Article

Self-harm and suicide in adolescents.

Centre for Suicide Research, University Department of Psychiatry, University of Oxford, Oxford, UK.
The Lancet (Impact Factor: 39.21). 06/2012; 379(9834):2373-82. DOI: 10.1016/S0140-6736(12)60322-5
Source: PubMed

ABSTRACT Self-harm and suicide are major public health problems in adolescents, with rates of self-harm being high in the teenage years and suicide being the second most common cause of death in young people worldwide. Important contributors to self-harm and suicide include genetic vulnerability and psychiatric, psychological, familial, social, and cultural factors. The effects of media and contagion are also important, with the internet having an important contemporary role. Prevention of self-harm and suicide needs both universal measures aimed at young people in general and targeted initiatives focused on high-risk groups. There is little evidence of effectiveness of either psychosocial or pharmacological treatment, with particular controversy surrounding the usefulness of antidepressants. Restriction of access to means for suicide is important. Major challenges include the development of greater understanding of the factors that contribute to self-harm and suicide in young people, especially mechanisms underlying contagion and the effect of new media. The identification of successful prevention initiatives aimed at young people and those at especially high risk, and the establishment of effective treatments for those who self-harm, are paramount needs.

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    ABSTRACT: Although the treatment of suicidal adolescents is complex and may be daunting to many clinicians, it continues to play an important role in suicide prevention. In this paper, we use case material to address questions that arise in psychotherapy, including the contending priorities of understanding the suicidal act in order to prevent repetition, versus connecting emotionally with the patient in the therapeutic relationship; and the use of an evolving understanding of the complexity of suicide that develops over time as patient and therapist engage in a deepening relationship which fosters life-sustaining development and psychic change. We present a case description of a patient in later adolescence, who began intensive psychoanalytic psychotherapy after a suicide attempt and explore key components of therapeutic action. From this discussion we emphasise the relational aspects of the transference and countertransference that enables interpretation and increased therapeutic receptivity through collaborative interaction. We conclude that collaborative interaction is foundational for therapeutic action with suicidal adolescents.
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    ABSTRACT: Worldwide, suicide among young men is a major public health concern in most countries. In Norway, as well as abroad, in spite of great efforts invested, we still have scarce scientific evidence of effective prevention strategies, and suicide rates among young men remain high. The failure of effective prevention may be related to the fact that most studies of suicide are based on clinical populations, and the detection and treatment of mental disorder is the main focus in suicide prevention strategies. Yet, a large portion of suicides are not preceded by symptoms of mental disorder (i.e. non-clinical suicides). However, research on non-clinical suicide is almost totally lacking. To further improve our ability to prevent suicide, a broader research focus is needed to understand the complexities of suicides among young men outside the mental illness paradigm. The present study was undertaken to provide a deeper understanding of the role of age, gender and the underlying psychological mechanisms, such as self-esteem, that regulate the dynamics in suicide among young non-clinical men, and thereby to provide knowledge that may lead to new issues for prevention. The three studies included in this dissertation utilised a unique dataset, consisting of 120 in-depth interviews and 12 suicide notes relating to 20 suicides among individuals with no prior psychiatric treatment and no previous suicide attempts (Dieserud, 2006). A sub-sample, consisting of ten cases of young men, aged 18-30, was the focus of this study. The first aim was to provide a deeper understanding of the role of self-esteem in the suicidal process of young non-clinical men who took their lives in the transition period from late adolescence to young adulthood (paper 1). In paper 2, the aim was to explore developmental issues and experiences of the deceased which may have left them vulnerable to suicide when facing adult challenges and defeats. Finally, the aim in paper 3 was to identify any signs in the period immediately before the young men ended their life that might have indicated risk of suicide in near term. All studies are qualitative, phenomenological and hermeneutical, utilising the competence of those close to the deceased; i.e. how they themselves were trying to understand how “he” so suddenly and unexpectedly could end his own life. In-depth interviews with mothers, fathers, male friends, siblings and (ex-)-girl friends brought forward how each one of them experienced the deceased and his conduct in all its complexity. In total 61 interviews, as well as six suicide notes, were analysed guided by Interpretative Phenomenological Analysis (IPA). The findings show that for these young men, the transition to young adulthood, a period of major life challenges, seemed to be associated with deficiencies in the affective capacity to regulate personal defeats. A main finding was that the understanding of these suicides was linked to how a discrepancy between ideal and actual self-performances appeared unsolvable. The analyses pointed to a psychological logic of suicide as a way out of unbearable mental pain; pain that was related to a collapse in the regulation of self-esteem. Developmentally, these young men appeared to have compensated for their lack of self-worth by exaggerating the importance of success and being successful and thus developed a fragile adult achievement based self-esteem, which left them vulnerable in the face of rejections and perceptions of failures. The vulnerability in these young men seemed to be related to how their indispensable efforts to achieve in relation to neglectful or judgemental fathers/father figures left them trapped in anger, and how their dependency in the relationship with their mothers rendered them weak and shameful. Consequently, it may be assumed that the intolerable discrepancy between ideal and actual self, when reaching adulthood (paper 1), is associated in particular with experiences of shame; from being unable to meet significant others’ ideal standards (paper 2). Contrary to previous research, suggesting that mental illness, and in particular depression, in the period prior to death is an important risk factor for suicide, few of the informants mentioned depression or other mental illnesses in their narratives. Thus, the analysis of the role of self-esteem regulation in the suicidal process of young men who in spite of accomplishment and success, unexpectedly took their lives in young adulthood (papers 1 and 2) provides knowledge that may increase our understanding of non-clinical suicides, which is of importance for tailoring better prevention strategies. A major challenge in this respect is related to the fact that most young men who take their own lives are not in contact with, nor seek help from, any health professionals prior to their death. Despite a vast amount of research on clinical risk factors for suicide, research on warning signs is scarce. Thus, the last part of this study was conducted to identify possible warning signs of non-clinical suicides among young men. According to the informants, the young men did not disclose any plans of suicide or make any direct request for help prior to death. Four indirect signs, related to the psychological condition of the young men in the period prior to ending their life, were identified: 1) repeatedly pointing to the irreversibility of a mistaken decision; 2) the desperation they felt in this respect; 3) using their own death as a threat; and 4) and referring to death as a place to go (paper 3). In summary, because non-clinical suicides are not preceded by identifiable symptoms of mental disorder, and most young men who take their life do not seek help prior to death, the present findings underscore that talk or actions indicating suicidality, as well as worrisome indirect appeals for emotional support, should not be left unquestioned, but rather explored directly with the person. Such interpersonal inquiries may mediate some understanding that despair and threats, as well as withdrawal, may be appropriate responses at a personal level, without being effective for problem solving at a social level. Guidelines to increase responsibility for young men under conditions of despair and isolation may carry the potential to save lives.
    03/2014, Degree: PhD Psychology, Supervisor: Kari Dyregrov, Hanne Haavind, Gudrun Dieserud
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Although the treatment of suicidal adolescents is complex and may be daunting to many clinicians, it continues to play an important role in suicide prevention. In this paper, we use case material to address questions that arise in psychotherapy, including the contending priorities of understanding the suicidal act in order to prevent repetition, versus connecting emotionally with the patient in the therapeutic relationship; and the use of an evolving understanding of the complexity of suicide that develops over time as patient and therapist engage in a deepening relationship which fosters life-sustaining development and psychic change. We present a case description of a patient in later adolescence, who began intensive psychoanalytic psychotherapy after a suicide attempt and explore key components of therapeutic action. From this discussion we emphasise the relational aspects of the transference and countertransference that enables interpretation and increased therapeutic receptivity through collaborative interaction. We conclude that collaborative interaction is foundational for therapeutic action with suicidal adolescents.
    Psychoanalytic Psychotherapy 01/2015; 29(1). DOI:10.1080/02668734.2015.1004188

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