Managing suicidal behaviour in adolescents

ManageMent

Managing suicidal behaviour in adolescentsRichard Harrington✠

This contribution describes the principles of managing suicidal behaviour in adolescents, the main clinical procedures and the evidence base for their efficacy.

Management principles

Assessment should provide a formulation of the adolescent’s suicidal behaviour in terms of individual, familial and wider social influences: occasionally, adolescents may have just one risk factor for self-harm, such as severe mental illness or an isolated episode of abuse or bullying. In most cases, however, suicidal behaviour is determined by multiple factors that include individual and family characteristics as well as peer, school and wider community influences (Figure 1). It is important, there-fore, that the initial formulation includes all these elements and that from the beginning management is conceptualized as a programme of interventions operating at multiple levels.

Interventions should be focused on the causes of the suicidal behaviour that were identified in the formulation: suicidal behaviour is a symptom, not a disorder or disease. Interventions should therefore be based on the assessor’s formulation of the multiple factors that lead to this behaviour. This will often mean that different interventions are used with different cases. This is in contrast to the treatment models that are often studied in research trials, which usually assume that suicidal behaviour is due to one or two processes, such as poor problem-solving, poor family com-munication or low levels of neurotransmitters in the brain.

Interventions should be action-orientated and focused on the here-and-now: suicidal behaviour in young people can be a serious problem, particularly when it is repeated frequently. This will often mean that an action-orientated approach to changing behaviour quickly is required. Therapists should usu-ally therefore focus first on proximal causes of the adolescent’s suicidal behaviour, such as family conflict, rather than on distal causes, such as a history of abuse.

Richard Harrington FRCPsych MD MPhil was Professor of Child and

Adolescent Psychiatry and Chair of the Department of Child and

Adolescent Psychiatry at the University of Manchester, UK. He qualified

from Birmingham University and trained in child psychiatry at the

Maudsley Hospital and Institute of Psychiatry, London.

✠ Author deceased

PSYCHIatRY 5:8 27

Interventions should seek not only to alleviate psychosocial problems but to develop strengths: young people engage in self-harming behaviours not only because they have risk factors for such behaviours but because they lack strengths that could protect them from these risks. These strengths include being par-ticularly good at something (e.g. games, music), having at least one positive adult role model and good academic attainments. Practitioners should therefore identify strengths within the ado-lescent or his/her family or community and help to develop them.

There should be ongoing assessment of the risk of repetition and completed suicide: the risk of self-harm or suicide is not static, but changes over time. Risk assessment should therefore be repeated regularly and reviewed in line with changing circum-stances. The degree of risk and the steps taken to minimize risk should be recorded in the case records.

The intensity of the intervention should be determined by the adolescent’s needs: it is not necessary to provide an intensive intervention for all suicidal adolescents. For many, all that is required is simple advice to the parents or school. Inten-sive interventions should be reserved for those with high levels of psychosocial need or who are at high risk of repetition of self-harm.

Main clinical procedures

Family workSuicidal behaviour in adolescents often occurs in the context of family problems and family work may therefore be needed to reduce the risk of repetition. Two kinds of family work can be undertaken: work focused on the self-harm episode itself (Table 1) and/or work on broader issues such as disciplinary practices.

Family work that is focused on the self-harm episode begins with helping the family to understand what actually happened. It is important that the parents understand exactly how the young person obtained tablets, for example, so that they can better protect their child in the future. Next, the therapist helps the family to adopt better ways of communicating. For example, the therapist may formulate the episode as the final point in a ‘communication spiral’, in which the adolescent and family tried to communicate in other ways but were unsuccessful. In other words, self-harm is viewed as a maladaptive way of trying to communicate something. Core communication skills may be modelled in the family session. Families may also find it use-ful to have one or two sessions on problem-solving. Finally, it is often helpful for the parents and adolescent to discuss what each of them understands about the day-to-day issues that ado-lescents have to deal with. The idea is to help parents to anti-cipate future difficulties, so that they are better able to deal with them.

Work on broader issues: the second indication for family work is when self-harm is precipitated by over-punitive or other maladaptive forms of parenting. A particularly common pattern is one in which irresponsible behaviour by an antisocial adolescent

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ManageMent

Correlates of suicidal behaviour

Suicidal behaviour

Family characteristics

Low warmth, punitive

Role models of suicidal behaviour

Parental problems (self-harm, substance abuse)

Peer and school characteristics

Deviant peers

Role models of suicidal behaviour

Unsupportive teachers

Individual characteristics

Psychiatric symptoms

Substance abuse

Cognitive distortions

Views suicidal behaviour in a positive way

Relationship problems

Community characteristics

Few taboos about suicidal behaviour

Neighbourhood drug and antisocial problems

Poverty

Figure 1

(e.g. coming home drunk at 3 a.m.) is followed by an inappropriate punishment (e.g. ‘you’re grounded for the next year’), which is in turn followed by self-harm. In such cases the focus of family work is on promoting responsible behaviour and decreasing irrespon-sible behaviour. For example, the therapist might help the parents to spell out contingencies more clearly, and in such a way that they fit the nature of the behaviour (e.g. coming in after curfew would require that the adolescent be grounded for the next week-end evening). The adolescent would be praised and rewarded (e.g. with extra spending money) for responsible behaviour; good behaviour should never be taken for granted.

Other work with parentsSuicidal behaviour is sometimes associated with other types of parental problems. These include mental health problems such as depression or substance abuse, and family difficulties like divorce. These problems need to be identified and interventions

PSYCHIatRY 5:8 27

designed accordingly. It is particularly important to establish whether parents are also engaging in self-harming behaviours; if so, they need to be encouraged to stop.

In a small proportion of cases, self-harm is a symptom of seri-ous parenting problems, abuse or neglect. In such instances a for-mal assessment by a social worker may be necessary. Persistent self-harm that is caused by unremittingly neglectful or abusive parenting may require that the young person is taken into care.

Individually orientated interventionsIndividually orientated interventions are useful when individual characteristics have contributed directly to self-harm. The two most common characteristics are poor problem-solving abilities and impulsivity.

Problem-solving: programmes for adolescents are similar to those employed with adults.

Core family interventions

Procedure Intervention

assessment assess the role of family factors in self-harm, family motivation, family problems, family coping strategies

Understanding the episode

and establishing the facts

Helping the family to understand what happened (e.g. the therapist asks each family member in turn to

describe what they were doing on the day, or gives the family the task of completing a drawing of where

they were before, during and after the episode of self-harm)

Improving communications Formulating self-harm for the family as a desperate form of communication. encouraging open

communication within the family

Problem-solving Helping the family to solve problems more effectively (e.g. the therapist initiates a discussion about a

specific problem then encourages the family to adopt a systemic approach to problem-solving (what the

initial response to hearing about a problem should be, getting agreement about precisely what the problem

is, generating several solutions, assessing the results))

Understanding normal

adolescence

Helping the family to understand the adolescent’s perspective and challenges (e.g. the therapist asks the

parent(s) and adolescent to list features of normal adolescence. there is then a discussion of some of the key

features (such as rebellion, increased narcissism, peer groups, increased sex drive, unpredictable attitudes))

Source: Kerfoot et al., 1995.

Table 1


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• The adolescent is first encouraged to identify a solvable problem and then to generate as many potential solutions to it as possible. • The best solution is chosen, the steps to carry it out are identi-fied and the adolescent tries it out. • Finally, the whole process is evaluated.

Impulsivity: several cognitive procedures can be used with impulsive adolescents. The general aim is to provide them with more self-control. At the core of most programmes are ‘stop-think-do’ approaches. • The adolescent is first taught to stop. • Then he or she must learn to think out loud while performing various tasks in a therapy session. The intention is that the ado-lescent learns to control behaviour by verbalization of thoughts, which can be monitored and corrected by the therapist. • Finally, the adolescent learns techniques to recognize problems and to apply strategies to deal with them, using techniques such as self-instruction. For example, while executing a plan for a suicidal attempt the adolescent is taught to pose questions to himself such as: ‘Stop: what am I trying to do?’

Treatment of mental disordersThe most common emotional and behavioural disorders that occur in conjunction with self-harm in adolescents are depression, substance abuse and conduct disorder (treatment of adolescent

PSYCHIatRY 5:8 27

depression is described in Harrington, 2002). In adolescents who self-harm, depression can resolve very quickly, so it is best not to offer treatment for depression unless it persists for several weeks. The first-line treatment is usually a psychological intervention such as cognitive–behavioural therapy or interper-sonal psychotherapy. Medication (usually a selective serotonin reuptake inhibitor (SSRI) such as fluoxetine) is indicated when depression is severe and/or has failed to respond to other inter-ventions. Substance abuse is often best managed by referral to a local drugs programme. Conduct disorder is often difficult to treat in adolescents, but may respond to an intensive combination of work with parents, social support and educational measures.

Intervening with the peer groupPeer interactions form an important context both in predisposing to problems in adolescents and in developing social competence. If the assessment shows that associations with deviant peers contribute to the adolescent’s problems (e.g. by providing role models of self-harm or other risk-taking behaviours, or by in-creasing substance abuse), interventions aimed at reducing the contact with deviant peers and increasing his or her association with prosocial peers may be necessary. The parents are usually the key to this. They need to be helped to: • monitor the adolescent’s whereabouts more carefully • know about their adolescent’s peers

Risk-management strategy in a 16-year-old who repeatedly self-harms

INDIVIDUAL

Risks Strengths Needs

Mild depression; sexually active and not using contraceptives reliably;

substance abuse

Attractive; average IQ; wants to be beautician; interested in drama

Monitor depression; refer GP for contraceptive advice;

refer local drug group

FAMILY


Mother depressed and has limited range of disciplining strategies;

self-harm often follows disciplinary crisis at home

Siblings have no problems; mother can be warm to Susan

Parenting advice to mother; refer mother for counselling

for depression

PEER AND SCHOOL


Some peers are known drug users; Susan easily influenced by role models of self-harm when in a

children’s home

Regularly attends school; school has good career advice for girls

Work with mother to reduce contact with deviant peers; discuss next

out-of-home placement with social services; refer school career service

COMMUNITY


Self-harm very prevalent; drugs easily available

Active community drug programmes; active youth drama group with clear ‘no drugs’ policy

Encourage attendance at drama group

Name Susan Therapist Date

Figure 2


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• help the adolescent to see the problems of being with deviant peers

• promote associations with prosocial peers.Occasionally, however, interventions with groups of adolescents who self-harm may be helpful, particularly those who repeatedly self-harm.

Risk-management strategyFinally, the interventions need to be combined into a coherent risk-management strategy (see Figure 2). The results of this strat-egy should be revisited regularly.

The evidence base for treatment

There has been relatively little research on the effectiveness of interventions for adolescents who have deliberately harmed themselves. There is, however, evidence that family interventions

PSYCHIatRY 5:8 278

may help to reduce suicidal thinking in non-depressed adoles-cents who have deliberately poisoned themselves. Pilot data suggest that the risk of repetition of self-harm may be reduced by cognitive–behavioural interventions. Studies in adults also suggest that active cognitive or behavioural procedures such as problem-solving may be effective. ◆

FuRTheR ReadIng

Harrington R. Depression and suicidal behaviour. PSYCHIATRY 2002;

1(8): 111–14.

Kerfoot M, Harrington R C, Dyer e. Brief home-based intervention with

young suicide attempters and their families. J Adolesc 1995;

18: 557–68.

nHS Centre for Reviews and Dissemination. Deliberate self-harm.

Eff Health Care 1998; 4: 1–2.

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Managing suicidal behaviour in adolescents