The Suicidal Adolescent

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The Suicidal Adolescent

By Nancy A. Hart Gladys C. Keidel

The thought of a teenager destroy- ing his young life is so appalling that one tends to minimize the extent of this problem. However, the adolescent suicide rate is rising dramatically; among 15 to 24 year olds the rate per 100,000 population was 4.0 in 1957, 10.9 in 1974, and 12.2 in 1975(1,2).

These figures become even more alarming when we realize that many suicides are not recorded as suicides but may be recorded as accidents.

For example, a physician may be reluctant to report a death as a suicide in order to "protect" a family he has served for a number of years. A death by suicide may be interpreted by the parents as a personal failure, whereas accidental death does not carry as heavy a burden of guilt.

Also, in many cases, it is very difficult to distinguish between a suicide and accidental death. Motor vehicle accidents rank as the second cause of death among young teenagers with a rate of 37.1 per 100,000(2). One-car accidents are often called "autocides" by suicidologists who believe that, in many cases, the driver chose to be involved in a fatal accident. An educated guess is that one-fourth of

Nancy A. Hart, R.N., M.A., is an assistant professor of pediatric nursing, Catholic Uni- versity, Washington, D.C. Her interest in suicide and the adolescent began in 1967 when she worked as a coleader for a senior high school church group.

Gladys C. Keidel, R.N., M.S.N. is an assistant professor at American University, Washing- ton, D.C. She is a psychiatric nurse who has also worked as a hot-line volunteer.

the drivers who die in auto accidents cause them subintentionally by reckless driving(3).

Other "accidental" deaths include drug overdoses and firearm accidents. Even homicides can be disguised suicides, as the suicidal person may provoke another person into anger in the hope that the ensuing fight will lead to his own death. The rate of death by homi- cide for the 15-to-24-year-old group is 13.3 per 100,000, and the rate for accidental deaths-the lead- ing cause of death among teenagers-is 58.7 per 100,000(2). It is frightening to realize that an incal- culable number of these deaths should properly be classified as suicides.

Why are teenagers taking their lives in increasingly greater num- bers?

Adults often think that adolescence is an ideal time of life because the typical middle-class teenager of today has money to spend, access to a car, many friends his own age, and few adult responsibili- ties. It is hard to comprehend why such a person would feel so desper- ate that suicide seems the only solu- tion.

The teenage years can be ex- tremely difficult and full of many stresses. The literature is replete with the psychological repercus- sions of being a teenager in society today. Some observers note that youth are more promiscuous sex- ually, less idealistic, and more criti- cal of the establishment than in previous times. They point to the increased use of drugs and alcohol, pregnancy, and venereal disease to show that the adolescent of today seems to be in more trouble than ever before.

Present-day social conditions

notwithstanding, adolescence as a state of development is a disrupting time even for a well-adjusted person. Indeed, "If the adolescent shows no signs of turbulence, important steps in development are being postponed or omitted."(4)

The central theme of adolescence is finding oneself. This leads to an intensified self-awareness- often seen as self-consciousness. The adolescent is concerned with his status in his peer group, and he strives to be as much like his peers as possible. At the same time, he is trying to be independent of his parents, but he needs their love and approval. A perceived lack of affec- tion and acceptance from parents and/or the peer group can be felt as unbearable pain, to be relieved only by death.

In his study of the life situa- tions of adolescents, Joseph Teicher discovered that suicide attempters went through a sequence of events that led to progressive unhappiness and pessimism: they became more isolated from important people in their lives, while the controls did not. An especially intense feeling of isolation occurred shortly before the suicide attempt(5).

Some theorists point to rtpid social change and the rising divorce rate with subsequent family alien- ation as a reason for the rising teenage suicide rate. Suicidologists are currently looking more closely at familial relationships as causative factors. Demographic surveys sug- gest that attempted suicide is strongly related to extreme family conflict and social disorganization(6). The key issue is the nature of the relationships between family members rather than such specific factors as the method of discipline used by the parents.

80 American Journal of Nursing/January 1979



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Williams and Lyons discovered that families of adolescents who had attempted suicide had the following characteristics:

* communications are not as productive as in families with no history of suicide attempt.

* communication revealed much conflict within family

* impaired problem-solving ability, which is probably related to the high level of conflict

* inconsistent positive rein- forcement is given to family members and a greater number of nega- tive reinforcements is used(7).

Finch carries this idea one step further when he says that adolescent suicidal behavior might be considered an expression of the unconscious wishes of the family(8). However, there is no one compre- hensive theory that satisfactorily explains all cases of suicide or attempted suicide.

Although the nurse should be aware of adolescent conflicts and troubles, they should not be over- emphasized. One must be careful not to take too seriously each emotional disturbance or rebellious act and wrongly consider the individual a possible candidate for suicide. The difficult task is to determine which adolescents are at a high risk.

The fact that suicide thrives on secrecy makes detection of poten- tial suicidal persons difficult. Some teenagers give blatant suicidal messages; others may keep their depression hidden within themselves.

Some teenagers can be identified as falling into high-risk groups. The following distinctive features were among those identified by Grollman as being characteristic of those most susceptible to suicide: ? previous suicide attempt ? has threatened suicide ? a family history of suicide ? has a chronic illness ? suffering bereavement ? has a severe depression ? alcoholism ? chronic use of bromides, barbi-

tuates, hallucinogenic agents * domestic difficulties(9).

A person who has attempted suicide has a greater risk of death by suicide as compared to the general population. The suicide risk is highest during the first five to six years following the attempted suicide(10).

Suicide attempters are also more likely to die of other causes. Pederson reports, "One of the most intriguing findings of the present investigation was the relationship between a history of a suicide attempt and the increased risk of death by natural causes, especially from respiratory and nervous sys- tem disorders"(ll).

What are the signs of impend- ing suicide in adolescents? Depres- sion in the teenager may be marked by acting-out tendencies or delin- quent behavior such as stealing, vandalism, or promiscuity. The adolescent may try to avoid facing his painful depressed feelings through excessive use of drugs, alcohol, and sex. All too often parents and professionals concentrate on discipline when these behaviors occur and overlook the fact that these behaviors may reflect an underlying depression.

Barbara Suter paints a typical picture of a socially isolated suicidal girl:

. one whose progressively deteri- orating relationship with her parents has left her with a sense of rejection, feelings of hostility, low self-esteem, and unfulfilled depen- dency needs. In adolescence, she turns to a boyfriend in an attempt to fulfill her emotional needs through a romantic alliance .... The word alliance is used deliber- ately, to connote that the relationship is not built on a genuine ability to relate to another individual. Rather, an alliance is built on the fear of being alone, [and] the need to recreate the parent-child relationship in an attempt to receive the nurturance and security which were not attained in that earlier context.

Thus, the isolated girl focuses all her energy on the relationship with a male, in the process alienat- ing herself from whatever girl- friends she has. She feels she can live only through the boyfriend. If she loses the boy, or even if the romance is threatened, she mayfeel that she has nothing to livefor; and in her terror at being alone, she may attempt suicide(12).

There are some behaviors that should be considered danger signs and immediate action taken:

giving away prized possessions such as a beloved record collection or stereo; becoming increasingly mo- rose and isolated; making such statements as "My family would be better off without me." "How do you leave your body to medical schools?" "This is the last time you'll see me;" and a sudden unex- plained elevation of mood.

How can a nurse help to keep these unhappy young persons from prematurely ending their lives? The nurse, either as a professional or as a knowledgeable citizen, has spe- cial understanding and skills that can be tapped to help the troubled teenager. The nurse can be highly sensitive to the dynamics of why adolescents might feel life is not worth living. Theoretically, these dynamics are related to identity cri- sis and lack of sufficient emotional support from significant others.

The first step toward helping is learning to cope with one's own feelings about suicide, to objectify one's own adolescent behavior, and to assess one's own personal and professional strengths.

The school nurse is in a unique position to help. She is close to the adolescent's world. If she perceives one of her roles to be a nurse counselor, she will be aware of the student who frequently comes to the nurse's office for minor com- plaints or to avoid school pressures. She can screen for the emotionally distressed student and determine how to handle each situation. What the teenager needs most may be someone to really listen to what he has to say. If the nurse feels she cannot handle the situation, she should refer the teenager to the school psychologist, guidance counselor, private physician, or a school physician. If she does this, it should be only after discussing her decision and rationale with the teenager so he will not feel he is being abandoned by yet another person. The nurse should try to get the parents involved in this process also.

The school nurse can educate school personnel, students, and parents about the nature of suicide. This can be done by developing an inservice education program for teaching staff, working with an individual teacher who has a concern about a particular student, collabo-




rating with the school guidance personnel, or speaking at junior high PTA meetings or to other groups. Nurses can become advo- cates for youth, for example, as volunteer leaders in organizations such as church, youth groups, 4H clubs, or athletic associations. Or a nurse may want to become involved with organizations that have more formalized youth advocacy programs, such as runaway houses. A nurse could work toward having laws changed that require parental consent for medical care and/or information.

The potentially suicidal adolescent is more apt to turn to an adult with whom he has had a personal relationship or one whom he sees as an advocate for youth. The principal preventive technique in any suicide is to show the person that you really care and are a friend who will not desert him. Interven- tion involves a personal relationship with a distressed person. This might include validating with the adolescent who has been in fre- quent automobile accidents, or

other kinds of accidents, his feelings about these occurrences and ex- pressing concern for his welfare.

Speaking honestly about suicidal feelings and thoughts can be a catharsis for the isolated, unhappy young person. Detailed questions about the teenager's proposed plan of suicide can assist that person in ventilating feelings of depression. The nurse can help the adolescent to widen his field of vision so that he can see the positive aspects of his life situation, for depression tends to restrict his outlook.

It would be unwise for the nurse who is not trained in psycho- therapy to probe too deeply into the area of unconscious motivation. This would also be true of the nurse who is working with an adolescent with a severe ego disorganization. Such persons should be referred to a therapist.

The nurse needs to remember the importance of getting others involved. Suicidal ideas should not be kept secret. By soliciting the help of others, the nurse shows her true concern about protecting the

Some teenagers may give blatant suicidal messages; others may keep their depression hidden deep within themselves.

adolescent from his own self-destructive behaviors. Trying to carry the heavy emotional weight of all the teenagers problems alone may be too stressful for the nurse, who may feel personally responsible for the potentially suicidal person's life.

Application of Caplan's idea of primary, secondary, and tertiary prevention of suicide is another approach to helping(l3).

Primary prevention would include such activities as promoting the inclusion of a unit on emotional health in health education courses in junior and senior high schools. Establishing hot lines can be worth- while.

The nurse must always keep in mind that some type of professional backup is crucial to the implementation of any such program.

Conferences and seminars about suicide and the adolescent are useful in disseminating information to other health professionals and/or the community.

A nurse can help with secondary prevention by being alert to the warning signs of potentially suicidal adolescents. Once she has identified a suicidal person, the nurse can use the good communication tech- niques she has developed to form a warm, caring relationship with the troubled adolescent.

The nurse needs to use assess- ment skills in determining just how suicidal the teenager might be. Areas that should be assessed, ac- cording to Tabachnick and Fabe- row, include: * interpersonal aspects, including conscious-unconscious intentions and ego organization; * interpersonal aspects, including the purpose, to whom, and what is being communicated in what type of environment; * implementation including lethal- ity of method, ranking most lethal to least lethal-firearms, jumping, hanging, poisoning, cutting nonvi- tal organs (wrist slashing), inhala- tion of gases, and ingestion of anal- gesics and soporific substances(l4).

Parents of teenagers will also need to be supported and involved in the total plan of care if at all possible. The nurse can help the teenager and/or parent by acting as a liaison between them and such prevention services as private or

American Journal of Nursing/January 1979 83



Possible Danger Signs Truancy from school and running

away from home could be signs of a troubled teenager. Other signs to watch for are:

Exaggerated or extended apathy, inactivity, or boredom

Subtle signs of self-destructive behavior, such as carelessness and accident proneness

Loss of appetite or excessive eat- ing

Decrease in verbal communication

Withdrawal from peer activities and from previously enjoyed activities

Substance abuse (drugs, alcohol) Sleep disturbance (nightmares,

difficulty falling asleep, early morning awakening)

Academic decline Unusually long grief reaction fol-

lowing a loss (death, divorce, girl- friend/boyfriend relationship)

Tearfulness Depressive feelings such as sad-

ness or discouragement, when they are more than transient, and especially if found in association with the break- down of relationships with significant others

Recent hostile behavior (e.g., ar- guments with parents, unruly behavior in school)

Recent increase in interpersonal conflict with significant others

A decrease in or inability to toler- ate frustration

Almost any sustained deviation from the normal pattern of behavior should be taken seriously and evaluated further.

public mental health clinics or a counseling service. She can help the family determine how mental health services might be beneficial to them as individuals or as a family unit.

If an actual attempt has been made, for example, swallowing pills or slitting the wrists, a physician or hospital emergency room should be visited immediately. The nurse can go with the young person to the local hospital emergency room where she can be a knowledgeable, supportive ally to both the adolescent and the family. All too often emergency room personnel are too busy carrying out lifesaving func- tions to give emotional support.

Whether the attempter is ad- mitted to the hospital or psychiatric service or returned home, the decision for treatment should be a

mutual one among all persons involved.

When the teenager returns home, an individualized plan including steps to relieve precipitat- ing causes and to give emotional support to the entire family should be developed. To what extent the adolescent's peers and school personnel should be involved will have to be evaluated on an individual basis.

Discharge from a psychiatric unit is a difficult time for the teenager and apprehensive parents. New roles and patterns of daily living need to be worked out. There may also be the added stress of the teenager's peers and parental atti- tudes. One newly discharged 15- year-old was told by her best girl- friend that her mother had forbid- den her to continue their relationship because she was a "crazy" person. Such irresponsible atti- tudes, which are unfortunately still prevalent today, can be changed by education about the philosophies of psychiatric facilities and the rea- sons for various treatment modali- ties.

The nurse who works in the hospital setting has specific guidelines to follow in working with suicidal persons. On the other hand, the nurse working as a pediatric practitioner, school nurse, public health nurse, or acting as a concerned citizen, is faced with the nagging question of liability and the consequences of personal in- volvement.

Dr. William Hauser lists three guidelines for "the imposition of liability in a malpractice suit:

a. The injury is of such a char- acter that it would not occur but for an act of negligence.

b. It was caused by an agency or instrumentality within exclusive control of the [practitioner].

c. It must not be due to any voluntary act of the patient" [in this case the teenager](14).

It is often too easy for the nurse to talk herself out of becoming involved. Once again, this leaves an already lonely teenager without knowledgeable support. Once the nurse has made a personal commitment to help a troubled teenager, she can creatively fill the real or imagined void the adolescent feels.

Postvention is the activity that takes place after a death due to suicide. This is a most traumatic time for parents, friends, peers, and teachers. They need to talk out this experience in an attempt to resolve such gnawing questions as "What did I do wrong?" or "What more could I have done?" If the teenager had been a high school student, the nurse could call together all those who were close to the deceased. In such a small group, feelings and thoughts could be shared. Thus, the experience could be used as a growth stimulus to improve the quality of life and relationships of those left behind.

The experience of working with a depressed, suicidal person is not an easy one but is full of poten- tial for personal and professional growth. The nurse may have the satisfaction of knowing that she has helped a young person struggling to grow and to live.

References 1. U.S. Division of Vital Statistics. Annual Sum-

mary for the United States, 1975 (Vital Statis- tics Report, Vol. 24, No. 13, June 30, 1978) Washington, D.C., U.S. Government Printing Office, 1976, p. 5.

2. Ibid., p. 10-11. 3. Grollman, E. A. Suicide, ed. by Clyde Dodder

and Barbara Dodder. Boston, Beacon Press, 1971.

4. Hofling, C. K., and Leininger, M. M. Basic Psychiatric Concepts in Nursing. Philadelphia, J. B. Lippincott Co., 1960, p. 137.

5. Teicher, J. D. Why adolescents kill themselves. IN Mental Health Program Reports. Bethesda, Md., National Institute of Mental Health, 1970, No. 4, pp. 55-57.

6. Lindsay, J. S. B. Suicide in the Auckland area. NZ Med.. 77:149-157, Mar. 1973.

7. Williams, Christopher, and Lyons, C. M. Fam- ily interaction and adolescent suicidal behavior: a preliminary investigation. Austr.NZ J. Psychiatry 10:243-252, Sept. 1976.

8. Finch, Stuart. Adolescent Suicide. Springfield, Ill., Charles C Thomas, Publisher, 1971, p. 22.

9. Grollman, op.cit., p. 83. 10. Paerregaard, Grethe. Suicide among at-

tempted suicides: a 10-year follow-up. Suicide 5:140-144, Fall 1975.

11. Pederson, A. M., and others. Risks of mortality of suicide attempters compared with psychiatric and general populations. Suicide 3:145- 157, Fall 1975.

12. Suter, Barbara. Suicide and women. IN Be- tween Survival and Suicide, ed. by B. B. Wolman. New York, Gardner Press, 1976, p. 150.

13. Caplan, Gerald. An Approach to Community Mental Health. New York, Grune and Stratton, 1961.

14. Tabachnick, N., and Farberow, N. The assess- ment of self-destructive potentiality. IN The Cry For Help, ed. by N. L. Farberow and E. S. Shneidman. New York, McGraw-Hill Book Co., 1961, pp. 61-77.

15. Hauser, William. The suicidal patient. Meed Insight 2:32, Apr. 1970.


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The Suicidal Adolescent