Table Of ContentSUICIDE IN ADOLESCENCE
Suicide in Adolescence
edited by
RENE FW. DIEKSTRA & KEITH HAWTON
•
1987
MARTINUS NIJHOFF PUBLISHERS
A MEMBER OF THE KLUWER ACADEMIC PUBLISHERS GROUP
DORDRECHT -BOSTON -LANCASTER
IV
Distributors
for the United States and Canada: Kluwer Academic Publishers, P.O. Box 358, Accord Station,
Hingham, MA 02018-0358, USA
for the UK and Ireland: Kluwer Academic Publishers, MTP Press Limited, Falcon House, Queen
Square, Lancaster LAI IRN, UK
for all other countries: Kluwer Academic Publishers Group, Distribution Center, P.O. Box 322,
3300 AH Dordrecht, The Netherlands
Library of Congress Cataloging in Publication Data
Main entry under title:
Suicide in adolescence.
Includes indexes.
1. Youth--Suicidal behavior--Addresses. essays,
lectures. 2. Suicide--Prevention--Address€s, essays,
lectures. I. Diekstra, R. F. W. II. Hawton, Keith,
1942- [ONLM: 1. Adolescent Behavior. 2. Suicide--
in adolescence. 3. Suicide--prevention & control.
HV 6546 59482J
HV6546.S8341986 362.2 85-29779
ISBN-13: 978-94-010-8388-1 e-ISBN-13: 978-94-009-4253-0
001: 10.1007/978-94-009-4253-0
Copyright
© 1987 by Martinus Nijhoff Publishers, Dordrecht.
Softcover reprint of the hardcover 1st edition 1987
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system,
or transmitted in any form or by any means, mechanical, photocopying, recording, or otherwise,
without the prior written permission of the publishers,
Martinus Nijhoff Publishers, P.O. Box 163, 3300 AD Dordrecht, The Netherlands.
v
Contents
Editors and Contributors VII
Introduction
P ART I Trends and factors 5
1. Suicidal behaviour among adolescents: an overview 7
Rene F. W. Diekstra and Ben 1.M. Moritz
P ART II The suicide of an adolescent girl 25
2. Renee: chronicle of a misspent life 27
Rene F. W. Diekstra
3. Renee or the complex psychodynamics of adolescent suicide 43
Rene F. W. Diekstra
PART II I Assessment and treatment 77
4. Assessment and aftercare of adolescents who take overdoses 79
Keith Hawton
5. Family therapy and psychotherapy following suicidal behaviour by
young adolescents 95
Michael Kerfoot
6. Assessment of suicidal behaviour in young children: case
demonstrations 113
Israel Orbach
PART IV Family and suicide 125
7. Families of suicidal children 127
Cynthia R. Pfeffer
8. The role of the family in suicide l39
Norman L. Farberow
PART V School and suicide 153
9. School and suicide: education for life and death 155
Charlotte P. Ross
VI
10. 'ASAP' - an Adolescent Suicide Awareness Programme 173
Diane M. Ryerson
Subject index 191
Author's index 195
VII
Editors and contributors
Dr. Rene F. W. Diekstra is professor of Clinical Psychology and Psychotherapy at
the University of Leiden, the Netherlands. He is director of the nation's leading
research group on depressive disorders and suicidal behaviour, and author of over
one hundred articles and several books on suicide research. He was the first to
receive the Stengel Award from the International Association for Suicide Prevention
and Crisis Intervention for his work in this field.
Dr. Keith Hawton is a Consultant Psychiatrist at the Warneford Hospital, Oxford,
lecturer in Clinical Psychiatry at the University of Oxford, UK, and one of the
leading psychiatric researchers in the field of suicidal behaviour. He has published
widely on the problem of attempted suicide, including the recent book "Attempted
Suicide: A Practical Guide to Its Nature and Management" (with Catalan, 1982).
Dr. Norman Farberow is Clinical Professor of Psychiatry (Psychology), University
of Southern California, School of Medicine. He is also founder and co-editor of the
Los Angeles Suicide Prevention Center, the first of its kind in the world. Prof.
Farberow is one of the world's leading scholars in the suicide research field, and
author of numerous articles and books. He is also a former president of the
International Association for Suicide Prevention and Crisis Intervention.
Dr. Michael Kerfoot is lecturer in Child and Adolescent Psychiatry, Department of
Psychiatry, University of Manchester, UK. He is author of several publications on
family relationships and suicidal behaviour.
Ben J.M. Moritz is lecturer in Clinical Psychology, University of Leiden, the
Netherlands, and currently carrying out research into the effects of suicide on
survivors.
Dr. Israel Orbach is lecturer in Psychology at the Department of Psychology, Bar
Han University, Israel, and had previously been affiliated to the University of
California, Los Angeles. He has made extensive investigations of children's
attitudes towards life and death and their relationship with suicidal behaviour, and
has regularly published on this subject.
Dr. Cynthia Pfeffer is an Assistant Professor of Psychiatry of the Cornell
University Medical College, and Chief of the Child Inpatient Unit of the New York
Hospital-Westchester Division. She is rapidly becoming one of the leading scholars
in suicidal behaviour among children, and has in recent years published extensively
on the subject.
VIII
Dr. Charlotte Ross is Director of the Suicide Prevention and Crisis Intervention
Center, San Mateo, California. She has written about a variety of the problem of
suicide and had recently begun a project on suicide prevention in schools. Currently
she also acts as the general secretary of the International Association for Suicide
Prevention and Crisis Intervention.
Diane M. Ryerson, is Coordinator Consultation and Education Services at the
South Bergen Mental Health Center, Inc., South Bergen, NY, USA. Since 1980 she
has been the director of ASAP, the Adolescent Suicide Awareness Program,
initiated at the centre.
Introduction
The official death rates from suicide vary considerably between countries in the
world for which data are available. They range from 3 to 45 persons a year, per
100,000 of population. Historically, the higher rates of suicide are in the older age
groups and in males. However, the general trend in the last twenty years has been
for suicide increasing in the younger age groups (15-34) and in femah;s. It has been
suggested that thi~ development is related to the phenomenon of attempted suicide,
of which the rates in most industrialized countries have doubled and in some
countries even tripled over the past two decades. The average rate of attempted
suicide is now estimated to be around 200 per 100,000 for males and 350 for females.
Almost two-thirds of these occur before the age of thirty. Although the majority
of attempted suicide are not intended to be lethal, once a suicide attempt has been
made, there is more likelihood of subsequent death by suicide. As many as ten
percent of people who have made a previous unsuccessful attempt commit suicide
at a later stage in their lives. rersons with increased likelihood to commit suicide
are youngsters from disrupted families and from families with a history of suicide,
drug and alcohol addiction, those who have failed at school, the unemployed and
those suffering from depression. The fact that both suicide and suicide attempt rates
are increasing most among the younger age groups may be attributed to the greater
vulnerability of young people to the social conditions that accompany economic and
cultural instability.
The focus of this book is therefore the group in which suicidal behaviour is
showing greatest increase, namely the young, and especially adolescents. Attention
is also paid to the relatively small, but nonetheless important problem of suicidal
behaviour among children and young adolescents.
In the light of the facts presented in the following pages, it will become apparent
that the scope for prevention of suicidal behaviour among young people is
considerable, comprising at least three main areas.
First, improving the underlying societal factors that seem to put strain on the
young individual - e.g. loss of career perspective, unemployment, school, stress,
family disruption - all of which suggest important possible means of intervention.
Although our present knowledge of the intricate web of contributory factors is
insufficient - and intensified research in this field is necessary - enough is known
to warrant positive action here and now.
Second, ways of strengthening the general ability of the young to cope with the
events of life - learning to cope includes learning how to evaluate situations,
recognize and utilize opportunities, make changes, and deal with periods of
transition, which are especially important during adolescence. The skills that enable
youngsters to control and direct their lives more effectively include the capacity to
formulate problems, find solutions and take decisions, to take part in social events
and resolve conflicts, to communicate effectively and to have the confidence to
2
question and intervene actively on their own behalf when necessary. Since
individuals, and especially youngsters, are rarely able to acquire and maintain such
skills on their own, strategies are needed that encourage family and wider
community networks to develop the coping ability of their members. The
establishment of more integrated and informed social networks and problem
solving groups in local communities for youngsters should be actively promoted.
Finally, since the majority of persons who commit or attempt suicide have been
seen shortly before by general practitioners or other health professionals, there has
often been an opportunity for preventive action. There is evidence, however, that
owing to lack of diagnostic and therapeutic training and skills, health professionals
are frequently not equipped to deal appropriately with suicidal patients. The same
applies to the staff of emergency and intensive care wards of general hospitals to
which attempted suicide cases are referred for medical treatment. Similarly, public
knowledge concerning the signs and circumstances of suicide risk is still relatively
sparse.
Both health personnel and the community should be involved in the detection,
assessment and care of those at risk. The training of health professionals should
include information on the social and clinical characteristics and management of
individuals most at risk, and on how to develop efficient policies for their after-care
and supervision in the community. Education of the public, and especially young
people in schools, in the causes and prevention of suicidal behaviour, and in the
management of life events that may lead to suicidal thoughts and actions, is
imperative. The aim of this book is to provide a thorough understanding of suicidal
behaviour in the young, through examination of trends and contributory factors,
and then to put forward systematic approaches to management and prevention.
Each author has been chosen because of his or her expertise in particular aspects
of this problem in young people. The following chapters therefore report much of
the latest thinking and work concerning this extremely important topic.
The first chapter and part of the book provide information on recent trends in
suicide and attempted suicide. It also gives an overview of social developments that
are associated with the rise in suicidal acts observed in western countries.
The next chapters centre upon the life and suicidal death of an eighteen year old
girl, Renee, who in more than one important aspect stands as a model for numerous
adolescents who die through their own hand. Chapter two essentially recognizes the
major experience and events that finally led to Renee's suicide, using diaries and
letters she left behind and information from interviews with her father. In the
following chapter an attempt is made to interpret these data within the framework
of prevailing theory and knbwledge on suicidal behaviour. In doing so, the format
chosen by Mack and Hickler (1981) in their beautiful book Vivienne: the suicide oj
an adolescent girl, was imitated with the purpose of providing the reader in a
personified way a profound insight into the complex dynamics of adolescent suicidal
behaviour.
3
Chapters four, five and six give a detailed presentation of currently available
methods of assessment and treatment of suicidal adolescents and children. In
Chapter four assessment and aftercare of adolescents (aged 12 - 18 years) who have
taken overdoses are discussed. Chapter five presents several possible therapeutic
interventions with suicidal youngsters, such as family therapy, individual therapy,
and, with specific regard to younger children, play therapy. The specific problems
posed by the assessment of suicidal intent and behaviour in younger children are
discussed in Chapter six.
The focus of Chapters seven and eight is both on the impact the family has on
suicide by children and adolescents as well as on the impact a child's suicide has on
the surviving family members.
The last two chapters of the book describe in detail the development, procedures
and evaluation of primary prevention projects aiming at educating adolescents and
significant others, such as parents and teachers, towards a better understanding of
and ability to cope with depression and suicidal tendencies. Both Chapter nine and
ten describe a programme for suicide prevention education in detail, illustrated with
examples of educational materials.
Although the programmes are of recent design and are still being modified and
revised, the experiences in working with them indicate that primary prevention
programmes in the area of suicidal behaviour are feasible and receive support both
from students, school personnel and the community. Although it is still too early
to say that such programmes have a substantial effect upon suicidal rates, they
certainly seem to be one of the most promising roads to an all important goal,
preventing the rejection and destruction of youth, that is prevention of avoidable
premature death.
