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KEY WORDS:adolescence; family therapy; Satir model; suicide; treatment; youth. This article is intended to share how the Satir model (Satir, Ban- men, Gerber, & Gomori, 1991) can be used to understand and treat youth who are suicidal. Youth suicide is a major concern in Western society, and measures need to be explored to reduce suicide among the adolescent population. In the United States the suicide rate among adolescents and young adults tripled between 1950 and 1980. The rate for people 15–34 years old during that time and throughout the 1990s Wendy Lum, MA, is a Child, Youth, and Family Therapist, Kelowna, British Colum- bia, Canada (e-mail: [email protected]). Jim Smith, BPE, RSW, is Director of Langley Youth & Family Services, 5569-204th Street, Langley, British Columbia, Canada V3A 1Z4. Judy Ferris, MA, MEd, is a Youth and Family Therapist, Langley Youth & Family Services, Langley, British Columbia. Canada.

*Portions of this paper were presented at the Canadian Association for Suicide Prevention (CASP) Conference, Vancouver, BC, October 2000.

*The authors wish to acknowledge the inspiration received from their involvement with the Suicide Intervention & Treatment Task Force, Satir Institute of the Pacific. Contemporary Family Therapy 24(1), March 20022002 Human Sciences Press, Inc. 139 140 CONTEMPORARY FAMILY THERAPY remained at approximately 15 per 100,000 population. By 1996, suicide was the third leading cause of death for adolescents and young adults (Maris, Berman, & Silverman, 2000). The suicide rate for 15–24 year olds is 12 per 100,000. The rate for 5–14 year olds is 0.8 per 100,000.

Approximately 10,200 people ages 15–34 years old kill themselves each year and 4,700 from ages 15–24. These numbers show the tragedy of despair amongst young people.

Everall (2000) highlighted the fact that in Canada, suicide is the second leading cause of death for young people aged 15–24 years.

Banmen (2000) suggested that youth suicide is a significant concern for mental health professionals. Youth struggle with internal coping in relationship to their external factors (e.g., family violence, disruption during key transitional periods at school, teasing/bullying, loss of signif- icant family member) and this factor may contribute to increased sui- cide rates. Clearly youth suicide is a societal issue that needs more effective education and intervention for prevention of suicide among adolescents.

COMMON THERAPIES FOR SUICIDAL ADOLESCENTS The Satir model (Satir, Banmen, Gerber, & Gomori, 1991) is a unique therapeutic system that offers hope for therapists who wish to connect with and to positively affect suicidal youth in making a choice to live. Satir’s model will be discussed in relationship to an actual case study. There are other therapeutic frameworks that are used to deal with youth suicide prevention and intervention. The methods, which are currently used to understand and intervene with suicidal youth, will now be reviewed.

The preferred treatment for working with the suicidal adolescent is individual therapy on an outpatient basis. Richman and Eyman (1990), examine the three major types of therapy used with suicidal patients—individual, group, and family. Issues such as fragile identity, conflicted self-expectations, and difficulty expressing emotions are dis- cussed. Hoover (1987) looks at the self in regard to suicidal behavior, stating that the distinguishing factor in suicide is the invalidation of the sense of self. Hoover and Paulson (1999) describe the journey away from self as a disconnection from self and others. The return to self occurs through reconnection through feeling, self-awareness, and hon- ouring the self.

Initially, crisis intervention is the treatment used to deal with the suicidal crisis. The immediate therapeutic task is to prevent self-harm. 141 WENDY LUM, JIM SMITH, AND JUDY FERRIS The work of therapy can focus on broadening the adolescent’s linkages to a wider network of resources and on the predisposing conditions that make the adolescent vulnerable. Suggested interventions are so- cial skills training, treatment of loneliness, cognitive-behavioral ther- apy and other behavioral approaches, problem-solving skills, training in anger, and aggression management. Solution-focused brief therapy uses the client’s strengths, competencies, resources, and successes (abil- ity to be resilient) to bring about change (Fiske, 1998). This approach emphasizes co-operation between client and therapist and offers tools in the form of questions when working with suicidal children and ado- lescents to help divert their attention from problems to possible solu- tions.

Ellis and Newman (1996) link cognition and suicidality. They state that hopelessness, problem-solving deficits, and perfectionism as well as dysfunctional attitudes and irrational beliefs are characteristic of individuals contemplating suicide. Cognitive-behavioral therapy is used with both adults and adolescents. This is a collaborative model in which client, therapist, and the family identify the client’s problems, strengths, and previous attempts at problem-solving. Problem-solving skills are further developed, and the client learns to develop alternative interpre- tations and beliefs so that suicide no longer seems the only viable option. Freeman and Reinecke (1993) refer to the techniques of activity scheduling, mastery and pleasure ratings, graded task assignments, behavioral rehearsal, social skills and assertiveness training, biblio- therapy, in vivo exposure, and relaxation, meditation, and breathing exercises. Cognitive techniques useful in developing adaptive responses to dysfunctional thinking are described. These include understanding of idiosyncratic meaning; decatastrophizing, guided association discov- ery, cognitive rehearsal, and development of cognitive dissonance.

Dialectical Behavior Therapy (Linehan, 1993; Linehan, MacLeod, & Williams, 1992) also uses a problem-solving strategy. However, it differs from cognitive behavioral therapy in that it tries to make the techniques more compatible with psychodynamic models. Fiske (1998) suggests DBT be modified for use with children and adolescents. Con- structive goals and reasons for living are the basis for this model.

The goal of psychoanalytic/psychodynamic approaches is to gain insight into the unconscious conflict of the client. In summarizing these approaches, Maris, Berman, and Silverman (2000) refer to object rela- tions theory, which states that suicidality represents a failure in the task of separation-individuation. Research on attachment styles among suicidal youth supports this aloneness.

Goals of family therapy are modifying communication patterns, 142 CONTEMPORARY FAMILY THERAPY increasing support for the adolescent’s attempts at self-care, and im- proving the family’s problem-solving behavior. A central goal is to de- velop an understanding within the family of the meaning of the adoles- cent’s suicidal behavior and to improve family functioning (Berman & Jobes, 1997; Maris et al., 2000). Group therapy provides a social support network for suicidal clients and provides a milieu where social skill development can take place (Maris et al., 2000). Themes emerging from group psychotherapy are family relationships, peer relationships, and the control of potentially overwhelming feelings and impulses (Rich- man & Eyman, 1990). SATIR MODEL THERAPY Virginia Satir initially developed a model of intervention that fo- cused on personal growth and accessing life energy for healing. Since then it has been developed further for use with suicidal clients to choose life. The Satir model (Satir et al., 1991) has many applications for therapists to learn in strengthening connection with suicidal youth.

This model recognizes that all human beings strive to survive and to grow. Satir had great faith in people’s ability to grow, as long as there is breath (Satir & Banmen, 1983). Satir believed in the life force that all humans have access to, and her therapeutic work was aimed at releasing this life force from within the person (Banmen & Banmen, 1991). When youth are suicidal, there is less energy for living, although they may summon up the energy to commit their final act. This model encompasses many aspects of theory and enables therapists to gain insight into the inner world of youth and their ways of coping. The Satir model recognizes the impact of family of origin disappointments, rules, expectations, and relationships. By working through and healing past unresolved hurts and resentments, youth may be better able to move in a positive direction toward future growth.

Within the Satir model, the Personal Iceberg Metaphor (Banmen, 1997; Satir et al., 1991) is a conceptual framework of the inner experi- ence, which can be used to assess, understand, reflect, interact, change, and transform youth. This concept is an intrapsychic psychological map of the inner world. There are seven components within the Personal Iceberg Metaphor (Self: I am/Spiritual Core, Yearnings, Expectations, Perceptions, Feelings about Feelings/Feelings, Coping Stances, and Behavior). The metaphor concept allows therapists to understand their own as well as another’s intrapsychic experience. The Personal Iceberg 143 WENDY LUM, JIM SMITH, AND JUDY FERRIS Metaphor enables therapists to process youths’ internal world, while at the same time acknowledging their external world. INNER EXPERIENCE Behavior of the Suicidal Youth The acting out behavior and verbal communication of suicidal youth is an expression of his or her internal experience. The Satir model looks at behavior and verbal communication as the result of the inner world of youth. Through using the Satir model and by focusing on changing adolescents’ internal world, destructive external behavior has the stronger possibility of being positively changed. Satir’s Personal Iceberg Metaphor (Satir et al., 1991) acknowledges behavior as only being a one-eighth part of the whole person, and that seven-eighths is hidden from external view, thus the iceberg metaphor.

In dealing with suicidal youth, therapy has often been focused more on identified behaviors. Some of these behaviors are displayed such as running away, disruptive behavior, challenging comments and actions, resistance to others, chronic nonattendance at school, notice- able mood changes, body movements, nonverbal responses, substance abuse (drugs and/or alcohol), sexual acting out, giving away posses- sions, and verbal comments (Banmen, 2000). Suicidal teenagers have a higher possibility of experiencing disruption and unpredictability within their family environment (Everall, 2000). Suicidal actions or intentions can be seen as a sign that within youth’s internal worlds, there may be a sense of hopelessness, helplessness, despair, and discon- nection. Coping Stances of the Suicidal Youth Satir (1972) suggested that in order to survive, people cope in different ways under stress. The four coping stances are referred to as the placating stance, the blaming stance, the super reasonable stance, and the irrelevant stance (Satir, 1972; Satir et al., 1991). Satir also viewed relationships as involving three crucial components: self, other, and context. This is how a person acts and feels in relationship to oneself, in relationship to another, and depending on the situation or environment in which the relationship is taking place.

Suicidal youth who use the placating stance under stress may not 144 CONTEMPORARY FAMILY THERAPY highly value themselves, but will value the other person and be aware of the context. These teenagers live in their feelings about themselves, others, and the world. The placating suicidal youth may experience a deep sense of worthlessness, unworthiness, hopelessness, and helpless- ness. There may be behaviors that indicate depression, and a deep unhappiness about themselves and their life. Suicidal adolescents may reject themselves, while expecting that others have given up on them.

The rejection could manifest as a giving up on themselves, which will inhibit their own life energy, hence possible depression. Suicidal youth may be very unhappy and disappointed that their needs are not being met by others (Banmen, 2000).

Suicidal youth who use the blaming stance under stress value themselves and are aware of the context, but will not value the other person with whom they are in a relationship. These adolescents have high expectations of others and the world. When their expectations are not met, a blaming stance will occur. The blaming suicidal youth may feel a deep sense of inner isolation and loneliness. Outwardly they may display verbal and/or non-verbal anger towards others through acting out, bullying others, drug abuse, and delinquent behavior. These teen- agers may also feel aggressive, revengeful, and indignant.

Suicidal youth who use the super reasonable stance under stress will be focused on the context, information, and details of situations.

The super reasonable suicidal youth may feel very fragile, and have a deep sense of isolation from others and within themselves. These youth may create distance from others by isolating themselves with books, games, and computers. Their behaviors may manifest outwardly through perfectionistic, obsessive, and/or compulsive behaviors.

Suicidal youth who use the irrelevant stance under stress, have no sense of belonging or sense of connection. Disconnection from self can be a constant state of being. The irrelevant suicidal youth may feel extreme pain and sensitivity. They may experience turmoil and chaos externally and internally. They can be very impulsive, spontaneous, and make poor choices due to their impulsive actions. These adolescents may not be focused on tasks or not be present within their own selves.

These youth may appear to be funny, joking, and class clowns, but internally the disconnection is extremely and deeply painful. These teenagers may struggle with creating a sense of self or have an inability to create a sense of self.

Adolescents are less able to access their strengths and resources while under stressful circumstances. Suicidal youth could use any of these coping stances, however one stance may be more prominent. Suicide 145 WENDY LUM, JIM SMITH, AND JUDY FERRIS results from a decision that comes from young peoples’ inability to transpose stresses in their daily life.

Feelings of the Suicidal Youth Feelings are our emotional response to ourselves, others, and the context (situations and events). Satir and associates (1991) believed that we have a right to feel our feelings, however we may have family rules that deny the display of these feelings or emotions. Often placating youth may be very aware of this feeling component in their lived experi- ence. Suicidal youth may be flooded with feelings of their emotions, or they can be numbed from feeling their emotions. Teenagers who are suicidal may feel hurt, sadness, depression, loss, abandonment, fear, anxiety, remorse, guilt, self punishment, disillusionment, confusion, and a sensitivity to being criticized by others (Banmen, 2000). The experience of loss can be accumulated over a period of time in childhood (Everall, 2000). Suicidal youth can also feel anger, rage, revenge, and retaliation and be critical of others. There may be a deep sense of rejection and betrayal that can create a helpless feeling. In summary, how suicidal youth cope will influence the kind of feelings that will be internally experienced. Feelings about the Feelings for the Suicidal Youth Satir and colleagues (1991) acknowledged the impact that feelings have on oneself, and attributed this to our feelings about having feel- ings. This is a component that deepens and displays the intricacy of the feeling experience. The feelings about the feelings component have an impact on suicidal teenagers with their sense of self-esteem, self- worth, and adequacy. Suicidal youth may experience feelings of shame, guilt, and worthlessness in relation to their initial feelings. Adolescents who are suicidal may also experience a sense of vulnerability, hopeless- ness, helplessness, and deep despair. Beliefs of the Suicidal Youth Suicidal youth will have perceptions and beliefs that influence their suicidal intentions and behaviors. Adolescents who use the super reasonable stance are likely to be highly aware of and focused on their intellectual perceptions in order to make sense of their world. How suicidal youth view themselves, others, and the world, will affect their 146 CONTEMPORARY FAMILY THERAPY decisions about life and death. Chandler and Lalonde (1998) found that four out of five youth (84%) who were actively suicidal did not believe that they had any connection to their past, present, or future. There may be a sense that they have lost control, or have never had any control over their world, and they may feel unable to change their circumstances. Suicidal youth may believe that they have no choice, or that committing suicide is the only choice that is left for them to make. Some suicidal youth may believe that they are emotionally invisi- ble to others and that no one will listen to them. Adolescents who are suicidal may have had numerous losses and believe that such losses will continue in their lives. A sense of being abandoned by others or the world can be predominant. Suicidal youth see rejection as an acknowledgment of their sense of being contaminated or flawed (Ever- all, 2000). These teenagers may believe that they are losers, and they could be on a downward spiral in relationship to their self-esteem.

Some suicidal adolescents may believe that they are unlovable, unac- ceptable, or incompetent. If these teenagers or their family members have high expectations of them, there can be a sense of failure for not living up to being perfect or successful.

Expectations of the Suicidal Youth Unmet yearnings will manifest in expectations of others to meet their yearnings, and this can interfere with teenagers’ taking responsi- bility for their lives. Suicidal youth who use the placating coping stance may be self-punishing and self-victimizing and expect that they cannot affect their world. There can be expectations which are negatively focused. Suicidal youth who use the blaming coping stance can be blaming, accusatory and controlling, especially if they expect others to meet their needs. Their expectations can be unrealistic, imagined, and contribute to disappointments. Often expectations are formed from family rules that involve “shoulds, musts, and oughts.” Suicidal adolescents may judge themselves for having failed their own expectations. High expec- tations that are realistic can help as a protective factor in preventing suicide. Yearnings of the Suicidal Youth Satir and colleagues (1991) believed that all humans have univer- sal yearnings for love, validation, belonging, connection, acceptance, 147 WENDY LUM, JIM SMITH, AND JUDY FERRIS acknowledgment, meaning, growth, and freedom. So no matter what age a person is, these yearnings are common, even for the adolescent population. When youths’ yearnings are met, then a sense of fulfillment, wholeness, and harmony will be experienced. When unfulfilled yearn- ings are not met, there is a negative impact on the internal worlds of these youth, and often these can turn into expectations of self or others, which lead into negative behaviors. If youth yearn to be loved and do not feel loved, then they may conclude that they are unlovable. If there is a yearning to feel a sense of worthiness and these yearnings are not met, they may think that they are worthless. When adolescents yearn for connection and these yearnings are not met, there is a disconnection from self. If youth yearn for attachment and these yearnings are not met, they may become detached and this detachment can be from Self:

I am and/or God. If there is yearning for belonging, but these yearnings are not met, they may experience social isolation or an isolation from self. When youth yearn to feel acknowledgment and these yearnings are not met, they may feel rejected. If youth yearn for growth and these yearnings are not met, then they may experience a sense of failure and stagnation. Yearnings are a significant component of the inner world that gives meaning to life.

Self of the Suicidal Youth The Self: I am is one’s connection to his or her soul, essence, core, or life force. It is through this life force that life’s energy is manifest.

When youth are fully connected with the life force of the Self: I am, then they will experience peace, inner calm, hope, faith, wisdom, harmony, a desire to live, high self esteem, and a willingness to take responsibility.

This deep connection with Self: I am can be a spiritual source for youth, which can also help to provide a sense of meaning in their lives.

When youth are disconnected from the Self: I am, there will be disruptions or blockages in their life force energy (Satir et al., 1991).

This disconnected energy may occur as a result of the impact of their family of origin experiences between family members (Everall, 2000; Satir et al., 1991). As a result of this disconnection, youth will experi- ence low self-esteem and self worth. This inner experience of self will affect youths’ intrapsychic world, which will in turn have an impact on their relationships with others. Suicide may be a rejection of the Self: I am, a punishment of Self: I am, a violence toward the Self: I am, or an abandonment of Self: I am. 148 CONTEMPORARY FAMILY THERAPY WHAT SUICIDE INVESTIGATIONS TEACH US “Wars come and go; epidemics come and go; but suicide, thus far has stayed. Why is this and what can be done about it?” (Jamison, 1999, p. 24).

The experiences of an individual youth suicide will be analyzed in the context of the Satir model. The information of the inner experience of the deceased individual has been gathered from the testimony of significant others in the youth’s life through an extensive investigative process. This collaborative view is derived from the case file taken from one of the authors (Smith) from his work as a Behavioral Investigator for the British Columbia Coroner’s Service, Canada, where he performs child, youth, and adult suicide investigations. Between 50 and 75 per- cent of approximately 500 child and youth suicides examined through the behavioral investigation program were not predicted by the parents, service providers, or gatekeepers. This was a surprising number of unpredicted suicides suggesting that precursors to child and youth suicide needed to be understood differently.

Looking at suicide through the theory of the Satir model brings forth new learning applicable to the living. In his work as director and therapist for a youth and family services agency, Smith has also had the opportunity to apply this new learning with suicidal youth.

Many reasons for suicide and attempted suicide have been put forth. We hear a lot about the external factors that are major contributors to the cause of suicide. These factors, including drugs and alcohol, loss and grief, divorce, peer pressure, re- duced job opportunities, economic competition, and world ten- sion have all been used to explain the suicidal scenario. The external, contextual, environmental, interactive factors are probably stronger stressors now than in previous decades. Yet, most teenagers seem to handle these stressors well. All of life is within a context. How we handle the impact of various stressors might be a more important consideration than the stressors themselves....TheSatir model (Satir et al., 1991) has some basic premises that might fit in our exploration of suicide. Satir believed that human beings have the internal resources they need to survive and grow. She also believed that internal change is always possible, even if we do not have control of our external world. She taught that the problem is not the problem, but how we cope with the problem is usually 149 WENDY LUM, JIM SMITH, AND JUDY FERRIS the problem. She found that most people choose familiarity over the discomfort of change, especially during times of stress. She also advocated that therapy needs to focus on health and growth possibilities instead of pathology (Ban- men, 2000, pp. 1–2).

The work of the behavioral investigation program is intended to illuminate the human factor in death investigations. Specifically, the program serves to assist the coroner in determining the classification of death and why certain deaths may have occurred and how they may have been prevented.

A behavioral investigation is a voluntary inquiry into the inner experience of the deceased. The information gathered includes: back- ground history of the parents and a multi-generational family history, information about the pregnancy, pre,-peri,-and post-natal history, de- velopmental milestones, marital and family history, significant events in the family and life of the deceased, and school information. In addi- tion, the behavioral investigator gathers testimonial descriptions of the deceased from significant others in the life of the deceased. This process adds important dimensions to understanding how the deceased experienced life. Those interviewed include parents, siblings, relatives, friends, employers, lovers, fellow students, coaches, leaders, teachers, therapists, psychiatrists, social workers, and medical doctors. The col- lective view of the possible experience of the deceased is gathered through a careful and sensitive interviewing process frequently lasting between three to four hours per interview. With these interviews the investigator gathers a body of information that when viewed through the Satir model (Satir et al., 1991) provides a means to understand behavior as coping.

Behavior patterns are analyzed and reported to the coroner. In addition, the behavioral investigators are required to speculate how each suicide death may have been prevented. This speculation has become the art of understanding the experience of the deceased. Consid- ering behavior as coping as seen through the Satir model shifts focus from the individual act of self death to the story behind the struggle to live and the meaning the individual may have attached to this struggle. For some, suicide appears not to be so much about wanting to die, but more about believing they can no longer endure the pain of living. This suggests that explanations for suicide might lie within himself or herself in relation to the world in which he or she exists. 150 CONTEMPORARY FAMILY THERAPY CASE STUDY Satir model theory regards behavior as the external manifestation of the internal experience. Understanding behavior in this way provides opportunity for earlier intervention into suicidal ideation. While invest- igating the suicide death of Paul, a pseudonym for a 16-year-old male, Smith was initially puzzled by the lack of information to explain the reasons for his suicide.

The information from the coroner’s office that Smith reviewed, included:

1. The suicide note left by the deceased.

2. Interview narratives with the principal of the high school that Paul last attended.

3. Attendance and disciplinary files profiles for grades kindergar- ten through to and including grade nine.

4. School records 1998 to January 1999.

5. Eulogy given by high school principal.

6. Interview narrative and psychological summary report of school district psychologist.

7. Interview narratives with Paul’s parents.

8. Interview narrative with teaching staff of the elementary school.

9. Psychological research questionnaire completed and provided by the coroner’s agent.

In addition to the information provided by the coroner’s agent, Smith conducted a telephone interview with Paul’s mother to gather birth and family system history. The suicide note contained messages of hopelessness and helplessness. It did not explain why or how Paul arrived at the state he was in at the time of his death. Smith wondered what indications he may have given that might have been seen as a precursor if not to his suicide, at least to his apparent suffering.

Through information taken from his school records (Table 1), Paul appeared to be quiet, compliant, and academically successful. When he reached high school he had become uncooperative, oppositional, and bullying in his behavior with absenteeism and suspensions. He appears to have coped with his feelings by withdrawing into himself. Adopting a compliant coping style, as Smith suspects Paul did, prevented others from understanding his personal internal experience.

Paul was unable to externalize his feelings of pain and/or fear.

This inability to externalize feelings, in Smith’s experience, is likely the meaning of his statement in his suicide note “There is no way I can explain what I did but it was done. I just couldn’t go on living.” Smith believes that Paul lacked a deeper understanding of who he 151 WENDY LUM, JIM SMITH, AND JUDY FERRIS TABLE 1 Paul’s School Records Days Grade Absent Comments Kindergarten 13 Nervous, high-strung, low self-esteem.

Grade 1 13 Grade 2 25.5 Grade 3 27 Hesitates to ask for help in class.

Grade 4 Unknown With learning assistance support achieved a B average.

Grade 5 05 A/B average Grade 6 8.5 A/C average Grade 7 35.5 Marks dropped. Achieved one B, other (middle marks were C, P and F. Lack of effort, school) disciplinary problems, missed assignments, disrupting others.

Grade 8 Unknown Several suspensions, spitting, intimidation, fighting, using drugs at school, extortion.

Grade 9 (3 Marks continue to fall, indefinite years in suspension, absenteeism, was repeating grade 9) grade nine for third time with marks ranging from B to F with an average of C−.

already was; that in a sense Paul felt he had yet to become a person.

This expression from Paul’s suicide note gives a feeling his life was not working out and that he lacked connection with his self. This expression from Paul’s suicide note also indicates the state of despair he was in at the time of the writing of the suicide note.

Paul succeeded academically in elementary school and appears to have done so with the external support of his teachers. In middle-school and high school, records show he struggled to succeed academically, indicating he may have continued to require external support and likely expected this support to continue as he progressed through his school years. Without this support, his performance dropped off, as did his compliance.

The attendance and comment profiles for grades Kindergarten through Grade 9 as recorded by the school, are a clear indication Paul could succeed academically when sufficiently motivated. 152 CONTEMPORARY FAMILY THERAPY School records for kindergarten indicate Paul presented at school as lacking self-esteem. These perceptions on the part of the school system resulted in academic support. In retrospect his low self-esteem presentation might more accurately have been seen as the external expression of his coping. Understanding externalized behavior as cop- ing with an internal state, nervous and tense behavior for Paul might have been about a deeper level state of fear. Interpreting Paul’s nervous and tense behavior as a deep level fear could have initiated an earlier referral for therapeutic intervention in elementary school. By Grade 3, Paul is experienced at school as withdrawn. His withdrawn behavior withholds his true feelings from the external world, and in Smith’s experience this withdrawn behavior might be the first sign that Paul is experiencing feelings of both helplessness and hopelessness.

With continued support at school he achieved a reasonably high standard of academic success through Grade 7. In his Grade 7 year Paul moved into middle-school at a different geographical location from his elementary school and with different teachers. His marks and the behavior comments from Grade 7 through to the end of his life reflect lack of effort, missed assignments, suspensions from school, fighting, intimidation of others, and drug use. Paul at this time is experienced as uncooperative, manipulative, and passive-aggressive, inviting reactive disciplinary action on the part of the school district. Smith suspects that he was possibly experiencing the combined painful feelings of fear of failure, disappointment, helplessness, hopelessness, and frustration.

Smith believes Paul may have been acting these feelings out through lack of effort, missed assignments, fighting, intimidation, and drug use.

Had the school district understood these externalized behaviors as coping, they likely would have referred Paul for psychological therapy, rather than only reacting to his behavior through disciplinary mea- sures.

Smith believes Paul was in a desperate emotional state through the later part of middle-school into high school and that this state is reflected in his angry acting out behavior. This was the last attempt Paul was able to make in order to have his life come out right. Smith believes he was likely in deep emotional pain of despair, and that he likely harbored expectations of himself, family, and teachers that had not been met at the time of his death. Without external support Paul was unable to succeed and eventually gave up trying. Smith believes the non-compliant behavior of Paul may have had the purpose of asking for support. By shutting down, he may have carried the hope he would receive the same support in middle-school and high school that he received in elementary school. Smith believes Paul likely experienced this absence of support as painful feelings of loneliness and abandon- ment, and that his drug use may have served to ease this pain. 153 WENDY LUM, JIM SMITH, AND JUDY FERRIS Smith discovered that Paul had at times performed acts of self- mutilation by digging into his hand, and exposed skin on his arms with a pencil or sharp instrument. Smith also discovered Paul drew pictures depicting violence and scenes containing blood. This self-mutilation behavior and graphic sadistic art provided another obvious opportunity for therapeutic intervention.

The ability to understand behavior differently may be the key to early intervention and prevention of suicide. Understanding behavior as the external expression of an internal state sees behavior as a dy- namic purposeful activity with attached expectations of self and others, and views expectations as linked to deeper unmet universal yearnings.

These universal yearnings are directly linked to the individual’s need to evolve and, when these yearnings remain unmet, can be the experi- ence of their life not working out.

SUICIDE TREATMENT USING THE SATIR MODEL This section will share how a therapist using the Satir model (Banmen, 1997; Satir et al., 1991) might have engaged in treatment with Paul while he was still alive. From the identified case study, Paul could have been referred to a therapist to deal with his sense of inadequacy at an earlier age; unfortunately his referral for therapy in Grade 9 was not initiated soon enough. Therapy could have been initi- ated at an earlier time when it was evident that Paul struggled with his school involvement. The behaviors he exhibited in Grades 7 and 8 could have alerted friends, family, teachers, school counselors, or principals that Paul was in need of therapy.

In the Satir model (Banmen, 1997) there are four main goals for therapy; to raise self esteem, encourage better choice-making, increase responsibility, and facilitate congruence. The Satir model recognizes the universal yearnings of all humans to be connected with themselves and with others. By facilitating a sense of connection, the therapist would be able to better explore Paul’s commitment to live. First of all, using the Satir model (Banmen, 1997) the therapist would intentionally connect and attempt to maintain connection with Paul throughout the treatment period. The therapist would share an attitude of acceptance, genuineness, and caring. Initially the therapist would assess Paul’s energy and willingness to engage in therapy throughout the first ses- sion and within each subsequent session. The therapist would use process questions throughout sessions, such as, “What would you hope 154 CONTEMPORARY FAMILY THERAPY would happen from our time together?” By listening closely to how Paul had perceived himself, others, and his situation, the therapist would gain valuable information into how to approach the therapy process. The therapist could ask, “Is there anything you would like to change in your life?” The therapist would listen for a possible goal and help Paul to define a goal for therapy. The therapist would check to see if he were committed to working with the therapist on attaining his goal. Once a commitment had been made, the therapist would remain conscious of his specific goal throughout the therapy period. If there were resistance from Paul, then the therapist might have to recheck the goal to see if he was still committed to this goal, otherwise there would be further exploration and a re-clarification regarding the goal of therapy. “Are you sure that this is what you really want for yourself?” With regard to self-esteem, the therapist would wonder about Paul’s self esteem, and ask questions such as, “What do you know about yourself? and “Who do you believe you really are?” As noted, it appeared that Paul had low self-esteem and was not well connected to himself.

The therapist would explore his relationship to himself, and foster a stronger inner connection to self. “When do you feel most alive?” “When do you experience inner calm?” The therapist would find ways to strengthen Paul’s self esteem, by increasing self-awareness, fostering self-acceptance, and self-validation. One way to get a sense about how Paul saw himself, would be to ask, “What are your hopes and wishes for yourself?” His answer could enable the therapist to understand which yearnings could motivate him to live. In the case of Paul, his dreams of becoming a rock star suggest a desire for acceptance and recognition. The therapist would find out how he could have found an acceptable way to express himself either through singing, playing an instrument, or possibly creating poetry. The therapist might be able to help him to realize his dream, or change his dream for one that could have been attainable.

The Satir model supports the idea of resilience within all people and the belief that each person has strengths and resources to deal with their lives. The therapist would listen to the problem, and reframe the problem into more positive possibilities. As the therapist listened to and continued to be engaged with Paul, there would be exploration on finding out how Paul experienced himself, others, and his world.

The therapist could ask, “How do you handle your loneliness?” “How do others see you?” “When have you felt supported and seen by others?” The therapist would use process questions throughout the therapy 155 WENDY LUM, JIM SMITH, AND JUDY FERRIS process, in order to find out if there were strengths or resources that had been developed by Paul as a result of his situation(s) and relation- ship(s). For example, “When do you feel good about yourself?” and “What do you do well?” The therapist would be creative in reframing negative perceptions into more positive resources. “Can you appreciate that you have deep, deep feelings, like the depths of a passionate song- writer?” Once the strengths and resources had been identified, the therapist would help Paul to take ownership for his strengths and resources, in spite of any perceived obstacles. “Right in this moment, can you be aware of your love of music? How does it make you feel inside?” Awareness of his strengths and resources could foster increased self-esteem.

One of the four goals of the Satir model is to help the client to make better choices. The choice to live is a crucial goal for the therapist to explore with suicidal youth. “Are you willing to live for yourself and not for others?” “Do you deserve to live in peace?” “Can you make a decision today to live and not to die inside?” Another important aspect of the Satir model is to create experiential moments for the client in therapy. During these moments when Paul was becoming aware of and experiencing his inner world, the therapist would gently challenge him to make some choices about his life. “Close you eyes and as you become aware of the pain, can you send compassion to that painful place, so it can begin to breathe?” If the therapist sensed that Paul had suicidal thoughts, it would have been important to explore whether he was willing to live for himself. The therapist would ask Paul to make a decision to live at the level of self while he was immersed in an experiential moment. “In this vulnerable place, can you find the inner strength to live and grow?” If Paul did not feel hopeful, then the therapist would suggest, “Will you accept my hope for you, so that we can work together until you gain your own hope?” The therapist would ask, “Are you willing to make a decision not to hurt yourself, while we are working together to change things?” If Paul felt suicidal when he was away from the therapy ses- sion, then the therapist would help him co-create a plan for coping that Paul could agree to.

Increasing responsibility is another one of the four goals of the Satir model. Working with and changing expectations is also a fundamental concept in the Satir model. Helping a client to either accept his or her expectations or to change those expectations can facilitate a client to take on responsibility for his or her life and to make different choices.

If the therapist heard any regret(s), then exploration could occur with 156 CONTEMPORARY FAMILY THERAPY having Paul accept that these were his expectations. The therapist would suggest that if Paul accepted and owned his expectations, then he could have been more willing to fulfill his expectations and let go of his expectations of others. “Are you willing to make a decision to stop hurting yourself, and to ease your pain?” “How can you let go of expecting that they should know about your painful hurt, when you hurt yourself?” If Paul would not let go of his expectations, then the therapist would explore the costs for him in keeping these expectations.

The therapist would suggest that he meet his own yearnings for accep- tance and validation, instead of waiting for others to meet his yearn- ings. Together they could make a concrete plan on how Paul could meet his yearnings. “How can you extend a caring, helping hand to yourself ?” “Are you willing to give yourself the gift of life, instead of waiting for someone else to give your life to you?” “Is it time to let love inside?” The facilitation of congruence, the last of the goals in the Satir model, involves helping with the ability to be honest and truthful in actions and words coming from one’s internal experience. As clients become more aware of interactions with self, other, and the context, there can be the opportunity to develop congruence. Gaining an under- standing of the impact of Paul’s past experiences in the family and within the school system would be very useful. “What happened for you when no one seemed to pay attention to you anymore?” The thera- pist could also include Paul’s family in family therapy, and involve his parents or siblings in the therapeutic process. The therapist would explore his past family experiences and past social experiences, and then work on reducing any negative impacts in the present. “Are you still waiting for your parents to really see you?” By changing how he experienced his memories of the past, Paul could have been freer to live his present life. “Your parents gave you the gift of life, are you now ready to accept their gift into your heart?” “Are you willing to forgive your parents for not understanding you in the way that you needed?” “Can you now forgive yourself for not taking better care of yourself in the past?” When Paul was not burdened by negative percep- tions of himself or others, then he would have been more able to become congruent. “Can you allow yourself to live with your mistakes, without having to punish yourself for having the courage to live?” Another important aspect of the Satir model would be reflected in the therapist’s listening closely to how Paul verbalized his world and any meaningful metaphorical words or concepts. The therapist would closely listen to and respond with specific and intentional conscious 157 WENDY LUM, JIM SMITH, AND JUDY FERRIS responses. “Are you willing to shine a warm, bright light on the part of you that feels isolated and invisible?” The pace and the tone of the therapist would match Paul’s energy level and pace in order to have created a close therapeutic relationship and shared language.

The Satir model also encourages therapists to strengthen their own abilities for observation of self, the client, and the context of the session. Throughout the session, the therapist would be observing in these three different ways. The therapist would pay close attention to Paul’s language, connection, and responses; pay attention to the responses that he or she shared with him; and would watch his or her own inner responses to Paul’s comments and interactions.

The therapist would notice Paul’s inner experience through using the framework of the Personal Iceberg Metaphor. The therapist would listen to, watch for and pay attention to Paul’s inner experience by using the components of the Iceberg metaphor. The therapist would be using his or her intuition to comprehend what kind of intentional responses might have been most effective with him. The therapist would be watchful of his behaviors, coping, feelings, feelings about having his initial feelings, perceptions, expectations of himself, expecta- tions of others, expectations of his world, yearnings, and Self: I am.

The therapist could ask questions that speak to the inner components of Paul’s world. For example: (behavior) “When you cut yourself, what is the wound saying?”; (coping) “How do you cope with the rejection?”; (feeling) “How do you feel right now as we explore this?”; (feelings about the feelings) “What is the feeling that lies beneath your anger?”; (perceptions) “What do you think would stop the pain?”; (expectations) “What do you expect they should have done when they saw your wounds?”; (yearnings) “If you were to live in that way you had hoped, what would be happening for you instead?”; (Self: I am) “Can you allow your favorite music to soothe your soul?” The therapist would look beyond Paul’s initially withdrawn behav- iors or his later external acting out behaviors. The transformational experience would be more likely to occur after the therapist was able to facilitate Paul’s acceptance, acknowledgment, forgiveness, honoring, loving, and commitment to his Self: I am. By helping to change Paul’s inner experience of himself, this would create the space for healing and growth. The Satir model would give the therapist a map into understanding Paul’s inner experience. It can also help the therapist to support him, to make new decisions to live, to increase his self- esteem, and support Paul to become more responsible for his life and to encourage congruence within. 158 CONTEMPORARY FAMILY THERAPY CONCLUSION Current treatment modalities often may address only separate components of youths’ inner experience. The Satir model gives a frame- work that encompasses an integrative and holistic view of their inner experience. This model can be effectively applied to the prevention, intervention, and treatment of suicidal youth. We can now begin to understand suicidal behavior differently by exploring and changing the inner world of youth. Seeing suicide through new lenses allows the focus of treatment to be internally based and transformationally focused.

The Satir model offers hope for therapists in facilitation of deep inner transformation in youth. We need to instill hope in youth, so that they can look forward to having a positive impact toward their future. As more of our young people find meaning and reason in living, there will be great hope for this and the next generation of youth. REFERENCES Banmen, A., & Banmen, J. (Eds.). (1991).Meditations of Virginia Satir: Peace within, peace between, peace among. Palo Alto, CA: Science and Behavior Books.

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Satir, V., Banmen, J., Gerber, J., & Gomori, M. (1991).The Satir model: Family therapy and beyond.Palo Alto, CA: Science and Behavior Books. Copyright of Contemporary Family Therapy: An International Journal is the property of Springer Science & Business Media B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.