Assignment 3 Template Corrections Case StudyNote Please downlo.docx

Assignment 3 Template: Corrections Case Study
Note: Please download this template, write the answers to the
following questions directly within the template, then submit
the completed template through the Week 10 Assignment 3
submission link in your Blackboard course shell.Please use the
naming convention “Assignment3_FirstName_LastName” to
name this file.
1. Describe the main methods Correctional Officers' staff use to
maintain order and safety in the prison. Take a position on the
effectiveness, risks, pros and cons, and ethics of these methods.
2. Choose one (1) of the inmates profiled in this video and
discuss their situation. Explain how they ended up in prison, the
main issues they described facing, and the methods they use to
cope with their time in prison.
3. Discuss the effect you feel the presence of the active armed
guards has on the violence level and overall safety within this

prison.
4. Describe the issue of isolation presented in this video and the
effects connections and contact with outside visitors can have
on the prisoners' mental status.
5. Identify at least two (2) issues inmates in gangs here
uniquely face. Identify at least one (1) method of protecting
inmate gangs against each of these identified issues.
6. Take a position on how you believe conditions at San Quentin
could be improved. Include at least two (2) specific actions that
could be taken to improve conditions (e.g., security and safety,
abuse and use of force, isolation, poor food quality, etc.).
Provide a rationale for your position.
© 2020 Strayer University. All Rights Reserved. This document
contains Strayer University Confidential and Proprietary
information and may not be copied, further distributed, or
otherwise disclosed in whole or in part, without the expressed
written permission of Strayer University.
CRJ 100 Template for Assignment (03/02/2020) Page 2 of 2

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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News & Analysis
jama.com (Reprinted) JAMA August 28, 2018 Volume 320,
Number 8 749
© 2018 American Medical Association. All rights reserved.
Downloaded From: https://jamanetwork.com/ by a Arizona State
University User on 06/03/2020
http://journals.plos.org/plosmedicine/article?id=10.1371/journal
.pmed.1002587
http://annals.org/aim/fullarticle/2679355/long-term-
effectiveness-sigmoidoscopy-screening-colorectal-cancer-
incidence-mortality-women
http://annals.org/aim/fullarticle/2679702/why-more-research-
needed-despite-overall-certainty-women-colorectal-cancer
https://www.nejm.org/doi/full/10.1056/NEJMoa1805233
https://jamanetwork.com/journals/jamapsychiatry/fullarticle/268
5324/?utm_campaign=articlePDF%26utm_medium=articlePDFli
nk%26utm_source=articlePDF%26utm_content=jama.2018.1204
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6736(18)30726-8.pdf
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um=articlePDFlink%26utm_source=articlePDF%26utm_content

=jama.2018.10903
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.
Human Sciences Press, Inc. 139

140
CONTEMPORARY FAMILY THERAPY
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.
141
WENDY LUM, JIM SMITH, AND JUDY FERRIS
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,
142

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
143
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
144
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
145
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
146
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,
147
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.

148
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
149
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.
150
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 …
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

T
hi
s
do
cu
m
en
t i
s
co
py
ri
gh
te
d
by

th
e
A
m
er
ic
an
P
sy
ch
ol
og
ic
al
A
ss
oc

ia
tio
n
or
o
ne
o
f i
ts
a
lli
ed
p
ub
lis
he
rs

.
T
hi
s
ar
tic
le
is
in
te
nd
ed
s
ol
el
y

fo
r t
he
p
er
so
na
l u
se
o
f t
he
in
di
vi
du
al

u
se
r a
nd
is
n
ot
to
b
e
di
ss
em
in
at
ed
b

ro
ad
ly
.
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
T
hi
s
do
cu
m

en
t i
s
co
py
ri
gh
te
d
by
th
e
A
m
er
ic
an

P
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A
ss
oc
ia
tio
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or
o
ne
o

f i
ts
a
lli
ed
p
ub
lis
he
rs
.
T
hi
s
ar
tic

le
is
in
te
nd
ed
s
ol
el
y
fo
r t
he
p
er
so
na

l u
se
o
f t
he
in
di
vi
du
al
u
se
r a
nd
is
n
ot

to
b
e
di
ss
em
in
at
ed
b
ro
ad
ly
.
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-
210 G. R. Cox et al.: Suicide Clusters in Young People
Crisis 2012; Vol. 33(4):208–214 © 2012 Hogrefe Publishing
T
hi
s
do

cu
m
en
t i
s
co
py
ri
gh
te
d
by
th
e
A
m
er

ic
an
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sy
ch
ol
og
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al
A
ss
oc
ia
tio
n
or
o

ne
o
f i
ts
a
lli
ed
p
ub
lis
he
rs
.
T
hi
s

ar
tic
le
is
in
te
nd
ed
s
ol
el
y
fo
r t
he
p
er

so
na
l u
se
o
f t
he
in
di
vi
du
al
u
se
r a
nd
is

n
ot
to
b
e
di
ss
em
in
at
ed
b
ro
ad
ly
.

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
G. R. Cox et al.: Suicide Clusters in Young People 211
© 2012 Hogrefe Publishing Crisis 2012; Vol. 33(4):208–214
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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.

212 G. R. Cox et al.: Suicide Clusters in Young …
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
Production Editor................Matthew Hoover
Editorial Director ............Jo-Ann Wasserman
Publisher.......................................Sue Lewis
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Photo: Jill Brody
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)
Crisis, 18 / 3 (1997) © 1997 Hogrefe & Huber Publishers

Columns106
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
Columns
Crisis, 18 / 3 (1997)
107
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.
Crisis, 18 / 3 (1997)
Columns108
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-

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