Families

Robert Allen, Director
Bureau of Psychiatric Services
New York State Office of Mental Health

1. Findings

   The relationship between the family unit and a suicidal adolescent family member is both complex and compelling. Despite a historical bias that emphasized how a negative family life could pose a risk to their offspring's mental health, there is growing evidence that a family's influence can and should be considered as a protective factor against their adolescents suicidal behavior. The key seems to turn on whether family influences - genetic, biological or environmental - are, on balance, essentially positive or negative for the family member's mental health. The capacity of the family unit to exert influence is undeniable; the content of that relationship varies from family to family. It is also not static, in that like individuals, family life can change over time in response to inner growth and external forces. Research has begun to examine the under-studied half of the equation - that of families as protective forces against suicidal behavior, including repeated attempts by their adolescent members.

   The Family as Risk Factor

   Psychiatric research has well established a family history of mental illness or suicide and general family dysfunction presently both increase the risk that an adolescent will become suicidal.

   • A 1996 report that adolescent suicide victims had significantly less frequent and less satisfying communication with their mothers and fathers;
   • Family aggression has been noted to be prevalent in suicidal children in the general community and in clinical settings.
   • A family history of suicidal behavior greatly increases the risk of completed suicide by an offspring. It may reflect a genetic factor rather than family chaos and psychopathology.
   • Families of suicide attempters and completers share an increased risk of affective illness, substance abuse, assaultive behavior and suicide attempts. (Brent, 1997)
   • The families of adolescent suicide attempters are characterized by substantial levels of dysfunction (Spirito et al., 1989)
   • There is a strong and specific association between deliberate self-poisoning in adolescence and family dysfunction (Harrington et al., 1998)
   • A family history of suicidal behavior has been shown to increase suicide risk even when controlled for poor parent-child relationships and parental psychopathology.
   • High rates of parental psychopathology, especially depression and substance abuse, have been associated with completed suicide in adolescence.

   The Family as Protective Factor

   Psychiatric research has long established that a past suicide attempt is a powerful predictor of a subsequent attempt at virtually any age. Regrettably, psychiatric research has not paid sufficient attention to:

   • The interrelationships between family variables, adolescent feelings and behaviors, and adolescent suicidality. (Brinkman et al., 2000)
   • The impact the return of an adolescent to the family after a suicide attempt has on the family's system and dynamics.
   • The positive role the adolescent's family can play in the prevention of another suicide attempt. While many studies have investigated the communication and behaviors of the family as background to the initial suicide attempt by an adolescent, very few have gone on to evaluate the post-suicide attempt family environment, or to gauge the family's capacity to serve as a protective force against a repetition of the first attempt.
   • Brinkman-Sull et al., (2000) observed that adolescent suicide risk factors focused primarily on psychiatric symptoms of the suicide attempter, neglecting the impact of the family. They further point out that in the follow-up period following a first attempt, the suicidal adolescent is more likely than not to be living apart from a parent or parents.
   • The scant attention afforded the family as a primary source of prevention for the adolescent who has attempted suicide is remarkable, in view of the fact that it is the family with which an adolescent spends much, if not most, of his/her time; the family that knows the adolescent best; and the family that exerts a critical influence - environmentally, genetically, and biologically - upon their offspring.

   While school personnel, mental health professionals, and others with whom the suicidal adolescent interacts must be part of any comprehensive suicide prevention strategy, it is arguably family members who are in the best position to reduce the risk of repeated attempts because they are there, with the at-risk adolescent.

   • Gould et al, (2003) point out that adolescent suicide prevention strategies have …"primarily been implemented within three domains - school, community, and health-care system." Many of these strategies, including suicide awareness curricula, skills training, screening and gatekeeper training, are undoubtedly valuable. However, corresponding research on and implementation efforts with the family's role in the secondary prevention of adolescent suicide has not been done. Moreover, little research has been done on the closely related question of the impact of the adolescent's first suicide attempt on the family. As Magne-Ingvar and Ojehagen, (1999) observed, "Most follow-up studies after a suicide attempt focus on the situation of the patient (but)...a suicide attempt also affects significant others."

   Because the family is the first line of defense in the secondary prevention of adolescent suicide, it is the family that bears the stress of adapting to the suicidal adolescent and acting to prevent another attempt. This adaptation can take the form of constant, close observation of the adolescent, driven by concern, fear and guilt, as well as by practical need; insistence on the adolescent's compliance with outpatient treatment, including medication management and making scheduled appointments with therapists.

   Both adaptation and action inevitably exhaust family members, and underscore the need for both respite care and treatment.

2. Action Steps.
   1. Modifying Suicidal Behavior.

      To overcome the propensity for first suicide attempts to lead to subsequent others will require a coordinated strategy by the family employing a range of protective elements. Ideally, evidence-based models of how families succeed in preventing adolescent suicide attempts can guide families and treatment professionals alike. The reality is given the paucity of both evidence and models, family members must depend on their own experience and intuition to prevent another attempt.

      While invariably each family will respond differently to this challenge, there are recommended practices that have worked for other families faced with this challenge.

      • Closely observe the adolescent's behavior and mood.
      • Pay Close Attention to all the adolescent's references to suicide. Pay particular attention to any reference to another attempt.
      • Encourage the adolescent to attend outpatient treatment.
      • Facilitate the adolescent's compliance with treatment recommendations, including taking medication as prescribed.
      • Communicate often with the treatment professionals involved.
      • Remove all firearms from the home.
      • Secure other potentially lethal agents, e.g. poisons and prescribed and over-the-counter medications, away from the adolescent.
      • Attempt to keep the adolescent away from alcohol and illegal drugs.

      Implementing any of these measures with an adolescent is likely to be very difficult. Individuals who have attempted suicide tend to be non-compliant with treatment, and many, perhaps most adolescents do not readily share their thoughts and feelings with parents. Moreover, these suggested steps require the family to vigilantly observe the adolescent's behavior and affect - observation which the adolescent may interpret as interference and control. For the family, there is no easy or sure path to the prevention of a second suicide attempt.

3. The Need for more Knowledge.

   There is a need for more research on the impact of an adolescent's suicide attempt on their family. Similarly, there is a need for more research on the ways that families cope in the aftermath of such an attempt. Much research has been focused on the family's role, both genetic and environmental, in the etiology of adolescent suicide. Similarly, there has been research on the effect of a completed adolescent suicide on surviving family members. Yet the family system after the adolescent returns home from an initial suicide attempt remains largely unknown.

   Once an adolescent has attempted suicide, the risk of a second attempt increases dramatically. Once the adolescent has attempted suicide, parents and other family members are directly confronted with the very real possibility that they might lose their loved one to another attempt. Families may well be key to preventing another such attempt. Many, if not most, families are willing to face their fear and meet the challenge, but they need the guidance that can only come from the psychiatric research community, and the support that must come from their extended family, communities and the wider society.

4. Action Steps
   1. Respite care for families having a suicidal individual is a critical service, as is therapy for family members and other care-providers. Respite care comes in many forms, including natural supports such as that provided by family and close friends. Whenever possible, such resources should be the first option sought.
   2. Much research has been focused on the family's role, both genetic and environmental in the etiology of adolescent suicide. However, there has been scant research conducted on the positive/protective role that families can play in recovery of a suicidal adolescent family member. This gap in our knowledge should be filled.

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