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Article Excerpt
Mental health counselors identify treating suicidal clients as one of the most stressful aspects of their work. Treating suicidal adolescents poses a range of additional challenges. Literature on suicidal behavior continues to grow and potentially efficacious treatments are being developed, however clinicians in the field are provided few guidelines for treating suicidal clients. In this paper we provide a brief review of evidenced-based treatments with suicidal adolescents and offer guidelines for the treatment of suicidal adolescents within outpatient settings. We conclude with a brief overview of special considerations for treating adolescents who are suicidal.
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Suicide remains a significant cause of death in the United States, particularly among youth. Suicide is the third leading cause of death among 15 to 19 year olds (National Center for Health Statistics, 2004), and rates of death from suicide increase with age from childhood through adulthood (Gould, Greenberg, Velting, & Shaffer, 2003). Consistent findings from the Youth Risk Behavior Survey conducted by the Center for Disease Control and Prevention have shown that significant numbers (e.g., 16.9%) of high school students reported serious suicidal ideation with plans in the proceeding year (Grunbaum, Kann, Kinches, et al., 2004). Furthermore, Grunbaum et al. (2004) documented that 8.5% of high school students reported attempting suicide within a 12-month period, and 2.9% made an attempt that required medical intervention. Thus, suicide remains a considerable problem among youth.
Suicidal behavior, including ideation and attempts, is one of the most commonly encountered emergencies for the mental health clinician (Beutler, Clarkin, & Bongar, 2000; Pope & Tabachnick, 1993), up to 20% of whom will have a client who dies by suicide during treatment (Campbell, 2006; Chemtob, Hamada, Bauer, Kinney, & Torigoe, 1988). Unfortunately, clinicians are often not adequately prepared for managing and treating suicidal clients (Bongar, 2002). Utilization of inpatient hospitalization for suicidal clients has significantly decreased in recent years due to the effects of managed care and findings that hospitalization confers little to no positive treatment effect (Comtois & Linehan, 2006; Rissmiller, Steer, Ranieri, Rissmiller, & Hogate, 1994). As a result, much of the responsibility for the care of a suicidal client falls upon clinicians working in outpatient care settings. Unfortunately, clinicians lack clear guidelines for treating suicidal persons; particularly suicidal youth. Our primary goals for this review are to provide a brief overview of empirically supported treatments for suicidal adolescents and to offer empirically based guidelines for working with suicidal youth. We will also briefly address special challenges specific to treating adolescents who are suicidal.
EMPIRICALLY SUPPORTED SUICIDE TREATMENT
The empirical literature regarding the treatment of suicidal persons is remarkably sparse, particularly with regard to suicidal adolescents (Gould et al., 2003; Hawton, et al., 1999; Miller & Glinski, 2000). Conclusions drawn from reviews of randomized controlled trials and uncontrolled studies of suicide treatments with adult samples are mixed at best. Generally, it appears as though cognitive-behavioral interventions that incorporate a problem-solving element have promise for reducing suicide ideation, attempts, and symptoms of concomitant disorders (Comtois & Linehan, 2006; Hawton, et al., 1998; Rudd, 2000). Furthermore, in a recent study of cognitive therapy, Brown and colleagues (2007) found that suicidal patients who received l0 sessions of cognitive therapy had significantly fewer suicide attempts and lower rates of depression at 18 months post-treatment. While it would appear that cognitive-behavioral based approaches may be best, other treatment modalities, such as interpersonal psychotherapy, have shown promise for reducing suicidality (e.g., Guthrie et al., 2001; Jobes & Drozd, 2004; Tryer et al., 2003). Based upon the limited existing research, it is premature to conclude that there is a single, preferred treatment approach for suicidal adults.
While much of the existing treatment literature relevant to suicidal adolescents focuses upon reducing co-occurring disorders such as depression (Emslie, Kratochvil, Vitiello, & CSCS, 2006; March, Silva, Vitiello, & TADS Team, 2006; TADS team, 2004), there are a few studies that have directly target suicidality. The approach predominantly used within these studies consisted of a cognitive-behavioral and problem-solving orientation, and were delivered through highly varied formats ranging from individual psychotherapy to intensive home-based interventions.
Individual Psychotherapy Approaches
We were only able to identify three controlled studies of individual psychotherapy for suicidal adolescents. In the only known randomized controlled trial, Donaldson, Spirito, and Esposito-Smythers (2005) randomly assigned adolescents who previously attempted suicide into one of two treatment conditions: skills-based treatment (SBT) or supportive relationship treatment (SRT). The authors hypothesized that SBT would be more effective than SRT in reducing suicidal ideation and future attempts; however, the results did not support the hypothesis. Adolescents in both treatment groups had significant reductions in all symptom areas. However, a particular flaw to this study was that both treatments were provided by the same clinicians so it is unclear whether the lack of difference between groups is due to treatment carryover confounds.
More promising, are results from a pilot study of cognitive-behavioral therapy for suicidal adolescents with co-occurring alcohol abuse. Esposito-Smythers, Spirito, Uth, and LaChance (2006) enrolled six adolescents in outpatient therapy that utilized individual cognitive-behavioral psychotherapy with family sessions as needed. At the end of the treatment period, five participants had completed treatment and all showed significant decreases in alcohol use and suicidality, although two of the five had re-attempted suicide. The sample size is too small to draw strong conclusions, but the results provide tentative evidence that outpatient cognitive-behavioral treatment of high risk suicidal adolescents is feasible and potentially effective. Further supporting this idea, are results from Rathus and Miller's (2002) quasi-experimental study of dialectical behavior therapy (DBT) with suicidal adolescents. The treatment consisted of 12 weeks of individual therapy and a family skills-training group (see Miller, 1999). At the end of treatment, adolescents in the DBT group had significantly fewer hospitalizations, higher rates of treatment completion than the treatment as usual group, as well as significant reductions in both suicidal ideation and general psychiatric symptoms from pre- to post-treatment. Based on these studies, it appears individual psychotherapy combined with family-based interventions that focus on skill building may prove useful in reducing suicidal behavior in adolescents. However, randomized controlled trials of specific individual treatments are greatly needed before strong conclusions can be drawn regarding effectiveness.
Group Therapy
Many group therapies for suicidal adolescents utilize a psychoeducational and skills-building approach that target areas such as social problem-solving and relationship building, which...
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