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

Section 22
Teen Suicide Intervention:  Healthy Identity Development

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Adolescent suicide remains an international tragedy, yet a common denominator continues to elude researchers. Some adolescents internalize rejection and respond with suicide; other troubled adolescents engage in homicide before ending their own lives. One factor underlying suicide concerns the failure to construct a healthy identity. Using Erikson's theories on identity development as a framework, this paper examines the motives for and contexts of suicide among preadolescents, adolescents, and young adults, identifies specific school-age populations that are vulnerable to suicide, and discusses implications.

Suicide is a complex problem with ideology or beliefs as a common element that interacts idiosyncratically with any number of emergent identities pressing on the individual. One factor underlying suicide concerns the failure to construct a healthy identity. Much of the research on this issue focuses on adolescence, the period of time when individuals are most engaged in developing a healthy identity (Erikson, 1968; Coleman & Remafedi, 1989; Bar-Joseph & Tzuriel, 1990; Newton, 1995). Erikson (1968) noted that in extreme instances of delayed and prolonged adolescence, complaints of "I give up" and "I quit" are more than signs of mild depression--they are expressions of despair. Erikson acknowledged that suicide itself is an identity choice for some adolescents. Furthermore, suicide is increasingly occurring among people who are not adolescents, which may have to do with the inability to master Erikson's stages of development throughout the lifespan, beginning early in life.

Accomplishing developmental tasks in a given cultural context requires a sense of connectedness. As the institution of the family, which is the primary engine for healthy socialization, has weakened in modern society, individuals' risk for disturbances in identity formation mounts. For suicidal individuals, the family and society may have failed to provide the necessary conditions for sound development.

New trends in suicide are emerging for practically all ages and walks of life. Children, adolescents, and young adults appear to share in this "mis-solution," yet for quite different reasons. The purpose of this paper is to examine, within an Eriksonian framework, the different motives for and contexts of suicide among these three groups, to identify specific school-age populations that are vulnerable to suicide, and to discuss implications for school counselors and others. In so doing we will also look at how firearms and gender differences relate to suicide in the United States.

Suicide within an Eriksonian Framework
The reasons for suicide vary, but seem to cluster around disruption of specific developmental tasks, vulnerability of the individual, and risk conditions in the immediate situation of the individual, such as lack of emotional support. From a sociocultural perspective, new norms may emerge (e.g., legalization of assisted suicide). Both the characteristics of the individual and the culture appear to interact in suicide ideation and attempts. This interaction becomes particularly life threatening when identity formation is obstructed in ways that the individual considers impossible to resolve.

Individuals who take their own lives vary in age. What prompts a 16-year-old to commit suicide as opposed to a 60-year-old? We need to recognize the different motives and life situations among children, adolescents, adults, and the elderly. According to Erikson (1963,1968), there are eight stages in the lifespan, each of which poses conflicts or crises that need to be resolved positively and in a prosocial manner. Failure to do so may impact a person's personality development in a negative and cumulative way. Such failure may be understood as an important risk factor in the etiology of suicide and violent behavior.

Erikson was among the first theorists to indicate the importance of social context in understanding individual development. He witnessed the violence that took place during much of the twentieth century, and conflict resolution figured prominently in his work as he sought to establish a nexus between the individual and society. Some extensions of his work and other cultural-context models are presented here, with a focus on suicide. It is hoped that this will provide a means for understanding the socioemotional disturbances influencing life-threatening behavior.

Preadolescents
Research by Greene (1994) dispels many myths surrounding the suicide of children. Greene showed that children under the age of six experience true depression and that they are cognitively and physically able to implement a suicide plan. As Pfeifer (1993,1994) shows, children are not too young to consider death. However, the exact mediating circumstances remain unclear from a theoretical perspective.

According to Erikson, how each developmental task is resolved (e.g., infancy: trust versus mistrust; early childhood: autonomy versus doubt and shame; preschool age: initiative versus guilt; school age: industry versus inferiority) defines to a considerable extent how healthy or unhealthy the person becomes and how well he/she is able to deal with future tasks or crises. The developmental history of the person varies depending on the extent to which trust was established in early attachments, a view that is currently well established (Bowlby, 1988). Failure to establish trust contributes to insecurity and poor adjustment in later life. Similarly, failure to establish autonomy leaves the individual subject to shame and doubt, which again can be carried over to the next stage. These may be seen as part of the maladjustment problems of children who internalize or externalize their anger. Anger emerges when socioemotional needs are not met in the contexts where development takes place, and this anger precedes violence. The antecedents of life-threatening behavior thus appear related to what may be regarded as a developmental sequence or syndrome rather than to any one specific experience.

If during this period prior to adolescence children are able to develop confidence by doing something well (i.e., learn to be competent and productive), they will be more likely to carry that confidence into the future. If during this time they fail at their endeavors and do not have a nurturing environment to give them support, they will more than likely carry feelings of inferiority and low self-esteem into their future developmental tasks. Parental separation and family dysfunction are generally associated with violent behavior at this age, particularly where conflict and auger have been present in the child's experience.

In our view, failure to resolve preadolescent crises successfully does appear to present a cumulative risk for suicide. This failure generally signals interference in the bonding process.

Adolescents
According to Erikson, individuals attempt to resolve the issue of identity versus role confusion during the teenage years. Adolescents try to answer the question "Who am I?" so as to establish an identity in the sexual, social, ideological, and career domains. They often experience considerable stress in a variety of contexts as they attempt to forge an identity (Lock & Steiner, 1999). For example, the changing sex roles of men and women may exacerbate identity confusion. In addition, environmental stressors such as parental pressure for academic achievement, family mobility, the availability of drugs, and peer pressure can lead to depression (Capuzzi, 1994). Suicide seems to occur when stress, cognitive immaturity, and lack of emotional bonding interact and overwhelm an individual's ability to cope and to reason clearly. In one study, adolescents who had attempted suicide reported significantly more stress related to parents, lack of adult support outside the home, and sexual identity than did control groups (Wagner, Cole, & Schwartzman, 1995). Mood disorders are generally found in this population (Archer & Slesinger, 1999).

Some teenagers come from families with high expectations which, when coupled with identity confusion, feelings of inferiority, biological changes, and low self-esteem, are often too much to handle. In one study, school professionals were asked to identify individual, familial, and sociocultural factors which might make adolescents more vulnerable to suicide. Of 450 responses, half focused on the impact of the family; lack of parental support and alienation from and within the family were considered key risk factors (Grob, 1983). In the literature, parental absence or unavailability, poor communication between family members, conflict within the family, high parental expectations for achievement, and overt family pathology are generally considered the main risk factors.

Suicidal ideation is related to psychosocial distress, drug involvement, family stress, and unmet school goals (Thompson, 1994). Many adolescents become involved with drugs or alcohol in an attempt to reduce tension. Further, many adolescents who commit suicide are heavy users of alcohol or drugs (Laws & Turner, 1993). This suggests a two-factor process. First, drugs may provide some initial relief from distress. However, in masking distress chemically, the individual's cognitive development is undermined just as he or she may be beginning the difficult transition to formal operations. Drugs also tend to alienate the individual from his or her sources of social support. This leads to exacerbation of the crisis, overwhelming the individual's resources and making suicide seem the only option.

In discussing motives for suicide, Adler (1964) considered adolescents to be irrational, unrealistic, and illogical: "In dismissing interest in life and committing suicide, adolescents are able to accomplish something no one else is able to do. A person who considers himself or herself too weak to overcome life's difficulties acts 'intelligently' according to his or her goal of coping with the difficulties of life" (p. 48). Adolescents' intellectual functioning is in a state of transition and instability, and their ability to project themselves and others into the future is often limited. Elkind (1978) has referred to this unevenness in thought as "pseudostupity." It can be observed in people who fail to take into account the consequences of a successful suicide, particularly the effects on their families. Typically, the stressful situation that precipitates suicidal action is of a transitory nature and will abate over time (for example, the loss of a girlfriend or boyfriend); however, the adolescent's egocentric, rigid here-and-now perspective reflects an inability to utilize his or her growing cognitive competencies.

Young Adults
During the early adult years, according to Erikson, the conflict of intimacy versus isolation is the predominant developmental issue. Individuals at this time seek companionship and love, Which puts them at risk for rejection. Once rejected, they may become fearful of attempting closeness again. Not wanting to be hurt again, they may isolate themselves, which can lead to depression. Efforts by others to help is often met with anger or avoidance (McNeely, 1977). This decreases the social feedback available, compounding cognitive and emotional dissonance. In general, these persons have not achieved a positive identity in adolescence. The clinical literature supports the view that the less successful adolescents and young adults are in establishing healthy identities and intimacy, the more at risk they are for serf-destructive behavior.

Suicide has been extensively studied among college students. Although research has shown that the overall suicide rate for this population is lower than it is for the population as a whole (Silverman, Meyer, Sloane, Raffel, & Pratt, 1997), there has been a dramatic increase in suicide among college students since 1950 (Lipschitz, 1995) and for those aged 15--24 in general (Hirsch & Ellis, 1993). Strang and Orlofsky (1990) reported that nearly 61% of college students experience some suicidal ideation during their college years--a frightening statistic.

It has been found that suicidal students have poorer parent relationships than do nonsuicidal students (Strang & Orlofsky, 1990) and come from families that are more rigid in their values, attitudes, and beliefs (Carris, Sheeber, & Howe, 1998). Associated with this rigidity, college students who feel that others have unrealistically high expectations of them are more likely to commit suicide (Dean, 1996). Adolescents from rigid families with unrealistic expectations often have problem-solving deficits and are unable to see a way out of perceived crises. Jones (1991) found that depression, hopelessness, helplessness, and loneliness were usually present in college students who attempted suicide, with hopelessness the best predictor of more lethal behavior. Certain personality types are more likely to be suicidal among college students, with introverts at higher risk than extraverts (Street & Komrey, 1994).

Issues surrounding the intimacy versus isolation conflict are key determinants of whether young adults will attempt suicide. Crucial to the resolution of this conflict are the problem-solving skills that young adults learn (or fail to learn) in earlier stages of life.

Gender Differences
Not only do the dynamics of each developmental period affect adolescents' response to suicide ideations, there are also gender-based issues that need to be considered. What differentiates males from females who commit suicide?  In general, males learn to suppress their feelings (i.e., to keep their emotions inside), while females are encouraged to express them (i.e., that it is acceptable to cry, vent, and reach out to others). Suicide attempts are often a cry for help.

Suicide rates increase sharply at adolescence, starting significantly earlier for boys than girls (Aro, 1993). The adolescent male often acts quickly, using more violent means. Females, for the most part, use passive means of self-destruction: poison, gas, or pills (they have greater access to prescribed drugs through more frequent use of medical services). As Grollman (1971) noted, they prefer not to shed their blood or disfigure their bodies. Changes in gender roles may reduce the gap between males and females in suicide rates, as women are increasingly encouraged to take on more male-oriented characteristics.

Risk Factors and Firearm Availability
Social learning theory (Bandura, 1977) is informative regarding adolescent suicide. Research has found that individuals whose parents had attempted suicide were more likely to attempt suicide than those without a family history of suicide. This is supported by social learning and cultural historical theory (Vygotsky, 1978). Grollman (1971) also reported that adolescents with a family history of suicide are more likely to take their own lives. However, how such patterns become established in the first place requires further research.

Some experts feel that suicide should not be discussed lest there be a "chain reaction." Often, when there is a suicide in a particular geographical area, others follow. This "solution" to an adolescent's problems seems driven by identification with the model or the model's situation. Males and females alike may also have a desire to "get back" at someone through suicide. The permanency of death may not be comprehended.

Each suicide attempt has an underlying message, and suicide completion indicates that the message was not received. Most people who attempt suicide threaten to do so beforehand, with over 80% of those contemplating suicide verbalizing their thoughts. Seventy-seven percent of adolescents state that if they were contemplating suicide they would first turn to a friend for help (King, 1999).

Whether a suicide attempt is successful often depends upon the method chosen. When someone uses a firearm, death is almost certain. Suicide by firearm is currently the third leading cause of death for adolescents and young adults in the United States (Duker, 1994), and 80% of suicides by older males are committed with firearms (Kaplan, 1994). Men tend to use firearms to kill themselves more often than do women, and this is attributed to the socialization of males in American society. For example, most males raised in the South have shot a gun before their thirteenth birthday. Females are less likely to be socialized to guns, and suicide by firearms is much less prevalent among them, except in the South, where female firearm suicide rates are highest. Recent studies, however, have shown an increase in the acceptance of firearms as a method of committing suicide for women (Adamek, 1996).

Conclusions
In attempting to understand suicide, it is difficult to specify a single pattern because those who commit suicide come from all walks of life and vary in background and motives. However, rates of suicide generally increase with age (Bingham, 1994) and males are more likely than females to commit suicide.

Suicide among the adolescent population is of major concern. The failure to resolve developmental crises, as described by Erikson, can lead to the belief that suicide is an acceptable solution to seemingly insurmountable problems.

Taking into account increasing economic difficulties for some, exposure to drugs and alcohol, and greater social alienation, suicide rates may continue to rise. Intervention needs to be multidimensional as well as developmentally differentiated. Research on suicide prevention (among adolescents in particular) indicates that there is a continuum of self-destructive behavior (Wolfle & Siehl, 1992). Pfeifer (1994) argues that a multifactorial approach that considers developmental concerns in all phases of life must be utilized to limit suicidal behavior.

Intervention, including screening, should begin early. Jackson, Hess, and van Dalen (1995) suggest that suicide intervention should begin at preadolescence. School counselors should be alert to the types of personal difficulties that could lead students to attempt suicide, and take appropriate and timely action. Awareness of the signs and symptoms of suicidal ideation should be a priority in the schools and in the community. Teachers and family members can work in partnership with school counselors to intervene when needed.

A family approach to intervention is especially important in light of recent evidence suggesting that parents may actually precipitate a child's suicide (Jacobson, Rabinowitz, Popper, & Solomon, 1995). A cost-effective strategy would involve educating parents in such areas as communication, problem-solving skills, and knowledge of child development, in an effort to avoid problems rather than merely react to them.

Interventions that help connect people and that improve an individual's self-worth can reduce potential suicides. These interventions can be conducted in a supportive social setting, such as the school. To the extent that families can be educated with regard to developmental issues, we may succeed in reducing individual vulnerability to maladjustment and neutralize external stressors. Further, families can be strengthened by macro-level economic policies.

A psychosocial model, focusing on the resolution of crises that constitute serious risk for suicide over the lifespan, offers direction to school counselors, psychologists, and teachers. This area is fertile for additional theory-driven research. Cross-cultural contrasts may also provide insights for suicide prevention and social promotion of psychological health. It is clear that there is a social learning component to self-destructive behavior and that the availability of guns interacts with unhealthy identity development. Thus, prevention is linked to the development of healthier conditions for positive identity development.
-Portes, Pedro R., Sandhu, Daya S., Longwell-Grice, Robert, Adolescence, Winter2002, Vol. 37, Issue 148
The article above contains foundational information. Articles below contain optional updates.

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Personal Reflection Exercise #8
The preceding section contained information about understanding adolescent suicide.  Write three case study examples regarding how you might use the content of this section in your practice.

Online Continuing Education QUESTION 22
According to Portes, what may reduce the gap between males and females in suicide rates in the future? Record the letter of the correct answer the CEU Answer Booklet.

 
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