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Teen Suicide: Practical Interventions for Adolescents in Crisis
10 CEUs Teen Suicide: Practical Interventions for Adolescents in Crisis

Section 21
4 Stage Model for Assessing Adolescent Suicide Risk

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Process Model
Given the high rate of adolescent suicide, the presence of these behavioral indicators warrants a more formal assessment of suicidal risk. Stoelb and Chiriboga (1998) suggest a four-stage process model for assessing adolescent risk for suicide. The model is based upon the common factors found in the research literature to be associated with suicidal behaviors in adolescents. The factors are divided into three categories: primary risk factors, secondary risk factors, and situational risk factors.

Stage One assesses the primary risk factors, which includes the presence of affective disorders, previous attempts, and hopelessness. The presence of an effective disorder is assessed by a comparison of the results from a clinical interview, observation, and third-party reports to the diagnostic criteria for depression in the DSM-IV (1994). The question of previous suicide attempts is best assessed by direct questioning of the adolescent. Hopelessness may be inferred from statements made by the adolescent or by the administration of a psychological test like the Beck Hopelessness Scale (Beck, Weissman, & Trexler, 1974). All three factors have been shown to increase the risk of suicidal behavior. The presence of any one of them (or even in their absence if the counselor intuitively senses a need for further assessment) suggests that the adolescent maybe at "severe risk" (Stoelb & Chiriboga, 1998, p.363). If none of the factors are present and the counselor does not sense any suicide risk, the adolescent can be considered "low risk" (p 363); however assessment continues with the next stage.

Stage Two is the assessment of ideation, intent, and plan (Stoelb & Chiriboga, 1998). Suicidal ideation refers to the thoughts and ideas regarding harming oneself. This is assessed by direct questioning (e.g., "Have you ever thought about or are you currently thinking about hurting yourself?"). A yes response to this question calls for further assessment regarding the frequency, duration, and intensity of the thoughts. The development of intent and plan is even more indicative of increased risk. This is also assessed by direct questioning (e.g., "Do you believe that you will kill yourself?" or "If you plan to kill yourself, how do you plan to go about doing it?"). Suicide risk increases with the specificity of the plan and the availability of the means (Bonner, 1990). This stage of the model requires the greatest reliance on clinical judgment, and it is more acceptable to make a false-positive judgment than a false-negative judgment error (Stoelb & Chiriboga, 1998). If there is evidence of suicidal ideation, intent, or plan, the estimate of severe risk from the first stage becomes the working model. It may be modified to "moderate risk" (p. 366) if it is not supported by presence of ideation, intent, or plan. A hypothesis of severe risk that resulted from clinical intuition and is not supported by ideation, intent, or plan may be modified to "low risk" (Stoelb & Chiriboga, 1998, p. 366).

Stage Three involves the assessment of secondary risk factors, particularly the presence of substance abuse and personality disorders (Stoelb & Chiriboga, 1998). These factors contribute to the presence of impulsivity and increase the risk of suicidal behaviors. If these factors are absent, the working model is unaltered. If either is present, the counselor may upgrade the level or risk and/or note the presence of impulsivity.

Stage Four consists of an assessment of situational factors such as family functioning and history, social relationships and support systems, exposure to suicide, life stressors, and homosexuality (Stoelb & Chiriboga, 1998). The presence of any one of these factors is indicated by adding the specifier "with situational factors" (Stoelb & Chiriboga, 1998, p. 367)

The process model by Stoelb and Chiriboga (1998) provides the counselor with a framework with which to begin the process of assessing an adolescent's risk for suicide. A strength of the model is its multifaceted nature. It was designed to decrease the likelihood of bias or errors in judgment. Further research using the model is warranted to establish its reliability and validity.

The model is useful also because it not only assesses risk but also the degree of risk. While any degree of risk warrants treatment, the more severe the risk, the more aggressive the treatment must be. Treatment may range from hospitalization for those with suicidal intent and plan to intensive outpatient individual, group, and/or family therapy for those with risk factors but without intent or plan.

Reasons for Living
An essential component that the process model proposed by Stoelb and Chiriboga (1998) fails to address is reasons for living. Reasons for living are an important cognitive factor in adolescent suicidal behavior and should be incorporated into screening, assessment and treatment procedures (Pinto, Whisman, & Conwell, 1998). Positive expectations about the future and beliefs in one's self-efficacy in coping with whatever life has to offer appear to most strongly differentiate between suicidal and nonsuicidal adolescents (Pinto et al., 1998). Beliefs in one's ability to cope with life's stresses are necessary and important in retaining the desire to live (Pinto et al., 1998). Risk factors for adolescent suicide include: few beliefs in ability to cope, lack of optimism, lower value on life, lower sense of responsibility to family, and fewer moral objections to suicide (Pinto et al., 1998). The Reasons for Living Inventory for Adolescents (RFL-A) has been shown to be a reliable and valid measure potentially useful in the assessment of adolescent suicidal behavior and may provide additional useful information to the process model (Osman et al., 1998).

Recommendations for Assessment of Depression and Suicide Risk
The task of diagnosing depression and assessing the risk of suicidal behaviors in adolescents is challenging for the mental health counselor. Assessment must be multidimensional and done in the context of an understanding of normal adolescent development and gender differences. While no professional wants to prematurely label a young person with a mental disorder, it is essential to make an accurate and early diagnosis that can lead to effective treatment. Assessment must minimally include:
-  A clinical interview with the adolescent client
-  Behavioral observations
-  Collateral information from parents, teachers, friends, and other significant individuals in the adolescent's life
-  Assessment of primary and secondary risk factors, situational factors, quality of family and peer support
-  Assessment of suicidal ideation, plan, and intent, and reasons for living
It may be necessary to supplement interview and observational data with formal psychological testing. Accurate and early diagnosis is essential because between 80% and 90% of depressed youth can be helped with treatment (NIMH, 2000).

Many adolescents are seen for treatment of their depression; however, data suggest that treatment has typically been quite brief. The modal length of treatment was seven or fewer sessions, and those who received treatment were as likely to relapse into depression in adulthood as those who did not (Lewinsohn & Clarke, 1999). While research on effective treatment for mental disorders in adolescents has lagged behind that of adults, recent research findings suggest that specific treatments such as cognitive behavioral treatment may be effective. An effective treatment approach must include psychosocial interventions, shown by research to be effective, as well as a consideration of the appropriate use of medication.

Psychosocial Interventions
Recent research demonstrates that cognitive behavioral treatment, both individual and group, may be effective for depressed adolescents (Lewinsohn & Clarke, 1999; Clarke, Rohde, Lewinsohn, Hops, & Seeley, 1999). An NIMH-supported study on treatment of adolescent depression found a 65% remission rate and a more rapid treatment response using cognitive behavioral treatment as opposed to either supportive or family treatment (Brent et al., 1997).

Lewinsohn and Clarke (1999) described the following common treatment elements found in the adolescent depression treatment literature: (1) cognitive techniques including constructive thinking, positive self-talk, being your own coach, coping skills, self-monitoring, goal setting, and self-reinforcement; (2) family treatment including conflict resolution, communication skills, and parenting skills; (3) behavioral treatment, including problem-solving skills, increasingly pleasant activities, social skills, assertiveness, making friends, and role modeling; and, (4) affective education and management including relaxation techniques and anger management.

One particular form of cognitive behavioral treatment, coping skills, is considered as "probably efficacious" according to American Psychological Association treatment guidelines (HHS 1999). Clarke et al. (1992) developed the coping-skills model from an intervention designed originally for treatment of adults. Results suggest that use of the model results in lower rates of depression, less self-reported depression, and increased activity levels (HHS, 1999). Further investigation is needed to validate these results.

Interpersonal and systemic family therapy show promise as effective treatments however further studies are required (HHS, 1999). A 12-week program of Interpersonal Psychotherapy for Depressed Adolescents (IPT-A) showed decrease in depressive symptoms and greater improvement in overall social functioning, functioning with friends, and specific problem-solving skills (Mufson, Weissman, Moreau, & Garfinkle, 1999).

Preventative and treatment efforts can be aimed at teaching adolescents to attach importance to beliefs about the value of life, developing self-efficacy, and optimism in coping with life's challenges and providing them with opportunities to practice those beliefs (Pinto et al., 1998). Group counseling strategies for adolescents aimed at preventing a host of problematic behaviors and their negative consequences have been developed by Wodarski and Felt (1997). They focus on the development of social, cognitive, and academic skills from a life-span development perspective. A life-skills-training approach (dealing with adolescent development, sexuality education, psychoactive substance use, anger control, coping with depression and suicide, comprehensive employment preparation, and family intervention) is the treatment of choice (Wodarski & Feit, 1997).

The differences in symptom presentation may call for interventions to be gender specific. Because depressed adolescent males tend to engage in more risk-taking and health-compromising behaviors, these issues must be specifically addressed in this population. Intervention strategies must interest the adolescent mate in activities that are less risky than the current choices. These young males must learn alternate paths to manhood and peer acceptance that do not necessitate risk taking and compromising their health (Langhinrichsen-Rohling et al., 1998).

Treatment Recommendations
Treatment should be provided in the least restrictive environment that is safe and effective (Birmaher, Brent, & Benson, 1998). The treatment setting (outpatient, partial hospitalization, day treatment, inpatient, residential) depends on the availability of a safe environment, severity of the illness, motivation of the adolescent and his or her family, and the severity of other psychiatric or medical conditions (Birmaher et al., 1998).

Counseling is an appropriate treatment for all adolescents with depressive disorder. The treatment of choice is cognitive behavioral treatment, focusing specifically on coping skills. Goals of counseling should be to assist the adolescents to understand themselves, identify their feelings, improve their self-esteem, change maladaptive behaviors, employ effective conflict-resolution skills, and interact more effectively with others (Birmaher et al., 1998).

Typically cognitive behavioral treatments are relatively short (1 to 2 months). However it is important that counselors incorporate an explicit maintenance or continuation component into treatment after the acute phase (Lewinsohn & Clarke, 1999). Continuing counseling after the remission of symptoms helps the adolescent and his or her family consolidate the skills learned during treatment and may also promote medication compliance (NIMH, 2000).

Engaging the parents in the treatment process may also be helpful. Enhancing the conflict resolution, parenting, and communication skills of the parents as well as providing support and education about their child's illness and treatment may be useful adjuncts to the adolescent's treatment protocol.

Conclusions

The rate of adolescent depression and suicide in the last decade constitutes a crisis in our society. It is a crisis that must be dealt with by accurate and early diagnosis and treatment of the disorder. The fact that 21% of completed adolescents saw a mental health professional within 3 months of their suicide is troubling. What is more troubling is the corollary of that statistic, 79% of youth that completed suicide did not see a mental health professional. Parents, school counselors, teachers, and other significant adults must be alerted to the signs and symptoms of depression and suicide in adolescents. Community mental health counselors can participate in this through preventative efforts in the community and through collaboration with school counselors.

The accurate and early diagnosis and treatment of depression in adolescents is essential to prevent impairment in academic, social, emotional, and behavioral functioning as well as to prevent suicide and increased risk for depression and suicide as an adult. Diagnosis is complicated by normal adolescent developmental issues, and counselors must be aware of the unique presentation of symptoms and the risk factors associated with adolescent depression and suicide. However, there is no replacement for clinical judgment. Counselors must rely not only on knowledge of normal development and risk factors but also they must be willing to listen to their own instincts. They must be aggressive in their treatment of both depression and suicide-risk if this disturbing trend is to be reversed.

Gender differences must be taken into consideration in both diagnosis and treatment. Counselors must not be too hasty to diagnose disruptive behavior disorders in male adolescents. They must consider the possibility of depression as a diagnosis alone or in combination with the behavior disorder, especially in adolescent males.

The role of medications and psychosocial methods require continued research to demonstrate their efficacy. Research to date suggests that SSRIs and cognitive behavioral treatment are both effective in the treatment of depression in adolescents. The presence of other psychiatric disorders confounds diagnosis and treatment. Further research is indicated to develop and test an all-inclusive model of treatment.
-Stanard, Rebecca Powell, Journal of Mental Health Counseling, Jul2000, Vol. 22, Issue 3
The article above contains foundational information. Articles below contain optional updates.

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Personal Reflection Exercise #7
The preceding section contained information about assessment and treatment of adolescent depression and suicidality.  Write three case study examples regarding how you might use the content of this section in your practice.

Online Continuing Education QUESTION 21
According to Stanard’s article, what may be an effective treatment for depressed adolescents? Record the letter of the correct answer the CEU Answer Booklet.

 
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