Alex : Let me look it up. [Alex finds the number and writes it on the safety plan.] Counselor : Anyone else? Alex : Not that I can think of. Counselor : Okay. So I suppose we need a back-up plan for all of this. If going for a walk, listening to music, watching a comedy, going to the YMCA, playing with your brother or cousin, and talking with Sarah and your uncle don’t work, let’s put down some emergency numbers. Here is the number for the local crisis center. [The counselor writes it down.] I’m going to also put down the address in case you need to get there. They are open 24 hours a day, so you can call or stop in anytime. This second number is the National Suicide Prevention Lifeline. If you want to talk with someone else, you can call that number. And don’t worry, it won’t go to someone in Cleveland. It will get routed to someone close to where you live. Aside from those options, you can always go to the nearest emergency room or call 911, if you are starting to think about what you would do to kill yourself. And of course, once we get you connected to Youth suicide intervention considerations Development of youth suicide interventions has made great strides over the past decade. Several studies have been conducted with suicidal youth to test individual and family psychotherapies, psychopharmacological approaches, and other interventions. While the development of effective interventions to reduce suicide in adolescents has been deemed a national imperative (David-Ferdon, Crosby, Caine, Hindman, Reed, & Iskander, 2016), to date, no interventions have shown effectiveness in reducing suicide deaths within this age group. This is likely due to the low base rate of youth suicidal behavior and the logistical challenges of following large numbers of at-risk youth for extended periods. However, meta-analytic research evaluating effects across multiple studies found that across 28 clinical trials of psychosocial interventions for youth suicidal behavior, there were at least moderate effects for these interventions in reducing suicidal ideation, suicide attempts, and NSSI (Calear et al., 2016). Thus, psychosocial interventions are showing much promise in addressing youth suicide, though further investigation and dissemination of such treatments is needed and there is not yet one gold standard treatment to provide (Cha, Franz, Guzman, Glenn, Kleiman, & Nock, 2018). On the other hand, pharmacological approaches, which often target depression, have drawbacks with regard to youth suicidality. Historically, studies on pharmacological interventions have: (a) struggled to show significant improvements in reducing suicidal ideation among active treatment groups compared to control groups, and (b) failed to recruit suicidal youth into randomized trials (Asarnow & Mehlum, 2019; Limandri, 2019). However, some pharmacological interventions have shown reductions in suicidal ideation in depressed youth with subclinical suicidal ideation at baseline, and there may still be potential benefits from psychotropic medication in treating suicidal thoughts and behaviors along with associated mood and/or anxiety disturbance (Limandri, 2019). Clearly, any medication approach when working with suicidal youth should
a therapist, you can talk with that person about his or her plan for emergencies. You can put any after-hours numbers on your safety plan, too. Discussion In this case study we see an excellent example of a clinician enacting suicide-safety planning. The clinician works collaboratively with the youth to identify relevant coping activities for when distress or suicidal ideation arises. They identify helpful interpersonal contacts to reach out to for help in the case of a suicidal crisis, including 24-hour crisis and emergency response contacts. The clinician also makes sure to write down the safety plan for the youth, which is necessary to ensure the youth can follow the necessary intervention steps even if having difficulty concentrating. To follow through with the safety plan, at this point the clinician should verify that the youth understands and is willing to follow the safety plan they developed together, and then document as soon as possible that the safety plan has been created. be discussed carefully with a prescriber specializing in youth mental health. Cognitive behavioral therapies are the preferred approach for adults but have not yet been proven as effective for youth (Cha et al., 2018). Most treatment interventions for suicidal youth have not demonstrated significant outcomes compared with control groups. However, interventions targeting the family have shown some effectiveness (Calear et al., 2016), suggesting that connecting with the attachment and support system for youth may be key to an intervention’s success. Nevertheless, the cost of broad dissemination of these interventions often precludes high-risk populations from accessing them. This has been most evident in one large, multimillion-dollar, multisite randomized study: the Treatment of Adolescent Suicide Attempters (TASA; Walkup, 2017). TASA was designed to randomly assign youth who had made a suicide attempt into one of three treatment groups: those receiving an antidepressant only, those receiving cognitive behavioral therapy only, or those receiving both an antidepressant and cognitive behavioral therapy. Following a black box warning on antidepressants from the Food and Drug Administration (described in greater detail in the section on psychopharmacology), the TASA study was redesigned as an open trial, which precluded concrete conclusions being drawn about the efficacy of the intervention. Yet, a critical finding emerged. Brent and colleagues (2009) found that subsequent suicide attempts in youth who had recently made an attempt often occurred very early in treatment (i.e., approximately one month after the previous attempt). As a result of the TASA study, there has been increased focus on developing front-end-loaded interventions that provide immediate impact on suicide risk reduction. This section will provide an overview of effective brief interventions that have shown promise as well as empirically supported psychotherapies. The impact of psychopharmacological intervention on youth suicide and the development of achievable treatment goals will also be discussed.
DEVELOPING EFFECTIVE TREATMENT GOALS
One challenge in therapy is developing treatment goals that meet the needs of both adolescents and their parents. While adolescents may be apprehensive about entering treatment, their parents may express a range of concerns, the most pressing being their fear that their child may end his or her own life. Parents may expect (or at least really want) the issues that brought the adolescent into treatment to be fully resolved within just one or two sessions and may want the focus of treatment to be solely on the adolescent’s suicidality rather than the functioning of the family system. Not establishing treatment goals that the family can agree on may be problematic
and perhaps convey a sense of hopelessness to the suicidal adolescent. Treatment goals for suicidal youth should be short-term and target specific outcomes. Because of the evidence that suicidal crises are often short- lived and may occur within the first month following a previous attempt, a safety plan should be incorporated into the treatment plan (Horowitz & Tipton, 2020). Specifically, the goal might read, “Patient will carry safety plan at all times and use it when in crisis.” A second goal that should accompany any treatment plan is a statement reflecting a commitment to treatment (Jobes, 2017), for example, “Patient
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