From January 2001 NASW NEWS
Copyright ©2001, National Association of Social Workers, Inc.

Hand-Tailored Treatment Is Key

Support Plan Links Suicidal Youth to Help

Illustration: John Michael Yanson

The thinking was, "How can we better meld what teens need with what we're offering?"

By Corinna Vallianatos, NEWS Staff

The Youth-Nominated Support Team Intervention (YST), a $1 million initiative at the University of Michigan, is a creative example of the latest in mental health professionals' thinking about suicide prevention. It targets two problems that characterize many suicidal adolescents: poor treatment adherence and negative perceptions of family and social support.

While providing youth at risk for suicide with a network of support from teachers, community members and family, what makes YST unique is that the adolescents themselves nominate who they want involved in their treatment, augmenting the healing process by making it more intimate, meaningful and collaborative.

The research project, funded by Ronald McDonald House Charities, was developed by clinical psychologist and University of Michigan Associate Professor Cheryl King and is administered by social worker Anne Kramer. It is meant to combat the high dropout rate of suicidal teens, particularly those aged 12 to 17, from treatment, and with its nearly attained goal of 450 participants, it will strive to determine whether its philosophical cornerstone, a network of youth-nominated support, indeed treats adolescent apathy, depression and withdrawal more effectively than traditional treatment.

YST, formerly known as Connect Five, was derived from academic and clinical experience of King's that told her that in the area of suicide intervention, what's offered and what's accessed are often very different.

"There is a consensus that adherence to standard treatment models is not good," King said. "My thinking was, 'How can we better meld what teens need with what we're offering?' Suicidal youth often feel unempowered, disconnected and in serious interpersonal conflict. We needed something to empower youth and help them with close relationships. We know that they're being influenced by their parents and other key adults. Let's try to make that influence positive." The youth-nominated support network was born.

YST is a six month-long randomized control trial run out of two hospitals — Child and Adolescent Psychiatric Hospital at the University of Michigan and Havenwyck Hospital in Southeastern Michigan — and two community mental health sites. Its stated goals are: to increase suicidal adolescents' perceptions of adult social support; increase suicidal adolescents' adherence with recommended treatments; decrease severity of suicidal ideation, depression and anxiety; and improve adaptive functioning and prevent suicide attempts.

Half of the participating adolescents in YST, the control group, are assigned traditional treatment, which usually involves individual therapy and medication. The other half participate not only in traditional treatment, but establish a handpicked, personal network of support. This group must be culled from a variety of settings: for instance, one family member, one teacher or coach and someone from church or the community.

King found that the use of peer support did not have a differential effect, and in fact slowed the project's start-up time because of the need to obtain parental permission from nominated peers. In the next funding cycle, peer support will be eliminated, and the project's duration will be cut to three months, which King ascertained was the most fertile and effective contact time period: "By that time, a natural change is taking hold."

After the suicidal adolescent's parents approve his or her selections, the network of support undergoes an hour and a half-long orientation, or psychoeducational intervention, that focuses on the adolescent's psychiatric disorder, the treatment plan, suicide risk factors, and the importance of treatment adherence.

Support persons are assured that it is all right to discuss the issue of suicide with the adolescent, and are encouraged to ask the adolescent about it if they notice any warning signs. They are provided with 24-hour emergency contact numbers. Additionally, they are told that they are not responsible for the adolescent's actions, and are not expected to function as mental health professionals.

After that, the members of the network meet casually and unobserved with the suicidal teen once a week. They inquire after the youth's weekly activities, listen to the youth's concerns, solve problems with the youth, ask about compliance with treatment and encourage continued compliance. Support persons also speak on the telephone once a week with YST staff.

"I consider YST to be a work in progress," said King. The project is in its third year of funding, and King has just applied for further funding from the National Institute of Mental Health.

"The social validity of a project is very important when you apply for federal funding," she said. "It is important to come up with something people will actually use. We're finding that YST is meeting that goal."

King and Kramer have found that 83 percent of nominated support network members said they would be willing to participate in the project. Ninety-three percent of suicidal adolescents were contacted weekly for three months.

Anne Kramer, who works at the Child and Adolescent Psychiatric Hospital at the University of Michigan, a hospital that was immediately interested in participating in the project, said that she knows from youth testimonials that YST is extremely beneficial.

"The project is proving to be especially effective with girls," Kramer said. King and Kramer speculate that this is because girls give a higher premium to interpersonal emotional support, such as having someone to talk to, while boys value instrumental support, such as being taken on an outing or given something. Suicidal boys also have a higher incidence of alcohol and drug abuse and disruptive behavioral factors, which make the treatment path rocky.

Kramer said suicidal adolescents tend to drop out of traditional treatment for a variety of reasons: the stigma that is attached to mental illness; the time that psychotherapy requires; the difficulty waiting for the time it takes for the medication to be effective; or because they don't like the side effects of the medication. Some adolescents may feel that, on medication, their personalities are dulled and that they're losing their edge. Others simply don't like the idea of being on medication at all. The inertia that so often accompanies depression and suicidal ideation, too, works against the teens' keeping appointments and following through with therapy.

Gerald Curley, a social worker who previously worked with YST as part of the Washtenaw County Community Mental Health system, predicts that the support network approach will also prove cost effective, a catch phrase that is worth more and more in the cost-conscious atmosphere of managed care.

"This approach maximizes dollars," said Curley. "I think it will be replicated. You can't give suicidal youth what they need from the inside of one office."

Suicide prevention initiatives got a shot in the arm in 1999, when Surgeon General David Satcher declared suicide a serious public health threat for the first time. His announcement launched an effort to educate school counselors, parents and other members of the community on how to spot and effectively respond to signs of trouble.

"This is a national tragedy and a public health problem demanding national leadership," said Tipper Gore, an advocate for mental health issues, who joined Satcher last year in releasing a "call to action." "Let's talk about the reality of suicide in our national life," she said. "Let's encourage all Americans to get the help they need."

Suicide is the third leading cause of death of people between the ages of 15 and 24. Five hundred thousand teens try to kill themselves each year, and 5,000 succeed. While men commit suicide four times more often than women (using violent methods such as shooting themselves), women are four times more likely to attempt suicide (by drug overdose or cutting themselves).

In the general U.S. population, suicide is the eighth leading cause of death, claiming about 30,000 lives in 1997, compared with 19,000 homicides. White males over the age of 65 account for 20 percent of the cases. But the suicide rate has doubled since 1980 among children aged 10 to 14.

YST offers educational material to augment its hands-on, community-involved suicide prevention efforts. Its brochure, adapted from the Washington State Department of Health and the University of Washington School of Nursing's "Stop Youth Suicide," details warning signs, prevention steps, questions to ask and how to call for help. The brochure notes that 80 percent of the time, people who kill themselves have given definite signals or talked about suicide previously.

Warning signs to pay attention to, according to YST, include: a previous suicide attempt; current talk of suicide or making a plan; strong wish to die, preoccupation with death and giving away prized possessions; signs of serious depression, such as moodiness, hopelessness and withdrawal; increased alcohol and other drug use; and a recent suicide attempt by a friend or family member.

YST also identifies other key risk factors that may contribute to the circumstance of a suicide, such as readily accessible firearms, impulsiveness or taking unnecessary risks, and lack of connection to family and friends, the last of which the support network model specifically targets.

In the area of prevention, examples of proactive dialogue for an adult to engage in with a youth are: "I'm concerned about you and how you feel"; "Tell me about your pain"; "You mean a lot to me and I want to help"; and "I'm on your side. We'll get through this."

Similarly, YST's brochure offers questions that can be asked of a suicidal teen, noting that talking with young people about suicide will not put the idea in their heads. To get the conversation started, one can ask: "Are you thinking about suicide?" "Are you thinking about harming yourself or ending your life?" "Have you thought about how you would do it?" and "Do you really want to die? Or do you want the pain to go away?"

Finally, the literature encourages adults to instill a sense of hope in the teen by not only showing concern, but moving forward actively to treatment. Some nonthreatening verbal ways to approach treatment are: "Together I know we can figure something out to make you feel better"; "I will stay with you. Let's call the crisis line"; "It's difficult to know what to do, but I know where we can get some help"; and "You're not alone. Let me help you."

Suicidal youth are a heterogeneous group, according to King and Kramer, and there will never be one intervention to address all suffering adolescents. The goal of YST is to keep tweaking the treatment model to know exactly who responds best to it so that, eventually, other hospitals and community mental health clinics can begin to initiate similar programs and better match the treatment to the teen.

To know when and for whom, said King, is the most important part.

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