suicide. For children under the age of 12 years, there were 13 cases (1.7%) of attempted suicide, but no completed suicides.

There was a significant association between children and adolescents treated with antidepressants and attempted suicide (odds ratio [OR]=1.52; 95% confidence interval [CI] 1.12-2.07]; 263 cases and 1,241 controls) and with suicide deaths (OR=15.62; 95% CI 1.65-infinity; 8 cases and 39 controls).

Children and adolescents were signifi- cantly more likely to attempt suicide if they had been treated with sertraline (p=0.003), venlafaxine (p=0.007) or tri- cyclic antidepressants (p=0.002) than those not treated with antidepressants (see Table 1).For the 8 children and adoles- cents who completed suicide (mean age 16 years), they were significantly more likely than controls to have been treated with an SSRI (37.5% vs 7.7%; p=0.005).

There was no significant association between the likelihood of attempting sui- cide and antidepressant treatment in adults.

For adults who committed suicide, approximately 52% had been treated with hypnotics, 23% with antipsychotics, and 17% with mood stabilizers within 60 days prior to their death. No children or adoles- cents treated with these medications died by suicide within the 60-day time period.

Nearly two thirds of all suicide attempts or suicide deaths occurred early after hospital discharge (in the first 4 months), and nearly 75% of suicide attempts and deaths occurred in the first 6 months following hospital discharge.

Since the current study was limited to patients immediately following hospital discharge for depression — a period of high risk — the results “tell us nothing

about the safety or effectiveness of antide- pressant treatment during lower-risk peri- ods,” Olfson told The Update.

One of the limitations of this case-con- trol study is that antidepressants may be prescribed to youth who are more severely depressed and, therefore, at increased risk of suicide. Although the cohort excluded patients with comorbid conditions that are known to affect risk of suicide (e.g., bipo- lar disorder and schizophrenia), with close matching of cases to controls using demo- graphic and medical criteria, Olfson and colleagues suggest that “the possibility of confounding illness severity of antidepres- sant drug treatment selection persists.”

The results are also limited by having used a relatively small sample of select suicide cases; the lack of matching cases to controls on factors such as family histo- ry of suicide, and stressful conditions lead- ing up to the suicide event; the lack of pill counts or electronic measures which may have yielded more accurate information on medication use; the accuracy of the cate- gory of death by suicide which because of religious beliefs or social stigma may con- tribute to underreporting; limiting the analysis to Medicaid beneficiaries whose pharmacological treatment may vary from patients who are private insured; and an upper age limit of 64 years.

Clinical implications The results of this study highlight the

importance of closely monitoring young patients for changes in mood or behavior after they begin antidepressant treatment, said Olfson.

In a practice setting, “child psychia- trists must grapple with the clinical chal- lenge of balancing safety concerns against the risks of not treating young people at high risk.” One of the key challenges that lies ahead will be to identify young patients who are most likely to benefit from antidepressant treatment and those who are “sensitive to the negative effects of antidepressants,” said Olfson. J • • • • • • • • • • • • • • • • • • • • • • • • • • • *Funded by grants from the National Alliance for Research on Schizophrenia and Depression, the American Foundation for Suicide Prevention, Agency for Healthcare Research and Quality, and the Carmel Hill Fund.

Olfson M, Marcus SC, Shaffer D: Antidepressant drug therapy and suicide in severely depressed children and adults. Arch Gen Psychiatry 63(8):865-872. E-mail: [email protected].

REFERENCES

Hammad TA, Laughren T, Racoosin J: Suicidality in pediatric patients treated with antidepressant drugs. Arch Gen Psychiatry 2006; 63(3):332-339.

FDA Public Health Advisory. Suicidality in children and adolescents being treated with antidepressant medications. October 15, 2004. www.fda.gov/cder/drug/antidepressants/ SSRIPHA200410.htm

Antidepressant use in children, adolescents, and adults. www.fda.gov/cder/drug/antidepressants

Table 1. Association of pediatric suicide attempt with antidepressant treatment Antidepressant % Cases* % Controls** p value§ Odds ratio (95% CI)

Fluoxetine 4.9 6.9 0.16 0.69 (0.35-1.37)

Paroxetine 9.9 7.4 0.27 1.36 (0.80-2.30)

Sertraline 12.9 7.7 0.003 1.88 (1.15-3.06)

Citalopram 2.3 3.8 0.21 0.68 (0.28-1.67)

Fluvoxamine 0.4 0.3 0.92 0.91 (0.09-8.93)

Tricyclic agents 4.2 1.4 0.002 3.09 (1.32-7.22)

Venlafaxine 7.2 3.4 0.007 2.33 (1.25-4.33)

Mirtazapine 3.8 2.1 0.13 1.64 (0.68-3.94)

Bupropion 4.9 4.6 0.97 1.07 (0.53-2.19)

Trazodone 4.9 4.0 0.59 0.86 (0.35-2.42)

Nefazodone 2.3 1.1 0.27 1.62 (0.58-4.53)

* N=263 ** N=1,241 § statistical significance > 0.05 Table adapted from Olfson et al., 2006.

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Family Therapy Techniques with Adolescent Suicide

Attempters

— 5th Column in a Series —

In the last column of this series, we discussed individual therapy tech- niques for adolescent suicide at- tempters. In this column, we review family therapy interventions. Fami- ly therapy is sometimes advocated as the most appropriate means for intervening in suicidal behavior, since family dynamics are often im- plicated in the etiology of suicidal behavior and depression. Suicide attempts not only have the power to disrupt the entire family system [Zimmerman & LaSorsa, 1995], they also have the potential to generate increased empathy and caring in a family [Richman, 1986]. In short, the family is a promising area for inter- vention because family problems are associated with both the onset and recurrence of adolescent de- pression and suicidality. Family therapy can help shift the focus from the individual adolescent to the family, and it allows conflictual issues that led up to the suicide at- tempt to be explored.

According to family systems theory [e. g., Haley, 1980], suicidal behavior serves to preserve the sta- tus quo in the family and prevents a role change that might upset the family homeostasis. The suicidal adolescent is viewed as the identi- fied expresser of the family conflict. Richman [1986], while not specifi- cally focusing on adolescents, inte-

grated family systems and psycho- dynamic perspectives in develop- ing family therapy for suicide at- tempters. Drawing from the psy- choanalytic teachings of Freud and others, Richman theorizes that sui- cide attempts are an extreme form of aggression turned against oneself [Richman, 1986, p. 79]. In addition, suicidal individuals are often the re- cipients of covert hostility and death wishes from other family members [Sabbath, 1969; Richman, 1986]. This hostility is thought to arise from symbiosis and separation anxiety. Richman proposes the fol- lowing questions to organize family therapy:

“Who did the person want to kill by his suicidal act? Who wanted him dead? What was the separation crisis behind the death wishes? What is the most con- structive solution?” [Richman, 1986, p. 79].

The eventual goals of family thera- py in Richman’s model include im- provements in communication, availability, cohesion, mutual re- spect, and individual autonomy, as well as a reduction in family isola- tion. Richman begins treatment of suicide attempters by interviewing each family member individually, asking them why they think the identified patient has become sui- cidal. Next, one obtains human fig-

ure drawings from each family member for screening and monitor- ing purposes. For example, Rich- man asserts that the figure draw- ings of suicidal people (and some- times their relatives) often contain potential indicators of affective la- bility or self-destructive tendencies, such as slash lines [Richman, 1986, p. 86]. In the initial family interview, Richman establishes a set of ground rules for communication (e. g., ask- ing family members to make “I” statements, rather than “you” state- ments), and then asks family mem- bers to face each other and discuss the suicide attempt. He suggests that therapists should avoid prema- ture intervention in this family pro- cess. In fact, according to Richman, the therapist should tolerate and even welcome intense, rageful fam- ily exchanges, since these outbursts reduce tension and pave the way for more constructive alternatives. Richman suggests probing directly for death wishes immediately after an aggressive family exchange, thereby replacing covert communi-

Anthony Spirito (in collaboration

with Julie Boergers)

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cation with direct communication. For example, the therapist might ask family members, “Do you sometimes feel fed up with your daughter?” Eventually, the thera- pist begins to reframe negative in- teractions in positive terms (e. g., as expressions of frustration, helpless- ness, caring, or separation anxiety), focusing attention on the love behind the aggression. Relabeling these interactions also serves to re- duce scapegoating and to reduce the family’s fears of separation and loss [Richman, 1986].

Zimmerman and LaSorsa [1995] presented another family therapy model, which integrates family systems and psychodynamic approaches to provide crisis inter- vention and brief outpatient family therapy to suicidal adolescents. Ac- cording to Zimmerman and La- Sorsa, suicidal adolescents and their families are often at odds regarding the speed at which separation and individuation should occur. For ex- ample, the adolescent may feel pres- sured to take on adult responsibili- ties for which they feel unprepared, or conversely the parents may feel that the adolescent is trying to grow up too quickly. Furthermore, the au- thors hypothesize that this asyn- chrony in “rate of development” may lead the adolescent to feel that their problems are insurmountable. The suicide attempt, then, is con- ceptualized as an effort to solve an ”insolvable problem.” Zimmerman and LaSorsa assert that the main task of treatment is to renegotiate family relationships so that the ado- lescent can begin to individuate ap- propriately within a context of strong family connectedness. They suggest that this can be accom- plished by reframing the family’s

conflicts in terms of differences in the speed at which development is occurring. For example, they pre- sent a “highway metaphor” to fam- ilies, in which the family is under- stood as “a group of people who have chosen to take a long trip to- gether in separate cars, such that each individual is in control of his or her own vehicle” [Zimmerman & LaSorsa, 1995, p. 178].

Cognitive-behavioral family therapy approaches have also been recommended for suicidal adoles- cents. Rotheram-Borus and col- leagues [1994] developed a highly structured, six-session outpatient family therapy program for adoles- cent suicide attempters and their parents. Known as “SNAP” (Suc- cessful Negotiation/Acting Posi- tively), this program is based on the idea that suicide attempts occur in response to unsolved family prob- lems. The overall goal of SNAP is to reduce the risk of a future suicide attempt by increasing positive fam- ily interactions and improving the family’s ability to negotiate conflict effectively. Since communication and problem-solving skills are often impaired in these families, SNAP endeavors to build skills in these ar- eas through a cognitive-behavioral approach which is also grounded in family systems theory [Rotheram- Borus et al., 1994].

Early in SNAP therapy, focus is put on creating a more positive fam- ily environment. For example, fam- ily members are asked to compli- ment each other at the beginning of each session and to comment on positive occurrences in the family. The therapist identifies family strengths and helps the family to be- gin to identify strengths on their own. SNAP maintains that it is cru-

cial for the therapist to communi- cate respect for the family, and to avoid blaming any family mem- bers. Thus, the suicide attempt (and subsequent family problems) are placed in a more positive and less blaming context by reframing to fo- cus attention on the problematic sit- uation, rather than the individual. Families are then taught specific steps for problem-solving, includ- ing defining the problem, generat- ing and evaluating potential solu- tions, and assessing the efficacy of the chosen solution. Families gener- ate problems in session and repeat- edly practice solving them with the help of therapist role-playing, mod- eling, and feedback. There is also an emphasis on building new coping and negotiating abilities. For exam- ple, families are taught active listen- ing techniques to replace hostile, impulsive responding. During fam- ily role plays, “feelings thermome- ters” are used to rate individual lev- el of affective arousal (ranging from 0, or no discomfort, to 100, or most discomfort). This helps family members to increase their ability to label and manage their own feel- ings. The therapist also helps the family to identify and modify obsta- cles to problem-solving such as dys- functional family roles or negative attributions about the behavior of other family members [Rotheram- Borus et al., 1994]. The use of SNAP therapy with 140 female minority adolescent suicide attempters indi- cated that SNAP reduced overall symptom levels in these patients [Piacentini et al., 1995].

Similarly, Brent and colleagues [1996] have described the use of sys- temic-behavioral family therapy (SBFT) for adolescent suicidal de- pression. In SBFT, early sessions are

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devoted to the assessment of family interaction and problem-solving patterns. There is an emphasis on reframing the family’s problems in a more positive light, so that all fam- ily members can fully engage in treatment without feeling alienated or attacked. In the behavioral phase of therapy [adapted from Robin & Foster, 1989], the primary goal is to improve the family’s communica- tion and problem-solving skills, thereby reducing family conflict and reducing the adolescent’s de- pression. Specific techniques in- clude positive practice during the session and at home as well as teaching family members self-mon- itoring skills. Families are also helped to restructure maladaptive family patterns. For example, par- ents are encouraged to work togeth- er in their role as parents and to avoid inappropriate alliances with children [Brent et al., 1996].

Brief family therapy approach- es for suicidal adolescents have also been described in the literature. For example, Walker and Mehr [1983] advocate a time-limited (4–6 weeks) crisis-counseling approach to fami- ly therapy with suicidal adoles- cents. They recommend that the therapist first assess the strengths and weaknesses of the family and help the family to share responsibil- ity for changing maladaptive be- havior patterns. Since families often minimize the adolescent’s attempt, one of the family therapist’s first roles is to ensure that all family members understand the adoles- cent’s pain, while not being para- lyzed by feelings of guilt. The ther- apist then helps parents to draw their adolescents back into the fam- ily and nurture them without creat- ing an overly dependent relation-

ship. At the end of brief family ther- apy, Walker and Mehr [1983] sug- gest that the therapist’s focus should be on helping the family to trust the adolescent again and help- ing the adolescent to achieve an ap- propriate level of autonomy.

Gutstein and Rudd [1990] have also advocated brief outpatient family crisis intervention for suicid- al adolescents. They observed that many suicidal teens have nuclear families that are isolated from their extended families. Because these isolated families have few resourc- es, they sometimes feel powerless to respond to adolescent crises. Gut- stein and Rudd designed the sys- temic crisis intervention program (SCIP) to mobilize and reconfigure the family’s kinship network. After an initial series of individual ses- sions to prepare family members, SCIP crisis teams assemble extend- ed family and friends and meet with them in one or two 4-hour sessions designed to encourage greater cohe- sion in the kinship network and to begin reconciliation among es- tranged members. The eventual goal is to use kinship networks to help buffer the transition to adoles- cence. One year follow-up indicated that youths who received the SCIP intervention demonstrated signifi- cant improvements on measures of patient behavior and family func- tioning [Gutstein & Rudd, 1990].

Is family therapy the best ap- proach for every family? In a sam- ple of hospitalized adolescent sui- cide attempters and ideators, King and colleagues [1997] found that on- ly 33.3% complied with recom- mended outpatient family therapy, whereas 50.8% followed through with recommended individual therapy, and 66.7% followed

through with medication recom- mendations. Factors associated with poor family therapy compli- ance were maternal depression, ma- ternal paranoia, and distant father- adolescent relationships. Similarly, Brent et al. [1996] found that it was difficult for families to follow through with family therapy until parental depression was addressed. Together, these findings indicate that it may not be realistic to expect all families to follow through with family therapy; they suggest that clinicians should carefully consider the likelihood of compliance prior to prescribing a treatment plan.

An alternate approach is to in- tegrate individual and family treat- ment for adolescent suicide at- tempters. For example, Zimmer- man and LaSorsa [1995] suggest that therapists label themselves as the “family’s therapist” and con- duct individual and family therapy concurrently in a flexible manner, as needed. They have found that diffi- cult issues are sometimes more eas- ily explored initially in an individu- al context, and then later brought to family meetings where they can be expressed in a controlled environ- ment and managed by the therapist. Brent et al. [1996] concurred, noting that in their ongoing clinical trial, many people in the family therapy group wanted some individual ses- sions, and similarly many people in the individual therapy group wished for some family involve- ment in therapy. The integration of individual and family therapy ap- proaches holds promise for the treatment of adolescent suicide at- tempters.

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References

Brent DA, Roth CM, Holder DP, Kolko DJ, Birmaher B, Johnson BA, Schweers JA. Psychosocial interventions for treating adolescent suicidal depression: A com- parison of three psychosocial interven- tions. In ED Hibbs, PS Jensen (Eds) Psy- chosocial treatments for child and adolescent disorders: Empirically based strategies for clinical practice (pp. 187–206). Washing- ton, DC: American Psychological Associ- ation, 1996.

Gutstein SE, Rudd MD. An outpatient treat- ment alternative for suicidal youth. Jour- nal of Adolescence 1990; 13:265–277.

Haley J. Leaving home: The therapy of disturbed young people. New York: McGraw-Hill, 1980.

King CA, Hovey JD, Brand E, Wilson R, Ghaziuddin N. Suicidal adolescents after hospitalization: Parent and family impacts on treat-

ment follow-through. Journal of the American Academy of Child and Ado- lescent Psychiatry 1997; 36:85–93. Piacentini J, Rotheram-Borus MJ, Cantwell

C. Brief cognitive-behavioral family ther- apy for suicidal adolescents. In L Vande- Creek, S Knapp, T Jackson (Eds) Innova- tions in clinical practice: A source book, Vol. 14 (pp. 151–168). Sarasota, FL: Profes- sional Resource Press, 1995.

Richman J. Family therapy for suicidal people. New York: Springer Publishing, 1986.

Robin AL, Foster SL. Negotiating parent-ado- lescent conflict: A behavioral-family systems approach. New York: Guilford Press, 1989.

Rotheram-Borus MJ, Piacentini J, Miller S, Graaw F, Castro-Blanco D. Brief cogni- tive-behavioral treatment for adolescent suicide attempters and their families. Journal of the American Academy of Child Psychiatry 1994; 33:508–517.

Sabbath JC. The suicidal adolescent—The ex- pendable child. Journal of the American Academy of Child Psychiatry 1969; 8:272– 289.

Walker BA, Mehr M. Adolescent suicide—A family crisis: A model for effective inter- vention by family therapists. Adolescence 1983; 18:285–292.

Zimmerman JK, LaSorsa VA. Being the fam- ily’s therapist: An integrative approach. In JK Zimmerman, GM Asnis (Eds) Treat- ment approaches with suicidal adolescents. NY: John Wiley & Sons, 1995.

Anthony Spirito, PhD, is director of child psychology at Rhode Island Hospital and as- sociate professor of psychiatry, Brown Uni- versity School of Medicine. Clinical duties include consultation to adolescent suicide attempters. He has written many book chapters on adolescent suicide attempters, and is currently conducting a project on the effectiveness of compliance-enhancement intervention for adolescents after a suicide attempt.

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Announcements

The European Regional Council/World Federation of Mental Health (WFMH) 1998 European Regional Conference is being held 2–4 July 1998, in Edinburgh, Scotland, UK. For further information, contact: Pe- numbra International, Gogar Park, 167 Glasgow Road, Edinburgh EH12 9BG, Scotland, UK (tel. +44 131 317-1337, fax +44 131 317-1410, e-mail 100435.377

@compuserve.com). The deadline for abstracts is 6 March 1998.

The World Federation of Mental Health (WFMH) World Congress is being held 5–10 September 1999, in Santiago, Chile. For further information, contact: Benjamin Vicente, MD, University of Concepcion, Casilla 60-C, Concepcion, Chile (tel. +56 41 240186, fax +56 41 312799).

The Editors and Publisher of Crisis welcome readers’ comments. If you wish to comment on any papers

published in the journal or on related topics, please con- tact either one of the Editors-in-Chief or the Publisher

at the addresses given in the front of this issue.

O R I G I N A L A R T I C L E

Efficacy of a Problem-Solving Therapy for Depression and Suicide Potential in Adolescents and Young Adults

Mehmet Eskin Æ Kamil Ertekin Æ Hadiye Demir

Published online: 23 November 2007 � Springer Science+Business Media, LLC 2007

Abstract Short-term and structured cognitive behavioral problem-solving therapy (PST) is a developmentally relevant mode of action for the treatment of emotional problems in young

people. This study aimed at testing the efficacy of a problem-solving therapy in treating

depression and suicide potential in adolescents and young adults. A total of 46 self-referred

high school and university students who were randomly assigned to a problem-solving therapy

(n = 27) and a waiting list control (n = 19) conditions completed a controlled cognitive

behavioral problem-solving treatment trial. Participants were administered the measures of

depression, suicide potential, problem solving, self-esteem and assertiveness. Twenty-two of

the 27 participants from the PST condition could be reached after 12-months for follow-up.

Participants completed depression and problem-solving measures at follow-up. Results showed

that post-treatment depression and suicide risk scores of participants within the PST condition

decreased significantly compared to the pre-treatment scores but post-waiting and pre-waiting

depression and suicide risk scores of participants within the WLC condition were unchanged.

Likewise, post-treatment self-esteem and assertiveness scores of participants within the PST

condition increased significantly compared to the pre-treatment scores while post-waiting and

pre-waiting self-esteem and assertiveness scores of participants within the WLC condition

were unchanged. At post-treatment, 77.8% of the participants in the PST but only 15.8% of

those in the WLC condition achieved full or partial recovery according to BDI scores. Sim-

ilarly, 96.3% of participants in the PST but only 21.1% of those in the WLC condition

achieved full or partial recovery according to HDRS scores. The improvements were main-

tained at 12-months follow-up. Therefore, it is concluded that problem-solving therapy should

M. Eskin (&) Department of Psychiatry, School of Medicine, Adnan Menderes University, Aydin, Turkey e-mail: [email protected] URL: http://www.mehmeteskin.com; [email protected]

K. Ertekin NP Hospital, Istanbul, Turkey

H. Demir Middle East Technical University Health Center, Ankara, Turkey

123

Cogn Ther Res (2008) 32:227–245 DOI 10.1007/s10608-007-9172-8

be considered as a viable option for the treatment of depression and suicide potential in

adolescents and young adults.

Keywords Efficacy � Problem-solving therapy � Adolescent � Young adult � Depression � Suicide � Follow-up

Introduction

Adolescence is a developmental period characterized by rapid changes in physical, psycho-

logical and social functioning. Although many young people pass this developmental period

problem free, the changes render some of the adolescents vulnerable to psychological prob-

lems. Studies indicate that, compared to childhood, the frequencies of mental health problems

during adolescence increase (Kim 2003). Compared to the past the data have shown an

increase in emotional problems during adolescence (Collishaw et al. 2004).

One of the most common mental health problems in young people is depression (Hamrin

and Pachler 2005). Although lifetime prevalence rates of depression are less than 3% for

children, the rates of depression for adolescents rise to 14% (Lewinsohn et al. 1998). In a study

with 966 adolescents, Schichor et al. (1994) reported that 22% of the sample felt themselves

frequently depressed. Depression is associated with reduced psychosocial functioning.

Untreated depression in young people is a serious risk factor for mental health problems

(Steinhausen et al. 2006; Wilcox and Anthony 2004) and obesity in adulthood (Franko et al.

2005). Depression is mostly comorbid with anxiety disorders (Ferdinand et al. 2005), and is a

serious risk factor for suicidal behavior in young as well as in adults (Kish et al. 2005;

Thompson et al. 2005).

Self-esteem and assertive social-skills are the two possibly protective factors against

depression in young people. Adolescent psychiatric patients are in general characterized by

low self-esteem compared to controls (Guillon et al. 2003). In early adolescents, MacPhee and

Andrews (2006) found low self-esteem to be the strongest predictor of depression. Following a

group of adolescents over a 6 years period Pelkonen et al. (2003) found that baseline low self-

esteem scores were predictive of depression. Likewise, adolescents with identifiable levels of

psychopathology are characterized by low level of social skills such as inappropriate asser-

tiveness (Landazabal 2006). Chan (1993) with Chinese university undergraduates found

nonassertive responses to correlate with depression. Assertiveness in adolescence promotes the

establishment of socially supportive interpersonal relationships. In a cross-cultural study

involving Swedish and Turkish adolescents, Eskin (2003) showed that more assertive ado-

lescents in both groups reported having more friends and receiving more social support than

their less assertive peers.

A related mental health problem in young people is suicide. Though rare during childhood,

suicide is the leading cause of death in young people and hence constitutes a significant mental

health concern (Brener et al. 2000; Johnson et al. 2000). Not only suicidal deaths but also

nonfatal suicidal behaviors are common in adolescents and young adults. Empirical evidence

shows that lifetime prevalence of suicidal attempts is about 10% while the lifetime prevalence

of suicidal thoughts is approximately 30% in youth (Evans et al. 2005). In one study with

1,262 Turkish university students, Eskin et al. (2005) found that 42% of the sample reported

suicidal ideation during the past 12 months or lifetime, and 7% reported that they attempted to

kill themselves during their lifetime or in the past 12 months. Past suicidal thoughts and

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attempts in young people are risk factors for future suicidality (Clark et al. 1989; Joiner et al.

2000; Lewinsohn et al. 1994; Rudd et al. 1996).

As with depression, self-esteem and assertive social skills are the two possibly protective

factors against suicidal behavior in young people. Gröholt et al. (2000), demonstrated that low

self-worth was a predictor of adolescent suicide attempts. Further, the work of Wild et al.

(2004) showed that low self-esteem in the family context was an independent predictor of

adolescent suicide ideation and attempts. In a similar, fashion suicidal young people were

characterized by inadequacies in assertive social skills. With a longitudinal research design

Sourander et al. (2001) showed that suicidal adolescents were characterized by low social

competence. Eskin (1995) found that deficiencies in positive assertion skills were related to

suicide risk scores of Swedish and Turkish high school students. Further et al. (1990) showed

that lack of assertiveness was related to suicidal intent in a group of suicide attempted ado-

lescent psychiatric inpatients.

There is an urgent need for effective treatment methods for depression and suicide potential

in young people. The literature suggests that treatment effectiveness for adolescent and young

adults is far less investigated than it is for adult populations. The use of Selective Serotonin

Reuptake Inhibitors (SSRI, the most widely used pharmacological agents for the treatment of

depression) in children and adolescents for treating depression include safety concerns. For

instance the use of SSRIs was found to be associated with increased risk for suicidal behavior

(Newman 2004; Richmond and Rosen 2005; Wohlfarth et al. 2006). However, the number of

depressed children and adolescents for whom psychotherapy/mental health counseling during

outpatient visits are prescribed decreased significantly over time (Ma et al. 2005). For Ryan

(2005) the debate about the best approach to treat child and adolescent depression continues.

Therefore, there is a need for the determination of effectiveness of short and structured

psychosocial interventions for child and adolescent depression and suicide potential.

A wide variety of research findings indicate deficits in problem-solving ability to have a key

role in the development and maintenance of depression and suicidal behavior. Deficits in

problem-solving ability were shown to be an important predisposing factor for the develop-

ment of depression (Nezu 1986; Nezu and Ronan 1988; Marx et al. 1992; Priester and Clum

1993) and suicidal behavior (Levenson and Neuringer 1971; Schotte and Clum 1987;

Sadowski and Kelley 1993; Reinecke et al. 2001; Chang 2002; Pollock and Williams 2004).

Recently, Speckens and Hawton (2005) reviewed the studies investigating the relationship

between problem solving and suicidal behavior in young people. They conclude that inef-

fective problem solving is an important vulnerability factor for suicidal behavior in youth.

Moreover, McAuliffe et al. (2002) found repeaters of parasuicide to exhibit more deficits in

problem solving than nonrepeaters.

Thus, one can presume that a problem-solving approach is an important intervention

strategy for the treatment of depression and suicide risk in young people. In line with this,

problem solving was identified as a prevention strategy for adolescent emotional problems

(Heppner et al. 1984; Spence et al. 2003). Empirical evidence suggests that problem-solving

therapy (PST) is an effective treatment for depression (Arean et al. 1993; Biggam and Power

2002; Dowrick et al. 2000; Nezu 1986) and suicidal problems (Lerner and Clum 1990; Sal-

kovskis et al. (1990; Townsend et al. 2001) in adults and to some extent young adults. Most

recently, Malouff et al. (2007) conducted a meta-analysis of 31 studies involving mostly adult

participants (n = 2,895) on the effectiveness of problem-solving therapy. They showed that

PST was significantly more effective than no treatment, treatment as usual and attention

placebo in reducing mental and physical health problems.

Adolescence and young adulthood are the life periods characterized by changes in bio-

logical, psychological and social domains. The young individual has to cope with these

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multiple domain challenges/changes. Therefore, young people need effective coping strategies

or skills in order to gain resilience against multiple domain changes/challenges. Problem

solving is an important life skill for coping and tackling with life difficulties and challenges

during these stages of life. Thus, the overall objective of this study was to assess the efficacy of

a problem-solving therapy in treating depression and suicide proneness in adolescents and

young adults. A second objective was to evaluate whether or not PST leads to improvements in

self-appraised problem-solving ability. A third objective was to investigate the impact of PST

on protective factors such as self-esteem and assertiveness.

Methods

Design

A randomized, controlled trial was carried out to compare a problem-solving treatment for

major depression and suicide potential to a waiting list control condition in a group of high

school and university students.

Recruitment

Participants were recruited through announcements describing the symptoms of major

depression according to DSM-IV (APA 1994). The announcements were placed on the boards

of 10 high schools in the city of Aydin and a university campus area in Ankara.

Exclusion Criteria

Students who did not meet the DSM-IV criteria for major depression, students who were

currently under medical treatment, those who were psychotic and students with bipolar illness,

and students whose parents did not consent were excluded from the study.

Site of the Study

The part of the study involving high school students was conducted at the psychiatry

department of Adnan Menderes University School of Medicine in Aydin. The part involving

the university students was done at the Health Center of the Middle East Technical University

in Ankara.

Participants

A total of 54 high school and 28 university students (n = 82) responded to the announcements.

Assessment with the Structured Clinical Interview-Clinical Version (SCID-I/CV) (First et al.

1997) for DSM-IV Axis I diagnoses revealed that all university and 25 of the high school

students (n = 53) received a diagnosis for major depression. Twenty-nine students not

receiving a depression diagnosis were excluded. Of participants who received a depression

diagnosis, 27 (high school = 13; university = 14) were randomly assigned to a PST condition

and 26 (high school = 12; university = 14) were randomly assigned to the WLC condition.

One high school and eight university students who were assigned to the WLC condition

dropped out. At the end, all (high school = 13; university = 14) participants who were

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assigned to the PST condition and 19 (high school = 11; university = 8) who were assigned to

the WLC condition (n = 46) completed the study. To see if attrition in the WLC condition

might have affected the findings, participants who dropped out of the WLC condition were

compared with those who stayed in the WLC condition on demographics and pre-treatment

scores and were found to be similar. Twenty-two participants (81.5%) from the PST condition

(high school = 10; university = 12) could be reached for follow-up after 12-months.

The demographic characteristics of participants are presented in Table 1. As the table

shows, a majority of the participants were of urban background, female and perceived their

family income as medium and had on average two siblings. Of participants who obtained a

diagnosis for major depression, two also obtained a diagnosis for social phobia, one for

posttraumatic stress disorder, one for dysthymia and another one obtained a diagnosis for

specific phobia.

Participants in the treatment and control conditions were found to be similar in terms of

group (high school vs. university), sex, background (urban vs. rural), perceived family income,

number of siblings, age, and paternal education, but mothers of participants in the problem-

solving condition had greater number of school years (mean = 10.1 years, SD = 4.3) than the

mothers of those in the control condition (mean = 6.6 years, SD = 5.1), t(44) = 2.5, P \ 0.05. Similarly, the two groups (high school and university) were similar in terms of sex,

background (urban vs. rural), condition, perceived family income, number of siblings, and

Table 1 Demographic characteristics of participants

Variables Group

Problem-solving therapy

Waiting list control Total

n % M SD n % M SD n % M SD

N 27 58.7 19 41.3 46 100

Sex

Male 7 25.9 7 36.8 14 30.4

Female 20 74.1 12 63.2 32 69.6

School

High school 13 48.1 11 57.9 24 52.2

University 14 51.9 8 42.1 22 47.8

Background

Urban 22 81.5 13 68.4 35 76.1

Rural 5 18.5 6 31.6 11 23.9

Perceived family income

Low 1 3.7 3 15.8 4 8.7

Medium 26 96.3 15 78.9 41 89.1

High 0 0.0 1 5.3 1 2.2

Number of siblings 1.7 1.8 2.3 2.6 2.0 2.1

Age 19.0 3.2 19.3 3.7 19.1 3.4

Maternal education (number of school years) 10.1 4.3 6.6 5.1 8.7 4.9

Paternal education (number of school years) 11.5 4.5 9.3 5.0 10.6 4.8

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maternal education, but fathers of university group had greater number of school years

(mean = 12.8 years, SD = 3.5) than the fathers of high school group (mean = 8.5 years,

SD = 5.0), t(44) = 3.3, P \ 0.005. The mean age of the high school group was 16.4 years (SD = 1.1) and it was 22.1 years (SD = 2.3) for the university group.

Measures

Hamilton Depression Rating Scale

The 17-item clinician-administered Hamilton Depression Rating Scale (HDRS) was used to

assess severity of the depressive symptoms (Hamilton 1960). The validity and reliability of the

Turkish version of the HDRS was well established (Akdemir et al. 1996). The test–retest

reliability coefficient of the Turkish HDRS was 0.85 and the internal consistency reliability

coefficient was 0.75. The Turkish HDRS had a correlation coefficient of 0.48 with Beck

Depression Inventory. The total HDRS scores range from 0 to 52. Higher scores indicate

greater depression. Patients with HDRS scores of 7 or less were considered to have clinically

recovered; patients with scores of 8–12 were regarded as partially recovered; and patients with

scores of 13 or more were seen as not recovered (Frank et al. 1991).

Beck Depression Inventory

A 21-item Beck Depression Inventory (BDI 1978 version) (Beck et al. 1979) is used to assess

self-rated depressive symptoms. The BDI is the most widely used self-report measure of

depression. Hisli (1988) translated the BDI into Turkish and assessed its psychometric prop-

erties. The respondent rates the frequency and the intensity of symptoms on a four-point scale.

The Turkish BDI had an internal consistency reliability of 0.80 and a split-half reliability of

0.74. It had a correlation coefficient of 0.50 with the MMPI depression subscale. The total BDI

scores range from 0 to 63. Higher scores indicate greater depression. Patients with BDI scores

of 9 or less were considered to have clinically recovered; patients with scores of 10–15 were

regarded as partially recovered; and patients with scores of 16 or more were considered as not

recovered (Shaw et al. 1985).

Suicide Probability Scale

The Turkish version of the Suicide Probability Scale (SPS) (Cull and Gill 1988) was used to

assess suicide potential. The SPS is a 36-item self-report measure of suicide risk to be used

with adolescents and adults. Participants rate each item on a 4-point Likert scale according to

the frequency with which they experience a specific emotion or behavior by selecting scale

anchors ranging from ‘‘None or a little of the time’’ to ‘‘Most or all of the time.’’ It consists of

four empirically derived subscales based on current theories of suicidal behavior. The sub-

scales are: (1) Hopelessness; (2) Suicide ideation: (3) Negative self-evaluation; and (4)

Hostility. The SPS was previously translated into Turkish and was found to be a reliable and a

valid instrument by Eskin (1993). The Turkish SPS had a test–retest reliability coefficient of

0.95 over a 48.7 days period and it had an internal consistency coefficient of 0.89. It correlated

inversely with perceived social support from family -0.60 and perceived social support from

friends -0.75. The total SPS scores range from 36 to 144. Higher scores indicate greater

suicide proneness.

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Problem-Solving Inventory

The Problem-Solving Inventory (PSI) developed by Heppner and Petersen (1982) was used to

measure self-appraised problem-solving ability. It has 32 items which the respondents rate for

the frequency of engaging in specific problem-solving behaviors on a 6-point Likert scale

ranging from ‘‘Always (1)’’ to ‘‘Never (6).’’ The PSI scores range from 32 to 192 and higher

scores indicate lower self-appraised problem-solving ability. The PSI was adapted into Turkish

by Şahin et al. (1993) and found to be a reliable and valid instrument. The internal consistency

coefficient for the Turkish PSI was 0.88 and the split-half reliability coefficient was 0.81. The

Turkish PSI had a correlation coefficient of 0.33 with BDI and it had a correlation coefficient

of 0.45 with the trait anxiety scores on the STAI (Şahin et al. 1993).

Scale for Interpersonal Behavior

Assertiveness was measured by Scale for Interpersonal Behavior (SIB) developed by Arrindell

and van der Ende (1985). The SIB is a 50-item multidimensional measure of assertiveness. The

respondent rates each item on a 5-point Likert scale for the frequency of engaging in a specific

assertive behavior. Forty-five of the 50 items are classified into four factorially derived cat-

egories of assertive behavior. The four SIB dimensions are: (1) Display of negative feelings;

(2) Expression of and dealing with personal limitations; (3) Initiating assertiveness; and (4)

Positive assertion. In addition to these subscales a total assertiveness score is computed by

summing the 50 items. Psychometric properties of the Turkish version of the SIB were

assessed and found to be highly reliable and valid (Eskin 1993). The test–retest reliability of

the SIB was 0.71 and its internal consistency reliability was 0.90. It had a correlation of 0.35

with perceived social support from friends. The SIB scores range from 50 to 250 with higher

scores indicating higher levels of assertiveness.

Rosenberg Self-Esteem Scale

The 10-item Rosenberg Self-Esteem Scale was used to measure self-esteem (Rosenberg 1965).

It is a global measure of self worth scored on a 4-point Likert scale. It has been adapted into

Turkish by Cuhadaroglu (1996). The scores range from 10 to 40, with higher scores repre-

senting higher self-esteem.

Therapeutic Alliance Scale

A 7-item short therapeutic alliance scale (TAS) designed by the first author was used to

measure the extent to which participants perceived being supported and understood by their

therapists. The TAS was designed to meet the specific requirements of the problem-solving

treatment approach used in this study. The items of this scale were as follows:

1. I feel that my therapist understands my problems.

2. I feel that there is a warm relationship based on mutual trust between my therapist and me.

3. I feel that my therapist has the right approach for the resolution of my problems.

4. I feel that my therapist and I are in agreement about what my problems and distresses are.

5. I feel that my therapist and I are in agreement about the causes of my problems.

6. I feel that my therapist accepts me the way I am.

7. I feel that my therapist works in cooperation with me during my treatment.

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Participants rated these items on 5-point Likert scales for how much they agree with the

content of each item. Response alternatives ranged from ‘‘totally agree (5)’’ to ‘‘totally

disagree (1).’’ The responses to seven items are summed to obtain a therapeutic alliance score.

The scores range from 7, indicating minimum alliance between the therapist and the patient, to

35 indicating maximum alliance. The internal consistency coefficient (Cronbach’s apha) for

the TAS with 27 participants was 0.80.

Procedure

Announcements describing symptoms of major depression according to DSM-IV were placed

on the announcement boards of high schools and a university to recruit the participants.

Permissions from the local branch of the Ministry of Education and the governing body of the

university were obtained to place the announcements. The announcements asked students to

apply for the treatment project free of charge.

All participants and the parents of the high school students were asked to sign an informed

consent form. Then, they were given an appointment for a SCID-I interview. Participants

meeting the criteria for a major depression diagnosis were administered the Hamilton

Depression Rating Scale and were also asked to fill in a questionnaire that included the above-

mentioned measures as well as socio-demographics. Participants obtaining a diagnosis for

major depression were designated as the study group. Then they were assigned randomly to a

problem-solving therapy and a waiting list control conditions. For ethical reasons, the students

not obtaining a major depression diagnosis were offered 2–3 sessions of counseling. In a

similar fashion, participants who were assigned to the WLC condition were also offered six

sessions of PST after the waiting period. Participants in the PST condition filled in the

Therapeutic Alliance Scale (TAS) after the completion of the third session. Therapists

recorded the session lengths and problems identified during the first sessions.

Treatment

An individual PST treatment using a manual consisting of 6 sessions was used. The PST used

in this study was modeled according to the PST approach developed by D’Zurilla and

Goldfried (1971) and D’Zurilla and Nezu (1999). Like the one used in the primary care by

Gath and Mynors-Wallis (2000) the PST used in this study did not include a problem-orien-

tation component. Two graduate students in clinical psychology (the second and third authors)

received education and supervision on the PST from the first author. The manual developed by

the first author included a brief introduction to the problem-solving treatment of psychological

conditions. Then the manual described six sessions of PST that correspond to the six stages of

problem solving. The treatment lasted for 6 weeks with weekly scheduled sessions. The

sessions were in brief as follows:

Session 1: Definition of problems: The rationale behind the problem-solving treatment was explained to the participants. Then the therapist and the patient worked together to define a

problem. Emotional symptoms of the patients were identified. The manual instructed

therapists to relate emotional symptoms to problems and to define problems in behavioral

terms.

Session 2: Goal setting: In this session, the therapeutic task is to set goals. Goals are set in collaboration. The manual instructs that the goals should be attainable, objective and

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realistic. It is also necessary to identify the strengths and resources of the patient at this

session.

Session 3: Generating alternative solutions: At this session the participant is encouraged to produce alternative solutions to the problem defined during the first session. ‘‘Brain-

storming’’ and ‘‘advice to a friend who has the same problem’’ methods are applied to

facilitate generating more alternative solutions. Therapist instructs the participant to be

nonjudgemental and produce as many solutions as possible.

Session 4: Decision making: The therapeutic task in this session is to choose the best solution to the problem. The best solution should be applicable by the patient and should

reach the goal set during the second session.

Session 5: Solution implementation: In this stage the solution should be implemented. In order to implement the chosen solution, the patient is taught necessary skills. To counteract

the skill deficit, the therapist may use techniques such as role-playing and the like to teach

the participant necessary skills for the implementation of the selected solution.

Session 6: Assessment and verification: In the last session, the solution implementation is assessed and verified.

Statistical Analyses

The data were analyzed by SPSS-9.0 for Windows. Repeated measures Analysis of Variance

(ANOVA) procedures were used to analyze the results, with condition and group as the

grouping factor, and time being the ‘within groups’ factor. A total of six conditions (PST and

WLC) by group (high school and university) by time (pre-/post-treatment/waiting) ANOVAs

were performed to compare the groups on five main outcome measures. Since condition by

time interaction effect tests the treatment efficacy, it is presented first in the results. Pre-

treatment/waiting and post-treatment/waiting means and standard deviations of measures

according to condition are presented in Table 2.

To further determine and quantify the efficacy of PST, controlled and uncontrolled (Feske

and Chambless 1995) effect sizes (Cohen’s d; Cohen 1988) were calculated. A controlled

effect size was calculated by subtracting the post-treatment mean of the treatment group from

the post-waiting mean of the control group divided by the standard deviation of the control

group. An uncontrolled effect size was calculated by subtracting the post-treatment mean of

Table 2 Means and standard deviations of outcome measures according to condition

Measures Problem-solving therapy Waiting list control

Pre-treatment Post-treatment Pre-waiting Post-waiting

M SD M SD M SD M SD

Depression

Beck Depression Inventory 26.7 9.4 10.7 10.4 28.0 9.0 22.0 5.5

Hamilton Depression Rating Scale 16.1 6.6 4.3 3.3 17.8 5.5 16.6 5.7

Suicide potential 84.1 15.1 71.9 15.5 77.9 16.4 75.2 14.9

Assertiveness 152.9 19.0 167.6 24.0 157.1 18.4 158.0 21.9

Problem solving 111.6 16.6 100.9 20.6 107.2 18.7 104.6 20.3

Self-esteem 23.8 4.6 28.0 5.2 23.3 4.8 23.4 5.1

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the treatment group from its pre-treatment mean divided by the standard deviation of the

treatment group (Butler et al. 2006).

Nonparametric tests were used to compare the scores of groups involving fewer than thirty

participants. In this case one cannot assume normal distribution of data. The Mann–Whitney

U-test which uses median rather than mean was used to compare the scores of two independent groups. Scores of two related groups were compared by means of Wilcoxon Signed Ranks Test

procedure. Proportions of participants who fully and partially recovered and not recovered

were computed. Chi-square tests were used to test the association between two dichotomous

variables. Pearson product-moment correlation coefficients were calculated between the PSI

difference scores (differences between baseline and follow-up scores) and depression scores.

Results

Number and Length of Sessions

All participants in the PST condition received six sessions of problem-solving therapy. Session

lengths ranged from 30 to 60 min with an average session length of 37.6 min (SD = 6.9).

Session lengths were longer in the university (mean = 42.6 min, SD = 5.3) than in the high

school group (mean = 32.1 min, SD = 3.3), Z = 4.2, P \ 0.0001.

Therapeutic Alliance

Mean therapeutic alliance scale score was 30.9 (SD = 2.5). High school students scored sig-

nificantly higher (mean = 32.1, SD = 1.9) than the university students (mean = 29.8,

SD = 2.2) on the therapeutic alliance scale, Z = 2.8, P \ 0.01.

Depression

BDI

The means and standard deviations for depression, suicide potential, problem solving, self-

esteem and assertiveness are given in Table 2. The ANOVA produced a significant condition

by time interaction effect, F(1, 42) = 10.3, P \ 0.01. The ANOVA revealed also a main effect for time, F(1, 42) = 43.8, P \ 0.0001, a main effect for condition, F(1, 42) = 9.7, P \ 0.01, and a main effect for group, F(1, 42) = 20.3, P \ 0.0001.

Although post-treatment/waiting BDI scores were smaller than the pre-treatment/waiting

scores, baseline BDI scores of participants within the PST and WCL conditions were similar

(Z = 0.6, P [ 0.05) but post-treatment BDI scores of participants within the PST condition were lower than the post-waiting BDI scores of participants within the WLC condition

(Z = 5.3, P \ 0.0001). Concerning the main effect for time, baseline BDI scores were higher (mean = 27.0) than post-treatment/waiting scores (mean = 16.3). Regarding the main effect

for condition, mean BDI scores of students in the PST condition were lower (mean = 18.8)

than the scores of students in the WLC (mean = 24.4). The group main effect showed that BDI

scores of high school students were higher (mean = 25.7) than the university students’ scores

(mean = 17.6).

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HDRS

The ANOVA gave a condition by time interaction effect, F(1, 42) = 37.7, P \ 0.0001. There was a main effect for time, F(1, 42) = 55.7, P \ 0.0001, a main effect for condition, F(1, 42) = 39.3, P \ 0.0001, and a main effect for group, F(1, 42) = 9.3, P \ 0.01.

Post-treatment HDRS scores were significantly lower than the pre-treatment scores within

the PST condition (Z = 4.5, P \ 0.0001) but pre- and post-waiting HDRS scores within the WLC condition were similar (Z = 0.4, P [ 0.05). Time main effect showed that the baseline HDRS scores were higher (mean = 17.2) than the post-treatment/waiting scores (mean =

10.2). Regarding the main effect for condition the HDRS scores of students in PST were

lower (mean = 10.2) than the scores of students in the WLC (mean = 17.8). The group main

effect showed that the HDRS scores of high school students were lower (mean = 12.1) than the

scores of university students (mean = 15.8).

An uncontrolled effect size from pre-treatment to post-treatment for HDRS was 2.4 and it

was 1.6 for BDI. A controlled effect size between PST and WLC conditions was 2.2 for HDRS

and it was 1.6 for BDI.

Suicide Potential

The ANOVA gave a condition by time interaction effect, F(1, 42) = 7.3, P \ 0.05, a main effect for time, F(1, 42) = 16.3, P \ 0.0001, and a main effect for group, F(1, 42) = 16.7, P \ 0.0001.

Post-treatment SPS scores were significantly lower than the pre-treatment SPS scores

within the PST condition (Z = 3.5, P \ 0.0001) but pre- and post-waiting SPS scores within the WLC condition were similar (Z = 1.4, P [ 0.05). The mean of the baseline SPS total scale scores was higher (mean = 80.4) than the mean of the post-treatment/waiting scores

(mean = 73.1). The mean of the SPS total scale scores of university students was lower

(mean = 69.1) than the mean scores of high school students (mean = 84.3).

An uncontrolled effect size from pre-treatment to post-treatment for SPS was 0.80. A

controlled effect size between PST and WLC conditions was 0.21.

Assertiveness

The ANOVA revealed a significant condition by time interaction effect, F(1, 42) = 7.5,

P \ 0.01, and a main effect for time, F(1, 42) = 10.0, P \ 0.01, on the SIB total scale scores. Post-treatment SIB scores were significantly higher than the pre-treatment SIB scores

within the PST condition (Z = 3.2, P \ 0.01) but pre- and post-waiting SIB scores were similar (Z = 0.5, P [ 0.05) within the WLC condition. Regarding the main effect for time, post-treatment/waiting SIB scores were higher (mean = 162.2) than pre-treatment/waiting SIB

scores (mean = 154.4).

An uncontrolled effect size from pre-treatment to post-treatment for SIB was 0.68. A

controlled effect size between PST and WLC conditions was 0.48.

Problem Solving

The ANOVA produced a nonsignificant condition by time interaction effect, F(1, 42) = 2.2,

P [ 0.05, but it gave a statistically significant main effect for time, F(1, 42) = 6.4, P \ 0.05,

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on the PSI total scale scores. Pre-treatment/waiting PSI scores were higher (mean = 109.4)

than post-treatment/waiting PSI scores (mean = 102.5).

An uncontrolled effect size from pre-treatment to post-treatment for PSI was 0.58. A

controlled effect size between PST and WLC conditions was 0.19.

Self-Esteem

The ANOVA gave a statistically significant condition by time interaction effect, F(1,

42) = 7.1, P \ 0.05, and a main effect for time, F(1, 42) = 7.3, P \ 0.05. A marginally significant main effect for condition, F(1, 42) = 4.0, P \ 0.10, was also detected.

Post-treatment self-esteem scale scores were significantly higher than the pre-treatment

self-esteem scale scores within the PST condition (Z = 3.5, P \ 0.01) but pre- and post- waiting self-esteem scores were similar (Z = 0.2, P [ 0.05) within the WLC condition. The main effect for time showed that post-treatment/waiting self-esteem scale scores were higher

(mean = 25.6) than pre-treatment/waiting self-esteem scale scores (mean = 23.5). Marginally

significant main effect for condition showed that self-esteem scale scores of participants in the

PST condition tended to be higher (mean = 25.9) than the self-esteem scale scores of students

in the WLC condition (mean = 23.3).

An uncontrolled effect size from pre-treatment to post-treatment for self-esteem was 0.89.

A controlled effect size between PST and WLC conditions was 0.93.

Post-Treatment Recovery

BDI

Table 3 presents the recovery rates according to post-treatment/waiting BDI and HDRS scores

by condition. A chi-square test between condition and recovery categories indicated that

participants in the two conditions differed significantly from one another in relation to per-

centages of recovery according to BDI, v2 = 19.3, d.f. = 2, P \ 0.0001. As the table shows, 77.8% of participants within the PST condition achieved full or partial recovery but only

15.8% did so in the WLC condition.

Table 3 Recovery rates according to post-treatment/waiting BDI and HRSD scores by condition

Recovery Problem-solving therapy Waiting list control

n % n %

Beck Depression Inventory

Recovered (BDI, 0–9) 14 51.9 0 0.0

Partially recovered (BDI, 10–15) 7 25.9 3 15.8

Not recovered (BDI, 16 and above) 6 22.2 16 84.2

Total 27 100.0 19 100.0

Hamilton Depression Rating Scale

Recovered (HDRS, 0–7) 22 81.5 1 5.3

Partially recovered (HDRS, 8–12) 4 14.8 3 15.8

Not recovered (HDRS, 13 and above) 1 3.7 15 78.9

Total 27 100.0 19 100.0

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HDRS

A chi-square test between condition and recovery showed that there was a significant asso-

ciation between the two variables, v2 = 31.1, d.f. = 2, P \ 0.0001. As it is seen in the table, 96.3% of the participants in the PST condition achieved full or partial recovery according to

post-treatment HDRS scores, while only 21.1% did so in the control condition.

Follow-up

Depression

Mean follow-up BDI scores were found to be 7.6 (SD = 7.3). Follow-up BDI scores were

statistically significantly lower than pre-treatment BDI scores, Z = 4.1, P \ 0.0001, but similar to post-treatment BDI scores, Z = 1.6, P [ 0.05. Mean follow-up BDI scores of uni- versity students were significantly lower (mean = 9.9, SD = 7.0) than the mean BDI scores of

high school students (mean = 5.6, SD = 7.4), Z = 2.0, P \ 0.05. Mean follow-up HDRS scores were 3.7 (SD = 1.9). Follow-up HDRS scores were statis-

tically significantly lower than pre-treatment HDRS scores, Z = 4.1, P \ 0.0001, but similar to post-treatment HDRS scores, Z = 0.1, P [ 0.05 (for pre- and post-treatment means see Table 2). Mean follow-up HDRS scores of university students were significantly lower

(mean = 2.6, SD = 1.5) than the mean follow-up HDRS scores of high school students

(mean = 4.9, SD = 1.7), Z = 2.6, P \ 0.05. According to predetermined criteria for remission, all the 22 patients (100%) achieved full

remission on the basis of follow-up HDRS scores (scores ranged from 1 to 7). Considering the

follow-up BDI scores, 17 participants (77.3%) achieved full remission, 2 (9.1%) achieved

partial remission, and 3 (13.6%) were still depressed.

Problem Solving

Mean follow-up PSI scores were 88.6 (SD = 15.6). Follow-up PSI scores were significantly

lower than pre-treatment, Z = 3.7, P \ 0.0001) and post-treatment PSI scores Z = 2.0, P \ 0.05 (for pre- and post-treatment means see Table 2). Follow-up PSI scores of university (mean = 90.4, SD = 8.2) and high school (mean = 86.1, SD = 18.7) students were similar,

Z = 1.1, P [ 0.05. The correlation coefficient between PSI difference scores and follow-up BDI scores was r = -0.41, n = 22, P \ 0.05 (one-tailed), and with HDRS it was r = -0.26, n = 22, P [ 0.05 (one-tailed).

Discussion

This study tested the efficacy of problem-solving therapy in treating depression and suicide

potential in adolescents and young adults. Forty-six self-referred high school and university

students who were randomly assigned to a problem-solving therapy and waiting list control

conditions participated in the study. A manual-based PST was used. Participants assigned to

the experimental condition received six sessions of PST for an average length of approxi-

mately 38 min per session. Participants in the problem-solving condition perceived their

therapeutic alliance as being highly satisfactory. The results obtained from the study indicate

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that problem-solving therapy is an effective and acceptable treatment method for emotional

problems in adolescents and young adults.

Depression is common in young people and causes considerable impairment in physical,

psychological, social, academic and vocational functioning. The potential of a problem-solving

approach for the treatment of depression and suicide proneness was anticipated in the litera-

ture. In line with findings from Nezu (1986), the results obtained in this study supported this

anticipation. Post-treatment depression scores of participants who received PST were found to

be statistically significantly lower than their pre-treatment depression scores while pre- and

post-treatment depression scores of participants in the WLC condition were unchanged. High

effect sizes (Cohen 1988) were observed between treatment and no treatment conditions, and

between pre- and post-treatment for depression. The effect sizes observed in this study make a

strong case for the use of problem-solving therapy in treating depression in young people. The

results of this empirical investigation are in line with findings from Arean et al. (1993),

Dowrick et al. (2000), and Nezu (1986) with adults. Further, the results of this study replicate

and extend the findings from Lerner and Clum 1990 with young adults and Biggam and Power

(2002) with incarcerated young offenders to a sample that included high school students.

Predetermined criteria for remission according to BDI and HDRS scores indicated that the

number of participants in the PST condition who recovered were greater than the number of

participants who did so in the WLC condition. As Table 3 shows, 77.8% of participants in the

PST condition achieved full or partial recovery while only 15.8% achieved only partial

recovery in the WLC condition according to BDI scores. According to HDRS scores, 96.3% of

participants in the PST condition achieved full or partial recovery while only 21.1% did so in

the WLC condition. At follow-up, 86.4% were still in full or partial remission according to

BDI scores whereas 100.0% were in full remission according to HDRS scores. The findings

from the study showed that the improvements in depression were maintained over a 12-month

follow-up period.

Suicidal behavior is a major mental health concern among adolescents and young adults.

Therefore, effective psychosocial treatment alternatives for the treatment of suicide problem

are needed in these populations. The results obtained in the present study are encouraging.

Post-treatment suicide risk scores (as measured by the SPS) of participants who received PST

were found to be statistically significantly lower than their pre-treatment suicide potential

scores while pre- and post-waiting suicide risk scores of participants in the WLC condition

were unchanged. The effect size between treatment and no treatment obtained in the study was

low but the effect size between pre- and post-treatment suicide risk was high. The present

results are consistent with findings from Townsend et al. (2001) and Salkovskis et al. (1990)

with adults. Comparing problem-solving therapy with supportive therapy for treating suicidal

ideation of university students, Lerner and Clum (1990) found that the two treatments were

similar. But problem-solving therapy was more effective at reducing depression, hopelessness

and loneliness than supportive therapy. Unlike findings from Lerner and Clum (1990), current

results indicate that problem-solving therapy is effective at reducing suicide potential. Thus,

the results from this study suggest that problem-solving therapy can be taken as a viable

treatment alternative for suicide problems in adolescents and young adults.

Traditional psychotherapy outcome studies have usually been conducted to investigate the

efficacy of a given intervention in reducing the levels of psychopathology (i.e., depression,

etc.). Very few studies were designed to see if a given intervention works in increasing the

levels of protective factors such as self-esteem and assertiveness. These protective factors are

important in a developmental period like adolescence and young adulthood during which

global changes take place. Thus, the present study aimed also at testing if PST increases the

levels of self-esteem and assertiveness while decreasing the levels of psychopathology. The

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data showed indeed that this is the case. As with scores of depression and suicide potential,

post-treatment self-esteem and assertiveness scores of participants in the PST condition were

found to be significantly higher than their pre-treatment self-esteem and assertiveness scores

while pre- and post-waiting self-esteem and assertiveness scores of participants in the WLC

condition were unchanged. The PST leading to increases in assertiveness is not surprising

because, according to therapist records, the problems identified to work with during the

treatment were mainly of interpersonal nature.

Kazdin and Nock (2003) discussed the importance of mechanisms of therapeutic change in

child and adolescent psychotherapy. Problem-solving therapy offers unique mechanism of

therapeutic change that fit the developmental needs of young people. One might have antic-

ipated an improvement in the post-treatment self-appraised problem-solving ability of

participants who received problem-solving therapy compared to self-appraised problem-

solving ability of participants in the WLC condition. Unlike findings from Nezu (1986) and

Biggam and Power (2002), the current results did not confirm this anticipation. However,

improvement in self-appraised problem-solving ability from baseline to follow-up was asso-

ciated with lower depression (e.g., Dixon 2000) suggesting a causal relationship between

problem-solving ability and depression. Although, post-treatment PSI scores of participants in

the PST condition did not improve compared to the pre-treatment scores, follow-up PSI scores

were statistically significantly lower than the pre-treatment scores. But this is valid only for

participants within the PST condition. Lack of support for the above anticipation may be due to

several reasons. First, PST may reduce psychopathology through other mechanisms of change

than the development of problem-solving ability. Second, PST applied in this study may not be

able to significantly improve global problem-solving ability as measured by the PSI. PSI scores

reflect problem orientation variables (i.e., attitudes toward problems and one’s own problem-

solving ability) as well as problem-solving skills (e.g., problem definition, generation of

alternative solutions). However, the present PST program focused only on problem-solving

skills. It did not address problem orientation. Nevertheless, following treatment, an

improvement in problem-solving performance that may have resulted from the PST program

may have eventually resulted in an improvement in problem orientation (see D’Zurilla and

Nezu 1999, 2007), which may be reflected in the significant improvement in the PSI scores of

the PST participants from post-treatment to follow-up. Third, the measure of problem solving

used in this study may not be an adequate instrument to show the development of problem-

solving skills. Fourth, since participants in the control condition were placed on a waiting list

there might have been a placebo effect.

Taken together, the findings from this study make a strong case for the use of problem-

solving therapy for the treatment of depression and suicide potential in adolescents and young

adults. The findings demonstrated that PST was able to reduce levels of psychopathology

(depression and suicide potential) and to increase levels of protective factors (assertiveness and

self-esteem). The improvements in depression were maintained over a 12-month follow-up

period. However, the present findings should be approached with caution when generalizing to

other samples for several reasons. First, therapists themselves administered the HDRS to

participants. Since they were not blind to the conditions this may have caused bias. Second, the

participants were a group of self-referred high school and university students. Therefore,

further investigations are needed to clarify to what extent our findings apply to clinically

referred adolescents and young adults. One outcome study on PST for depression in adults

found that a PST program that included a problem orientation was significantly more effective

than a PST program that focused only on problem-solving skills (Nezu and Perri 1989). It is

possible that a similar effect might be found with PST for depression and suicide potential in

adolescents and young adults. Third, a problem-orientation component was not part of the PST

Cogn Ther Res (2008) 32:227–245 241

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offered in the study. Studies employing PST with a problem-orientation component are

therefore warranted.

Acknowledgements The authors would like to offer their deep appreciation to Dr. Rick E. Ingram (Editor) and the two anonymous reviewers for their valuable comments and suggestions.

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Almost Depression among Teens and Young Adults

Yashvi Italiya and Preeti Nakhat

The aim of this research was to find the ratio of teens and young adults who are Almost Depressed. This age group was chosen because Almost Depression is very common and mostly it is ignored considering normal hormonal changes during this span of life. The paper focuses mostly on the main symptoms and it also differentiates Persistent Depressive Disorder also known as Almost Depression from Major Depressive Disorder. We used survey method for our study. There were a total of 576 participants. There were 36 questions asked to the participants with options and the last question being open ended. The analysis states that there are around 64.32% participants who are Almost Depressed. The research brought the end conclusion that even though people pretend to be happy and give a smile, most of them are going through a certain amount or beginning to fall into the trap of Almost Depression. Even though there are lot of professionals to help, the patients do not seek their help due

Keywords : Almost Depression, Dysthymia, PDD, Anxiety

1. INTRODUCTION

Almost Depression is also known as ‘Low-grade Depression’, ‘Persistent Depressive Disorder’, ‘High Functioning Depression’, and ‘Dysthymia’. According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Persistent Depressive Disorder (PDD) is a category that includes numerous forms of Chronic Depression in which depressive symptoms are present on most of the days over at least a 2-year period. This concept was earlier known as Dysthymia and it was later introduced as PDD in late 1970s as a replacement of “depressive personality”.

PDD may start from as early as before age 21 years or as late as at age 21 years or older. Dysthymia is a chronic form of Depression that can cause people to lose interest in their normal day-to-day activities, have low self-esteem and an overall feeling of, feelings of hopelessness, inadequacy and difficulty with productivity. Given the chronic

Journal of Psychosocial Research Vol. 14, No. 2, 2019, 411-418 DOI No. : https://doi.org/10.32381/JPR.2019.14.02.19

Corresponding author. Email : [email protected], [email protected] ISSN 0973-5410 print/ISSN 0976-3937 online ©2019 Dr. H. L. Kaila http//www.printspublications.com

Yashvi Italiya and Preeti Nakhat

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nature of Dysthymia, these feelings can continue for years and negatively impact relationships, education, employment and other daily activities.(Association, 2013)

People going through this stage often feel irritated by the presence of others. Their actions and words often tend to frustrate them. They lose interest in activities which involve conversing with other human beings. Anxiety is very common in Almost Depression. People find they are nervous and feel the panic rising in their body even during small situations. Anxiety lives in them and makes them aware of its presence all the time. It becomes almost permanent even if they have cured from Almost Depression or Depression.

Other signs and symptoms are as follows:

1. Extreme moodiness. Mood swings are terrible and people, who are Almost Depressed, go through them almost every day. It becomes a sign when it reaches extreme amount.

2. Changes in eating. Due to extreme stress and pressure on the mind and thought procedure of a human brain, people often start taking out their frustration on eating. They either lose their appetite or start eating a lot.

3. Low self-esteem. Everything seems gloomy and doom. People often, start comparing themselves to others and feel low when they realise that they are not up to the benchmark of the society.

4. Problem in concentrating. Poor concentration is not something everyone has since birth, and when they develop it in later stages when they go through some mental disorder, it becomes a challenge in itself to handle this change.

The causes

Researchers say that the causes of Dysthymia are not known exactly. But it is assumed that various factors like family background, past experience of the subject, traumatic incidence, changes in neurotransmitters, rebirth of previous bad memories, stressful events, abuse, etc can be some of the reasons of Dysthymia.

The effects

1) Lacking self-love. As the days passes by, loving own self goes from easiest to toughest task. By the time people realise the change, it is too late.

2) Anger issues. Taking out anger on others as well as own self becomes a daily habit. This costs the subject their friendship and other relations.

3) Drop-off in productivity. People lose curiosity in learning new things or even continuing old thing and drop in between.

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How is PDD different from major Depression?

1) While Major Depressive Disorder (MDD) is major as the name itself suggests, PDD is chronic, mostly for two to five years of duration, and minor in nature than MDD.

2) The symptoms of Almost Depression are visible in the patients of MDD for two weeks while it is visible in the patients of PDD for continuously two months for two years.

3) MDD patients may feel normal when the symptoms are gone for a while whereas PDD patients do not know what it feels like to be not Dysthymic.

II. LITERATURE REVIEW

1) The researchers of “Persistent Depression as a Novel Diagnostic Category: Results from the Menderes Depression Study”, Ildirli, Sair, Dereboy (2015) got their article published in Turkey in the Journal Archives of Neuropsychiatry. The sample of the study was 140 depressive patients. The analyses state that, 61% fulfilled the criteria for PDD and 39% fulfilled for episodic MDD. The PDD patients displayed different characteristics with respect to clinical intensity and suicidal behaviour.(Saliha Ildirli, Yaşan Bilge Şair, Ferhan Dereboy, 2015)

2) The researchers Adler, Irish, McLaughlin, Perissinotto, Chang, Hood, Lapitsky, Rogers, and Lerner wrote a research article named “The work impact of Dysthymia in a primary care population” which was published in July, 2004 in Boston, USA. 69 patients diagnosed with DSM-IV Dysthymia without concurrent MDD were compared to 175 non-depressive controls. The result that the Dysthymic group had low level of social support than MDD controls it also had more physical health vexation. (David A. Adler, Julie Irish, Thomas J. McLaughlin, Carla Perissinotto, Hong Chang, Maggie Hood, Leueen Lapitsky, William H. Rogers, and Debra Lerner,, 2004)

3) The title “Persistent Depressive Symptoms are Independent Predictors of Low- Grade Inflammation Onset Among Healthy Individuals” is a research conducted by the researchers Franco, Laurinavicius, Lotufo, Conceição, Morita, Katz, Wajngarten, Carvalho, Bosworth, Santos at Brazil (2017). The research method is quantitative. 1,508 young individuals underwent two routine health check- ups, 134 had persistent depressive symptoms and 1,374 had negative symptoms. The analysis states the frequency of low-grade symptom was more frequently observed in the BDI+ group compared to the BDI- group (Fábio Gazelato de Mello Franco, Antonio Gabriele Laurinavicius, Paulo A. Lotufo, Raquel D. Conceição, Fernando Morita, Marcelo Katz, Maurício Wajngarten, José Antonio

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Maluf Carvalho, Hayden B. Bosworth, Raul Dias Santos,, 2017).

4) The authors of “Chronic, Low-grade Depression in a Nonclinical Sample: Depressive Personality Or Dysthymia?” (2001), Ryder, R. Bagby, and Dion, aimed to examine whether Dysthymia and depressive personality disorder are distinct in nature. 81% of 467 individuals selected for questionnaire were analyzed. The analysis state that they evaluated four different latent models. Model A tested the assumption that Dysthymia and DPD are non-distinct. Model B assigned the six symptoms of Dysthymia. Model C tested another two-factor model with the seven traits from DPD and the two Dysthymia symptoms of low self-esteem and hopelessness. For Model D, the symptoms of low self-esteem and hopelessness loaded onto both the Dysthymia and DPD factors. (Andrew G. Ryder, R. Michael Bagby, and Kenneth L. Dion, 2001).

5) The authors Garrison, Waller, Cuffe, Mckeown,. Addy, Jackson came up with the title of the research “Incidence of Major Depressive Disorder and Dysthymia in Young Adolescents” (April 1997) in Columbia. The method they used was the diagnoses were based on the Schedule for Affective Disorders and Schizophrenia for School-Age Children. It resulted in the following: One-year MDD were 3.3% and Dysthymia were 3.4%. Factors for Dysthymia were not significant.(Carol Z. Garrison, Jennifer L. Waller, Steven P. Cuffe, Robert E. Mckeown, Cheryl L. Addy, Kirby L. Jackson, 1997).

6) R. Howland is the sole author of the paper “General Health, Health Care Utilization, and Medical Comorbidity in Dysthymia” which was published on September 1, 1993. The method Howland used was medline. Only those studies were selected which included health data of patients with Dysthymia. The analysis of the same is that Dysthymic patients frequently use medical services and are at increased risk of poor general health. (Howland, 1993).

7) The title “The categorisation of Dysthymic disorder: Can its constituents be meaningfully apportioned?”(2012) is a work of Rhebergen, Graham, Hadzi- Pavlovic, Stek, Friend, Barrett, Parker. The study was on 18 patients attending the Black Dog Institute Depression Clinic. The result was Depression groups mostly differed on factors of intensity.(Didi Rhebergen, Rebecca Graham, Dusan Hadzi- Pavlovic, Max Stek, Paul Friend, Melissa Barrett, Gordon Parker, 2012).

III. METHODOLOGY

RESEARCH QUESTION

Our major research question is ‘what is the proportion of teens or young adults who are prey of Almost Depression?’

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QUESTIONNAIRE

The questionnaire was prepared by the authors. The further procedure was carried out by formulating Google form. 1 out of 36 questions were open ended and the rest were provided with multiple choice options.

PROCEDURE

Survey method was used. The sample population was 16 to 25 years old people. 576 students or just pass outs responded to the questionnaire.

STATISTICAL ANALYSIS

The responses were analysed using Microsoft excel. The responses of last question were bifurcated into numerous groups and then taken into consideration for analysis.

IV. ANALYSIS AND RESULT

The first analysis was on Trouble in sleeping. It is also a primary symptom of Low- grade Depression. 30.55% faces the problem of oversleeping or has found it as change in their sleeping pattern. 19.61% faces the problem of insomnia as a recent change in their sleeping pattern while rest 49.82% find no trouble in sleeping. This shows that most of people belonging in the age group 16-25 are neutral when trouble in sleeping is considered. While there is problem with rest 49% as they are either indulged in oversleeping or Insomnia. In either case, the sign of Almost Depression is present.

Expressing emotions is very necessary. If people start keeping emotions and feelings to themselves, it will keep bugging them in one or the other way. And not sharing or expressing is somehow responsible for Almost Depression because people’s emotion torture them from inside more than some outside force do. So, when the participants were asked about the changes in their way of expressing emotions, 67.9% said yes. It means that either they have stopped expressing or they have started expressing. By analysing the answers of other questions, we interpreted that most of them have stopped expressing. 20.4% people said no which means that they find no change. And the rest 11.7% belong to the third part of the answer which says that they are not sure.

It would be really difficult to deal with day to day life if people can’t focus in their daily activities like reading, watching, writing, learning, etc. When participants were asked whether they face problem in concentrating in daily activities as such, 52% said yes. These many people are showing sign of anxiety which is indirectly showing sign of Almost Depression. 38.2% said no, meaning these people are fine or as they prefer to show. Rest of the 9.8% people are not sure about their answers.

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Next question is ‘can you imagine ‘Almost Depression’ being with you like other diseases such as diabetes throughout your life?’ Just 34.3% said that it is bearable while rest of the 65.7% said that it is a terrible thought. It brings to the conclusion that most of the participants are terrified by this thought even if they do not show the sign of Low-grade Depression.

The last analysis was of -‘Describe your life in a few sentences’. This was open ended and out of 576 participants only 278 of them answered it. 16.1 % people think their life should go on the way it is going while just 14.3% think their life requires a few changes. Just 5% says unpredictable and only 1% says bored. 12.5% combined are tired, frustrated and lost while 8.9% feel lonely and alone. It is good to know that at least 3% of 278 feels ambitious and is fighting. 8.9% combined is confused about their life and has mood swings and over thinks a lot. 10% people are more sad than happy. Another 10% says that they are living less and surviving more than living. Later, the last category is the people who have given up and are in the worst phase of their life was analysed. There are total 17.9% people, which is the highest of all, who are in the worst phase. This data confirms that the people of this generation themselves do not know about it but they are mostly going through Almost Depression.

V. CONCLUSION

1) When being asked about frustration on little things, 49.65% agreed that they get frustrated easily while 29.86% denied. There were 20.48% people who were not sure. From age group of 16-25, most people who agreed were of age 19. As for ‘I am not sure’, there is a tie between age 18 and 19. This may happen due to hormonal changes also. But, if the same person also agrees to other symptoms or questions given in the questionnaire, it can be the case of Almost Depression.

2) Anger is an emotion teenagers often develop during this age due to hormonal change. But it is also one of the major symptoms of Low-grade Depression. And so it is difficult to recognise it amongst people of this age. The question asked was – ‘Often when things go out of hand, is anger the first thing that consumes your mind?’ 53% said yes which means that more than half of the participants get automatically angry on little things. Only 36% of them said and that means that the youth is mostly short tempered. Rest 11% is not sure.

3) 62% sample population wants to run away from their own self. They want to run away from reality and their problems. 24.8% people are happy as they do not want to run but solve their problems instead.

4) Over thinking is a major problem most of the people face. This was one of the questions asked to the participants 70.9%, which is very high in value, said yes. It

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means that these many people are tired of their irrational and unnecessary thoughts while only 17.9% are not. On the other hand, just 10.8% are not sure. Tiredness from over thinking shows sign of Almost Depression because they are not able to handle their thoughts and understand their own thought processes.

VI. LIMITATIONS

1) We fell short of reading materials for our research due to rarity of topic.

2) The theory of Almost Depression is not found yet.

VII. IMPLICATIONS

Escitalopram- It is a kind of drug that is used for treating Dysthymia, Depression and Anxiety. One of the studies by National Center for Biotechnology Information supports this treatment by conducting a meta-analysis to compare it with other antidepressants. Another intervention was Placebo treatment. It is a preparation containing no medicine and administered to cause the patient to believe that he is receiving treatment. National Center for Biotechnology Information did a study on this and found out positive response from the people who went through this treatment. The researchers also suggest parents, teachers, peers and other stake holders to be a good and patient listener. People feeling Almost Depressed should visit a therapist and undergo therapy for recovering.(Sonawalla, Rosenbaum, 2002), (Kennedy, Andersen, Lam, 2006).

REFERENCES

Andrew G. Ryder, R. Michael Bagby, and Kenneth L. Dion. (2001). CHRONIC, LOW-GRADE DEPRESSION IN A NONCLINICAL SAMPLE: DEPRESSIVE PERSONALITY OR DYSTHYMIA? (r. f. krueger, & j. m. oldham, Eds.) Journal of Personality Disorders, 15 (1), 84-93.

Association, A. P. (2013). Diagnostic and statistical manual of mental disorders, (5th ed.). Washington, DC: American Psychiatric Publishing.

Carol Z. Garrison, Jennifer L. Waller, Steven P. Cuffe, Robert E. Mckeown, Cheryl L. Addy, Kirby L. Jackson, (1997). Incidence of Major Depressive Disorder and Dysthymia in Young Adolescents. Journal of the American Academy of child and adolescent psychiatry, 36 (4), 458-465.

David A. Adler, Julie Irish, Thomas J. McLaughlin, Carla Perissinotto, Hong Chang, Maggie Hood, Leueen Lapitsky, William H. Rogers, and Debra Lerner. (2004). The work impact of dysthymia in a primary care population. (j. c. huffman, Ed.) general hospital psychiatry, 26 (4), 269-276.

Didi Rhebergen, Rebecca Graham, Dusan Hadzi-Pavlovic, Max Stek, Paul Friend, Melissa Barrett, Gordon Parker. (2012). The categorisation of dysthymic disorder: Can its constituents be meaningfully apportioned? Journal of Affective Disorders, 143 (1-3), 179-186.

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ABOUT THE AUTHORS

Yashvi Italiya – A-501, Salaj Homes, near Sagar Sankul, Ugat Canal road, Jahangirabad, Adajan, Surat,

Gujarat- 395005

Dr. Preeti Nakhat – 27/B, Vishwa kunj colony, Balia kaka road, Nr Meera cross roads, Ahmedabad- 380028

Fábio Gazelato de Mello Franco, Antonio Gabriele Laurinavicius, Paulo A. Lotufo, Raquel D. Conceição, Fernando Morita, Marcelo Katz, Maurício Wajngarten, José Antonio Maluf Carvalho, Hayden B. Bosworth, Raul Dias Santos,. (2017). Persistent Depressive Symptoms are Independent Predictors of Low-Grade Inflammation Onset Among Healthy Individuals. arquivos brasileiros de cardiologia, 109 (2), 103-109.

Howland, R. (,1993). General Health, Health Care Utilization, and Medical Comorbidity in Dysthymia. The International Journal of Psychiatry in Medicine , 23 (3), 211-238.

Kennedy, Andersen, Lam. (2006). Efficacy of escitalopram in the treatment of major depressive disorder compared with conventional selective serotonin reuptake inhibitors and venlafaxine XR: a meta-analysis. J Psychiatry Neurosci, 31 (2), 122-131.

Saliha Ildirli, Yaşan Bilge Şair, Ferhan Dereboy. (2015). Persistent Depression as a Novel Diagnostic Category: Results from the Menderes Depression Study. Archives of neuropsychiatry , 52 (4), 359-366.

Sonawalla, Rosenbaum. (2002). Placebo response in depression. Dialogues Clin Neurosci, 4 (1), 105-113.

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INTERNATIONAL JOURNAL OF BEHAVIORAL CONSULTATION AND THERAPY 2014, VOL. 9, NO. 3

Adolescent suicide and self-injury: Deepening the understanding of the biosocial theory and applying dialectical behavior therapy Elizabeth A. Courtney-Seidler, Karen Burns, irene Zilber, and Alec L. Miller Cognitive & Behavioral Consultants, LLP - White Plains, NY

Abstract The promise of Dialectical Behavior Therapy (DBT) has been substantiated by a growing body of work demonstrating its efficacy for addressing suicidal and non-suicidal self-injury as well as pervasive emotional and behavioral dysreg- ulation, among adolescents. Research elucidating the neurobiological correlates and biosocial factors contributing to the development of emotion dysregulation and self-harm is presented. A recent milestone is the completion of the first randomized controlled trial of DBT with self-harming adolescents. The results of this five-year study are presented along with an overview of the treatment as adapted for this population.

Keywords Dialectical Behavioral Therapy (DBT), suicidal and non-suicidal self-injury, emotional and behavioral dysregulation, adolescents, self-harm, neurobiological correlates, biosocial factors, randomized controlled trial.

D ialectical Behavior Therapy (DBT) was first adapted for use with multi-problem suicidal adolescents nearly twenty years ago in response

to a dearth of empirically supported psychosocial treatments for this population (Miller, Rathus & Linehan, 2007; Miller, Rathus, Linehan, Leigh & Wetzler, 1997). Miller, Rathus and colleagues retained the core principles and strategies of Linehan’s (1993) original DBT treatment manual for suicidal women with Borderline Personality Disorder (BPD), and made modifications based on developmental and contextual considerations for adolescents and their families. Three review articles by Groves, Backer, van den Bosch, & Miller (2012), MacPherson, Cheavens, & Fristad (2013), and Neece, Berk, & Combs-Ronto (2013) all found growing evidence, based on the review of over a dozen quasi-experimental and open-trial pilot studies, to suggest that DBT may be a promising treatment for adolescents with a range of problematic behaviors, including but not limited to suicidal and non-suicidal self-injury. Ritschel, Miller & Taylor (2013) recently proposed DBT as transdiagnostically applicable to adoles- cents who present with more pervasive emotional and behavioral dysregulation often evidenced in mood disorders, substance use disorders, eating disorders, and disruptive behavior disorders, in addition to the more standard applications of DBT to self-harming individuals often diagnosed with BPD. More recently, Mehlum and colleagues (in press) have completed the first randomized con- trolled trial of DBT with self-harming adolescents and found DBT to be a highly effective treatment for this population.

This paper reviews adolescent suicide and self-in- jury and the neurobiological bases for some of these behaviors. Next the paper provides further support for Linehan’s (1993) Biosocial theory of emotion dysregulation, that informs DBT treatment with adolescents. Finally, the paper briefly describes DBT treatment with adolescents along with a brief review of the results of the first adolescent DBT randomized controlled trial (RCT).

Adolescent suicide and self-injury Suicidal behavior is among the leading causes of death among adolescents (Bridge et al., 2006; Spirito & Esposito-Smythers, 2006). The estimated lifetime prevalence for suicidal ideation, planned attempts, and suicide attempts is 12%, 4%, and 4.1% respectively (Nock et al., 2013). Non-suicidal self-injury (NSSI) is often a correlate and precursor to suicidal behaviors among adolescents (Andover et al., 2012; Miller et al., 2007;). The lifetime prevalence of NSSI in adolescent community samples is 15-28% (Claes, Luycks, Bijtte- bier, 2014; Laye-Gindhu & Schonert-Reichl, 2005; Nixon et al., 2008; Whitlock & Knox, 2007) and is found in up to 60% of adolescent clinical samples (Nock & Prinstein, 2004). The typical age of onset for NSSI is between 12-14 years (Nixon, Cloutier, & Aggarwai, 2002; Nock & Prinstein, 2004; Ross & Heath, 2002) and cutting and hitting oneself are the most frequent forms of NSSI (Muehlenkamp & Gutierrez, 2004, 2007; Ross & Heath, 2002). Adoles- cents who engage in NSSI are more likely to attempt suicide (Whitlock & Knox, 2007), with 70% of adolescents who engage in NSSI reporting at least one suicide attempt and 55% reporting multiple suicide attempts (Nock, Joiner, Gordon, Lloyd-Richardson, & Prinstein, 2006; Zlotnick, Donaldson, Spirito, & Pearlstein, 1997).

Although suicidal behavior is mentioned as a symptom of Borderline Personality Disorder (BPD) in the DSM-IV and ICD-10 classification systems, and research has provided ample support for this diagnostic relationship (Nock et al., 2006), suicidal and non-suicidal self-injury in adolescence is also detected in internalizing and externalizing disorders (Nock et al., 2006). There is ample research on the diagnostic correlates of suicide and NSSI in adoles- cents (See Nock et al., 2006 for review). Despite the progress in identifying psychosocial risk factors for adolescent suicidal behaviors, such as psychiatric diagnoses, the neurobiological alterations that contribute to the pathogenesis of suicide are less well understood in adolescents (Currier & Mann, 2008; Mann, 2003).

Neurobiology of suicidal behaviors and non-suicidal self-injury Substantial evidence exists supporting the asso- ciation between deficits in 5-HT functioning and conditions and behaviors characterized by impul- sivity, aggression, and affective instability (Kamali, Oquendo, & Mann, 2002). A relationship between the serotoninergic system and suicidal behaviors is the most consistent finding regarding biological contributions to suicidality (Mann, 2003; Zalsman et al., 2006). Pandey and colleagues’ (1997, 2002, 2004) post-mortem research indicates that adolescent suicide completers have increased serotonin 5-HT2a receptors, protein, and mRNA expression in the prefrontal cortex and hippocampus compared to normal controls. More recent research from Pandey and colleagues (2012), found that proinflammatory cytokines, which play an important role in stress and depression, were elevated in the prefrontal cortex compared to normal controls. Brain-derived neurotrophic factor (BDNF) dysregrulation has also been associated with adolescent suicidality, independent of psychiatric diagnoses (De Leo, 2011; Pandey, 2004). BDNF plays a significant role in the regulation and growth of neuronal development in children and adolescents. Research hypothesizes that the serotonin dysfunctions found in adolescents with suicidal behavior may be related to deficits in BDNF (De Leo, 2011).

A majority of neuroimaging studies of NSSI and suicidal behavior have been with adolescents diag- nosed with BPD. Studies have detected alterations in brain maturation with electroencephalography among adolescent females with BPD symptomatology (Ceballos, Houston, Hesselbrock, & Bauer, 2006; Houston, Ceballos, Hesselbrock, & Bauer, 2005). This research and others thus far indicate neurobiological alterations in the anterior cingulate cortex (Chanen, Jovev, et al., 2008; Chanen, Velakoulis et al., 2008; Goodman et al., 2001; Whittle et al., 2009), pituitary gland (Jovev et al., 2008), and the dorsolateral cortex and the orbitofrontal cortex (Brunner et al., 2010). Goodman and colleagues (2011) found that among female adolescents diagnosed with co-morbid BPD and Major Depressive Disorder (MDD), greater BPD symptom severity and number of suicide attempts, and not depression, was associated with greater ACC abnormalities. Research findings of frontolimbic dysfunction in both male and female adolescents with BPD symptomatology and suicidal behaviors support the specific roles of emotion dysregulation and impulsivity in the development of suicidal behaviors.

There is less research on the neurodevelopmental abnormalities in adolescents with NSSI and suicidal behaviors who do not meet criteria for BPD. One neuroimaging study using a heterogeneous diagnostic sample (e.g., MDD, Dysthymia, PTSD, and BPD) compared 18 adolescent females with and without a history of NSSI on an emotional processing task (Plener et al., 2012). Results indicated that adolescent females with NSSI had increased activity in the amygdala, anterior cingulate cortex (ACC) in the inferior and middle orbitofrontal cortex, and reduced sensitivity in the cuneus and right inferior frontal cortex (Plener et al. 2012). Plener and colleagues (2012) argue that these altered neural patterns provide

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evidence for adolescents with NSSI having a reduced ability to interpret social cues and regulate emotions. These findings are consistent with a model proposed by Nock (2010) that proposes that increased negative emotions coupled with social problem solving and communication deficits, leads to increased risk for engaging in maladaptive emotion regulation strategies such as NSSI.

Neuroimaging research has found differential patterns of neural activity during emotional pro- cessing tasks of mild and ‘protypical’ angry, happy, and neutral facial expressions in adolescents with and without a history of a suicide attempt (Pan et al., 2013). Pan and colleagues (2013) found that adolescent suicide attempters of both genders had elevated activity in attention control circuitry and reduced anterior cingulate gyrus connectivity, an area that supports emotional processing, and the regulation of emotional responses (Etkin et al., 2011), compared to non-attempters when processing mild intensity angry faces. Neuroimaging findings of al- tered activity with only mild angry facial expressions is consistent with research finding milder intensity facial expressions to be more indicative of social displays of emotion compared to 100% prototypical intensity facial expressions (Surguladze et al., 2005). Pan and colleagues (2013) propose that adolescent suicide attempters increased attention and processing of mild social displays of disapproval may contribute to a vulnerability to suicidal behavior. Taken together, the neuroimaging findings of altered neural activity in the brain structures mentioned above support theoretical models that implicate poor emotional processing in social situations and affective dysreg- ulation in NSSI and suicidal behaviors (Nock, 2010; Nock & Prinstein, 2005).

Physical pain processing. Research suggests that adolescents who engage in NSSI experience emotional dysregulation and higher physiological reactivity (e.g., skin conductance measures) in response to stressful situations (Deliberto & Nock, 2008; Nock & Mendes, 2008). Nock and Mendes (2008) compared skin conductance measures during a distressing task for 62 adolescents with a history of NSSI to 30 matched controls without a history of NSSI. Increased physiological arousal was found among adolescents with NSSI. Physical pain processing is also different in adolescents who self-harm. Nock & Prinstein (2005) found that adolescent psychiatric inpatients with a history of self-injury reported little to no pain when engaging in NSSI behaviors. These findings are consistent with experimental studies showing that individuals who self-injure have a lower pain sensitivity and greater ability to tolerate pain for a longer period of time compared to those without a history of self-injury (Bohus et al., 2000; Russ et al., 1999). Elevated levels of endogenous opiates in individuals who self-injure has been hypothesized to account for the presence of this lower pain sensitivity (Nock, 2009). Neurological structural and hormonal changes in the processing of emotional distress and pain put adolescents at greater risk for making impulsive decisions and affective instability, which contribute to a greater vulnerability to NSSI (Ballard, Bosk, & Pao, 2010).

 Association of NSSI and suicidal thoughts and behaviors

As previously mentioned, chronic NSSI in and of itself is an important risk factor for suicidal behavior in adolescents (Joiner, 2005; Wichstrom, 2009). In a recent longitudinal study examining the temporal relationship between NSSI and suicidal behaviors, college aged students who had any history of NSSI were three times more at risk for concurrent or later suicidal thoughts or behaviors (Whitlock et al., 2013). These findings are consistent with the most widely supported theory of suicide, the Interpersonal Theory of Suicide (IPTS; Joiner, 2005; Van Orden et al., 2010). The IPTS posits that acquired capability, which is defined as the capacity one has to perform a lethal suicide attempt, is a necessary component for suicidal desire (encompassed by thwarted be- longingness and perceived burdensomeness) to develop into suicidal behavior. Joiner and colleagues (Joiner, 2005; Van Orden et al., 2010) hypothesize that acquired capability develops from a reduced fear of death and increased pain tolerance, which often occurs through repeated exposure to painful experiences (e.g., trauma, NSSI). Recent research supports IPTS’s proposed relationship between NSSI and suicidal behavior, with repeated experience with NSSI mediating the relationship between low distress tolerance and suicide attempts (Anestis et al., 2013).

Psychiatric disorders characterized by low levels of distress tolerance and emotion dysregulation such as Borderline Personality Disorder (Linehan, 1993) and Substance Abuse Disorders (Howell et al., 2011) have been found to have higher rates of suicidal behavior and death by suicide (Bornovalova et al., 2011; Skodol et al. 2002).

Clinically these findings highlight the importance for therapeutic interventions aimed at reducing sui- cidal behavior to increase emotionally dysregulated individuals’ abilities to tolerate distress and not engage in maladaptive emotion regulation strategies such as NSSI.

 The biosocial model

Providing the theoretical framework for D BT, Linehan’s Biosocial Theory (1993) posits that a problematic and pervasive transaction between a biologically vulnerable individual and an invalidating environment yields emotional dysregulation in individuals, many of whom present with suicid- al behavior and borderline personality disorder. Along with a biological vulnerability described earlier in the paper as it relates to suicide, self-in- jury and BPD, an invalidating environment is the other key component of this theory. While the research reviewed previously in this paper has indirectly emphasized the neurobiology aspect of the biosocial theory, less is understood about the components of the invalidating environment. Thus, the remainder of this section explores different etiological pathways and expressions of invalidation that should be considered when working with suicidal multi-problem youth.

Broadly speaking, an invalidating environment is one that responds to the individual’s communi- cations of his/her internal emotional experiences

with skepticism, derision, or punishment (Linehan, 1993). According to Linehan (1993), invalidation questions the accuracy of the individual’s experience and representation of his/her emotions, either overtly or in more subtle ways, and may even suggest that the emotional responses of the individual – positive or negative – result from undesirable personality traits, such as being manipulative, overly sensitive, dramatic, or paranoid. This is especially true when events in the environment don’t appear to support the validity of an emotional response, or one of such intensity or duration.

While any environment can be invalidating at times, the characteristics of an emotionally dysreg- ulated individual – sensitivity, reactivity, and slower return to emotional baseline – make it more likely that the environment will respond to the expression of emotion with invalidation more chronically. Additionally, while such pervasive invalidation may be distressing for those with normative capabilities to regulate emotions, it is even more challenging for individuals who experience their emotional states as highly intense and difficult to manage, and can exacerbate their disposition toward dysregulation. The view of one’s emotional experiences as generally “wrong” in some way can become internalized by some individuals, leading to mistrust in the accuracy of emotional responses and shame in the face of their inability to easily resolve problems. Over time, the individual seeks out external cues for appropriate emotional responses to events and punishes him/ herself for failures to navigate difficulties more skillfully, leading to the development of maladaptive behaviors including but not limited to suicidal and non-suicidal self-injurious behaviors.

Caregiver emotion socialization and invalidation

The prevailing DBT theory posits borderline symp- tomatology as, fundamentally, a deficit in emotion regulation skills. According to Gross (2013), emotion regulation is a process involving both the up-reg- ulation and down-regulation of the intensity or duration of emotions, occurring either intrinsically or extrinsically. Gross’s information-processing model proposes that the process involves situation selection, situation modification, attention deployment, cog- nitive change (i.e. such strategies as suppression or reappraisal), and response modulation. Disturbances in emotion regulation may therefore result from poor awareness of emotional responses or poor selection of goals or strategies for managing responses. Addi- tionally, Gross (2013) believes regulation is primarily achieved via extrinsic means in infancy but changes throughout the lifespan.

Undoubtedly, the environment exerts powerful influence on the development of such skills. Yet it has proven difficult to quantify the exact nature of such invalidating environments. The existing conceptualization characterizes the invalidating environment as one in which the caregiver rejects or punishes emotional expression, thereby leading to escalation of affect by the dysregulated individual, which is subsequently intermittently reinforced by the caregiver providing support or removing an aversive stimulus in response to the extreme expression.

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Citing the work of Chess and Thomas, Linehan (1993) points to “poorness of fit” between child and environment, wherein the child’s temperament or expressions of mood are ill-suited to the expec- tations or resources/abilities of the environment to effectively manage, as an early manifestation of an invalidating environment. It would follow that characteristics of the caregiver, as well as of the infant and the environment, play a role in the invalidating dynamic. In terms of individual qualities of the caregiver that would result in such mismatch, Keenan (2000) identified caregiver responsiveness and supportiveness as factors that were negatively correlated with infant cortisol level and negative affect – indicators of dysregulation – exclusive of infant temperament. An investigation of familial emotion socialization among parent-teen dyads by Buckholdt, Parra, and Jobe-Shields (2014) found that self-reported dysregulation in parents was correlated with higher rates of invalidation of their adolescents’ emotional expression, which predicted adolescent emotion dysregulation. This finding suggests that dysregulation may be transmitted from parent to child not just via biological processes but also by way of modeling and transactional processes.

Research focusing on interactions between care- givers and children in early childhood has provided clarification of the processes by which emotion reg- ulation is facilitated or hindered by parental emotion socialization. Krause, Mendelson, and Lynch (2003) examined the effect of invalidation in childhood – as recalled by subjects – on subsequent mental health outcomes in a community sample of individuals between the ages of 18 and 30 years old. Defining invalidation as parental reactions to emotional expressions characterized by minimization, criticism, punishment, or distress, the authors found that such negative emotion socialization was associated with poorer mental health outcomes in adulthood, as reflected by Beck Depression Inventory and Beck Anxiety Inventory scores. However, this result was mediated by the subjects’ emotional inhibition – a style of responding to emotionally-arousing expe- riences with ambivalence, conscious suppression, or situational and/or chronic avoidance. Eisenberg and colleagues (2001, 1996, 1994, as cited by Krause et al., 2003) concluded via multiple studies that punitive, dismissive, or dysregulated caregiver responses to children’s emotional expressions (as reported retrospectively) predicted emotional inhibition and avoidance. Krause et al. theorize that the develop- ment of an inhibited style of emotion regulation serves adaptive function in an environment where more demonstrative and expressive styles evoke aversive responses. It must be noted that this line of research is limited by the fact that it relies primarily on retrospective reports of communication around emotional expression.

Applying a methodology less vulnerable to recall biases, Crowell et al. (2013) looked at patterns of verbal escalation in interactions between mothers and teens (using a primarily female sample) in real-time discussions of conflict areas. Compared to non-self-injuring controls, dyads with self-in- juring teens had greater frequency of utterances coded high-aversiveness (as opposed to low- and

intermediate-aversiveness). These dyads also exhibit- ed patterns in which maternal de-escalation occurred most frequently in response to high-aversiveness communication by teens and with reduction to intermediate-level aversiveness, supporting one hypothesis that dysregulated communication and be- havior is maintained via caregiver reinforcement. In contrast, control dyads exhibited patterns of maternal matching at low- and intermediate-aversiveness levels and most frequent de-escalation to low-aversiveness. Put more simply, mothers in self-injurious dyads did not de-escalate conflict until it was highly aversive, and then de-escalated to a smaller degree than mothers in control dyads, who de-escalated more readily and to a more significant degree. While teens in both conditions exhibited a pattern of de-escalating from high- to intermediate-aversiveness, self-in- juring teens were more likely to escalate low and intermediate-level interactions while control teens matched aversiveness at low and intermediate levels. Additionally, critical (invalidating and/or coercive) maternal statements were associated with higher teen anger and oppositionality across groups, and lower respiratory sinus arrhythmia (RSA), a commonly used marker of psychophysiological dysregulation. Wedig and Nock (2007) examined the relationship between the related construct of parental expressed emotion

– operationalized as parental over-involvement and criticism – and self-injurious thoughts and actions in subjects between the ages of 12 and 17 years old. They found that high parental criticism, but not over-involvement, was correlated with self-injurious behaviors and suicidal ideation, plans, and attempts, but was moderated by self-critical cognitive styles among the teen subjects.

Based on a similar pathway in the development of conduct disorder among impulsive youth, Crowell, Beauchaine, and Linehan (2009) looked at trait impulsivity as a vulnerability factor distinct from emotion dysregulation that transacts with the envi- ronment in early childhood to produce maladaptive coping traits and behavior. According to Crowell and colleagues (2009) a resurgence of risk occurs in mid- to late-adolescence when the established dysregulated coping patterns undermine the individual’s ability to effectively navigate the social environment.

Abuse and invalidation

Many studies have examined the impact of more extreme forms of invalidation: physical, emotional, and sexual abuse. Trull (2001) established that childhood physical or sexual abuse was directly correlated with borderline features and the rela- tionship partially mediated by trait disinhibition and negative affectivity in a sample of 18-year-old male and female college students, while Westphal et al. (2013) found that among an urban primary care sample made up mostly of women, a history of interpersonal trauma (physical/sexual abuse or assault) conferred eight times more risk of also having BPD. Shields and Cicchetti (1998) established that the relationship between various forms of abuse and adolescent behavioral dysregulation is mediated by emotion dysregulation. A similar conclusion was

reached by van Dijke, Ford, van Son, Frank, and van der Hart (2013), who found that underregulation of emotion – characterized by higher frequency and intensity and slower recovery from negative emotions, as well as the use of maladaptive coping skills – par- tially mediated the relationship between childhood trauma by a primary caregiver (emotional, physical, or sexual) and future development of borderline personality disorder in a clinical sample, whereas overregulation did not. However, a more inhibited emotional regulation strategy was implicated in the relationship between trauma and borderline features in the work of Gaher, Hofman, Simons, and Hunsaker (2013), who established that the positive correlation between exposure to traumatic events and subsequent borderline symptoms was mediated by alexithymia in a college-aged sample. According to Horwitz, Widom, McLaughlin, and White (2001), the relationship between abuse and negative outcomes is mediated by environmental responses to disclosures of abuse, a finding that substantiates the theory that invalidation of emotional responses is a catalyst for subsequent dysfunction.

Childhood sexual abuse (CSA) and its role in the acquisition of borderline pathology and emotion dysregulation have received special attention. CSA differentiated between individuals with BPD and those with depression in Horesh, Sever, and Apter’s (2003) sample of adolescents and adults. In a prospec- tive study by Yen et al. (2004), the correlation between a history of CSA and suicidal behavior was mediated by emotion dysregulation. Similarly, Brodsky et al. (1997) found that the relationship between CSA and number of future suicide attempts was mediated by impulsivity, corroborating the aforementioned work by Crowell, Beauchaine, and Linehan (2009) that identified impulsivity as another potential pathway between life experiences and negative outcomes.

While these studies suggest that abuse has lasting detrimental effects on the individual’s ability to regulate emotions, Fruzzetti, Shenk, and Hoffman (2005) point out that although victims of abuse are more likely to develop personality pathology, the vast majority of abuse victims do not develop such difficulties. Clearly, more work is needed in order for specific mechanisms governing the relationship between abuse and BPD to be clearly understood.

Sociocultural invalidation

Crowell, Beauchaine, and Linehan (2009) point out that in addition to the strong role of family in the transactions governing the development of emotion regulation capabilities, sociocultural factors exert a strong impact, particularly during adolescence. According to Gross (2013), while adolescence is a developmental period marked by emotional changes, as well as significant changes in social and educational landscape, it is also a time when the desire for au- tonomy may lead to rejection of extrinsic regulation. Silk et al. (2009) established that subjects in mid- to late-stage puberty demonstrated greater emotional reactivity – as measured by pupil dilation, an index of brain activation – during an emotional word identifi- cation task than their pre- to early-stage counterparts.

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Adolescents also exhibited greater stress responses (as indicated by neuroendocrine and cardiovascular responses such as cortisol, blood pressure, and heart rate) than younger subjects when faced with situations simulating performance evaluation and social rejection (Stroud et al., 2009). While these studies were conducted with non-clinical samples rather than multi-problem youth, they highlight the existence of increased emotional and stress reactivity related to the normative neurobiological changes of puberty, distinct from any pre-existing biological vul- nerability, which dovetails with increased risk-taking also seen during this stage (Silk et al.). As a result, invalidation in the peer environment at this time of myriad biological and environmental shifts presents an even greater challenge for adolescents prone to dysregulation and lacking in effective self-regulatory skills. The impact of difficulties in peer and parental relationships on NSSI in a female adolescent clinical sample was studied by Adrian, Zeman, Erdley, Lisa, and Sim (2011). These investigators found that the effect of problematic peer and family relationships on increased NSSI was mediated by emotion dysreg- ulation and that the direct effects of peer and family difficulties on NSSI were only marginally significant. Similar results were observed in a community sample of girls aged 10- to 14-years-old, in which the quality of communication with peers moderated the rela- tionship between peer victimization and NSSI (Hilt, Cha, & Nolen-Hoeksema, 2008). These findings underscore the pivotal role of social invalidation in potentiating existing risk factors of the emotionally dysregulated individual.

Applying the rejection sensitivity model to the BPD population, Berenson, Downey, Rafaeli, Coifman, and Paquin (2011) found that individuals with BPD reported higher levels rejection sensitivity compared to control subjects, meaning that cues associated with rejection, as well as neutral and ambiguous cues, more easily trigger processing biases and maladaptive behavioral responses. The BPD subjects were also more likely to experience rage in response to rejection cues than non-BPD controls. While these studies support the hypothesis that characteristics of the individual transact with aspects of the environment to produce increased emotional and behavioral dys- regulation, and pinpoint rejection as one particularly salient event in the interpersonal domain, it is unclear whether such rejection is perceived as invalidating or simply aversive. A potentially clarifying line of inquiry would be to further assess cognitions of individuals in situations of social rejection about their emotional experiences.

The aforementioned concept of poorness of fit raises the question of what other types of environ- ments may become chronically invalidating to the emotionally vulnerable individual. Mismatches between an individual’s values or sense of identity and those of the prevailing environment could occur around any number of issues. For example, sexual minority status was identified as one of several independent predictors of past-year and lifetime NSSI in a college-aged sample (Wilcox et al., 2012), while harassment on the basis of gender identity or sexual orientation conferred greater risk for NSSI in a nonclinical sample of sexual minority

subjects aged 13 to 22 years old (Walls, Laser, Nickels, & Wisneski, 2010). Interestingly, Walls et al. (2010) found that degree of “outness” about sexuality was positively correlated with NSSI, while having an adult confidant with whom the subject felt safe discussing issues related to sexuality decreased risk for NSSI, which led the investigators to surmise that sexual minority youths who are more “out” experience greater environmental invalidation, thereby putting them at greater risk for self-harm. Additionally, it would seem that having a source of emotional support was protective. Clearly, the emotional experiences of socially marginalized groups have a bearing on the understanding of the different contexts in which chronic invalidation may occur.

Linehan’s Biosocial Theory has gained further support from the past twenty years of research examining the biological and environmental factors that may contribute to emotional dysregulation, suicide, and self-harm. Emotion dysregulation has been identified as one of the primary routes by which early experiences of invalidation yield outcomes such as deliberate self-harm, suicidal behavior, and poor interpersonal functioning. This theory directly informs the treatment. Teaching teens emotion regulation skills acknowledges their biological makeup and subsequent skills deficits in this domain. Teaching teens (and their families) validation skills in DBT honors their reality of experiencing pervasive invalidation in their day-to-day lives.

 Adolescent dialectical behavior therapy

Dialectical Behavior Therapy (DBT) for adolescents is a comprehensive, multi-modal intervention that uses individual psychotherapy, multifamily skills training groups, family therapy, telephone coaching for patients and family members, and therapist consultation meetings to simultaneously address both suicide risk factors and a multitude of other problems (Miller, Rathus, & Linehan, 2007). DBT is comprised of four treatment stages and an additional pretreatment stage, each of which matches the level of severity and complexity of the patient’s problems. Each Stage includes a hierarchy of specific treatment targets (i.e., behaviors to increase or decrease). The responsibility for meeting these behavioral targets is spread among the various treatment modes. The pretreatment stage aims to orient patients and their families to DBT, obtain their commitment to participate in treatment, and establish agreement on treatment goals, including the reduction of suicidal and non-suicidal self-injurious behavior. Patients initiate treatment in this stage, and return to it if their commitment or engagement declines.

Stage 1 of treatment, which has been the focus of treatment studies to date, aims to increase safety and establish behavioral control by addressing four primary behavioral targets that are prioritized in the following order: decreasing life-threatening behaviors; decreasing therapy-interfering behaviors; decreasing quality-of-life interfering behaviors; and increasing behavioral skills. During this treatment stage, the targets are addressed hierarchically and recursively as higher-priority behaviors reappear.

Within Stage 1, life-threatening behaviors refer to suicide-related behaviors, including suicidal ideation, intention, plan and non-suicidal self-injury. These behaviors are addressed before all other treatment targets, based on the rationale that the patient must be alive for therapy to be helpful. Stages 2 thru 4 of treatment are characterized by patient’s being in good behavioral control and increased functioning. Stage 2 aims to increase emotional experiencing of past traumatic experiences. This is the stage that Post Traumatic Stress Disorders (PTSD) would be treated. Stage 3 DBT focuses on achieving individual goals associated with problems of living. Lastly, Stage 4 aims to increase a feeling of completeness, and finding increased freedom and joy in one’s life. A more detailed description of DBT stages of treatment with adolescents can be found elsewhere (Miller, Rathus & Linehan, 2007; Rathus & Miller, in press).

Mehlum and colleagues (in press) recently com- pleted a five-year randomized controlled trial to determine whether a 16-week version of DBT is more effective than enhanced usual care (EUC) to reduce self-harm, suicidal ideation, depression, hopelessness, and symptoms of borderline personality disorder in adolescents. The sample was comprised of 77 teens with recent and repetitive self-harm treated at community clinics in Oslo, Norway. Results of the study found DBT was superior to EUC in reducing self-harm episodes, suicidal ideation, depression, and borderline symptoms. Total number of treatment contacts was found to be a partial mediator of the association between treatment and changes in the severity of suicidal ideation, although no mediation effects were found on the other outcomes or for total treatment time.

 Conclusions and future directions

Despite the increasing body of research and un- derstanding regarding adolescent suicide and non-suicidal self-injurious behaviors, much remains to be learned about the neurobiology, associations between suicidality and NSSI, as well as the invali- dating environments beyond those involving care- givers and peers. In particular, future neurobiology research may establish biological markers that place some individuals at risk for suicide and NSSI behaviors. Psychological research may elucidate how some of the environments outside the home (e.g., school, afterschool programs, social clubs, religious events) may be invalidating and the potential ad- verse pervasive effects on emotionally vulnerable students. DBT with adolescents has begun to be applied to schools (Mazza, Mazza, Murphy, Miller, & Rathus, in press; Rathus & Miller, in press), and research on the efficacy of DBT across settings may help to understand the increased precision of the treatment targets and delivery of its components. Finally, more research will need to evaluate the effectiveness of targeting emotionally vulnerable youth and their invalidating environments as we continue to attempt to understand the frequency and severity of suicidal and non-suicidal self-inju- rious behaviors among youth. ■

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 Author contact

Elizabeth Courtney-Seidler, Ph.D.

Cognitive & Behavioral Consultants, LLP (Westchester and Manhattan) 1 North Broadway, Suite 704 White Plains, NY 10601 Email: ecourtney-seidler@cognitivebehavioralconsul- tants.com

Karen Burns, Psy.D.

Cognitive & Behavioral Consultants, LLP (Westchester and Manhattan) 1 North Broadway, Suite 704 White Plains, NY 10601 Email: [email protected]

Irene Zilber, Ed.M., M.S.

Cognitive & Behavioral Consultants, LLP (Westchester and Manhattan) 1 North Broadway, Suite 704 White Plains, NY 10601 Email: [email protected]

Alec L. Miller, Psy.D.

Cognitive & Behavioral Consultants, LLP (Westchester and Manhattan) 1 North Broadway, Suite 704 White Plains, NY 10601 Email: [email protected]

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