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The interpersonal theory of suicide emphasizes the importance of connectedness and places family therapists in a critical position to prevent suicide. Family therapists often work with suicidal youth and their families; yet, there is currently a dearth of clinical literature focused on youth suicide prevention in the field.
Given the high emotional and financial costs of youth suicide, more effective outpatient treatment models are needed. Fortunately, there is a growing body
of empirical studies demonstrating the efficacy of interventions for suicidal populations. There has been little effort, however, to bring these approaches
into the community settings where patients can benefit. It has become well recognized that the gap between science and practice is wide and deep. The following will provide insights into research-based clinical approaches for working with youth who present with suicidal ideation and behavior.
Suicide assessment
Don’t be afraid of suicide; the family already is! In order to effectively intervene, it is critical that family therapists are able to assess suicidal thoughts, intent and behavior. This requires therapists to be comfortable talking about suicide. Taking
a moment to think about your level of comfort working with suicidal youth is
an important place to start. Specifically, imagine how you would talk to an adolescent about whom you are concerned. Would you ask her directly if she were thinking of “suicide” or “killing” herself?
Or would you be more vague by using phrases like “take your own life” or “make it all stop”? Being direct and clear is the best approach (Granello, 2010). The language we use with our clients can help them take their concerns seriously and also allows therapists to identify levels of risk.
The ongoing use of assessment tools can serve to increase confidence when working with suicidal youth. One particularly helpful tool is the Columbia Suicide-Severity Rating Scale (C-SSRS; Posner et al., 2011). The C-SSRS is an interview-based rating scale designed to assess the level of suicidal ideation, type of suicidal behavior, and lethality of attempts. The C-SSRS has become
the gold standard for interview-based suicide risk assessment. In addition to
interview tools like the C-SSRS, there
are also self-report measures that can
be easily distributed to clients during session visits. One such assessment is the Suicidal Ideation Questionnaire- Junior (SIQ-JR; Reynolds & Mazza, 1999). The SIQ-JR consists of 15 questions to assess clients’ thoughts of suicide over the past month. Thoughts are rated on a scale to determine how often the client has them, ranging from 0 (never had this thought) to 6 (almost every day). Family therapists can then total all responses
to create an overall score. Scores of 0 to 19 indicate a normative level of suicidal ideation; scores of 20 to 29 indicate an elevated level of ideation; and scores
of 30 or above indicate a high level of suicidal ideation. These self-report and interview tools can aid family therapists in conducting comprehensive suicide assessments and documenting their efforts to maintain client safety.
Suicide prevention treatment
Several individual psychotherapy approaches have been shown to be helpful in treating suicidal thoughts and behaviors. Cognitive-behavioral therapy (CBT; Brent, Bridge, Johnson, & Connolly, 1996) and dialectical behavior therapy (DBT; Linehan et al., 2006) are the two most widely used approaches. The primary goal of CBT for suicide prevention, or CBT-SP (Stanley et al., 2009), is to identify the behaviors and thoughts that result from life events. It is believed that ideation can be reduced by changing the way one thinks about
these events, often relieving feelings of hopelessness. A core element of CBT for suicide is chain analysis. Chain analysis involves identifying triggers and precipitating events that lead to suicidal risk. Clients are encouraged to gain awareness of these triggers and events while the therapist helps them identify coping techniques (Stanley et al., 2009). Chain analysis is not unique to CBT
and can be considered a common factor across many therapeutic approaches. DBT also helps clients change their approach to challenging life situations and has received attention for its focus on clients with borderline personality disorder and persistent suicidal or self- injurious behaviors. A core therapeutic element of DBT involves teaching clients skills to regulate their emotion. In order to effectively manage suicidal thoughts and behaviors, therapists help clients practice these skills in times of distress. Both CBT and DBT have been well supported by decades of research.
Family approaches also have demonstrated a strong potential for suicide prevention by targeting relationships as a mechanism for change. Carl Whitaker (1989), the creator of symbolic-experiential family therapy, was one of the first to view suicidality from a systemic lens. Relational factors may be particularly impactful
for youth for whom the family context
is unescapable (Maccoby & Martin,
1983). It has been shown that changes
in family functioning and reductions in attachment-related avoidance are primary
PROFESSIONAL RESOURCES
Columbia-Suicide Severity Rating Scale (C-SSRS) for Risk Assessment
The C-SSRS is a questionnaire used for suicide assessment developed by multiple institutions, including Columbia University, with support from National Institute
of Mental Health. The scale is evidence-supported and has been successfully implemented in schools, college campuses, the military, fire departments, justice systems and in research. The Suicide Prevention Lifeline offers the scale here with further details: https://goo.gl/JzcN3S (URL is case sensitive).
To complete C-SSRS Training for Clinical Practice, visit http://c-ssrs.trainingcampus.net.
For more general information, see http://cssrs.columbia.edu.
Youth Assessment: Suicidal Ideation Questionnaire (SIQ-JR)
The National Action Alliance for Suicide Prevention offers information on the SIQ-JR, developed for use with youth aged 12-14. Youth are asked a series of questions to help identify those who have histories of suicide attempts or who may make future suicide attempts. Visit https://goo.gl/7P8ypk for more information (URL is case sensitive).
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