Self-Destructive Behavior and Suicide Prevention in Adolescence

Self-Destructive Behavior and Suicide Prevention in AdolescenceAN EXISTENTIAL AND MEANING-CENTERED PERSPECTIVE

Timo Purjo [email protected]

© Timo Purjo

Doctor of philosophy (philosophy of education, ethics, valueeducation), University of Tampere, Finland

Diplomate Educator in Logotherapy, Viktor Frankl Institute of Logotherapy

Founder, Vice-Chairman and Director (R&D) of Non Fighting Generation (NGO), Finland

Faculty member of the Viktor Frankl Institute of Logotherapy

Chairman of Friends of Viktor Frankl Institute ry, Finland

Outline

1. Introduction

2. Research questions

3. Method/key literature

4. Findings

5. Discussion/conclusion

6. References

7. Time for questions

© Timo Purjo

1. Introduction

What keeps us alive in times of suffering?

Remarkable in Frankl's work and philosophy: ability to develop such an unconditionally positive view of life in spite of the suffering he confronted through his work with suicidal patients and through his own trial in the Nazi concentration camps.

© Timo Purjo

1. Introduction

Presentation based on research and experiences in Finnish youth education organization Non Fighting Generation: specialized in helping violently behaving young persons since 1996

Recently 3-years research project on the subject of suicidal andself-destructive behaviors of young people (adolescence acting violently against themselves), in co-operation with National Institute for Health and Welfare (THL)

Now started a new 3-years project in Finland, also with THL, in which all gathered theoretical knowledge is being put into practice

© Timo Purjo

1. Introduction

Target group 13-25-years old adolescents and young adults who suffer from experiences of lovelessness, meaninglessness, and despair,and who also have symptoms of some kind of self-destructive or suicidal tendencies

Aim of the project

1) to anticipate and prevent youth suicides and all kinds of self-destructive behavior as early as possible (at least before a first suicide attempt);

2) to encourage self-destructive adolescents to find, despite their disturbances and difficult life situations, some valuable point of references to themselves, to their lives, and to the world around them;

3) to promote meaningful experience in their lives

© Timo Purjo

1. Introduction

© Timo Purjo

Means

to develop existential and meaning-centered methods for youth suicide and self-destructive (a) risk assessment, (b) short-term intervention, and (c) longer-term individual counseling and support based on a logotherapeutic approachfor the use of health workers and psychiatric nurses working in schools and public health centers

2. Research questionsFocus of the presentation

© Timo Purjo

• To discuss the phenomenon, i.e. the self-destructive and suicidal behaviors of young persons

• To introduce some of the basic principles and viewpoints of our existential and meaning-centered approach in preventing young person’s suicides

• To examine research on risk factors as well as protective factors for suicidal behavior in adolescence

• To analyze critically the currently dominant view of self-destructive behavior and its prevention and treatment

3. Method/key literature

• Key literature: 32 articles, 5 books

• The paper (Pyry Hannila & Timo Purjo) and/or bibliographyavailable upon request: [email protected], [email protected]

© Timo Purjo

mailto:[email protected]


4. FindingsSuicidal and self-destructive behaviors

• Occasional thoughts of death or suicidal ideation are common and normal. In adolescence, the suicidal thoughts are often related to current difficulties. Milder, transient suicidal ideation without suicidal plans does not usually involve a conscious desire to die; however, behind these thoughts there may be an unvoiced wish that a difficult situation or state of affairs would get better. Instead, recurrent or persistent suicidal thoughts or plans have more a serious character — especially if the ideas are related to a suicide plan or a strong desire to die.

© Timo Purjo


• Worldwide life-scale prevalence of suicidal ideation is about 9%, and suicide attempts about 2.7%. Age is negatively associated with suicidal behavior; that is, young people and young adults are strongly represented in suicidal behavior. Evans et al. (2011) investigation indicates that up to 30% of young people have thought of committing suicide and about 10% have attempted suicide.

• Some studies suggest that up to 17% of the people harm themselves during the life course (Whitlock et al., 2006). Furthermore, non-suicidal self-injury increases the risk of suicide (Hooley, 2008.) Non-suicidal self-harm is particularly common among young people. In Western countries, 5-9% of young people harm themselves each every year (Skegg, 2005).

© Timo Purjo


• In one Finnish study (Laukkanen et al., 2008), up to 11.5% of young people aged 13-18 had harmed themselves. In particular, young women appear to be at risk in this respect: Female’s self-harm figures are up to eight times higher than those of males, however, in adulthood, the gap narrows considerably between the genders (see Hooley, 2008).

© Timo Purjo

4. FindingsResearch on risk and protective factors for suicide and suicidal behavior in adolescence

• Research on risk factors for adolescent suicide provides the basis for suicide prevention. The vast majority of research on suicide risk and traditional suicide risk profiles has focused on negative factors that predict suicide attempt risk and increase the chances of an individual engaging in deliberate self-harm.

• Current research with adolescence has found that (1) previous suicide attempt, (2) presence of a mental disorder (especially mood disorders), and (3) presence of substance/alcohol misuse constitute the most prominent risk factors for completed suicide.

© Timo Purjo

4. FindingsResearch on risk and protective factors for suicide and suicidal behavior in adolescence

• Recent research evidence in China, based on psychological autopsy studies of suicide decedents, have indicated substantially lower rates of mental disorders in Chinese suicide victims compared with those in respective Western studies (Phillips, 2010; see also Pelkonen et al., 2011).

• As Pelkonen, Karlsson and Marttunen (2011) have pointed out, this may have important implications for both the theoretical modeling of suicidal behavior and the development of suicide prevention strategies — especially given the fact that China accounts for as much as 1/3 of global suicides.

© Timo Purjo

4. FindingsCritique of current theoretical model of suicide prevention

• Marsha M. Linehan (2008) has stated, ‘the central theory of suicide and suicide prevention that has shaped suicide prevention research to date contends that suicide is a symptom of a mental disease and prevention of suicide requires treatment of the underlying disease’.

• Yet, none of numerous published randomized clinical trials, which have investigated interventions for depression, substance abuse, or schizophrenia – disorders commonly associated with suicidal behaviors – have not shown that reducing the symptoms of mental disorders would also reduce the incidence of suicide attempts or suicide. Moreover, treatments targeting suicidal behavior alone have been much more effective than those targeting presumed underlying mental disorders.

© Timo Purjo


• Utilizing a complementary approach, suicidal ideation, suicide attempts, and completed suicides are not reduced to the symptoms of mental health problems (e.g., depression). Instead, Linehan(2008) contends that suicidal behaviors should be conceptualized as ‘dysfunctional and disordered individual and social behavior’.

• From this point of view, self-destructive and suicidal behaviors could be conceptualized as inability to cope with life demands as a result of lack of sufficient individual and social resources. This different approach to suicide risk assessment, which has been studied during the last three decades, has been conceived mainly as a result of the development of the Reasons for Living Inventory (RFL; see e.g., Linehan et al., 1983).

© Timo Purjo


• While most studies have focus primarily on negative risk factors, RFL has been developed to investigate the factors that protect and preventindividuals from committing suicide, and inspire them to live in the face of hardship and adversity. Linehan and colleagues (1983; 2007; 2008) emphasize that suicidal compared to non-suicidal individuals lack positive beliefs and expectances in life and have fewer concerns regarding the consequences of suicide for their social environment.

• Linehan and colleagues have identified six reasons for living. Individuals who possess these reasons for living (e.g., “I believe I can find other solution to my problem” and “I have courage to face life”) reflected in the inventory are hypothesized to be less likely to attempt suicide than those who do not. This hypothesis could play an important role in understanding suicide risk.

© Timo Purjo


• Having more reasons for living differentiates between those who do not have a history of suicide attempt and those who do — despite comparable severity of mental health problems and recent adverse life events.

• Emphasis on reasons for living is also consistent with an existential and meaning-centered approach to understanding suicide in which the emphasis is placed on human strengths and well-being rather than on emotional vulnerability and symptoms of mental health problems. From an existential and meaning-centered perspective, it is particularly important to investigate these positive factors — the strengths and resiliency — that help to protect and prevent person from suicidal behavior in spite of mental health problems or stressful circumstances that can lead to despair.

© Timo Purjo

© Timo Purjo

4. FindingsAn existential and meaning-centered approach to young person’s suicidality

Between stimulus and response there is a space.

In that space is our power to choose our response.

In our response lies our growth and our freedom.

(Viktor E. Frankl)

• What is ‘suffering’, after all?

• From an existential point of view, different kind of mental health problems, substance misuse or abuse, extremely stressful life events, or self-destructive behaviors, can all be understood as the manifestations of the larger human phenomena — frustration in the search for meaning (‘existential frustration’), feeling of inner emptiness (‘existential vacuum’), and meaninglessness. Suffering without meaning leads to despair, as Frankl has stated, and despair caused by these kinds of devastating destinies or functional disturbances, may lead to such a crisis where a young person can’t find a way out but by suicide.

© Timo Purjo


• Viktor Frankl’s book, Man's Search for Meaning, ends with a Chapter on Tragic Optimism. By the use of this term Frankl expresses the view that everything can be taken away from a human being, except the last area of freedom — the freedom to choose one's attitude towards unavoidable circumstances. Thus, our existential and meaning-centered approach does not concentrate so much on the background of the suicidal behavior (e.g., above-mentions risk factors) but instead to an individual’s distinctive possibilities as a person.

• What does this mean from a practical point of view in treating a young person who has some suicidal tendencies?

© Timo Purjo


• One of the central issues in working with suicidal adolescents is their self-centered focusing on deficits, disturbances, and problems in their life and in themselves, which diminishes any positive aspects and hinders their ability to create some distance between themselves and their problems.

• However, even a high risk person is always more than their disturbances, problems, incapacities, or self-destructive behavior. That is one of the reasons why suicidal adolescents should not be approached through their deficits or derangement. Furthermore, when a young persons gets caught in this kind of a vicious circle of rumination and identifying themselves with these negative attributions and adverse symptoms, it can make their situation even worse (Morrison & O’Connor, 2008; Miranda et al., 2013).

• Frankl calls this state hyper-reflection. © Timo Purjo


• Hyper-reflection can be counteracted with de-reflection, which helps one to redirect their attention from problems to unique meaning potentials life offers from moment to moment. This technique is based on the self-transcendence, the human capacity to become directed to something, or someone, other than itself — be it a meaning to fulfill or another human being to encounter lovingly. Furthermore, although some people have the intuitive capacity to resort to their inner resources and power of will challenging life circumstances; in preventing youth suicides, it is extremely important to help adolescents to become aware of and develop their defiant power of the human spirit, so they can overcome their biological, psychological, or sociological limitations, and resist their disfavorable abilities, circumstances and experiences—to the extent that they can permanently avoid getting assailed by such destructive forces.

© Timo Purjo


• An aid and support should not either stop at the point when the acute crisis has passed; on the contrary, there is so much more that can be accomplished. Crisis is always both a threat (to freedom) and a possibility (for growth). Once the threat has passed, one can begin to take advantage of all the opportunities the crisis has provided. In logotherapeutic healing the target is not only to restore one’s pre-crisis operational capacity, but to find ways to enjoy a more meaningful and purposeful life for the future (Long, 1997). Thus, the fundamental purpose of intervention is help those in distress become people who are able to intuitively activate their defiant power of the human spiritin the face of crisis and maintain the sense of meaning and purpose in spite of adverse circumstances

© Timo Purjo


© Timo Purjo


Stage 7

“Transcending the Trauma”

Stage 1

Current Level of Stage 6

Functioning Return to Previous

Stage 2 Baseline Level of Level of Functioning

Onset of Crisis Functioning

-------------------------------------------------------------------------------------------------------------------------

Stage 3

Rapid Descent Stage 5

into Despair Progressive Improvement

during Clinical Intervention

Stage 4

“Bottoming Out”

Long, Jerry L. Jr. (1997) LogotherapeuticTranscendental Crisis Intervention,The International Forum for Logotherapy,20 (2), 104-112.


• Existential issues, like meaninglessness, are a central part of suicidality. Anton Nindl (2004) has stated: the ‘question of meaning is the one we have to confront again and again while working with suicidal people’. Meaning-centered approach, which emphasizes the spiritual side of human being and the significance of meaning in life, brings a fresh perspective to mental health treatment and etiological examinations.

• When adolescents indicate that they find that suicide is the only possible route out of suffering, focus should be on keeping them alive by providing hope and meaningful reasons for living. However, this should not be based on false promises or empty hopes but on a dialogue which reveals to a young person that there is some meaningfulness in world, positive reasons for living, and something valuable in oneself.

© Timo Purjo


• In suicide prevention, it is a question of the spiritual empowerment of a young person, which is guided to finding life as meaningful through the defiant power of the human spirit and acts of self-transcendence.

• Concentrating on the healthy aspects of individual and the possibilities that are still available, regardless of adversities and handicaps that constrain a person’s life, makes it also comforting:

There is no situation without any hope, and there is no one who could not reach for the possibility of a meaningful life

© Timo Purjo

6. References

• List of sources available upon request: [email protected], or [email protected]

© Timo Purjo



7. Questions?

You may also contact us later-on:Project Coordinator and Method Developer Pyry Hannila, [email protected], orDirector (R&D) Timo Purjo, [email protected]

© Timo Purjo



Education

Self-Destructive Behavior and Suicide Prevention in Adolescence