Timo Purjo's presentation, Vienna 2016

SUICIDE PREVENTION IN ADOLESCENCE: A MEANING-CENTERED APPROACH

The Future of Logotherapy3rd International Viktor Frankl Congress

Vienna, September 22-25, 2016

Timo Purjo, PhD

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TIMO PURJOBiographical Sketch

Degrees earned:Doctor of Philosophy, University of Tampere, Finland

Diplomate in Logotherapy, Viktor Frankl Institute of Logotherapy, Abilene, Tx, USA

Other:Accredited member of the International Association of Logotherapy and

Existential AnalysisChairman of Viktor Frankl Institute Finland

1996-2015: Vice-Chairman and Director (R&D) of Non Fighting Generation (NGO), Finland

Correspondence and contactPostal address: Timo Purjo, Heinätie 8, 12700 Loppi, Finland.

E-Mail address: [email protected] (mobile, both daytime and evening): +358-400-607792. 9/24/2016

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OUTLINE1. Introduction2. Objectives and goals3. Methods4. Research project: Findings & conclusions5. Development project: Outputs6. Development project: Results7. References8. Comments and questions

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1. INTRODUCTION• Focus of the presentation• the phenomenon of human suffering and the ultimate

outcome of it, suicide, and how it can be prevented among adolescents by a meaning-centered approach

• Presentation based on• research and practical experiences in Finnish youth

education organization Non Fighting Generation • Non-governmental organization specialized in helping violently

acting (against others and/or self) young persons; 1996-

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1. INTRODUCTION 3-years research project (2011-2013) on the subject of

suicidal and self-destructive behaviors of young people (adolescence acting violently against themselves), in co-operation with National Institute for Health and Welfare (THL)

Subsequently 3-years development project (2013-2015) - also with THL - in which all in the previous project gathered theoretical knowledge was put into practice

The purpose was specifically on providing for health professionals new methods that give them greater visibility of the risks of suicidality than with currently dominant methods, and enable them to make interventions with the intention to prevent self-destructive behavior as early as possible

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1. INTRODUCTION• Target group: 13-25-years old adolescents and young

adults who suffer from experiences of lovelessness, meaninglessness, and despair, and who also have symptoms of some kind of self-destructive or suicidal tendencies

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2. OBJECTIVES Research project

To discuss the phenomenon, i.e. the self-destructive and suicidal behaviors of young persons

To introduce some of the basic principles and viewpoints of our existential and meaning-centered approach in preventing young person’s suicides

To examine research on risk factors as well as protective factors for suicidal behavior in adolescence

To analyze critically the currently dominant view of self-destructive behavior and its prevention and treatment

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2. PURPOSE AND GOALS Development project

Create methods that help professionals1. to anticipate and prevent youth suicides and all kinds of self-

destructive behavior as early as possible (at least before a first suicide attempt);

2. to encourage self-destructive adolescents to find, despite their disturbances and difficult life situations, some valuable point of references to themselves, to their lives, and to the world around them;

3. to promote meaningful experience in their lives

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3. METHODS Research project

Integrative literature review Reviewing research literature, discussing it and making conclusions Key literature: 32 articles, 5 books

Development project Development

Developing existential and meaning-centered methods for youth suicide and self-destructive behavior

a) risk assessment, b) short-term intervention, and c) longer-term individual counseling and support based on a Logotherapeutic

approach for the use of health workers and psychiatric nurses working in schools and public health centers

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3. METHODS …Development project

Training pilots 23 sessions

Piloting• 58 professionals from 9 organizations in different-sized cities in Southern (Helsinki /

metropole region), Middle and Eastern Finland• Adolescents participated during developing and as target persons• Separate methods piloted 863 different times with 621 adolescents

Reporting Theory book Method manual (open access)

Spreading 6 presentation and training seminars 105 professionals Information through piloting organizations and by email up to Northern Finland

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4. RESEARCH PROJECT: FINDINGS & CONCLUSIONS

• See www.slideshare.net/TimoPurjo: Self-Destructive Behavior and Suicide Prevention in Adolescence, Presentation at 19th World Congress on Logotherapy, June 19-23, 2013, Dallas, Texas, USA

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4. FindingsSuicidal and self-destructive behaviors

• Occasional thoughts of death or suicidal ideation are common and normal. In adolescence, the suicidal thoughts are often related to current difficulties. Milder, transient suicidal ideation without suicidal plans does not usually involve a conscious desire to die; however, behind these thoughts there may be an unvoiced wish that a difficult situation or state of affairs would get better. Instead, recurrent or persistent suicidal thoughts or plans have more a serious character — especially if the ideas are related to a suicide plan or a strong desire to die.

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• Worldwide life-scale prevalence of suicidal ideation is about 9%, and suicide attempts about 2.7%. Age is negatively associated with suicidal behavior; that is, young people and young adults are strongly represented in suicidal behavior. Evans et al. (2011) investigation indicates that up to 30% of young people have thought of committing suicide and about 10% have attempted suicide. • Some studies suggest that up to 17% of the people harm

themselves during the life course (Whitlock et al., 2006). Furthermore, non-suicidal self-injury increases the risk of suicide (Hooley, 2008.) Non-suicidal self-harm is particularly common among young people. In Western countries, 5-9% of young people harm themselves each every year (Skegg, 2005).

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• In one Finnish study (Laukkanen et al., 2008), up to 11.5% of young people aged 13-18 had harmed themselves. In particular, young women appear to be at risk in this respect: Female’s self-harm figures are up to eight times higher than those of males, however, in adulthood, the gap narrows considerably between the genders (see Hooley, 2008).

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4. FindingsResearch on risk and protective factors for suicide and suicidal behavior in adolescence• Research on risk factors for adolescent suicide provides

the basis for suicide prevention. The vast majority of research on suicide risk and traditional suicide risk profiles has focused on negative factors that predict suicide attempt risk and increase the chances of an individual engaging in deliberate self-harm.• Current research with adolescence has found that (1)

previous suicide attempt, (2) presence of a mental disorder (especially mood disorders), and (3) presence of substance/alcohol misuse constitute the most prominent risk factors for completed suicide.

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4. FindingsResearch on risk and protective factors for suicide and suicidal behavior in adolescence• Recent research evidence in China, based on psychological

autopsy studies of suicide decedents, have indicated substantially lower rates of mental disorders in Chinese suicide victims compared with those in respective Western studies (Phillips, 2010; see also Pelkonen et al., 2011). • As Pelkonen, Karlsson and Marttunen (2011) have pointed

out, this may have important implications for both the theoretical modeling of suicidal behavior and the development of suicide prevention strategies — especially given the fact that China accounts for as much as 1/3 of global suicides.

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4. FindingsCritique of current theoretical model of suicide prevention• Marsha M. Linehan (2008) has stated, ‘the central theory of

suicide and suicide prevention that has shaped suicide prevention research to date contends that suicide is a symptom of a mental disease and prevention of suicide requires treatment of the underlying disease’.• Yet, none of numerous published randomized clinical trials, which

have investigated interventions for depression, substance abuse, or schizophrenia – disorders commonly associated with suicidal behaviors – have not shown that reducing the symptoms of mental disorders would also reduce the incidence of suicide attempts or suicide. Moreover, treatments targeting suicidal behavior alone have been much more effective than those targeting presumed underlying mental disorders.

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4. FindingsCritique of current theoretical model of suicide prevention• Utilizing a complementary approach, suicidal ideation, suicide

attempts, and completed suicides are not reduced to the symptoms of mental health problems (e.g., depression). Instead, Linehan (2008) contends that suicidal behaviors should be conceptualized as ‘dysfunctional and disordered individual and social behavior’. • From this point of view, self-destructive and suicidal behaviors

could be conceptualized as inability to cope with life demands as a result of lack of sufficient individual and social resources. This different approach to suicide risk assessment, which has been studied during the last three decades, has been conceived mainly as a result of the development of the Reasons for Living Inventory (RFL; see e.g., Linehan et al., 1983).

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4. FindingsCritique of current theoretical model of suicide prevention

• While most studies have focus primarily on negative risk factors, RFL has been developed to investigate the factors that protect and prevent individuals from committing suicide, and inspire them to live in the face of hardship and adversity. Linehan and colleagues (1983; 2007; 2008) emphasize that suicidal compared to non-suicidal individuals lack positive beliefs and expectances in life and have fewer concerns regarding the consequences of suicide for their social environment. • Linehan and colleagues have identified six reasons for living. Individuals

who possess these reasons for living (e.g., “I believe I can find other solution to my problem” and “I have courage to face life”) reflected in the inventory are hypothesized to be less likely to attempt suicide than those who do not. This hypothesis could play an important role in understanding suicide risk.

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4. FindingsCritique of current theoretical model of suicide prevention• Having more reasons for living differentiates between those who do

not have a history of suicide attempt and those who do — despite comparable severity of mental health problems and recent adverse life events.• Emphasis on reasons for living is also consistent with an existential

and meaning-centered approach to understanding suicide in which the emphasis is placed on human strengths and well-being rather than on emotional vulnerability and symptoms of mental health problems. From an existential and meaning-centered perspective, it is particularly important to investigate these positive factors — the strengths and resiliency — that help to protect and prevent person from suicidal behavior in spite of mental health problems or stressful circumstances that can lead to despair.

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• What is ‘suffering’, after all? • From an existential point of view, different kind of mental

health problems, substance misuse or abuse, extremely stressful life events, or self-destructive behaviors, can all be understood as the manifestations of the larger human phenomena — frustration in the search for meaning (‘existential frustration’), feeling of inner emptiness (‘existential vacuum’), and meaninglessness. Suffering without meaning leads to despair, as Frankl has stated, and despair caused by these kinds of devastating destinies or functional disturbances, may lead to such a crisis where a young person can’t find a way out but by suicide.

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4. FindingsAn existential and meaning-centered approach to young person’s suicidality

• Viktor Frankl’s book, Man's Search for Meaning, ends with a Chapter on Tragic Optimism. By the use of this term Frankl expresses the view that everything can be taken away from a human being, except the last area of freedom — the freedom to choose one's attitude towards unavoidable circumstances. Thus, our existential and meaning-centered approach does not concentrate so much on the background of the suicidal behavior (e.g., above-mentions risk factors) but instead to an individual’s distinctive possibilities as a person.• What does this mean from a practical point of view in

treating a young person who has some suicidal tendencies? © Timo Purjo


• One of the central issues in working with suicidal adolescents is their self-centered focusing on deficits, disturbances, and problems in their life and in themselves, which diminishes any positive aspects and hinders their ability to create some distance between themselves and their problems. • However, even a high risk person is always more than their disturbances,

problems, incapacities, or self-destructive behavior. That is one of the reasons why suicidal adolescents should not be approached through their deficits or derangement. Furthermore, when a young persons gets caught in this kind of a vicious circle of rumination and identifying themselves with these negative attributions and adverse symptoms, it can make their situation even worse (Morrison & O’Connor, 2008; Miranda et al., 2013). • Frankl calls this state hyper-reflection.

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• Hyper-reflection can be counteracted with de-reflection, which helps one to redirect their attention from problems to unique meaning potentials life offers from moment to moment. This technique is based on the self-transcendence, the human capacity to become directed to something, or someone, other than itself — be it a meaning to fulfill or another human being to encounter lovingly. Furthermore, although some people have the intuitive capacity to resort to their inner resources and power of will challenging life circumstances; in preventing youth suicides, it is extremely important to help adolescents to become aware of and develop their defiant power of the human spirit, so they can overcome their biological, psychological, or sociological limitations, and resist their disfavorable abilities, circumstances and experiences—to the extent that they can permanently avoid getting assailed by such destructive forces.

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• An aid and support should not either stop at the point when the acute crisis has passed; on the contrary, there is so much more that can be accomplished. Crisis is always both a threat (to freedom) and a possibility (for growth). Once the threat has passed, one can begin to take advantage of all the opportunities the crisis has provided. In logotherapeutic healing the target is not only to restore one’s pre-crisis operational capacity, but to find ways to enjoy a more meaningful and purposeful life for the future (Long, 1997). Thus, the fundamental purpose of intervention is help those in distress become people who are able to intuitively activate their defiant power of the human spirit in the face of crisis and maintain the sense of meaning and purpose in spite of adverse circumstances

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Stage 7 “Transcending the Trauma” Stage 1 Current Level of Stage 6 Functioning Return to Previous Stage 2 Baseline Level of Level of Functioning Onset of Crisis Functioning

------------------------------------------------------------------------------------------------------------------------- Stage 3 Rapid Descent Stage 5 into Despair Progressive Improvement during Clinical Intervention Stage 4 “Bottoming Out”

Long, Jerry L. Jr. (1997) LogotherapeuticTranscendental Crisis Intervention,The International Forum for Logotherapy,20 (2), 104-112.

4. Conclusions• Existential issues, like meaninglessness, are a central part of

suicidality. Anton Nindl (2004) has stated: the ‘question of meaning is the one we have to confront again and again while working with suicidal people’. Meaning-centered approach, which emphasizes the spiritual side of human being and the significance of meaning in life, brings a fresh perspective to mental health treatment and etiological examinations. • When adolescents indicate that they find that suicide is the only

possible route out of suffering, focus should be on keeping them alive by providing hope and meaningful reasons for living. However, this should not be based on false promises or empty hopes but on a dialogue which reveals to a young person that there is some meaningfulness in world, positive reasons for living, and something valuable in oneself.

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4. Conclusions

• In suicide prevention, it is a question of the spiritual empowerment of a young person, which is guided to finding life as meaningful through the defiant power of the human spirit and acts of self-transcendence. • Concentrating on the healthy aspects of an individual and the

possibilities that are still available, regardless of adversities and handicaps that constrain a person’s life, makes it also comforting:

There is no situation without any hope, and there is no one who could not reach for the possibility of a

meaningful life

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5. OUTPUTS: DEVELOPMENT PROJECT

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• Handbook: Hannila, P., Hoisko, S. & Juurinen, H. ”Tutkimusmatka Tarkoitusten merellä: Tarkoituskeskeinen menetelmä nuorten itsemurhien ehkäisemiseksi” (Exploration on the Sea of Meanings: Meaning-Centered Method for Adolescent Suicide Prevention) *)

1. What is meant by self-destruction2. Why an adolescent wants to die?3. Meaning-centered approach4. Exploration on the Sea of meanings5. Appendices & forms

*) © 2015 Authors and Non Fighting Generation ry

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305. OUTPUTS

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3. Meaning-centered approacha) Encountering as a holistic personb) Values as signposts for meaningful lifec) Dialogical principles of the meaning-centered method : 3-

step model Commonality in every encounter• Step 1. Concerns and reasons for dying• Step 2. Will to live: strengths, resources and reasons for

living• Step 3. Engagement with life: towards meaningful

deeds, experiences and attitudes

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315. OUTPUTS

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4. Exploration on the Sea of meanings Methods that complement established approaches Instructions and exercises for implementing the meaning-

centered approach for professionals without logotheoretic background

Forms to be used during exercises Developed together with professionals in healthcare, youth

work and education Psychologists, psychiatric nurses, psychotherapists School social workers, school health nurses Teachers, study advisors Outreach youth workers, youth workshop workers

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5. OUTPUTS

Exploration on the Sea of meanings

Α. Life inventoryValue anchor

Lighthouse of hopeReef of disappointments

Ω. Harbour of trust

Pictures © 2015 Haaja & Arwo Design Oy

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5. LIFE INVENTORYReview of self-destructiveness

Analysis of hopelessness, cf. existential analysis

Opening up / feelings and emotions Treasure island of emotions

Opening up / thoughts Ask about self-destructive

thoughts Lines of life

Value of life -scaleAt the end Life-protecting thoughts

Reasons for living

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5. VALUE ANCHORAnalysis of the valuable things in life and the life-values of the adolescent

Values as anchor protecting in hardship and as map or compass to

meaningful life

Diverse valuation system cf. doubtful and desperate adolescents (E. Lukas)

Ask about life-values

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5. VALUE ANCHOR EXERCISE 1. Valuable elements of life

EXERCISE 2. Valuable things in life Value-map

EXERCISE 3. Spiritual compass

EXERCISE 4. Beautiful views on the route

(cf. Meanings of the moment)

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5. LIGHTHOUSE OF HOPE Ask about hope

EXERCISE 1. Visualization of hopeEXERCISE 2. Memory of hopefulness

EXERCISE 3. Hope rising from experience of survival

EXERCISE 4. Horizon of hope

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5. REEF OF DISAPPOINTMENTS Ask about disappointments

EXERCISE 1. Exploration on the island of emotions

Treasure island of emotionsEXERCISE 2. Becoming your own best

friendEXERCISE 3. As well on good as on

bad days Comic strips (Bad day, Good day, From a bad day into a good one)EXERCISE 4. List of meaningful

alternatives

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5. HARBOUR OF TRUST Ask about dreams

EXERCISE 1. SouvenirsEXERCISE 2. Logbook of good

momentsEXERCISE 3. Stream of dreams

EXERCISE 4. Meaningful narratives Fourfold table (Experienced

difficulties and hardship – Missed good in life – Experienced and

received good, beautiful and valuable – Good, beautiful and valuable that I

want to experience and fulfil)

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5. TREASURE ISLAND OF EMOTIONS

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• Cf. James C. Crumbaugh & Leonard T. Maholick (1964) Purpose in Life Test (PIL) • Helps to specify reasons, why the adolescent wants to die or harm himself• 12 lines with statements at both ends. Left extreme of each

line indicates possible self-destructiveness, and right extreme indicates experience of life’s meaningfulness. The adolescent puts a cross (x) on the line in a place that best reflects his experiences.• Not an actual measure (no scale), but basis for open

dialogue on concerns of the adolescent and interpretations he gives for his own situation and experiences

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5. LINES OF LIFE

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1. Vapaa-aikani tuntuu…

tyhjältä, ilottomalta hyvältä, antoisaltaja epätoivoiselta ja innostavalta

2. Sosiaalisissa tilanteissa…

minusta tuntuu usein, koen, että minustaettä en ole tervetullut pidetään ja kuulunmuiden seuraan osaksi porukkaa

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5. LINES OF LIFE

X

X

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1. My leisure time feels…empty, joyless and desperate

good, rewarding and inspiring 2. In social situations…

I feel often that I’m not welcome to the company of othersIt seems that I am liked and I am a part of the group

3. It seems that I am to my relatives…only a burden; they would be better off without me

a source of joy and strength; a vital part of their lives4. For other people…

I am totally uselessI am very important

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5. LINES OF LIFE

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5. As a girl / boy (woman / man) I feel that I am…in some way totally wrong

okay just the way I am6. When I face problems or adversity…

I feel that everything is falling on me and there is nothing to be done I can trust that I’ll survive and that I get help when needed

7. When I feel bad…I begin to dwell on and worry about everything, what is wrong in my life

I try to concentrate on meaningful things and doings8. When I am in an intense emotional state…

I am often doing on the whim things that I regret laterI keep my head and consider carefully what I’ll do or emit

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5. LINES OF LIFE

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9. I have the feeling that…I have no influence on my life

I am able to influence my life10.It seems that my life is…

compulsive performing against my own will full of possibilities from which I can choose according to my own

valuations11.If I could choose…

I would not have wanted to be born I would not change a single day from my life

12.My future looks…dark and hopeless

bright and hopeful

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5. LINES OF LIFE

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5. REASONS FOR LIVING• Cf. Marsha M. Linehan et al. (1983) & Augustine Osman et

al. (1996) The Reasons for Living Inventory (RFL) • Questions 1-10: personal reasons for living; values and

valuations, meanings and purposes• Questions 11-26: life situation, e.g. family relationships

and friendships that provide grounds for living; responsibility / responsibleness• Questions 27-36: “lived experience”, e.g. survival beliefs

that support staying alive; hope of future

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466. RESULTS: DEVELOPMENT PROJECT

• Most used tool in individual work (N=173) Lines of life -exercise• Answers of adolescents (crosses on lines) scored afterwards

by dividing the lines in 7 sectors• Total score thus max. 84 (12x7), grouped in 6 categories• Among self-destructively acting adolescents (according to

perception of a piloting professional, N=45, 28%), scores centred around lower categories and among those without self-destructiveness scores were situated in upper categories• Cronbach's alpha 0,9175: Internal consistency (reliability) of

Lines of life -exercise is excellent9/24/2016

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• Of single statements highest correlations with total score: 10. (0,86), 4. (0,83), 12. (0,82) and 3. (0,81) • Highest correlation with self-destruction: statement 10. • However qualitative value of some questions much higher

than statistical significance, e.g. 2. and 5. important for gathering of information

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• Well-being of the adolescents was evaluated before and after working with the method • 2-9 meetings• N=15• 5 of them signalized self-destructiveness

• WHO-5 (5-item World Health Organization Well-being Index): In the case of four, changes were positive, with one no changes (unchanged)

• Qualitative contribution of the method for the pilots and adolescents much greater than can be measured by statistical analyses

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7. REFERENCES•www.slideshare.net/TimoPurjo

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8. COMMENTS AND QUESTIONS• You may also contact me later-on…

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Healthcare

Timo Purjo's presentation, Vienna 2016