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

Section 6
Depression and Facets of Anger as Predictors of Suicide Attempt

CEU Question 6 | CEU Test | Table of Contents | Crisis CEU Courses
Social Worker CEUs, Counselor CEUs, Psychologist CEs, MFT CEUs

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On the last track, we discussed six risk factors for teen suicide.  These six risk factors are abuse, childhood loss, school performance, personality traits, parental relationships, and family patterns.

On this track, we will discuss the four step Hook technique for helping a teen client deal with the anger component of his or her depression.  The four steps in the Hook technique are identify the hook, the hook book, identify the need, and fill the need.

Craig, 15, had been brought the crisis center by his school security guard and the school counselor after a classmate found him in the boy’s restroom holding a gun to his chest.  When I asked Craig about what had happened, he stated, "My mom wants me to be the first person in the family to graduate high school, but this morning I found out I failed my English midterm and am in danger of flunking.  Last night, my girlfriend Tasha told me she wants to see someone else.  I hate everything.  I just want it all to stop!" 

Craig’s school counselor informed me that Craig had been having anger-related disciplinary problems at school over the past couple of months, mostly small incidents including punching lockers and shoving students who made fun of his gangly frame or shabby clothes.  The school counselor also informed me that Craig was one of seven children, and although both his parents had steady employment money was very tight.  Craig later stated, "Twice last year the gas company threatened to shut our heat off.  Bill collectors are always calling."

My early interventions with Craig, of course, focused on contracting for his safety and assessing his suicide risk.  As our sessions continued, it became clear that a primary precipitating factor for Craig suicidal thoughts was anger and frustration.  I asked Craig to try the Hook technique for identifying and managing anger as a strategy to help Craig gain control over the thoughts and reactions that led to his suicidal ideations.

4 Steps for Effective Use of the Hook Technique

Step #1 - Identify the Hook
The first step in the Hook technique which I introduced to Craig is to identify the hook.   I stated to Craig, "Close your eyes and think back to a time when you were really angry.  Now try to picture your anger as a physical thing.  What does it look like?  How is it stored?"  Craig stated, "It looks like steam building up in a narrow, rusty pipe.  It just builds up more and more until the pipe starts to bulge and creak.  When I feel that pipe is about to break, that’s when I just want to get away from everything, even if I have to kill myself to get away."

I next stated to Craig, "Now let’s try visualizing the anger that results in you feeling a need to self harm to relieve the pressure in a different way.  Imagine yourself as a fish swimming through a ‘sea of life.’  As you are swimming along, you notice a hook with tasty looking bait on it drop down right in front of you.  This hook is anything that could make you angry or upset for a good reason.  If you take the bait, you get hooked into the feelings of anger and frustration that make you feel like a pipe about to burst." 

I explained to Craig that there are two kinds of hooks, injustice and incompetence.  Injustice hooks, of course, are minor or major stress situations characterized by the word ‘unfair.’  Incompetence hooks describe situations characterized by the feeling that you or someone else is inept, incapable, unqualified, stupid, or lazy.

Step #2 - Keep a Hook Book
A second step in the Hook technique is to keep a hook book.  I provided Craig with a pen and notebook small enough to fit in his pocket.  I stated, "I’d like you to draw a line down the middle of each page.  On the top of one column, write ‘anger event’.  At the top of the other column, write ‘hook’.  Each time you feel provoked and angry at yourself or something else, quickly jot down a brief description of what happened.  Try to figure out what kind of hook the situation is for you." 

An example that Craig came up with for an anger event is "Failed my English test."  Craig described his hook in this situation as "I feel too stupid to finish school," which he identified as an incompetence hook.  I asked Craig to carry his hook book in his pocket for a week, and bring it to our next session.  In our next session, Craig and I used his hook book to identify the most common types of situations that precipitated his anger responses.

Step #3 - Identify the Need Behind the Hook
In addition to identifying the hook and the hook book, a third step in the Hook technique is to identify the need behind the hook.  Clearly, the goal of this step was to help Craig stop the rumination over his anger that often resulted in suicidal ideation.  As you know, there are several basic needs which, being unmet, can lead to injustice or incompetence hooks.  I decided to continue to focus on Craig’s anger event concerning failing an English test.  I asked Craig to take several deep breaths, than asked him to visualize the anger event in his mind while concentrating on identifying a need that may be unmet. 

Craig stated, "When I do bad in school, I feel angry at myself because I’m letting myself and my family down I need to respect myself, but how can I if I’m so bad at school that I’m failing?"  I stated to Craig, "So you’re saying that you feel your need for self esteem and self respect is not being met?"  I asked Craig to make a new Hook Book, this time with four columns instead of two.  After the first two columns, ‘anger event’ and ‘hook’, I asked Craig to make a column marked ‘Need’. 

Step #4 - Filling the Need
A fourth step in the Hook technique is filling the need.  After Craig had identified his need as the need for self respect, I asked him to label the fourth column in his Hook book "desire".  When I asked Craig to come up with a desire related to the anger event involving failing a test, Craig stated "My desire is to do well in school so I can graduate on time." 

I stated to Craig, "Now that you’ve identified the need and desire behind your anger, we can start to work directly on filling that need.  Let’s talk about some strategies for studying, managing your time, and talking to your teachers that can help you do better in school."  Craig’s focus was now on taking direct, specific action, rather than on the ruminations and angry feelings that led to suicidal ideation. I asked Craig to continue using his four-column hook book over the next few weeks. 

I found that having Craig keep the hook book helped reduce the intense anger and frustration Craig had been experiencing, and consequently I observed a reduction in the number of suicidal thoughts Craig reported.  In addition, the hook book provided me with information about specific skills and situations to work on in my sessions with Craig.  Think of your Craig.  Would using the hook technique be helpful in helping him or her reduce incidents of ruminative thinking in response to anger?  Would reducing anger and rumination help him or her reduce suicidal thoughts?

On this track, we have discussed the four step Hook technique for helping a teen client deal with the anger component of his or her depression.  The four steps in the Hook technique are identify the hook, the hook book, identify the need, and fill the need.

On the next track, we will discuss the first four myths the families of suicidal teen clients may have about suicide.  These four myths are teens who talk about suicide will not commit suicide, all suicidal people want to die, if you ask someone about suicide it might give them the idea, and suicide happens without warning.

Peer-Reviewed Journal Article References:
Bamwine, P. M., Jones, K., Chugani, C., Miller, E., & Culyba, A. (2020). Homicide survivorship and suicidality among adolescents. Traumatology, 26(2), 185–192.

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.

Cheng, Q., Shum, A. K. Y., Ip, F. W. L., Wong, H. K., Yip, W. K. K., Kam, A. H. L., & Yip, P. S. F. (2020). Co-creation and impacts of a suicide prevention video: A case study of a YouTube short film on youth suicide prevention. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 41(1), 7–14.

Price, S. D., Salekin, R. T., Klinger, M. R., & Barker, E. D. (2013). Psychopathy and depression as predictors of psychosocial difficulties in a sample of court evaluated adolescents. Personality Disorders: Theory, Research, and Treatment, 4(3), 261–269. 

Sadeh, N., & McNiel, D. E. (2013). Facets of anger, childhood sexual victimization, and gender as predictors of suicide attempts by psychiatric patients after hospital discharge. Journal of Abnormal Psychology, 122(3), 879–890.

Santiago-Menendez, M., & Campbell, A. (2013). Sadness and anger: Boys, girls, and crying in adolescence. Psychology of Men & Masculinity, 14(4), 400–410. 

Online Continuing Education QUESTION 6
What are four steps in the Hook technique? To select and enter your answer go to CEU Test.

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