Treatment of Recent Suicide Ideation Among Adolescents by a Program of Meaningful Purposeful Goals

ABSTRACT

This study examines the effects of a meaningful, purposeful goal intervention program on adolescents who have recently been identified with suicide ideation. Using participants from S.A.F.E. Intensive’s residential treatment center in Webster Groves, Missouri, we hope to find that adolescents participating in Making Goals for the Future will have fewer suicide attempts than those not in the intervention program. Throughout treatment we hope to see a significant decrease in current suicide ideation on participant’s scores on the Beck Depression Inventory (BDI-II), Beck Hopelessness Scale (BHS) and Beck Scale for Suicide Ideation (BSI) and an increase in meaning in life and purpose in life utilizing Purpose in Life test (PIL) and Life Purpose Questionnaire (LPQ).

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INTRODUCTION

According to the National Institute of Mental Health in 2010, suicide is one of the major

leading causes of deaths in youths between the ages of 10 and 24. Girls are more likely to

attempt suicide, while boys are more likely to commit suicide through the most violent means

(i.e., firearms). Suicide is extremely devastating to not only members of the family, but to one’s

peers and the community at large, making it an important public health problem in the United

States.

Adolescents who attempt suicide often report feeling trapped, lonely, worthless and

hopeless about their lives and their future (Beck, Steer, Kovacs, & Garrison, 1985; Beck, Brown,

& Steer, 1989; Beck et al., 1990; Kidd, 2004). Suicidal adolescents often lose a sense of purpose

or meaning in life (Beck, Steer & Kumar, 1993) which makes suicide as a possible way out.

Adolescents to attempt suicide once are at risk for attempting it again (Lewinsohn, Rohde, &

Seeley, 1994).

Statement of Problem

The purpose of this study is to identify adolescents who have expressed recent suicide

ideation and help them resolve this issue by participating in a meaningful, purposeful goal

oriented program. Since having a reason for living and leading a meaningful life are

incompatible with suicide, it is possible that realizing important personal goals might enhance

hope and meaning in life, two protective factors against suicide.

Review of the Literature

Multiple studies in the 20th century (Beck, Steer, Kovacs, & Garrison, 1985; Beck,

Brown, & Steer, 1989; Abramson et al., 1989; O’Connor & Cassidy, 2007; O’Connor & Sheely,

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2000; O’Connor, Connery & Cheyne, 2000) focus on identifying risk factors. These studies have

led to the development of various suicide prevention strategies such as help lines, early

identification and treatment of depression, crisis intervention, restriction of access to suicide

methods (such as gun control), access to and improvement of mental health services and

treatment, and educational programs for health professionals (Lapierre, Dubé, Bouffard & Alain,

2007; DeLeo &Scocco 2000; Jenkins & Singh, 2000). However, the effectiveness of these

suicide prevention services is extremely limited (DeLeo, 2002; Lester, 2002; Hepp, Wittman,

Schnyder & Michel, 2004).

Risk Factors

There is an abundance of research indicating that an individual’s suicidal ideation is

associated with hopelessness (Brown, Beck, Steer, & Grismam, 2000; Abramson et al., 1989), a

negative perception of one’s future (O’Connor & Cassidy, 2007; O’Connor & Sheely, 2000;

O’Connor, Connery & Cheyne, 2000), and a lack of meaning in one’s life (Frankl, 1959 & 1985;

Melton & Schulenberg, 2007). MacLeod’s 1997 study found a lack of positive future thinking is

associated with suicide risk. In other words, suicidal individuals are impaired at generating

positive future expectancies. Williams (2001 & 2005) Cry of Pain Model builds upon

Baumeister’s 1990 study where it states that suicide is a response to entrapment rather than an

escape. William’s Cry of Pain model took this further by stating “suicidal behavior is reactive, a

response to a stressful situation that has three components: defeat, no escape, no rescue”

(O’Connor, MacHale & Masterton, 2008).

Frankl (1959 & 1985) theorizes that the most basic human motivator is a will to meaning.

When will to meaning is interrupted, or blocked, existential frustration develops and

consequently boredom and apathy emerge. Frankl believes that life has meaning under all

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circumstances, even when involved in intense and unavoidable suffering. With the opportunity,

individuals can decide on an individual basis what is meaningful and, therefore, this enables the

individual to sustain suffering with dignity, rather than focusing on emptiness and hopelessness.

Meaningful, Purposeful Goals

Setting new goals and looking to the future can benefit an individual’s psychological

well-being and happiness (Lapierre, Dubé, Bouffard & Alain, 2007; Sheldon & Houser-Marko,

2004; Brunstein, 1993). According to Snyder & Rand (2004) people who have hope believe that

they can improve their situation, take responsibility for their own well-being and actively commit

themselves to solving their problems. Additionally, past longitudinal studies have shown that

personal commitment in the pursuit of goals predicts psychological well-being (Sheldon &

Houser-Marko, 2004 and Brunstein, 1993).

In recent studies (Lapierre, Dubé, Bouffard & Alain, 2007 and Dubé et al., in press) found

that a goal-intervention program could have a positive impact on participants’ psychological

well-being, enhance their quality of life, find meaning in their lives and actualize their potential,

and, therefore, decrease their suicidality (Lapierre, Dubé, Bouffard & Alain, 2007; Edwards &

Holden, 2001; Malone et al, 2000; Jobes & Mann, 1999). More specifically Lapierre, Dubé,

Bouffard & Alain’s 2007 study used Dubé et al. (in press) goal prevention program on 154

participants who were transitioning into retirement. Out of those 154 participants 27 had suicidal

ideation. Despite their small sample size, they found that the goal-intervention program increased

the participant’s psychological well-being and decreased depression in the participants with

suicidal ideation.

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Statement of the Hypothesis

Although the previous studies (Lapierre, Dubé, Bouffard & Alain, 2007 and Dubé et al.,

in press) focused on retirees and was not offered to an entirely suicidal population, this research

team speculates that this goal intervention program will be valuable to adolescent suicide

prevention. Having a reason to live and leading a meaningful life have been found to be

protective factors when it comes to suicide ideation. An individual realizing an important

personal goal might enhance hope and meaning in life, as well as protect the individual from

future attempts on one’s own life. The present study will focus on youth who have expressed

recent suicide ideation. It is hypothesized that adolescents who have been identified with recent

suicide ideation and who participate in a purposeful, positive goal oriented therapy will exhibit

significantly fewer suicide attempts than adolescent who are just being treated at a residential

facility.

METHOD

Participants

Participants will be recruited for this study from S.A.F.E. Intensives residential

treatment program. S.A.F.E. Intensives is located in Webster Groves, Missouri. S.A.F.E

Intensives specifically focuses on the treatment of adolescents who engage in self-injurious

behavior. The participants will be between the ages of 12 to 21 years old and will be one of the

36 newly admitted clientele.

The study chose this site especially because of its no medication policy, which focuses

on tolerating distress, learning new coping skills as well as teaching the adolescents appropriate

ways to manage their feelings and providing them with a sense of mastery over their emotions.

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Also, the site’s program lasts 10 to 12 weeks which is a perfect match for our goal-intervention

program.

Assessment Instruments

Beck Depression Inventory (BDI-II) The BDI-II is a 21 item self-report questionnaire that assesses severity of depression. This instrument is one of the most widely used assessment measures in both research and clinical settings.

Beck Hopelessness Scale (BHS)The BHS examines an individual's thoughts and beliefs about the future. This self-report questionnaire consists of 20 true-false items that measure 3 major aspects of hopelessness: feelings about the future, loss of motivation, and expectations. The hopelessness construct is a factor in many mental disorders and is highly correlated with measures of depression, suicidal intent, and ideation.

Beck Scale for Suicide Ideation (BSI)The BSI is a 21-item self-report questionnaire that may be used to identify the presence and severity of suicidal ideation. Items on this measure also assess the respondent's suicidal plans, deterrents to suicide, and the level of openness to revealing suicidal thoughts.

Purpose in Life test (PIL)Crumbaugh & Maholick in 1964 designed the PIL test operationalize Frankl's ideas. The PIL isa 20-item self-report that may be used to quantify the respondent’s experience of meaning andpurpose in life. Each item is rated on a 7-point scale and total scores therefore range from 20 (low purpose) to 140 (high purpose) Examples of the 20 items include: "I am usually: completely bored (1) — exuberant, enthusiastic (7)"; "As I view the world in relation to my life, the world: completely confuses me (1) — fits meaningfully with my life (7)," and "With regard to suicide, I have: thought of it seriously as a way out (1) — never given it a second thought (7)."

Life Purpose Questionnaire (LPQ)The LPQ is a 20-item self-report with an agree/disagree response instrument designed to measure an individual's sense of life meaning. Although, Hablas & Hutzell made this self-report to aid comprehension to their participants in their 1982, we will use this in addition to the PIL to make sure there is internal validity and internal consistency in our study.

Description of the Program

Participants are given the opportunity to join a program called Making Goals for the

Future, which invites the participants to identify a meaningful, personal goal and pursue it

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effectively. The participants are encouraged to learn how to manage their life goals in order to

achieve enhanced and lasting well-being (Lapierre, Dubé, Bouffard & Alain, 2007).

Based on a cognitive-behavioral approach and goal-intervention literature, the desired

therapeutic changes are to increase the participant’s ability to identify and modify irrational

beliefs that are detrimental to the goal-identification process, promote cognitive factors that

improve regulation of goal-directed action, as well as increase the participant’s ability to view

alternative means to achieve a goal. In addition, another objective of the intervention is to create

warm, interpersonal relationships and mutual support among the participants. During

adolescence peer support plays an important role in the teenager’s need for acceptance and

psychological well-being (Sullivan, 1953; Steinberg, 2008). Billie-Brahe & Jensen (2004) found

that social support is a protective factor against suicide.

Making Goals for the Future program will include 10 to 12 meetings of 2 hours each

week of 3 small groups of 6 participants each. Each group will be conducted by graduate

counseling students who have been trained in the goal-intervention program.

Appendix 1 presents the content and purpose of each step of the program: goal setting, goal

planning, goal pursuit and outcome evaluation, with an introductory meeting and a follow-up

meeting as well. During the program, each participant will be expected to identify, plan, pursue

and realize one personal, concrete, meaningful, purposeful goal.

Procedure

The participants will be divided up randomly into 6 groups. Three groups with 6

participants in each group will take part in the goal-intervention program; the other 3 groups

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with 6 participants in each group will participate in S.A.F.E. Intensive program which involves

group, individual, milieu and family therapy, impulse control management, case management,

education and support, as well as after-care planning.

The study will include three measurement points: pretest, midtest and the post-test at the

end of the intervention program, which will include a follow-up, 6 months later. During the

preliminary meeting (shown in Appendix 1) informed consent will be obtained and the

participants will be provided a brief description of the study. Also, the first assessment will be

administered to the participants in order to obtain an initial, baseline score. The control group

will also complete the questionnaires at this time. The same action will take place during

meetings 5 and then during meeting 11. The study will take 3 to 4 months to complete. Follow

up meetings according to participant’s wishes can occur. Once follow up meeting are adjourned,

the data will be collected and analyzed.

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