Challenging Dogma - Fall 2008

Wednesday, December 17, 2008

Combating Teen Suicide: A Revolutionary Skill Building Intervention –Daniel Prevost


This paper will propose a revolutionary skill building intervention addressing the deadly issue of teen suicide. This new intervention will be referred to as a Skill Building Intervention (SBI). SBI will directly address the flaws of screening teens for suicidal ideation pointed out in the attached paper, Survey Screening for Suicide is Suspect. The first section of the paper will outline a group level model and explain how it is more effective than the individual level model critiqued in the initial paper. The first section explains how this intervention will target specific groups of teens who are most in need. The second section of the paper will explain how SBI will proactively intervene with teens as opposed to the inefficient reactive method of screening. SBI will actively address reasons teens feel suicidal and teach them ways to deal with their feelings. This has the added benefit of helping teens who are depressed and in need of better coping skills but aren’t necessarily suicidal. The third section explains the ways SBI will address the barriers to treatment with a focus on reducing stigma. Throughout the paper, the terms teens and adolescents will refer to people in the age group 15-24.

A brief overview of the intervention

This Skill Building Intervention will focus on groups of adolescents known to be at risk for suicide. Using Marketing Theory, SBI will conduct interviews with members of at-risk groups to find out what they want most. After the interviews, their desires will be marketed back to them in a way that encourages them to join an after school club. Club members will engage in fun social activities that create a feeling of acceptance and teach important life skills. Each year the group will put on an event that is open to the public and aims to reduce the stigma surrounding mental health issues; it will also educate parents and fellow students about access to mental health care. The event will serve as a fundraiser and donations will be accepted to provide more funding for group activities and advertising. Fundraising will make this intervention more accessible to poorer communities. The following three sections will argue that SBI is significantly more effective than screening interventions.

A group intervention targeted toward at-risk groups of adolescents

This Skill Building Intervention (SBI) is superior to screening interventions because it intervenes at a group level as and it specifically targets at risk groups as opposed to simply targeting individual; SBI goes on to target at-risk groups instead of wasting recourses screening all teens. SBI is strongly supported by social network theory and Marketing. Social Network Theory states that people behave similarly in groups (2). This theory supports the premise that an effective intervention has to address a group or groups of people, not individuals. Individuals do not make decisions in a vacuum; outside factors including the behavior of their peers, shape an individuals behavior. Research has identified which groups of adolescents are at greatest risk for suicide. The following groups have been identified to be at an elevated risk for suicide: teens in special education classes, adolescents with substance abuse issues, and adolescents who isolate themselves from their peers (7,22,5). Marketing theory has outlined ways to change the behavior of a target group of people (6). SBI will target these at risks groups using this theory. Marketing theory seeks to identify the wants of the target population and then sells a desired behavior change back to the target population coupled with satisfaction of those wants (6). SBI will utilize focus interviews to identify the wants of the target population. Then advertising will be used to promote an after school group activity. Advertisements will be based on the results of the interviews. For example, a common want of the isolative group may be the need to feel accepted. In this case, advertisements would promise that if the targeted adolescents attended the SBI after school group, they will feel accepted. These advertisements would be supported by visual images. SBI will use marketing theory to combat teen suicide much like the successful Truth Campaign used marketing principles to reduce teen smoking in Florida (23). This intervention will be significantly more successful than screening interventions because it is based on proven social science theories and it targets groups of teens, specifically groups that are at high risk for suicide.

A new proactive intervention

This Skill Building Intervention (SBI) proactively teaches teens how to deal with feelings that lead to suicide making SBI far superior to an intervention that screens for suicide and only intervenes when a teen is already feeling suicidal and desperate. Screening for suicide is analogous to screening for lung cancer instead of basing an intervention on preventing people from smoking. It is far better to focus on teaching teens life skills that help them work through feelings of anxiety and depression. This will prevent them from feeling suicidal in the first place. Instead of wasting time and money screening teens for suicide, it is much better to invest time and money into this preventative after-school program that uses group activities and discussion to help teens deal with stressors that can lead to suicidal ideation. This program is likely to reduce the need for hospitalization and the number of teens who end up feeling so overwhelmed that they want to kill themselves.

SBI is proactive because it teaches teens how to deal with stressors that can lead to suicidal ideation. Some stressors that can lead to suicidal ideation and attempts are: a lack of interpersonal skills, a lack of problem solving skills, and feelings of hopelessness (24-25). Another stressor that can contribute to suicidal ideation is feeling isolated from one’s school environment (26). SBI will teach these skills through after school activities. These activities - for example, “save the world from toxic waste” - give members a challenging task that they have to work together to complete. These groups will give members the opportunity to practice problem solving and social skills. These activities will be designed to impart skills that will prevent teens from feeling suicidal. Activities will be followed by a group discussion to ensure maximum educational benefit from the activity.

The effectiveness of group activities to prevent teens from feeling suicidal is supported by Social Learning Theory. Social Learning Theory states that people learn to behave by observing the behavior of those around them (1). These group activities provide an atmosphere for adolescents to learn from one another. For example, if one member of the group has good social skills and poor problem solving skills, while another member has good problem solving skills and poor social skills, these individuals working together will learn from each other. These group activities would require participants to use social skills and problem solving skills to complete an activity. According to Social Learning Theory, teens participating in these groups will learn these skills by watching how other group members behave.

Reducing stigma and the barriers to getting help

This section of the paper is dedicated to explaining how this intervention will reduce the barriers to getting help for a mental disorder. The focus will be on reducing the stigma associated with mental disorders. Group members will have the challenge of planning an event that will increase awareness of mental disorders and promote the normalcy of seeking help and dealing with mental health issues. The key to this event is for it to be grand enough to attract media attention and a large number of students, parents, and community members. This event could last as long as a weekend and would include attractions like guest speakers, skits, information booths, and food. Each event would be designed by the group members and would be unique to the region, culture, and group organizing the event.

This event would use agenda setting theory to help reduce the stigma of mental illness. Agenda setting theory states that people’s views about what are important issues are shaped by the media (27). So if this event is broadcast by the media through TV, radio, and/or newspapers, it will influence people’s ideas about mental illness. This will reduce stigma by encouraging people to talk about mental health issues and by spreading the awareness promoted by the event.
This event would also make use of the Diffusions of Innovations Theory to reduce the stigma of mental disorders. Diffusions of innovations theory states that behavior changes in groups, in an S-shaped curve. The change happens slowly at first then catches on and there are mass amounts of people changing their behavior and then tapering off as most people have incorporated this behavior change (21). Guest speakers would talk about their past experiences with mental health issues. These speakers would share stories of how they opened up about their mental health issues and found support, treatment, and acceptance. According to the Diffusions of Innovations Theory, once the masses see a few people engaging in mental health seeking behavior it will catch on in the form of an s-shaped curve and the majority of people in need will take the initiative to get help.

This event would address additional barriers to treatment. For instance there will be a section of the event providing information about the accessibility of mental health care. The purpose will be to educate people that hospitals have to admit people who are suicidal regardless of their ability to pay for the hospitalization, and anyone who dials 911 and reports feeling suicidal will have an ambulance ride to the hospital, again, regardless of their ability to pay for the service. The event would also provide information about local support groups. Support groups are free and there are groups offering support for a variety of issues from substance abuse to depression. This event will also have a fundraising element. Attendees to the event can make donations that will provide additional funding for after school group activities and advertising. The fundraising component to these events will make this intervention more accessible in poorer communities. Planning this event is an example of a group project that will help members build self-esteem, develop social skills, and create a sense of belonging to their community. For all these reasons SBI significantly reduces stigma and other barriers to seeking help for mental health issues specifically suicidal ideation. SBI effectively addresses barriers to treatment using social science theories unlike screening interventions which do nothing to combat stigma or any other group level barriers.

This Skill Building Intervention (SBI) is superior to screening interventions because it considers group level factors, takes a proactive approach to suicide prevention, and it addresses barriers to getting help. Screening interventions have been abandoned due to their cost and impractical use of resources (10). SBI effectively uses resources by targeting high risk groups. Screening interventions react when a teen is at the point of desperation; SBI takes a preventative approach that teaches teens how to cope with feeling such as anxiety and depression while building social support for that teen. This approach has the potential to have a lasting impact on the community. While reducing the number of suicidal teens it can also help other teens lead more productive lives because they have learned effective coping skills. SBI addresses the epidemic of social stigma surrounding mental health in society. It uses social sciences to provide the necessary framework to reduce social stigma and reduce additional barriers that prevent people from seeking help for mental disorders. The use of research and the incorporation of social sciences has given SBI the potential to improve the lives of countless adolescents across the world in ways that screening interventions never could.

Survey Screening for Suicide is Suspect
Suicide is the third leading cause of death for the adolescents (1). The numbers are astonishing and are under reported due to the shame associated with suicide (1). A current trend in public health is to screen adolescents to determine if they are at risk for attempting suicide. At a glance this may appear to be a good idea; however, there are some fundamental problems with this method of intervention. Social science theories and scientific research caution against this intervention. This intervention attempts to change behavior at an individual level which is ineffective for creating a complex behavior change. Complex behavior changes must be addressed at a group level and should be targeted to groups that are most at risk. The methods used to evaluate if an adolescent is at risk are flawed. The screening does not accurately assess if a person is at risk or not, it lacks racial consideration, and puts a dangerous label of “at risk for suicide” on many adolescents. Finally, this intervention does not address barriers to treatment. There are many obstacles to treatment for example access to health care, race, and ethnicity. The most important barrier that screening interventions fail to address is the social stigma associated with suicide.

Two of the better known screening interventions are Teen Screen and Signs of Suicide (SOS). Teen Screen is set up in schools and communities and the objective is to find out if an adolescent is at risk for attempting suicide. This is done by administering a questionnaire to the adolescent. If the questionnaire shows that the teen is at risk for suicide then they meet with a clinician to determine if they are truly in danger of attempting suicide. If they are deemed to be at risk by both questionnaire and counselor, then their parents are notified. Then the hope is that parents will seek treatment for their child. The SOS differs in two primary ways. The first is that it incorporates a psycho-educational component where adolescence are taught how to deal with friends who are suicidal and the second is that the screening process is self evaluated by the adolescents with the hope that this will encourage the adolescent to seek treatment on his or her own. This critique will focus on the general dangers and failures of screening for suicide in adolescence, not the dangers and failures of any one particular model. The research statistics presented in this paper that refer to adolescence will be representative of ages fifteen through twenty-four. Throughout the paper the terms adolescents and teen will be used interchangeably to refer to the same age group.

Failure at a Group Level

Screening interventions fail to target groups that are at a high risk for suicide; it focuses on promoting a behavior change in an individual not in a group of individuals. Social networking theory states that people behave in ways that are similar to the behaviors of those around them (2). This theory suggests that it is more effective to target an intervention towards a group of people as opposed to an individual, because people’s behavior is impacted by those around them. Using social network theory and research groups of people who are at high risk for suicide can and have been identified. Screening interventions are limited to individuals and treat all individuals as if they were at the same risk for suicide, which is false. Time and money would be better spent if this intervention were targeted and devoted to groups that are at a high risk for suicide. Some groups that are at high risk of suicide are adolescents that are in special education classes and adolescents with poor social skills. A major limitation to screening interventions is the failure to address the fact that people behave similarly in groups and the failure to focus on high risk groups.

Kids in school socialize in groups. Many typical classifications among adolescents are jocks, nerds, gangsters, preps, kids in special education classes, band geeks, popular people, druggies and outcasts. Adolescents with higher levels of social competence and the ability to maintain supportive friendships report that they have lower levels of behavior problems and increased levels of self-worth, motivation, leadership skills, and school performance (3-4). Another study that emphasizes the importance of social skills in relation to suicidal ideation is a study by Rich, Sherman & Fowler (5), found social withdrawal to be the most prevalent symptom in adolescents who complete suicide. Based on these studies targeting a group of people with poor social skills, for example outcasts, would lead to a stronger intervention. This intervention does not account for different groups of adolescents. It also does not consider which of those groups are at the highest risk for feelings of isolation and suicide. In order to have an effective intervention, different groups must be addressed in specific ways that are appealing to them. For example, advertising theory works to get at the heart of what a specific target population wants and then sells that idea back to them with a behavior change. In this case the target population might want social acceptance. Advertising for a support group in a way that promises social acceptance to a group of people who really want to be accepted is likely to create a behavior change for this group of people. (6).

Due to lower levels of emotional and cognitive functioning, adolescents in special education classes are not going to interpret and answer the screening questionnaire the same way as a person who is an honors student. So a questionnaire is not a wise intervention for this high risk group of teens. Special education kids in particular face challenges of isolation and a lack of social skills (7). Furthermore, they face difficult stressors of being bullied, antagonized and teased by peers, thus contributing to feelings of isolation. These factors put this group at higher risk for suicide.

Pablo, a special needs student, told interviewers, “When my grandpa died, (I was) very depressed and then when the kids teased me at school, that’s when I got more depressed…” (7). Another important consideration that is unique to this group is that they are at a higher risk for suicide due to cognitive defects and limited problem solving skills (8-9). Failing to consider the specific needs of different adolescent groups that are at high risk for suicidal ideation is a significant detriment to this intervention.

Screening Methods: Flaws and Detriments

Questionnaires used to evaluate adolescents’ risk of suicide have many drawbacks. A significant flaw is that the questionnaires consistently yield inaccurate results. Depending on the questionnaire used they tend to either yield false negatives or false positives. A false negative abandons a suicidal teen by considering him or her not to be at risk. A false positive tells a teen who is not at risk that he or she is at risk for suicide. The screening is even less accurate for non-white peoples; therefore, the intervention neglects this portion of the population. Finally, it subjects adolescences to the dangers of being labeled as suicidal.

There are a number of questionnaires available to screen for risk of suicide in teens. These questionnaires do not provide reliable results. The amount of times that the questionnaires predictions are wrong makes them impractical to use. Interventions like Teen Screen use questionnaires like the Columbia Suicide Screen (CSS), the Diagnostic Predictive Scales, (DPS), and the Suicide Risk Screen (SRS). The Signs of Suicide intervention uses the Columbia Depression Scale. Other examples include: the Risk of Suicide Questionnaire (RSQ), the Suicidal Ideation Questionnaire (SIQ), the Suicidal Ideation Questionnaire-JR (SIQ-JR) and the Suicide Probability Scale. (10) These questionnaires score youths a false negative for suicidal ideation, up to 52% of the time (11). This fails to identify half of the adolescents who are at risk suicide. Questionnaires that have fewer false negatives and higher false positives are more commonly recommended for school interventions (10). They are recommended for use in schools so that teens who are at risk for suicide do not go unidentified. These rates of false positives make implementing screening interventions in schools impractical (12). For example, in a study conducted by Halfors and colleagues utilizing the SRS, 37% of students were identified as at risk, but only about one out of every three of those was deemed to be at risk by clinicians. That means in a school with 1000 screened teens about 228 teens are falsely told that they are in danger of suicide. The time and cost of screening all these individuals have caused schools to abandon screening methods because they are impractical (12). Questionnaires either under or over identify at risk teens. The problems with under identifying are clear; teens in need do not get help. The problems for over identification are two fold. First, the high number of false positives makes screening too time consuming and costly. Second, it can be detrimental to falsely label a teen as being at risk for suicide.

Labeling an adolescent as suicidal has the potential to be deadly business. Any person who is labeled or put into a certain category is more likely to act in ways similar to others with this label (13). This increases the likelihood that a person who is suicidal might make an attempt after being labeled as at risk for suicide. Possibly even more dangerous, with the high number of false positives, this theory suggests that an adolescent who was not suicidal is at an increased risk of becoming suicidal as a result of this label. This theory is supported by the concept of self-fulfilling prophecy, introduced by social psychologist Robert Merton (1984). Self-fulfilling prophecy is when a person’s initially inaccurate expectations lead to actions that cause that expectation to come true (13).

Another significant flaw in the questionnaire is the lack of consideration for different racial groups. Manetta and Ormand caution that suicide screening questionnaires may not be appropriate for use with all racial and ethnic groups. Questionnaires have been developed and tested using whites as the majority of the sample population (14). The lack of testing for validity among non-white groups renders them useless for minority populations. Suicide rates among youth ages 15-24 is 11 in every 100,000 for whites and 7.9 in every 100,000 for non-whites (15). Although the rate of suicide completion is less for non-whites, they represent a significant proportion of the adolescents committing suicide. It is unethical to use a screening tool with a population that the tool has not been tested for. It is irresponsible of researchers to exclude non-whites in their research. Furthermore, it perpetuates a racial disadvantage to these ethnic groups who are already oppressed by many other socio-cultural factors. Due to the many flaws in the screening method: the lack of accurate questionnaire results, the lack of consideration for the non-white population, and the dangers of labeling adolescents as suicidal, screening interventions should be abandon.

Living Outside the Vacuum: Barriers to Treatment

Screening interventions do not address barriers that prevent adolescents from seeking treatment. Some of these barriers include: stigma, access to healthcare, family history, socio-economic status, culture, and ethnicity. The model hopes to give teens and parents an idea of whether they are suicidal or not. Then it hopes that parents and teens will act rationally and obtain professional help. However this logic is flawed because many times people do not act rationally (16). Behavior is much more complex. While this intervention fails to successfully address nearly every environmental barrier perhaps its largest failure is not addressing stigma. Stigma exists in social circles, among family, friends, and communities.

Fear of social stigma is a huge barrier to treatment for mental disorders. About two thirds of people with mental disorders do not seek treatment (17). For adolescents stigma can be a larger barrier that is more difficult to over come then it is for other age groups. Adolescents have to deal with forming their own identity in addition to forming their own ideas about mental disorders (18). They also must deal with their peers’ ideas regarding mental disorders. The majority of adolescents have a unique challenge because they are not in control of their access to treatment. For example, if a teen’s parents believe that being treated for a mental disorder is shameful and is associated with weak character then the parents may not allow their child to seek treatment. If a teen’s parents control access to transportation and access to medical coverage, then treatment can be virtually inaccessible to this adolescent. This intervention does nothing to break down the stigma of mental disorders within peer groups or with parents. One could argue that it reinforces the stigma because it secretly singles out teens as suicidal and out of the norm. This feedback can be detrimental to suicidal teens that commonly have issues with feeling socially isolated (19).

The stigma associated with mental disorders is deeply entrenched in society. It goes beyond the fact that many people lack education and understanding about mental disorders and their treatment. The idea that mental disorders are shameful and sinful has been past down through generations. There is also a lack of equality in the medical field between medical and psychological disorders. In many states it remains legal for insurance companies to reimburse physicians less for mental health services and to limit the amount they will spend on mental health services (20). A physician can spend the same amount of time diagnosing a patient and prescribing them medication and if the diagnosis is a mental illness as opposed to physical illness then most insurance companies will provide the physician with less compensation. This gives less credit and legitimacy to psychiatric disorders in the medical community and to the general public. This intervention does nothing to reduce the stigma of mental disorders in the community. Even if all suicidal teens in the U.S.A. were identified, there would not be a significant change in the number of teens seeking treatment so long as this stigma remains.
Diffusions of innovations theory proposes that behavior changes in groups, in an S-shaped curve. The change happens slowly at first then catches on and there are mass amounts of people changing their behavior and then tapering off as most people have incorporated this behavior change (21). This theory suggests that if stigma could be reduced and people were open about receiving mental health care it would break down the stigma and cause a major health behavior change. Given this change a huge barrier to people receiving mental health care would be removed. Of the people who complete suicide two thirds were not receiving mental health treatment at the time of their death and about half of them have never seen a mental health professional (17). Screening adolescence for depression or suicide does not work to reduce stigma which is a far greater obstacle for teens or anyone else who is in need a psychiatric treatment than identifying suicidal feelings.

Screening interventions focus on helping teens and their parents identify teens that are at risk for suicide. Most adolescence have learned in childhood how to identify feelings and emotions and have mastered the ability to communicate (1). By the onset of adolescence the average teen is able to identify and communicate that they have thoughts and feelings about killing themselves, therefore, identification is not the problem. The problem is that there are many barriers such as social stigma that prevent adolescents from communicating these feelings. This intervention has failed to address the barriers that could truly lead to saving teens lives.


This screening intervention is merely a diagnostic tool and it does a poor job at that. Its success is rooted in using questionnaires to increase health seeking behavior but it does not address the true barriers that prevent adolescents from seeking treatment. Focusing on the individual and failing to address the complexity of group dynamics is a huge flaw of this intervention. The intervention also neglects to address groups of people who are most at risk. The questionnaires are impractical to use because they yield too many false positives and/or false negatives. They also neglect the non-white population. This intervention does not account for the dangers of labeling an adolescent as at risk for suicide. Finally this intervention does not address external barriers that prevent teens from seeking help for suicidal ideation. The intervention assumes that suicidal teen needs to be identified, when the real barrier lays in stigma and other socio-cultural forces. Screening teens is ineffective, dangerous, and a waste of resources; this intervention has failed and should be discarded.

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