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TREATING SUICIDAL ADOLESCENTS: ADDRESSING FAMILY STRUCTURE AND ROLE ASSIGNMENT

TEEN SUICIDAL BEHAVIOR. Suicide increasing nationwide in recent yearsSuicide is the third leading cause of death for 15-24 year olds and sixth for 5-14 year olds. Suicidal Warning Signs. Withdrawal from family, friends, and regular activitiesDrug, alcohol useDepressionLoss of interest in pl

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TREATING SUICIDAL ADOLESCENTS: ADDRESSING FAMILY STRUCTURE AND ROLE ASSIGNMENT

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    1. TREATING SUICIDAL ADOLESCENTS: ADDRESSING FAMILY STRUCTURE AND ROLE ASSIGNMENT Steve Livingston, Ph.D., LMFT, LMHC Assistant Director – Associate Professor Mercer University School of Medicine Family Therapy Program - Atlanta 404-605-2288 livingston_s@mercer.edu

    2. TEEN SUICIDAL BEHAVIOR Suicide increasing nationwide in recent years Suicide is the third leading cause of death for 15-24 year olds and sixth for 5-14 year olds

    3. Suicidal Warning Signs Withdrawal from family, friends, and regular activities Drug, alcohol use Depression Loss of interest in pleasurable activities Violent actions, rebellious behavior, or running away Unusual neglect of personal appearance Marked personality change Change in eating, sleeping habits Frequent somatic complaints Boredom, difficulty concentrating, or a decline in schoolwork

    4. Teenagers Planning Suicide May Also: Give verbal hints of suicide Give away favorite possessions Become suddenly cheerful after depression Be highly self critical

    5. 10 Danger Signs of Suicidal Potential Quiet, withdrawn, few friends Changes in behavior Increased failure or role strain Recent family changes, recent loss of family member Feelings of despair and hopelessness Symptomatic acts Communication of Suicidal thoughts/feelings Presence of a plan Negative feelings toward treatment Impasse in therapy Richman, 1986

    6. SUICIDAL ADOLESCENT FAMILY STRUCTURE LITERATURE Richman (1979) 7 observed characteristics of families with suicidal adolescents: Inability to accept necessary change A disturbed family structure A depressed family affect system Communication problems Unbalanced intrafamilial relationships Double-bind relationships An intolerance for crisis

    7. Pfeffer(1981) 5 observed characteristics of families with suicidal children A lack of parental generational boundaries Severely conflicted spousal relationships Parental feelings projected onto the child Symbiotic parent – child relationships An inflexible family system

    8. FAMILY STRUCTURE LITERATURE Adolescent suicidal behavior significantly higher in chaotic and unstable families (Adams, et. al., 1982) 70% of events precipitating adolescent suicidal behavior related to family issues (Golombek & Garfinkle,1983) Relationship between family dysfunction (boundary, double binds) and adolescent suicidal behavior (Koopmans, 1995) Family functional level influences suicidal behavior (Martin et. Al., 1995) Family rigidity linked to adolescent suicidal behavior (Carris, Sheeber, and Howe, 1998) Family structural issues correlate with adolescent suicidal behavior, family cohesiveness impacts on risk. (Rubenstein et. al., 1998)

    9. CIRCUMPLEX MODEL Adaptability Refers to the families ability to modify in response to environmental changes Optimally functioning families display: Egalitarian leadership and democratic discipline Success in negotiating Share roles Have negative and positive feedback Individual members are assertive but not passive or aggressive Dimensions range from extreme rigidity to extreme pliability Olson, 1979

    10. CIRCUMPLEX MODEL Cohesion The emotional bonding of family members and the autonomy of individuals within the family system Optimally functioning families tend to have: Internal and external boundaries, but not too rigid Family members spend time together and alone Have public and private space Have individual and family friends and activities Have moderate independence and interdependence Decisions are made by individuals and by the family as appropriate Dimensions range from enmeshment (extreme bonding-no autonomy) to disengagement (extreme autonomy-no bonding)

    11. Circumplex Model

    12. FACES III

    13. ROLE ASSIGNMENT SUICIDAL ADOLESCENT LITERATURE The suicidal child is usually the expendable child, either the scapegoat or lost child (Sabbath, 1969) The lost child has the most potential for suicidal behavior due to depression/isolation associated with this role. (Wegscheider,1981) The suicidal adolescent in a family tends to be the scapegoat. (Richman, 1986) Adolescent suicidal behavior results from alienation from the family consistent with the lost child and scapegoat roles. (Hendlin, 1987) The suicidal child is usually isolated and alienated from the family, consistent with the lost child role. (Johnson and Maile, 1987) The scapegoated child is the role most likely to become suicidal (Lester, 1988)

    14. ADOLESCENT FAMILY ROLES Hero Helpful to the family in many ways and successful Provides the family with hope and pride Responsible and appearing competent Compelled to be successful and an overachiever Parentified Organizied, structured, and dependable The hero’s above stated qualities help reduce stress in the family. Wegschieder, 1981

    15. ADOLESCENT FAMILY ROLES Enabler Tend to be over responsible in family affairs, having much power and control Tend to worry Have difficulty relaxing and having fun Tend to be caretakers This is the child who protects family members from the consequences of their actions and is able to soothe the emotional needs of the family. Wegschieder, 1981

    16. ADOLESCENT FAMILY ROLES Mascot Attention through comedic acts, humorously expresses tension Feels the family tension and feels a responsibility to diffuse it. Behavior is reinforced by positive family attention. Groomed by family to be an attention seeker. This child receives special, positive attention for their comedic acts. Their behavior tends to distract the family from tension with a refocusing of attention. Wegschieder, 1981

    17. ADOLESCENT FAMILY ROLES Scapegoat Usually violates family rules Seen as irresponsible, gets in trouble a lot Receives much criticism from other family members Opposite of the hero child Seeks attention negatively They tend to reduce the tension and stress in the family by negative, distracting behavior. Wegschieder, 1981

    18. ADOLESCENT FAMILY ROLES Lost Child Tend to be self-sufficient, quiet, shy, and loners Less or little interest paid by family to this child Builds a vivid fantasy life out of isolation or: Invests intensely in peer groups Places little demand on the family Go along in a detached, quiet manner This child tends to withdraw and detach from the family emotional system. Wegschieder, 1981

    19. CHARACTERISTICS OF FAMILIES WITH A SUICIDAL ADOLESCENT An inability to accept necessary change, including: An intolerance for separation A symbiosis without empathy Role conflicts, failures, and fixations A closed family structure including: A closed family system A prohibition against intimacy outside the family Isolation of the suicidal person within the family A quality of family fragility

    20. CHARACTERISTICS OF FAMILIES WITH A SUICIDAL ADOLESCENT Affective difficulties, including: Patterns of aggression Family depression and a sense of hopelessness Pervasive separation Sexual disturbances An intolerance for affect Unbalanced intrafamilial relationships, including: Scapegoating Double-binding relationships Turning the suicidal individual into the bad object

    21. CHARACTERISTICS OF FAMILIES WITH SUICIDAL ADOLESCENTS Transactional difficulties, including: Communication disturbances Excessive secretiveness An intolerance for crises Richman, 1986

    22. Purpose of Study The purpose of this study was to explore the relationship between family dysfunction, adolescent roles within the family and adolescent suicidal behavior. Family roles and family structural dysfunction were used as predictor variables to differentiate between suicidal and non-suicidal adolescents. The alpha level of significance was set apriori at p <.05

    23. Demographics A total of 104 subjects ( 52 clinical, 52 non-clinical) Age range 13-18 (mean age 15.2) Gender – clinical group 56% female & 44% male non-clinical 52% female & 48% male Race – each group 96% Caucasian and 4% African American

    24. Frequencies for Groups by Age Clinical Group Non-Clinical Group Age Frequency Age Frequency 13 10 13 11 14 10 14 7 15 8 15 9 16 12 16 11 17 11 17 12 18 1 18 2

    25. Race Clinical Group Non-Clinical Group Race Frequency Race Frequency Black 2 Black 2 Caucasian 50 50 Other 0 0

    26. Gender Clinical Group Non-Clinical Group Gender Frequency Gender Frequency Female 29 Female 27 Male 23 Male 25

    27. School Grade Point Frequencies Clinical Group Non-Clinical Group Grade Frequency Grade Frequency A 1 A 9 B 12 B 20 C 28 C 20 D 8 D 3 F 3 F 0

    28. Parental Divorce Rate Clinical Group Non-Clinical Group Divorced Frequency Divorced Frequency Yes 26 Yes 21 No 26 No 31

    29. Hypothesis I-A Adolescents from the inpatient, clinical group can be differentiated from adolescents in the non-clinical comparison group by using a linear combination of their scores on the five scales of the Role Behavior Inventory.

    30. Analysis I-A Discriminate Analysis Significant at .0065 15% of variation explained by roles Canonical Discriminant Function for the RBI E.V. Can. C. Wilks L. Chi Sq. D.F. Sign. .17599 .3868 .8503 16.130 5 *.0065

    31. Hypothesis 1-B The role profile will differ, based on scores on the five scales of the RBI, between adolescents in the inpatient, clinical group and adolescents in the non-clinical, comparison group.

    32. Analysis 1-B Discriminate Analysis Significant difference in the two groups Scapegoat role (.013) Lost Child role (.003)

    33. Hypothesis II Adolescents from the inpatient, clinical group will report more family dysfunction, as measured by the DFCS derived from FACES III, than adolescents in the non-clinical, comparison group.

    34. Analysis - II One tailed T tests for independent samples Significant at .0025 Rigidly enmeshed and Chaotically disengaged

    35. Suicidal Adolescent Study

    36. CLINICAL IMPLICATIONS Family structure and role assignment are established as important variables in adolescent suicidal behavior. Family Therapy focus on promoting: individuation vs. rigid enmeshment mutuality vs. isolation flexibility vs. rigidity role reciprocity vs. rigid role assignment clear vs. diffuse generational boundaries direct, clear communication Clinical focus on issues of inclusion

    37. Treatment Protocol Systemic Family Therapy For Suicidal Adolescents Crisis Intervention/Stabilization Individual and Family Focus Lethality/Risk Assessment Inpatient/Outpatient

    38. Outpatient Treatment Combine Individual and Family Therapy Home Visit Early in Therapy Co-Therapist for Parents if Possible Focus on Systemic Issues of Family Structure and Role Assignment Varied Theoretical Approach ( Structural, Bowenian, Solution Focused) Focus on Inclusion

    39. Individual Therapy Focus on validation, differentiation, connection Home visit early in therapy Use of Bowenian, Solution Focused, and Narrative techniques

    40. Techniques Bowenian – Differentiation Solution Focused – Exceptions, Miracle Question Focus on solutions, de-emphasize pathology Narrative – Externalizing the problem

    41. Family Therapy Structural Family Therapy – Help family reorganize structure: individuation vs. rigid enmeshment mutuality vs. isolation flexibility vs. rigidity role reciprocity vs. rigid role assignment clear vs. diffuse generational boundaries direct, clear communication Techniques: Joining, Challenging, Enactments, Reframing, Tasks

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