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According to family systems theory [e. g., Haley, 1980], suicidal behavior serves to preserve the sta- tus quo in the family and prevents a role change that might upset the family homeostasis. The suicidal adolescent is viewed as the identi- fiedexpresserof the family conflict.

Richman [1986], while not specifi- cally focusing on adolescents, inte-grated family systems and psycho- dynamic perspectives in develop- ing family therapy for suicide at- tempters. Drawing from the psy- choanalytic teachings of Freud and others, Richman theorizes that sui- cide attempts are an extreme form of aggression turned against oneself [Richman, 1986, p. 79]. In addition, suicidal individuals are often the re- cipients of covert hostility and death wishes from other family members [Sabbath, 1969; Richman, 1986]. This hostility is thought to arise from symbiosis and separation anxiety. Richman proposes the fol- lowing questions to organize family therapy:

“Who did the person want to kill by his suicidal act? Who wanted him dead?

What was the separation crisis behind the death wishes? What is the most con- structive solution?” [Richman, 1986, p. 79].

The eventual goals of family thera- py in Richman’s model include im- provements in communication, availability, cohesion, mutual re- spect, and individual autonomy, as well as a reduction in family isola- tion. Richman begins treatment of suicide attempters by interviewing each family member individually, asking them why they think the identified patient has become sui- cidal. Next, one obtains human fig-ure drawings from each family member for screening and monitor- ing purposes. For example, Rich- man asserts that the figure draw- ings of suicidal people (and some- times their relatives) often contain potential indicators of affective la- bility or self-destructive tendencies, such as slash lines [Richman, 1986, p. 86]. In the initial family interview, Richman establishes a set of ground rules for communication (e. g., ask- ing family members to make “I” statements, rather than “you” state- ments), and then asks family mem- bers to face each other and discuss the suicide attempt. He suggests that therapists should avoid prema- ture intervention in this family pro- cess. In fact, according to Richman, the therapist should tolerate and even welcome intense, rageful fam- ily exchanges, since these outbursts reduce tension and pave the way for more constructive alternatives.

Richman suggests probing directly for death wishes immediately after an aggressive family exchange, thereby replacing covert communi- Anthony Spirito (in collaboration with Julie Boergers) Crisis, 18 / 3 (1997) © 1997 Hogrefe & Huber Publishers Columns 106 cation with direct communication.

For example, the therapist might ask family members, “Do you sometimes feel fed up with your daughter?” Eventually, the thera- pist begins to reframe negative in- teractions in positive terms (e. g., as expressions of frustration, helpless- ness, caring, or separation anxiety), focusing attention on the love behind the aggression. Relabeling these interactions also serves to re- duce scapegoating and to reduce the family’s fears of separation and loss [Richman, 1986].

Zimmerman and LaSorsa [1995] presented another family therapy model, which integrates family systems and psychodynamic approaches to provide crisis inter- vention and brief outpatient family therapy to suicidal adolescents. Ac- cording to Zimmerman and La- Sorsa, suicidal adolescents and their families are often at odds regarding the speed at which separation and individuation should occur. For ex- ample, the adolescent may feel pres- sured to take on adult responsibili- ties for which they feel unprepared, or conversely the parents may feel that the adolescent is trying to grow up too quickly. Furthermore, the au- thors hypothesize that this asyn- chrony in “rate of development” may lead the adolescent to feel that their problems are insurmountable.

The suicide attempt, then, is con- ceptualized as an effort to solve an ”insolvable problem.” Zimmerman and LaSorsa assert that the main task of treatment is to renegotiate family relationships so that the ado- lescent can begin to individuate ap- propriately within a context of strong family connectedness. They suggest that this can be accom- plished by reframing the family’sconflicts in terms of differences in the speed at which development is occurring. For example, they pre- sent a “highway metaphor” to fam- ilies, in which the family is under- stood as “a group of people who have chosen to take a long trip to- gether in separate cars, such that each individual is in control of his or her own vehicle” [Zimmerman & LaSorsa, 1995, p. 178].

Cognitive-behavioral family therapy approaches have also been recommended for suicidal adoles- cents. Rotheram-Borus and col- leagues [1994] developed a highly structured, six-session outpatient family therapy program for adoles- cent suicide attempters and their parents. Known as “SNAP” (Suc- cessful Negotiation/Acting Posi- tively), this program is based on the idea that suicide attempts occur in response to unsolved family prob- lems. The overall goal of SNAP is to reduce the risk of a future suicide attempt by increasing positive fam- ily interactions and improving the family’s ability to negotiate conflict effectively. Since communication and problem-solving skills are often impaired in these families, SNAP endeavors to build skills in these ar- eas through a cognitive-behavioral approach which is also grounded in family systems theory [Rotheram- Borus et al., 1994].

Early in SNAP therapy, focus is put on creating a more positive fam- ily environment. For example, fam- ily members are asked to compli- ment each other at the beginning of each session and to comment on positive occurrences in the family.

The therapist identifies family strengths and helps the family to be- gin to identify strengths on their own. SNAP maintains that it is cru-cial for the therapist to communi- cate respect for the family, and to avoid blaming any family mem- bers. Thus, the suicide attempt (and subsequent family problems) are placed in a more positive and less blaming context by reframing to fo- cus attention on the problematic sit- uation, rather than the individual.

Families are then taught specific steps for problem-solving, includ- ing defining the problem, generat- ing and evaluating potential solu- tions, and assessing the efficacy of the chosen solution. Families gener- ate problems in session and repeat- edly practice solving them with the help of therapist role-playing, mod- eling, and feedback. There is also an emphasis on building new coping and negotiating abilities. For exam- ple, families are taught active listen- ing techniques to replace hostile, impulsive responding. During fam- ily role plays, “feelings thermome- ters” are used to rate individual lev- el of affective arousal (ranging from 0, or no discomfort, to 100, or most discomfort). This helps family members to increase their ability to label and manage their own feel- ings. The therapist also helps the family to identify and modify obsta- cles to problem-solving such as dys- functional family roles or negative attributions about the behavior of other family members [Rotheram- Borus et al., 1994]. The use of SNAP therapy with 140 female minority adolescent suicide attempters indi- cated that SNAP reduced overall symptom levels in these patients [Piacentini et al., 1995].

Similarly, Brent and colleagues [1996] have described the use of sys- temic-behavioral family therapy (SBFT) for adolescent suicidal de- pression. In SBFT, early sessions are Columns Crisis, 18 / 3 (1997) 107 devoted to the assessment of family interaction and problem-solving patterns. There is an emphasis on reframing the family’s problems in a more positive light, so that all fam- ily members can fully engage in treatment without feeling alienated or attacked. In the behavioral phase of therapy [adapted from Robin & Foster, 1989], the primary goal is to improve the family’s communica- tion and problem-solving skills, thereby reducing family conflict and reducing the adolescent’s de- pression. Specific techniques in- clude positive practice during the session and at home as well as teaching family members self-mon- itoring skills. Families are also helped to restructure maladaptive family patterns. For example, par- ents are encouraged to work togeth- er in their role as parents and to avoid inappropriate alliances with children [Brent et al., 1996].

Brief family therapy approach- es for suicidal adolescents have also been described in the literature. For example, Walker and Mehr [1983] advocate a time-limited (4–6 weeks) crisis-counseling approach to fami- ly therapy with suicidal adoles- cents. They recommend that the therapist first assess the strengths and weaknesses of the family and help the family to share responsibil- ity for changing maladaptive be- havior patterns. Since families often minimize the adolescent’s attempt, one of the family therapist’s first roles is to ensure that all family members understand the adoles- cent’s pain, while not being para- lyzed by feelings of guilt. The ther- apist then helps parents to draw their adolescents back into the fam- ily and nurture them without creat- ing an overly dependent relation-ship. At the end of brief family ther- apy, Walker and Mehr [1983] sug- gest that the therapist’s focus should be on helping the family to trust the adolescent again and help- ing the adolescent to achieve an ap- propriate level of autonomy.

Gutstein and Rudd [1990] have also advocated brief outpatient family crisis intervention for suicid- al adolescents. They observed that many suicidal teens have nuclear families that are isolated from their extended families. Because these isolated families have few resourc- es, they sometimes feel powerless to respond to adolescent crises. Gut- stein and Rudd designed the sys- temic crisis intervention program (SCIP) to mobilize and reconfigure the family’s kinship network. After an initial series of individual ses- sions to prepare family members, SCIP crisis teams assemble extend- ed family and friends and meet with them in one or two 4-hour sessions designed to encourage greater cohe- sion in the kinship network and to begin reconciliation among es- tranged members. The eventual goal is to use kinship networks to help buffer the transition to adoles- cence. One year follow-up indicated that youths who received the SCIP intervention demonstrated signifi- cant improvements on measures of patient behavior and family func- tioning [Gutstein & Rudd, 1990].

Is family therapy the best ap- proach for every family? In a sam- ple of hospitalized adolescent sui- cide attempters and ideators, King and colleagues [1997] found that on- ly 33.3% complied with recom- mended outpatient family therapy, whereas 50.8% followed through with recommended individual therapy, and 66.7% followedthrough with medication recom- mendations. Factors associated with poor family therapy compli- ance were maternal depression, ma- ternal paranoia, and distant father- adolescent relationships. Similarly, Brent et al. [1996] found that it was difficult for families to follow through with family therapy until parental depression was addressed.

Together, these findings indicate that it may not be realistic to expect all families to follow through with family therapy; they suggest that clinicians should carefully consider the likelihood of compliance prior to prescribing a treatment plan.

An alternate approach is to in- tegrate individual and family treat- ment for adolescent suicide at- tempters. For example, Zimmer- man and LaSorsa [1995] suggest that therapists label themselves as the “family’s therapist” and con- duct individual and family therapy concurrently in a flexible manner, as needed. They have found that diffi- cult issues are sometimes more eas- ily explored initially in an individu- al context, and then later brought to family meetings where they can be expressed in a controlled environ- ment and managed by the therapist.

Brent et al. [1996] concurred, noting that in their ongoing clinical trial, many people in the family therapy group wanted some individual ses- sions, and similarly many people in the individual therapy group wished for some family involve- ment in therapy. The integration of individual and family therapy ap- proaches holds promise for the treatment of adolescent suicide at- tempters. Crisis, 18 / 3 (1997) Columns 108 References Brent DA, Roth CM, Holder DP, Kolko DJ, Birmaher B, Johnson BA, Schweers JA.

Psychosocial interventions for treating adolescent suicidal depression: A com- parison of three psychosocial interven- tions. In ED Hibbs, PS Jensen (Eds)Psy- chosocial treatments for child and adolescent disorders: Empirically based strategies for clinical practice(pp. 187–206). Washing- ton, DC: American Psychological Associ- ation, 1996.

Gutstein SE, Rudd MD. An outpatient treat- ment alternative for suicidal youth.Jour- nal of Adolescence1990; 13:265–277.

Haley J.Leaving home: The therapy of disturbed young people. New York: McGraw-Hill, 1980. King CA, Hovey JD, Brand E, Wilson R, Ghaziuddin N. Suicidal adolescents after hospitalization:

Parent and family impacts on treat-ment follow-through.Journal of the American Academy of Child and Ado- lescent Psychiatry1997; 36:85–93. Piacentini J, Rotheram-Borus MJ, Cantwell C. Brief cognitive-behavioral family ther- apy for suicidal adolescents. In L Vande- Creek, S Knapp, T Jackson (Eds)Innova- tions in clinical practice: A source book,Vol.

14(pp. 151–168). Sarasota, FL: Profes- sional Resource Press, 1995.

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New York: Springer Publishing, 1986.

Robin AL, Foster SL.Negotiating parent-ado- lescent conflict: A behavioral-family systems approach. New York: Guilford Press, 1989.

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Sabbath JC. The suicidal adolescent—The ex- pendable child.Journal of the American Academy of Child Psychiatry1969; 8:272– 289.Walker BA, Mehr M. Adolescent suicide—A family crisis: A model for effective inter- vention by family therapists.Adolescence 1983; 18:285–292.

Zimmerman JK, LaSorsa VA. Being the fam- ily’s therapist: An integrative approach.

In JK Zimmerman, GM Asnis (Eds)Treat- ment approaches with suicidal adolescents.

NY: John Wiley & Sons, 1995. Anthony Spirito, PhD, is director of child psychology at Rhode Island Hospital and as- sociate professor of psychiatry, Brown Uni- versity School of Medicine. Clinical duties include consultation to adolescent suicide attempters. He has written many book chapters on adolescent suicide attempters, and is currently conducting a project on the effectiveness of compliance-enhancement intervention for adolescents after a suicide attempt. Columns Crisis, 18 / 3 (1997) 109 Announcements The European Regional Council/World Federation of Mental Health (WFMH) 1998 European Regional Conference is being held 2–4 July 1998, in Edinburgh, Scotland, UK. For further information, contact: Pe- numbra International, Gogar Park, 167 Glasgow Road, Edinburgh EH12 9BG, Scotland, UK (tel. +44 131 317-1337, fax +44 131 317-1410, e-mail [email protected]). The deadline for abstracts is 6 March 1998.

The World Federation of Mental Health (WFMH) World Congress is being held 5–10 September 1999, in Santiago, Chile. For further information, contact:

Benjamin Vicente, MD, University of Concepcion, Casilla 60-C, Concepcion, Chile (tel. +56 41 240186, fax +56 41 312799). The Editors and Publisher of Crisis welcome readers’ comments. If you wish to comment on any papers published in the journal or on related topics, please con- tact either one of the Editors-in-Chief or the Publisher at the addresses given in the front of this issue.