“Mind Yourself”: The development of an evidence based suicide prevention programme for Irish adolescents
Kiera Cosgrove & Dr. Paul Gaffney
Rath na nÓg, Ireland
In order to fully appreciate the methods employed to prevent suicide in young people, it is important to examine some of the individual factors influencing suicidality. Factors considered in this paper include depressive disorders, hopelessness and problem-solving deficits along with some environmental and situational considerations. In addition to discussing examples of feedback from young people, consideration is given to the possible role of optimism and Cognitive Behavioural Therapy in suicide prevention for adolescents. In conjunction with this, some current thought on general youth suicide prevention strategies and possible future directions are discussed. This is all undertaken with particular reference to how this was applied to the design and development of an Irish suicide prevention programme for adolescents called “Mind Yourself”.
Evidence Based Approach to Programme Development
“Mind Yourself” is the name given to a suicide prevention project for adolescents that operates in the counties of Cavan and Monaghan in Ireland. The programme that has been developed by this project is an evidence-based mental health promotion and prevention programme. This programme has been designed based upon the evidence as outlined in this paper. The programme is intended for use is a range of environments, from schools to early-school leavers’ programmes to high support care residential units.
In developing the Mind Yourself programme the primary consideration was a strong evidence base should guide the programme development. This meant drawing upon published scientific research evidence and on the experience of those working in suicide prevention. In Ireland, such an approach has been endorsed at a national level by “Reach Out: National Strategy for Action on Suicide Prevention” (2005). Another major consideration in designing the programme was the involvement and input of young people’s perspectives in the development of a programme that aims to work with them. This was felt to be necessary in order to keep the programme youth-focused and to make it more meaningful for the young people who would participate in it.
What follows in this paper is a review of the literature that created the evidence base for the development of the “Mind Yourself” programme. The inclusion of young people’s perspectives is discussed and included as a part of this evidence base. It is felt that this inclusion is a validation of young people’s input into programmes that aim to work with them. This position enables the programme to remain focused on its relationship with the youth population while staying grounded in a scientific evidence base.
Individual Factors in Suicidality
Many factors have been associated with suicidal ideation and suicidal behaviours in young people. Some of these are external, such as the occurrence of stressful life events (e.g. interpersonal losses), or family factors (e.g.,family history of suicidal behaviour) (Gould & Kramer, 2001). Here however, we are going to concentrate on factors that are more internal in nature such as depressive disorders and cognitive factors. (Gould & Kramer, 2001). The following is not a comprehensive list of internal factors, but rather, highlights some that would be of particular interest in the development of a suicide prevention programme for young people.
A clear link has been demonstrated between adolescents experiencing depressive symptoms and an increased risk of suicidal thoughts and behaviours (Evans, Hawton and Rodham, 2004; Thompson, Mazza, Herting, Randell & Eggert, 2005). In addition to this strong and direct relationship, increased anxiety and low self-esteem appear to be co-morbid with depression (Evans et al, 2004; Thompson et al, 2005). Unsurprisingly, symptoms of depression such as sleep problems (e.g. tiredness, nightmares and difficulties sleeping) and impaired self-esteem have shown to be associated with suicidal phenomena (Evans et al, 2004). There is a strong direct association between lowered self-esteem and suicidal ideation and behaviours (Evans et al, 2004).
Hopelessness, another symptom of depression, has also been shown to have an association with suicidality (Gould & Kramer, 2001). Thompson et al (2005), for example, have shown direct effects of hopelessness on suicidal behaviour for adolescent males and females. It has also been shown to be associated with completed suicide in youth (Schaffer et al, 1996).
Hopelessness has not, however, consistently proven to be an independent predictor of suicidal behaviour once depression has been taken into account (Gould, Greenberg, Velting and Schaffer, 2003; Evans et al, 2004). Ellis (2001) reports that hopelessness has been shown as a key mediator between depression and suicidality with significant predictive validity. This finding appears important in addressing the role of hopelessness in the individual at risk of suicide, particularly where other depressive symptoms co-exist.
Levels of hopelessness may be linked to coping skills. Elliott & Frude, (2001) found that the increased use of problem-focused coping strategies by self-poisoners, for example, was significantly related to their exhibition of decreased levels of hopelessness. An example of a problem-focused coping strategy might be where the individual takes active steps to remove the stressor or lessen its negative effects.
Poor interpersonal problem-solving ability has also been reported to differentiate suicidal from non-suicidal youths, even after adjusting for depression (Gould et al, 2003; Gould et Kramer, 2001). This research emphasises the necessity to focus on relationships young people have with each other, their families and all those they come into contact with. Irish research has also associated suicidal ideation and behaviours and problem-solving deficits (McAuliffe, Corcoran, Keeley & Perry, 2003).
Further, in relation to problem solving, is Ellis’ (2001) description of suicidal patients having shown themselves to have a greater tendency to believe that their emotional problems are caused by external events. In addition to this, Reinecke and Didie (2005) describe the hypothesis that when faced with an external stressor, a suicidal individual is unable to generate solutions (i.e. helpless) and consequently, they become progressively overwhelmed and hopeless in the face of their problems.
The above evidence suggests that we need to think carefully about the role of helplessness as well as hopelessness when working to prevent suicidal behaviours in young people.
Environmental and Situational Considerations
Some other factors to take into consideration are around alcohol, other drugs and sexual behaviour. Excessive alcohol use has been associated with suicidal behaviour and this association is probably direct (Evans et al, 2004). Incidents of deliberate self harm with suicidal intent increases with consumption of stronger alcohol (e.g. spirits). Drug taking has been associated with increased incidence of suicide ideation and suicide attempts. With harder drug use, the link has shown to be more direct (Evans et al, 2004).
Smoking was also linked to suicide ideation and suicide attempts, but it is unclear whether the association is direct. For young adolescents, there was a significant association between suicidal phenomena and engaging in sexual intercourse (Evans et al, 2004). Perhaps this reflects an increase in risk-taking behaviours among these young people.
What do young people have to say?
The UN Convention on the Rights of the Child (1989) was ratified by 192 countries as of November 2003. Article 12 of the Convention enshrines the right of children to express their views in all matters that concern them and requires these views to heard and given due weight in accordance with the child’s age and maturity. It is important, therefore, that young people are consulted and listened to as well about matters regarding their own mental health for, as Sullivan, Arensman, Keeley, Corcoran and Perry, (2004) have pointed out, adolescents will give invaluable insight into what is going on for them when they are asked.
Over 3,800 young people in the counties of Cork and Kerry in southern Ireland completed The Lifestyle and Coping Survey (Sullivan et al, 2004). Young people (15-17 years old) were asked about the kinds of problems that they face and how they coped with them. These young people indicated that they most often look to their relationships with friends, family and other resources when they are going through difficult times. For example, most said that they would talk to someone if they were worried or upset. The young people said that if they had a problem, they would most often go to friends to talk. After friends, the next person they were likely to talk to was their mother, then to their brother/sister, and then to their father. They also expressed a desire to know how to help each other out during such times. This opens up an opportunity to strengthen the abilities that young people have to help each other through difficulties. By highlighting the importance of their relationships with friends and family, the young people can be shown how they already have opportunities to help within their everyday interactions.
These young people were also asked to make recommendations as to what they thought could be done to improve things for young people. The report from this study, which included recommendations in promoting positive mental health for young people, included points such as:
• Give young people relevant and meaningful information on mental health.
• Regularly ask young people about what kind of information they want to hear.
• Make young people more aware of the help and treatment services that are out there.
• Make sure that services that are provided for young people are ‘youth friendly’.
• Give young people information so that they will look for help if they are going through a tough time.
• Makes it easier for young people to look for help in schools and in the community.
• Teach young people and their families what they can do if their friends or children/brothers/sisters are going through a difficult time.
The East Cavan Project (Russell, Gaffney, Collins, Cahill, Stewart, Bergin and Lowry, 2002) asked 71 young men in the East County Cavan in Ireland about the kinds of problems they faced. When they were asked to suggest ways of promoting positive mental health for young people, they thought that school was the best place to promote awareness about mental health difficulties. They also said that while it was really quite easy to access help for problems if you wanted to, they would be unlikely to go in search of such help.
In extrapolating from these findings to develop a suicide prevention strategy, the following points are to be noted:
• Information and services should be made as accessible as possible to young people.
• An attempt should be made to destigmatize help-seeking behaviour.
• Young people should be equipped with skills to identify internal and external resources for coping with problems.
• Young people should have a say in how information should be presented to them to ensure that it is “youth friendly”.
The above points should be carefully considered in examining the relationships between young people and the services that exist to help them. Accordingly, these services need to listen to young people in order to relate and respond in a real way to their needs when they are experiencing difficulties. Furthermore, it is important to consider the above points in conjunction with the results of evidence-based prevention approaches, when considering the development of programs for youth..
General Youth Suicide Prevention Approaches
Given that individual factors discussed above have been shown to be correlationally associated with suicide and suicidal behaviours, it would be reasonable to expect a suicide prevention programme to address these areas. There is some evidence to show that such an approach is useful in suicide prevention and may be more effective than a more direct, ‘suicide awareness’ style of programme (Harden, Rees, Sheperd, Brunton, Oliver & Oakley, 2001; Patton & Burns, 1998; Gould et al, 2003; Gould & Kramer, 2001). It is important to note, however, that when suicide prevention programmes for young people are based solely on suicide awareness education, there is limited evidence for resultant prevention of suicide (Harden et al, 2001; Patton and Burns, 1998; Gould, Greenberg, Velting and Schaffer, 2003). Patton and Burns (1998) found that when suicide prevention is incorporated into a broader holistic life skills approach more consistent evidence of effect is shown but the efficacy of the suicide – specific element is uncertain (Gould et al, 2003).
Carr (2002) further supports this point of view, in his review of psychological prevention programmes for children and adolescents. When discussing suicide prevention, he recommended multisystemic prevention programmes, which include school, based didactic instruction and discussion, bibliotherapy, and behavioural–coping skills for adolescents and other members of their social networks. In their review of suicide prevention strategies, Harden et al (2001) found that education combined with general coping skills training did have beneficial effects on suicidal potential and depression. Furthermore, they found that workshops on inner experiences and life difficulties reduced suicidal tendencies and increased coping, but did not reduce hopelessness. Skills training programmes emphasize the development of problem solving, coping, and cognitive skills, as suicidal youths appear to have deficits in these areas (Gould et al, 2003).
The Youth Suicide Prevention: Evidence Briefing (2004) was carried out by the Public Health in Ireland and NHS Health Development Agency. They conducted a review of reviews on suicide prevention strategies. Their overall finding was that holistic, multidimensional self-esteem based programmes were found to have positive impacts on young people’s mental wellbeing. O’Connor & Sheehy (2000) proposed five general education and prevention strategies that fit in with the above recommendations for a holistic approach to suicide prevention for young people:
1. Promote the importance of communication. They place particular emphasis on the importance of encouraging males to communicate their worries and anxieties. This suggestion is founded on the findings of research that shows at-risk individuals to have difficulty communicating with others.
2. Young people should be educated in coping strategies. Proactive coping strategies should form part of education packages and these coping strategies should draw on communication.
3. Destigmatise stressors and difficulties with coping. Change the perception that inability to cope with a stressful situation is a personal weakness.
4. Destigmatise affective disorders (e.g. depression). Educate the general population as to the prevalence of depression and suicide risk in general.
5. Promote awareness of existing services and destigmatise counselling and other helping services. Publicise the existence of these services and encourage young people to avail of them in times of distress.
The holistic approach that is recommended through the above strategies relies upon strong communication. This communication is integral in destigmatising mental health difficulties at individual and societal levels.
Resilience can be described as the capacity to survive, to progress through difficulty, to bounce back, to move on positively again and again. Children who are described as being resilient appear to be able to withstand and adapt to stress and underlying emotional distress and succeed despite it. Children who are able to do this can be expected to have a continued lower susceptibility to future stressors. (Garmezy & Rutter, 1988).
Benard (1992) identified 4 attributes characteristic of resilient children:
1. Social competence: This includes socially motivated qualities such as flexibility, empathy, communication skills and a sense of humour.
2. Problem solving skills: These might include the capacity for abstract thought, reflection and the ability to generate and implement alternate solutions to problems.
3. Autonomy: This incorporates qualities such as independence, perceived power and self-efficacy, impulse control and high self-esteem.
4. A Sense of Purpose: Healthy expectations, motivation and hopefulness give resilient children an optimistic view of the future.
The importance of social competence in building resilience highlights the significance of constructive relationships within a young person’s life. Similarly, security within relationships can add to a sense of autonomy and building upon self-esteem.
In his appraisal of suicide prevention strategies, Singh (2000) concludes that attempts in suicide prevention need to focus on both society and the individual in terms of increasing resilience and intervening appropriately. In terms of the individual, this may be addressed through psycho-education and focused therapy. Society intervention may incorporate the raising of awareness of suicide risk factors among the general public and attempts to reduce the stigma that often surrounds suicide and suicidal behaviour.
Hope and Optimism
Carr (2002) talks of the importance of nurturing hope and optimism. As hopelessness has been linked to suicidality and people suffering from depression and/or anxiety do appear to see things much more negatively, hope and optimism are important areas to focus on. Optimists tend to develop less health problems, do better at school/work and tend to cope with distress more constructively (e.g. coping after a loss). Carr suggests that we can help young people with hope and optimism by using the following approaches:
• When talking about past events, focus on more positive events (e.g., exams passed, good stories re child/friends, achievements, human qualities)
• Remember that we are all better and worse at some things and none of us can be good at everything all the time. To keep trying is more important
• Responding to events (e.g., problems with friends, bullying, disappointments) is more important than the events themselves as we can sometimes only respond. Model this for young people in how we respond
• Help the young person see that there is very rarely only one explanation for any event
• Help the young person see that we can always dispute positive and negative causes
The efficacy of the above approaches will depend greatly upon the relationship that exists between us the young person.
Individual Focused Interventions
Cognitive Behavioural Therapy and Suicide Prevention
Elliott and Frude (2001) recommend the development of coping skills, especially problem-solving skills through Cognitive Behavioural Therapy (CBT). Reinecke & Didie (2005) note that controlled outcome studies suggest that CBT can be effective for treating clinically depressed adolescents. Furthermore, CBT shows promise as a means of reducing suicidal ideations and behaviours (Barbe, Bridge, Birhamer, Kolko & Brent, 2004).
CBT provides for interventions that directly address problem-solving deficits and that aim to enhance the client’s abilities to identify problems and generate solutions. We have seen that all of these factors play important roles in suicidality so it is reasonable to hope that such CBT interventions might impede suicidal phenomena. The efficacy of CBT has already been shown in these areas (Barbe et al, 2004; Bryant, Harvey, Dang, Sackville & Basten, 1998; deAlmedia & Neto, 2003). More specific treatments, such as CBT, have been shown to be more effective in treating depressed adolescents than non-directive treatments such as Non-directive Supportive Therapy (NST) (Barbe et al, 2004).
When CBT was used to enhance social problem-solving abilities, levels of suicidality and hopelessness were reduced, whereas social problem-solving ability, positive self-perceptions and a perceived ability to cope with problems were increased. Problem-solving therapy was found to be more effective than treatment-as-usual for suicidal young adults and these gains were maintained 12 months later (Reinecke & Didie, 2005).
To address the role of helplessness in suicidality, it is hoped that by enhancing problem-focused and emotion-focused coping skills through CBT, depression and hopelessness will be reduced. The reduction of these factors may, in turn, reduce suicidality. To address the role of hopelessness in suicidality, a CBT approach would need to address the young person’s sense of pessimism and demoralisation. Focus should instead be placed on effective problem-solving methods and optimism.
Developing Youth Suicide Prevention Strategies
There is much to be taken from the material examined above. A range of elements need to be taken into account: factors involved in suicidal phenomena; the recommended approaches to suicide prevention from the relevant literature; the role of hope and optimism and Cognitive Behavioural Therapy in suicide prevention; and what young people tell us that they want.
In combining these elements it is possible to see an appropriate way forward in developing an intervention programme for young people. Essential features of such an intervention might include:
• A holistic life-skills approach encompassing coping and problem-solving skills.
• A strengths-based approach, which focuses on hope, optimism and is solution-focused.
• A relational approach that will take into account the impact young people’s relationships has on the way in which they view themselves; how they cope with their problems; and how they access resources when experiencing difficulties in their lives.
• A whole population approach to working with young people. This way, those who are more “at risk” but may never come into contact with services might be reached.
• A community based approach that will remember to consult young people on their needs.
• A firm grounding in CBT strategies to enhance problem-solving skills and emphasise optimism and promote resilience among adolescents.
• The provision of information on resources and services available to young people.
• An empirical evaluation of the intervention programme so as to measure its effects on helplessness and hopelessness. Levels of depression, self-esteem, problem-solving strategies, coping methods etc. might be looked at here.
From the evidence discussed, it seems reasonable to assume that suicide prevention programmes for young people should address their need to develop the coping skills we all require to deal with life’s stressors. Another desirable facet of such a programme would be for it to be developed within a community context wherein we all take responsibility for the roles we play in young people’s lives.
The “Mind Yourself” Programme
Having based its design on the evidence as presented above, the “Mind Yourself” programme has been constructed as an evidence-based mental health promoting and prevention programme. The following is a brief outline of how this was done and what the programme entails.
Young people were consulted in focus groups as to how they would like the programme to be presented to them and what areas they felt it were important that it cover. Based on the feedback from these focus groups and in conjunction with the recommendations as reached in this paper, the programme was developed.
Features of the “Mind Yourself” programme are:
• A two session intervention targeted at an audience of older adolescents (15-17 year olds)
• It is a CBT based programme encompassing exercises in coping and problem-solving skills training.
• The programme employs a strengths-based approach focusing on optimism.
• The programme adopts a relational approach wherein the relationship between the facilitators and the young people is key in identifying the resources that are available to the young people.
• The programme is offered to all secondary schools and early school-leavers programmes in the area
• A “Resource Kit” is given out to each participant in the programme. This kit comprises of information on various topics that have been identified as relevant as well as listing of contact details for many local, regional and national services.
This programme is to be fully evaluated by examining its effect on measures such as depressive symptoms, anxiety and problem-solving skills among the young people who participate in the intervention.
The “Mind Yourself” programme aims to follow the evidence-based, mental health promoting strategy of suicide prevention for adolescents as is outlined in this review. It is necessary to test the feasibility of operating such programmes with groups of young people while concurrently trying to reach the broadest possible audience. To further measure the efficacy of this strength-based, life-skills focused approach, evaluation of programmes such as “Mind Yourself” is necessary. The future directions indicated in this review recommend moving out to put these theories into practice in the community and then comprehensively evaluate the resulting effects.
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