Working with suicidal adolescents and adolescents who self-harm

When working with adolescents who may be at risk of self-harm or suicide, special attention needs to be paid to this subject in the confidentiality contract, discussed and signed at the beginning of therapy. The counsellor needs to explain to their client that in the event of them disclosing plans of suicide, then other people, such as the clients' GP or a professional emergency team, will need to be informed. It is best, however, whilst always taking into account legal, ethical and professional requirements, to try and give the client as much control over the disclosure of their intentions as possible (Geldard & Geldard, 1999).

Once the risk factors of suicide in adolescents have been identified, it is important for counsellors to be familiar with the best ways of working with them. Baumeister (1990) considers that helping adolescents who have attempted suicide, or threatened to commit suicide, to find goals is vital. His 'escape theory' holds that suicidal adolescents deliberately ignore broader goals and values that usually provide meaning to people's feelings, thoughts and actions.

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Transitions in personal beliefs, goals and emotions are often fundamental to suicide, and therefore when working with this client group, short-term and long-term goals can be useful. This point of view is also shared by Greenberger (1992) who believes that, "the cognitive therapy approach to treating suicidal patients is to focus on the thoughts, assumptions, and beliefs that accompany the suicidal intent. Understanding the cognitive component of the suicidal patient can be instrumental in treatment planning and eventual therapeutic success" (p.

139). Anderson (2000), however, would argue that psychodynamic therapy is more helpful, especially during the assessment process.

He believes that psychodynamic factors can be used to broaden and advance the quality of assessment of adolescents at risk of self-harm, and that a consideration of the internal and external factors and their interaction, as manifested in the transference between client and therapist, and also considering the clients history and present circumstances, allows form and intensity to be added to the assessment.

Anderson (2000) recommends that an assessment of risk consist of being aware of the known risk factors, and putting these into context with that young persons situation at the time of the assessment, their history, and their personality characteristics. The more information that can be gathered the better the chance of receiving an explanation of that person's behaviour. A calming effect on the client's mind, and on those carrying the responsibility and anxiety, can be achieved by them perceiving that they are understood.

Therefore, a good assessment can already reduce the risk of suicide before the therapy has even begun. Orbach (1988) comments that assessment of the familial dynamics and external events and situations is vital when evaluating risk of suicide or self-harm, as these are the major risk factors and determinants associated with this type of behaviour. Orbach suggests when working with suicidal adolescents, to try and obtain an idea of what death means to them. Do they see death as an improved life, for example?

An analysis of the adolescent's specific fantasies about death is in itself useful, as it can give a way of understanding the distress in their life. He suggests also that identifying the "unresolvable problem" (p. 232) is important, and that the therapist must constantly ask what processes, situations, relations or facts bring this client to feel that there is no other way of coping than to take their own life. Family therapy is recommended by Orbach as a way to deal with difficulties between an adolescent and their parents, or one parent.

This may involve in-depth work with one or both of the parents exclusively. Suicidal behaviour is often an attempt to solve the unresolvable problem, and if the problem can be resolved in therapy, then this will hopefully avoid the tragedy of a suicide. According to Orbach, therapeutic treatment for suicidal children and adolescents should focus on bringing about change in destructive behavioural patterns, unravelling the unresolvable problem, providing corrective experiences, and satisfying basic needs.

Distinguishing principles include, " the examination of the death fantasy, empathetic participation in considering suicide, splitting of the self-image, and alliance with sources of strength" (p. 244). In conclusion, it is clear that there are a number of risk factors that occur during the period of adolescence that can, and will, in some cases, lead to suicide. Every individual will have a different experience of these problems - some will experience all of them intensely, others will experience them all to a lesser degree, and maybe others will experience only one of these risk factors, or triggers, and just find it too much to bear.

Rutter (1991) compares developmental stress to a model of work stress, commenting that the number, nature, and patterning of the developmental task demands is one factor, and how well someone copes with these is dependent on four other factors, namely social support, external resources for meeting those demands, personal coping skills, and the socioecological context in which the demands must be met. He argues that the developmental tasks need not cause adverse emotional consequences if the four other factors measure up to the demands of those tasks.

He suggests that future priorities for public health and research agendas, regarding adolescents, should be to accurately identify the developmental tasks for adolescents in today's society; a description of the conditions, both material and physical, psychological and social, for their successful achievement in adolescents; and a clear description of who is responsible for ensuring these conditions are met. Obviously counsellors can be involved in helping to ensure these conditions are available, by providing emotional and psychological support to adolescents who need some help in achieving their developmental tasks.

Whilst it is vital that counsellors have the ability to identify and correctly deal with suicidal thoughts and behaviour to avoid the occurrence of tragedy, it is also paramount that they know their own limits: counsellors who are working with suicidal clients need to work under close supervision and seek help from other specialist helpers when they need it (Geldard & Geldard, 1999). When looked at as a statistic, seventy-one per million seems a very small percentage, which of course it is.

However, one life that is wasted through the act of suicide is one too many, and usually it is the case that when one life is taken, several more lives are ruined. The devastation suffered by family members and friends cannot be under-estimated, and the effect on communities and schools is severely detrimental. Therefore, by researching, understanding and learning more about all the processes, risk factors and fundamental causes that are associated with suicide, many more lives than that small percentage can be saved.