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

Section 17
I’m Sick of Being Me:
Developmental Themes in a Suicidal Adolescent

CEU Question 17 | CEU Answer Booklet | Table of Contents | Crisis CEU Courses
Psychologist CEs, Social Worker CEUs, Counselor CEUs, MFT CEUs

Introduction
Although suicidal ideation and behavior is relatively rare for those under the age of 13, rates increase dramatically as children make the transition into adolescence. Recent statistics support the severity of this problem as approximately 16.9% of adolescents seriously consider attempting suicide, 16.5% develop a suicide plan, 8.5% attempt suicide, and 2.9% require emergency medical treatment following a serious suicide attempt (CDC, 2004). Despite commonalties in suicidal behavior across the lifespan, suicide rates, patterns, and the variables influencing suicidal behavior all vary according to developmental stage (Stillion & McDowell, 1991). Examining developmental tasks may be helpful in determining why the prevalence of suicidal ideation and behavior is so high during the teen years.

Adolescence is a period of important developmental change. In addition to the biological events of puberty, enormous social, emotional, and cognitive transitions take place. Although the importance of developmental factors in adolescent emotional distress has been generally recognized, research into the role of developmental processes and their influences on suicidality has been limited (Aro, Marttunen, & Lolnnqvist, 1993; Borst, Noam, & Bartok, 1991). Increasing our understanding of the developmental processes most prominent during adolescence may enhance our conceptualization of adolescent suicidality (Bar-Joseph & Tzuriel, 1997). An examination of age- or maturity-related developmental influences may also illuminate our understanding of underlying reasons for suicidal tendencies, teens' abilities to cope with suicidality, as well as risk and protective factors (Pfeffer, 1994).

The limited literature in this area suggests that three major developmental processes, cognitive development, identity formation, and autonomy-seeking, may have an important impact on adolescent suicidality. Using a case study approach, the purpose of this paper is to illustrate the role these factors played in one teenager's experience of becoming and overcoming being suicidal. Recently, researchers have argued for qualitative investigations to increase our understanding of suicidal processes (Cutcliffe, 2003). Due to the limited research in this area, understanding developmental factors through qualitative methods is well suited for building the foundation for future research. The case study methodology provides the opportunity to explore suicidal behavior and developmental issues from the perspective of the suicidal person. This method offers unique insight into an adolescent's thoughts, feelings, and perceptions.

Cognitive Development
Adolescence is characterized by rapid transitions in cognitive development. This shift brings with it the start of formal operational thinking, allowing for the emergence of logical, hypothetical, and abstract reasoning abilities (Piaget & Inhelder, 1969). However, the progression of cognitive development occurs in a maturational pattern unique to each individual and mature perspectives may vary depending upon situational and emotional contexts. Inconsistent cognitive development in some domains may complicate adolescents' adjustment to normal social and physical changes and abilities to cope with increasing stresses in various circumstances. Cognitive changes may also influence the psychological and emotional states of individuals in this age group and play a role in the development of suicidal thinking and behavior.

Hypothetical reasoning abilities provide adolescents with the capability of thinking beyond the present and envisioning idealized worlds, future possibilities, and situations different from actual reality. How ever, as immature cognitiveabilities can limit teens' abilities to reasonably evaluate the world, many see their lives solely from their own perspective. Disillusionment, frustration, and unhappiness may result from this type of thinking as adolescents begin to see the discrepancy between "what is" and what could be" (Stillion & McDowell, 1996).

The development of formal operational thought allows adolescents to take the perspective of others and anticipate the reactions of those around them. Teens' new capacity for perspective-taking is often characterized by the assumption that those around them are as preoccupied with their appearance and behaviors as they are, resulting in the formation of an imaginary audience (Elkind, 1981). While teens gain the ability to think about the thoughts of others, they lack the skill of determining congruence between their beliefs and the actual opinions of others. As adolescents increasingly focus on their bodily changes and appearance, they become more self-conscious and egocentric. Often, small embarrassments become huge traumas as they feel they are "on stage" to those around them.

Studies have found adolescent egocentrism to be more prevalent among females than males and to continue into late adolescence (Peterson & Roscoe, 1991; Rycek, Stuhr, McDermott, Benker, & Swartz, 1998). Recently, it has been suggested that self-consciousness during adolescence exists because of strong pressures to live up to social and behavioral standards that have real social and personal consequences (Bell & Brommick, 2003). It has been argued that young people's belief that they are being watched and judged is an accurate perception that emerges as a result of actually being under constant scrutiny (Vartanian, 2000). Real or imagined, adolescents' self-conscious focus can result in the development of negative feelings, criticisms, and low selfworth often associated with adolescent suicidality (Stillion & McDowell, 1996).

Elkind (1981) also suggested that adolescents develop a personal fable, exaggerating their importance in the world and viewing themselves and their feelings as unique and different. Adolescents often become disillusioned, alienated, and lonely, believing they will never be understood. The lack of life experience to see that others have survived similar problems with positive outcomes results in stressful situations being viewed as unique and inescapable. Additionally, teens are vulnerable to feelings of hopelessness because of the perception that all future situations will produce continual negative outcomes.

Adolescents tend to become introspective and spend time focusing on their thoughts and feelings. As their cognitive abilities undergo developmental transitions, overgeneralizing or rigid thinking may cause a stressful experience to be seen as solvable only through suicide. Suicidal adolescents are also vulnerable to selective abstraction whereby they dwell on negative experiences and ignore positive ones. This may contribute to depressive or suicidal thinking (Stillion & McDowell, 1996). Teens may also anticipate the effect of their suicide on others while ignoring its finality (Allberg & Chu, 1990).

A transition phase in cognitive development allows adolescents to experiment with an increased variety of problem-solving strategies. Because they are not yet fully developed cognitively and have limited life experiences, however, teens may be vulnerable to limited decision making skills, poor problem-solving abilities, and irrational decision making when overcome by stress, intense affect, or inescapable conflict. Research suggests that suicidal individuals may have cognitive distortions regarding their ability to solve problems, thereby resulting in a negative attitude toward problem solving (Esposito, Johnson, Wolfsdorf, & Spirito, 2003). Due to this mind-set, suicidal adolescents may fail to attempt problem-solving and doubt the effectiveness of generated solutions.

Identity Formation
Adolescence is a period of self-discovery when internal and external factors impact individuals' increasing awareness of who they are, what they believe in, where life is taking them, and how they fit into a complex society. According to Erikson (1968), the central task of this developmental period is to resolve the issue of identity versus identity confusion. The healthy resolution of teens' exploration of the world and their relationships with others results in the establishment of a clear sense of personal identity that joins the past, present, and future into a strong and meaningful sense of self. Those who have difficulty achieving an identity often struggle to discover their role in life, fail to cope with challenges and responsibilities, and are vulnerable to identity confusion.

Adolescents experience a variety of stresses and anxieties as they explore their strengths, skills, values, and feelings while seeking out a personal identity (Arnett, 1999). Research has shown that identity achievers enjoy greater psychological well-being, higher self-esteem, less self-consciousness, and lower levels of preoccupation with personal concerns in comparison to those who have not resolved their identity issues (Meeus, 1996; O'Connor, 1995). Erikson (1968) posits that the adolescent identity exploration process can be characterized by an identity crisis during which teens experience discomfort, confusion, impulsive and acting-out behavior, mood swings, reduced ego strength, and impaired coping. Consistent with Erikson's definition of an identity crisis, Meeus, Iedema, Helsen, and Vollebergh (1999) concluded that the identity state characterized by high levels of exploration and low levels of commitment was associated with low levels of psychological well-being. Thus, research supports the view that the formation of personal identity is a potentially challenging process.

In comparison to low-exploring peers, teens actively involved in identity exploration have been found to show greater levels of inner confusion, agitation, dissatisfaction, unhappiness, and depression implying a reduced capacity for coping with problems and stress (Kidwell & Dunham, 1995). Stillion and McDowell (1991) suggest that identity difficulties are associated with maladaptive coping and are a significant risk factor for adolescent suicidality. In support of this argument, Bar-Joseph and Tzuriel (1990) found that suicidal youth score significantly lower on most ego identity factors in comparison to non-suicidal peers. These researchers concluded that a stable and secure ego identity could provide teens with inner strength and serve as a protective factor against suicidality.

Autonomy versus Attachment
Attachment refers to an enduring affectional bond characterized by mutual trust, support, and emotional connection (Armsden & Greenberg, 1987). Adolescence continues a developmental process in which attachment with caregivers from birth form individuals' minds and shapes their behaviors in ways that are either adaptive or maladaptive (Allen & Land, 1999). During adolescence, important relational transitions occur as teens strive to reach a balance between autonomy striving and attachment-related systems. Adolescent autonomy-seeking behavior is part of a process that reduces emotional dependence upon parents and frees adolescents to explore other meaningful relationships. Without independent exploration it would be difficult for teens to accomplish many of the major tasks of social development such as establishing long-term romantic relationships and engaging in productive careers. Research has shown that both attachment and autonomy are positively related to indices of psychosocial adjustment (Arnett, 2000; Lee & Bell, 2003; Noom, Dekovic, & Meeus, 1999).

Although the development of an autonomous self is a key task during this time period, researchers are increasingly seeing that adolescent autonomy is established with less difficulty in an environment of secure and enduring relationships and not at the expense of attachment relationships with parents (Allen & Land, 1999; Meeus, Ooster wegel, & Vollebergh, 2002). Families characterized by a healthy attachment foster autonomy-seeking by allowing teens age-appropriate opportunities for independent exploration and experimentation within supportive and guiding parent-teen relationships. A background of secure attachment allows adolescents to rely on attachment figures if truly needed, thereby facilitating the exploration of living independently from parents (Allen & Land, 1999; Meeus et al., 2002). Because encouragement of autonomy optimally occurs within the context of positive and supportive relationships with parents, the attachment system plays a vital role in helping adolescents through this developmentally challenging time of life.

Interactions in families of insecure adolescents are often particularly problematic when the teen's striving for autonomy creates tension and conflict in the adolescent-parent relationship (Allen, Kuperminc, & Moore, 1997). The moodiness, changing relationships, strain, and growing emotional and behavioral independence that characterize adolescent development cause tension and increase the impact of an insecure parent-teen relationships (Allen & Land, 1999). Troubled adolescents and their families have difficulty developing parent-teen relationships consisting of equality and mutual respect among family members (Scharf, Mayseless, & Kivenson-Baron, 2004). Teens who experienced their parents as insensitive and unavailable are at increased likelihood of depressed mood, poor self-regard, and aggression and hostility toward others (Goldsmith, Fyer, & Frances, 1990; Noack & Puschner, 1999).

Inadequate negotiation of autonomy and attachment systems has significant consequences for social and psychological well-being and is related to adolescent suicidal behavior (Kaplan & Worth, 1993). Teens who perceive their parents as a trusting source of emotional support and as encouraging autonomy may be at lower risk of suicidal ideation and behavior than those who regard their parents as unsupportive, restrictive or otherwise hindering autonomy-seeking behavior. A history of suicidal ideation or suicide attempts among adolescents has been associated with perceptions of attachment figures as being unavailable (West, Spreng, Rose, & Adam, 1999), low levels of attachment security and individuation (de Jong, 1992), and low levels of care and high levels of overprotection by mothers (Adam, Keller, West, Larose, & Goszer, 1994).

Evidence also suggests that adolescent suicidality is related to low levels of close friendship support (Prinstein, Boergers, Spirito, Little, & Grapentine, 2000), and poor social acceptance by peers (Allen, Moore, Kupermine, & Bell, 1998). Attachment needs are usually transferred from parents to peers who become increasingly important sources of support, intimacy, feedback, social influence, and lifelong partnerships. Healthy individuals develop new extra-familial support systems, while at the same time maintaining the parent-child bond that provides parental comfort and support during times of distress (Allen & Land, 1999). Bonds with peers become the basis for future reciprocal attachments during adulthood as adolescents evolve from being the recipients of care to serving as caregivers for others. Therefore, poor connections and feelings of belonging to a social group are important. Overall, supportive and secure connections and bonding with both parents and peers has been found to act as protective factors against adolescent suicidal ideation and behavior (Rubenstein, Heeren, Housman, Rubin, & Stechler, 1989).
-Everall, Robin D., Bostik, Katherine E., Paulson, Barbara L., Adolescence, Winter2005, Vol. 40, Issue 160
The article above contains foundational information. Articles below contain optional updates.

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Personal Reflection Exercise #3
The preceding section contained information about developmental themes in a suicidal adolescent.  Write three case study examples regarding how you might use the content of this section in your practice.

Online Continuing Education QUESTION 17
What factors contribute to teen vulnerability regarding limited decision making skills, poor problem-solving abilities, and irrational decision making when overcome by stress, intense affect, or inescapable conflict? Record the letter of the correct answer the CEU Answer Booklet.

 
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