A risky partnership: Working with the adolescent suicide attempter

Adolescent Psychiatry,  2002  by Ponton, Lynn E

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I believe that the stories of our adolescent patients and their families best inform and educate us about clinical care. In this chapter, I address the topic of adolescent suicide with an overview of theoretical models, assessment of two adolescents and their families, epidemiology, treatment, related psychopathology, preventions, 10 guidelines for working with suicidal teenagers, and a summary.

Even the most skilled clinician can find the acute assessment of suicidal adolescents and their families difficult. Clinicians need to know how to identify those at greatest risk, but it is important to remember that, even with a complete assessment, the future behavior of a suicide attempter is not always predictable. Even the process of risk assessment can be viewed as a partnership-at times an uneasy or even unwilling one in which the clinician or, ideally, a team of clinicians works with the adolescent and his or her family with the goals of assessing the acute situation and determining what, for the teen, will be the best outcome.

Here I examine factors including whether suicidal behavior is predictable, circumstances of the suicidal behavior, psychopathology both in the family and in the adolescent, coping skills, communication skills of both the family and the adolescent, family support, and environmental stress.

I begin by briefly discussing two cases-Maura, a 16-year-old girl admitted to the emergency room of the hospital where I work after making several sharp gashes on her wrist with a razor (Ponton, 1997), and Alena, a 17-year-old girl admitted to the intensive care unit after taking an overdose of pills.

The predictability of Maura's suicide attempt initially seemed low, but my view of her changed after I spent more time with her and obtained more information. Her attempt was not planned, was only "moderately lethal," and took place near others (i.e., in a bathroom with friends from her soccer team). Maura told me that she was feeling sad and that she had been struggling with depression for several years.

In contrast, Alena's suicide attempt initially appeared to be highly predictable, but the predictability decreased as I discovered that her attempt was planned, had the potential for severe lethality, and had occurred when she was alone. She, too, struggled with depression, but she also showed some characteristics of borderline personality disorder.

Maura's father and stepmother had accompanied her to the emergency room. They had no prior knowledge of Maura's previous cutting episodes and had not recognized that she was struggling with depression and suicidal thoughts. Her father was a physician who felt that all that had to be done at the time of her admission to the emergency room was to repair the cuts she had made on her body and prevent scarring. Maura had cut herself after a soccer match at which she had felt berated by her father; she also believed that she was participating in the sport solely for him, not for herself. She had wanted to spend the afternoon of the match writing an English paper. The ongoing conflict between what she wanted and what her father wanted for her made her feel confused; she told me that, when she cut herself, she felt intensely alive and much more aware of her own feelings. Cutting her body allowed her not only to address some of her suicidal feelings but also to release some of the anger she felt toward her father. Initially, she reported that she was quite hopeless about her situation, that she felt powerless to change her father, and that she believed that she did not have very good impulse control. Her story remained consistent throughout the time I spent with her, beginning with our first meeting in the emergency room.

Family support was initially poor, but Maura's father and stepmother rallied after a family assessment session in which I outlined their daughter's behavior and indicated the high risk connected with it. There was significant additional environmental stress at the time of the cutting episode-stress related to the extreme pressure Maura felt at the academic high school she attended.

Alena, the 17-year-old who had taken pills, initially appeared to have a much higher predictability for a suicide attempt than Maura did. A number of things worked to change this. First, Alena's presentation altered dramatically over the course of four separate brief assessments (of approximately 20 minutes each) conducted over an afternoon. It became clear that Alena had planned her attempt with the pills. She had looked them up in the Physician's Desk Reference and found the lethal amount. She had been alone and had intended to die when she took the pills. It also became clear that she had made two prior attempts that she had told no one about. Her communication was quite inconsistent; she initially lied to me about the two prior attempts but highlighted them later in the interview process. She subsequently lied about the prior attempts with another interviewer later in the evaluation period, again demonstrating inconsistency. Alma's mother and father-her father was also a physician-did not want to believe that their daughter had made suicide attempts. This disbelief did not change over the course of the two- to three-hour period I spent with the family. It also surfaced that the parents had been made aware of the prior suicide attempts but had "forgotten" them. Like Maura, Alena came from a high-stress school environment and was facing serious academic pressure.