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

Section 19
Importance of Mother-Daughter Relationships in Suicide Attempts

CEU Question 19 | CEU Test | Table of Contents | Crisis CEU Courses
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Family Domain
For suicidal adolescents of both Hispanic and non-Hispanic ethnic origin, dysfunctional family environments (low cohesiveness, familial and marital conflict and violence, low parental support and warmth, parent-adolescent conflict) and impaired parental psychological functioning attenuate the families' capacity to aid distressed adolescents (Fremouw, Callahan, & Kashden, 1993; King, Raskin, Gdowski, Butkus, & Opipari, 1990; Wagner & Cohen, 1994). Interestingly, Razin et al. (1991) noted that the suicide attempt often results in some improved family functioning.

The link shown between sociocultural and familial domains may be related to the degree of traditionalism observed in the families of those that attempt suicide. Traditionally structured (that is, patriarchal and male-dominated) Hispanic families tend to emphasize restrictive, authoritarian parenting, especially with regard to girls. This traditionalism may affect a family's capacity to respond flexibly to a daughter during a developmental move toward autonomy and individualism, even when the father is absent. Some research bears out this hypothesis, because adolescents of Hispanic origin tend to report more authoritarian parenting than white adolescents, and adolescents with authoritarian parents, although they are more obedient and conforming, tend to have poorer concepts of self (Dornbusch, Ritter, Leiderman, Roberts, & Fraleigh, 1987).

Interpersonal stress associated with the break-up with a boyfriend, parental opposition to the boyfriend, parental discovery of the adolescent's sexual involvement, and recurrent conflicts with parents, especially the mother, appear to influence the suicide attempts by adolescent Hispanic females more than other peer-related stresses (Berne, 1983; Ng, 1996; Razin et al., 1991; Zayas & Dyche, 1995). Seventy-five percent of Berne's (1983) Hispanic respondents, for example, attributed the suicide attempt to conflicts with mothers or boyfriends.

Canino's (1982) findings on transactional family patterns in parent-daughter relationships of ethnic Puerto Ricans support our conceptual framework and may be extrapolated to other families of Hispanic origin. Canino found that well-functioning Puerto Rican families living in the United States allowed daughters to express ideas different from their parents, to have friends outside the home, and to have a modicum of privacy, all highly valued by adolescents. Despite the fact that traditional sex roles existed, flexible accommodation characterized the parents' interaction with each other, their daughters, and their environments. The integrative model hypothesizes that inflexibility in families causes a high degree of conflict; that authoritarian parenting is characteristic of family environments in which Hispanic females may attempt suicide, relative to families in which suicide is not attempted; and that rigid or maladaptive family environments correlate highly with adolescent depression, low self-esteem, and poor coping capacity.

Absence of Fathers. The integrative model highlights the mother-daughter relationship as a subdomain of the family domain that interacts with adolescent female developmental processes. However, it is essential to proceed with a caveat. The literature has described a more pronounced effect of the mother-daughter relationship than of the father-daughter relationship on suicide attempts. What appears to account for this is the absence of fathers and preponderance of mothers in the samples. Mothers are overrepresented because mothers, after divorce or separation, typically retain custody of their children and are most likely to accompany the adolescent to the doctor or clinic. The result is that the focus of attention is placed unfairly on mothers. Ng (1996), Razin et al. (1991), and Zayas and Dyche (1995) found that adolescent Hispanic females who attempt suicide had lived fewer years with their fathers than those who did not attempt suicide. It is also possible that the adolescent may feel blame for her father's absence and may experience a sense of loss. Little is known about this link with the father, and investigating it will enhance understanding of suicide attempts by Hispanic adolescent females.

In the integrative model, fathers are an important element in the family structure. Their interaction with adolescent daughters and mothers has vital effects on creating the conditions for a suicide attempt. Fathers' absence, lack of support for families, or overstrict adherence to traditional gender roles seem to influence the mother-daughter relationship and the mother's interaction with the daughter. Furthermore, it appears that mothers, mostly foreign born, have not been socialized to go outside their marriages and families for friendships and support. This normal developmental socialization that was adaptive in the original culture where extended families abound may not be functional in the host culture. Because of the erosion of extended family supports resulting from immigration and the absence of a spouse to balance the family system, mothers of those who attempt suicide may seek their daughters' companionship. Rather than create an impression that mothers have the primary effect on their daughters' suicide attempts, the integrative model underscores that father absence and limited extended family support create imbalances in the family system.

Mother-Daughter Subdomain. Based on the literature, the model proposes that mother-daughter relations become characterized by diffused generational boundaries, low tolerance for differentiation, overinvolvement of the mother with the child, and social isolation (Canino, 1982; Razin et al., 1991; Zayas & Dyche, 1995). Mothers of adolescent Hispanic females who have attempted suicide often display ambivalence about their daughters' developmental and acculturative strivings and become overdependent on their daughters, creating a situation in which the adolescent feels she must parent her mother, be a confidant and nurturer to her mother, and protect or care for her mother (Razin et al., 1991). Also, maternal social isolation, lack of social support from other adults, and mistrust of friends and extended family members are elements detected in symptomatic Hispanic females (Razin et al., 1991). Suicidal behavior may be modeled also within the family, through the mother's own suicidal or other acting-out behavior during her own adolescence. The literature indicates that mothers of suicidal Hispanic females report histories of adolescent or early adulthood suicide attempts or other maladaptive behaviors themselves, such as sexual acting out, adolescent pregnancies, and running away (Razin et al., 1991; Zimmerman, 1991). Often the mother's conflicts in adolescence were related to her relationship with her own mother, reflecting a possible intergenerational dynamic encompassing grandmothers, mothers, and adolescent daughters. However, this maternal transgenerational process is speculation and should be investigated further.

The integrative model also proposes that mother-daughter mutuality and the mother's limited capacity to mentor and support her daughter are linked to the suicide attempts of adolescent females. Mutuality in this model refers to the empathy, engagement, authenticity, diversity, empowerment, and zest (that is, energy-releasing quality of the relationship) that take place between mothers and daughters (Genero, Miller, Surrey, & Baldwin, 1992). Mutual interchanges in intimate relations have been shown to foster self-disclosure, emotional resilience, coping strategies, and social support and to diminish social isolation (Genero et al.). Research and clinical case reports (King et al., 1990; Razin et al., 1991; Zimmerman, 1991; Zimmerman & Zayas, 1995) pointed to interruptions in mutuality between suicidal adolescents and their mothers.

Because of the demands placed on the daughter in acculturating to a dominant culture that presents definitions of women's roles different from those familiar to the immigrant Hispanic mother, the mother's capacity to mentor her daughter also may be strained. Daughters are bereft of an experienced mentor who can guide them through choices in various aspects of life. The integrative model defines an effective mentor as an individual who conveys to the adolescent that they can be counted on, who believes in and cares deeply for the adolescent, who inspires the adolescent to do her best, and who influences the adolescent's behaviors and choices positively, without possessiveness or threat of withdrawal of affection (Rhodes, Contreras, & Mangelsdorf, 1994). Mothers of female adolescents who have attempted suicide often expect daughters to adhere to the traditional Hispanic culture sex roles and cannot adequately support or mentor their daughters in adapting to the demands of balancing traditional and acculturated roles. Feminist research has shown that adolescent girls who experience relationships characterized by dominance rather than mutuality feel a chronic sense of stress and that girls who perceive their mothers as allies and mentors are more resilient and have better coping skills (Debold, Wilson, & Malave, 1993; Werner & Smith, 1992).

Developmental Factors
As the Hispanic female adolescent struggles to have her mother or mother surrogate see her for who she is and not for what her mother assumes she is, conflicts emerge. The mother-daughter struggle between self-affirmation and acquiescence and between original culture and new culture, and connection (Zimmerman, 1991) create a relational breach. This dilemma rests on the mother's ambivalence (that is, daughter's desire for autonomy threatens cultural and family ties and reminds mother of her own situation) and daughter's ambivalence and distress (that is, connection to mother means a loss of her own "voice," but to disconnect means a loss of the mutuality that is buttressed by the powerful cultural emphasis on familism). The suicide attempt is an act of despair and an attempt to connect (Zimmerman, 1991; Zimmerman & Zayas, 1995).

Conflicts relating to boyfriends among the teenager and her parents precede most suicide attempts among adolescent Hispanic females. The conflicts embody the movement toward greater autonomy and growing sexual awareness. They are complicated further by the low self-esteem and depression that are common among adolescent females. Inadequate mentoring compounded by the effects of family dysfunction, inadequate or nonexistent fathering, poor self-esteem and self-concept related to inadequate male parenting, poor coping skills, and parental restrictions create a climate in which conflicts with parents leave adolescent Hispanic females confused, despairing, and angry.

Psychological Domain
The integrative model places emphasis on a few key factors in the psychological domain. Depression and depressive symptomatology, low self-esteem, inadequate self-concept, and poor coping skills are among the salient factors in suicide attempts by adolescents in general (Campbell, Milling, Laughlin, & Bush, 1993; Kovacs et al., 1993; Rotheram-Borus, Trautman, Dopkins, & Shrout, 1990; Spirito, Francis, Overholser, & Frank, 1996; Spirito, Stark, Grace, & Stamoulis, 1991; Wagner & Cohen, 1994; Wagner et al., 1995). The factors in the psychological domain act in concert on the suicide attempt. Depression is a well-known correlate of suicide across gender, ethnic, racial, and age groups. People who attempt suicide frequently lack adequate cognitive and social problem-solving skills and display poor coping abilities (Rotheram-Borus et al., 1990; Spirito et al., 1991, 1996).

Among adolescents who attempt suicide, a key factor in coping is how they manage anger. Because of the cultural prohibitions on women's direct expressions of anger, the adolescent Hispanic female also may be socialized by her own more tradition-bound parents to suppress her anger. In tandem, having limited abilities to cope with anger and lacking appropriate problem-solving skills may interact to trigger the suicide attempt.

Adolescent Hispanic females who attempt suicide often perceive themselves as "bad" and to blame for family problems (Razin et al., 1991), underscoring the effect of low self-concept. The suicide attempt itself often is intended to solve an interpersonal problem or draw the attention of others who can assist the adolescent in coping. Compas and Wagner (1991) reported that adolescent females tend to report high interpersonal stress, which is positively correlated with psychological symptoms, and that family stresses are more related to psychological symptoms among low-income families. The normative intensity of friendships common in adolescence and interpersonal stresses (that is, peer and family related) reported in the literature (see Grosz et al., 1995) are similar for Hispanic teenagers. However, peer-related stress appears to be a less salient feature in the suicide attempts of adolescent Hispanic females than that of family-related stress.

The integrative model described here is intended to help inform clinicians' understanding of suicide attempts by adolescent Hispanic females. In developing this integrative model, we have focused on factors in four domains (sociocultural, familial [including a mother-daughter subdomain], developmental, and psychological) that appear to interact in the suicide attempts by adolescent Hispanic females. The current state of knowledge does not permit certainty regarding the relative weight contributed by each factor in this process or what constitutes critical interacting factors that lead to the attempt. It also does not permit us to draw conclusions about which resilience and protective factors intervene in those cases that do not result in suicide attempts. Rather, we have attempted to underscore the ways in which issues in each domain and subdomain tend to amplify those in other domains. By proposing an integrative model, this article tries to bring some order to understanding this phenomenon and to provide clinicians and researchers with a way of viewing the myriad issues that converge on suicide attempts.

The model does not exhaust all the possibilities that practitioners can explore in their work. For example, the influence of religious differences in Hispanic families essentially remains unexamined in the literature and requires that clinicians keep in mind its potential effect. Also, practitioners can explore the resilience factors that they see in nonsuicidal adolescent Hispanic females to better understand why the same protective factors are not present or active in suicidal teenagers. Through clinical reports and research, more attention can be given to the effect of the father's absence and on the daughters' relationships with their fathers. Whether fathers are involved actively with their daughters or completely absent through death, distance, or neglect, they remain psychologically and emotionally present in their daughters' experience.

For clinicians, it is evident that working with the young women's internal representational models of their fathers and the effect of desperation on suicide attempts will help them reflect more on the dynamic of the suicide attempt. Exploring the mother-daughter relationship is vital, with the adolescent first given the opportunity to vent emotions associated with the relationship with her mother. The role of anger, the cultural prohibitions against its direct expression by females, and the suicidal Hispanic female's ability to cope with angry impulses deserve additional investigation. Cognitive behavioral models and techniques for stress reduction, anger management, social problem-solving skills, and verbalization of internal emotional states can go a long way toward teaching the person who has attempted suicide more adaptive approaches. For example, self-efficacy and adaptive distancing can mitigate the stress the adolescent feels.

Joint mother-daughter sessions are extremely beneficial for creating the grounds necessary for developing mutuality. The developmental need for the adolescent female to establish a connection with her mother can be explored to help the adolescent understand this factor in herself. Individual sessions with the mother can begin the process of having mother understand her reactions to her daughter, as well as aiding her in developing the mentoring skills she may need to reconnect with her daughter. In these sessions, the mother's lack of social support from extended family, her social isolation, and her dependence on her daughter can be addressed more extensively than could be done in joint sessions with the daughter or in family sessions.

The literature reviewed here implies that adolescent Hispanic females who have attempted suicide may live in nuclear families that have less contact with extended families than adolescents who do not attempt suicide. Some writers have suggested that acculturated Hispanic adolescents whose parents rely on them for assistance in coping with the new culture may not be "parentified" or "enmeshed" as might be the case in families from other cultures (Inclan & Herron, 1991; Kaplan & Munoz, 1997). Having aunts, uncles, cousins, and others who can provide the necessary support, guidance, mentoring, and modeling the Hispanic female needs may help prevent the suicide attempt. The central role played by the mother-daughter relationship in adolescent female's development warrants closer scrutiny by clinicians and researchers.
- Zayas, Luis H., Kaplan, Carol, Turner, Sandra, Romano, Kathleen, Gonzalez-Ramos, Gladys, Social Work, Jan2000, Vol. 45, Issue 1

Personal Reflection Exercise #5
The preceding section contained information about understanding suicide attempts by adolescent Hispanic females.  Write three case study examples regarding how you might use the content of this section in your practice.

Peer-Reviewed Journal Article References:
Ali, A., & Gibson, K. (2019). Young people's reasons for feeling suicidal: An analysis of posts to a social media suicide prevention forum. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 40(6), 400–406.

Braun, M., Till, B., Pirkis, J., & Niederkrotenthaler, T. (2020). Suicide prevention videos developed by and for adolescents: A qualitative study. Crisis: The Journal of Crisis Intervention and Suicide Prevention. Advance online publication.

Finan, L. J., Ohannessian, C. M., & Gordon, M. S. (2018). Trajectories of depressive symptoms from adolescence to emerging adulthood: The influence of parents, peers, and siblings. Developmental Psychology, 54(8), 1555–1567.

Online Continuing Education QUESTION 19
According to the integrative model, what factors in mother daughter relations have been linked to the suicide attempts of adolescent females? Record the letter of the correct answer the CEU Test.

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