Suicide is a major public health issue in the United States and worldwide that accounts for most violent deaths and causes a significant economic burden. Globally, suicide-related fatalities exceed all homicides and battle-related casualties combined. Recent suicide rates have shown an upward trend, with adolescents being disproportionately affected. Indicated preventive treatments seek to modify suicidal ideation or behaviors in this group and are normally delivered in school settings. In this proposal, a web-based, psychoeducational intervention for adolescents is developed and evaluated to improve suicide-related outcomes for high-risk students. This chapter provides a statement of need, the condition and age group of focus, and the prevalence and impact of adolescent suicide and concludes with a mini summary of the analysis.
Adolescent suicide is a serious but preventable public health problem. The rising suicide-related mortality and morbidity (hospitalization after attempted suicide) mean that prevention is a priority in public health areas worldwide. Adolescent suicidality encompasses broad presenting symptoms, including suicidal ideation, planning, self-harm, and suicide attempt. These behaviors are a concern for America’s youth, as they are linked to adverse outcomes, such as premature death and high hospitalization costs. Therefore, prevention of adolescent suicide through interventions targeting symptoms potentially amenable to change is needed.
The rationale for requiring group work is that modifying maladaptive misperceptions and depressive symptoms can benefit from knowledge-based interventions. The purpose of psychoeducation is to teach patients to recognize depressive symptoms and suicidal behavior, helping them become actors of their disease (Bailey et al., 2017). The intervention is appropriate for group work that includes adolescents with a diagnosable mental disorder and adults requiring positive psychological skills to cope with suicidal behavior. Psychoeducation is needed by young people to enhance their awareness of suicidal behavior and risk factors to prevent suicide.
Conceptually, suicide interfaces with many other terms that describe suicidal conduct and preparatory acts. It is defined as a fatality due to self-harm behavior intended to cause death (Ghoncheh et al., 2016). In contrast, a suicide attempt refers to a potentially self-injurious act with a nonfatal outcome. Suicidal ideation precedes suicide attempts; it includes passive thoughts about dying but does not involve preparatory acts. On the other hand, self-harm entails deliberate self-injurious behavior that results in bodily harm.
The proposed psychoeducational intervention is designed for adolescents (14-19 years). The individuals in this age group experience significant changes in different domains, including cognitive, emotional, behavioral, and physical aspects (Ghoncheh et al., 2016). Social factors related to family structure and processes and socioeconomic pressures also impact development during these transition years. The complex developmental factors at play during adolescence predispose adolescents to psychological distress that, if unaddressed, may manifest as suicidal behavior, attempt, or completed suicide.
Adolescent suicide has been rising despite intensified efforts to address risk factors. In the United States, it is the second leading mortality risk among youth aged 15-24 years (Hill & Pettit, 2016). The magnitude of this problem is illustrated by the high number of adolescents nationally reporting suicidal ideation, attempting suicide, or dying from it. The suicide rate among young people in the 14-19 and 20-25 age groups rose by 28% and 31%, respectively, between 2000 and 2017 (Hetrick et al., 2017). Depression is a major risk factor for suicide-related behavior, including suicide attempts, among adolescents due to their vulnerability to psychological stress. In the US, the prevalence of anxiety disorders and lifetime risk of depression is highest in the 13-18 years age group, at 31.9% and 17-25%, respectively (Hetrick et al., 2017). These statistics highlight the disproportionate impact of suicide on youth in adolescence.
Adolescent suicidality is associated with high direct and indirect costs. Elevated premature deaths and high healthcare cost burden related to suicide attempts cause loss to families and disrupt socio-economic processes (Robinson et al., 2016). Other indirect costs may come from lost productivity due to debilitating self-inflicted injuries. The rising adolescent suicide also has implications for public healthcare spending. Investment in counseling and psychotherapeutic care in community settings has increased in response to a sharp rise in suicide rates. Medical treatment for survivors of suicide attempts adds to high hospitalization spending. The emotional costs of suicide-related behavior are even more significant. The loss of a child can be emotionally distressing to the families, schools, and communities.
In summary, this chapter has introduced suicide in adolescence and the need to address it. The proposed psychoeducational activity is described as an effective suicide-prevention group intervention – it increases awareness and builds positive psychological skills. Suicide is associated with fatal outcomes, but related terms such as suicide attempt and self-harm involve nonfatal results. Adolescence involves complex changes in many developmental domains, which increase the predisposition to psychological distress – a suicide risk factor. Suicide prevalence both in the US and globally is high, and depression is the main cause. The burden of adolescent suicide is significant for American families and society. It negatively impacts productivity, healthcare spending, and the emotional well-being of communities and schools.
In this paper, a psychoeducational group to increase student awareness of suicide-related behavior and prevention information is developed for an adolescent cohort. The analysis in the previous section reveals the pervasiveness of suicide in this group. A knowledge-based intervention is needed to address this problem and the associated negative outcomes. The following integrated literature review will highlight the use of psychoeducational groups in preventing adolescent suicide based on empirical evidence. Its effectiveness with this population, delivery models, and risk factors addressed are also examined to inform the current group’s procedures. This chapter will conclude with the purpose and goals of the proposed psychoeducation.
A psychoeducational group can help adolescents take an active role in their treatment and deal with distress. It is an adjunctive method often designed according to the cognitive-behavioral therapy (CBT) model or its variants (dialectical behavior therapy) to diminish depressive symptoms and maladaptive cognitions and develop metacognitive skills to reduce suicidal ideation, depression, or despair in adolescents (Hill & Pettit, 2019; Robinson et al., 2016). Psychoeducational therapy may involve a universal or selective approach to target specific risk factors, such as perceived burdensomeness, and enhance awareness of collective suicide experiences in a safe, non-stigmatizing environment. Motivational interviewing (MI) can be the basis for a psychoeducational intervention. Grupp-Phelan et al. (2019) used MI to refer high-risk adolescents aged 12-17 years to psychoeducation. The approach was effective in screening for suicide risk factors in non-suicidal youth.
The group is often homogenous, composed of individuals with specific characteristics, including a similar age group or grade. Schilling et al. (2016) selected ethnically diverse ninth-grade students for a Signs of Suicide (SOS) program, while McCauley et al. (2018) sampled 12-18-year-old participants for dialectical behavior therapy (DBT). The specific inclusion criteria aim to strengthen group relational dynamics and provide a defined psychoeducational experience. The maximal group size and number and duration of education sessions are important programming considerations to foster desired suicide-related outcomes. For example, Bailey et al. (2017) delivered eight modules (15-20 minutes each) of psychoeducational therapy during the safeTALK workshop to a group of 21 high school students. Psychoeducation ends with outcome measurements of help-seeking behavior, suicide literacy, and suicidal ideation to assess the intervention’s efficacy.
Psychoeducational action is conveyed through channels considered safe and non-stigmatizing to adolescents. For example, internet-based CBT delivered by school staff through workshops has been used in the safeTALK and Reframe-IT programs (Bailey et al., 2017; Hetrick et al., 2017). Additionally, a selective intervention for adolescents called LEAP was provided via the web to target perceived burdensomeness to decrease suicidal ideation (Hill & Pettit, 2019). Delivery via the internet can help achieve better outcomes than traditional approaches. It offers safe, youth-friendly conditions, and tailored information that enhances the psychoeducational experience (Thorn et al., 2020). Useful online resources and support pathways also contribute to the overall success of web-based interventions.
Studies have shown significant improvements in suicide risk and suicidal behavior among adolescents after a psychoeducational intervention. King et al. (2019) found that youth-nominated support team (YST) intervention reduces suicide-related mortality significantly for individuals aged 13-17 years, at 12 months follow-up, compared to usual care. The YST psychoeducational experience decreased suicidal ideation, accounting for this positive outcome. Self-efficacy and self-confidence to deliver education to youth aged 12-20 years were also shown to improve among professional gatekeepers such as police and school staff (Ghoncheh et al., 2016). As a result, they were able to identify symptoms and intervene to reduce self-harm, suicidal ideation, and suicide rates.
The purpose of the current group is to reduce suicide-related behavior in a cohort of high school students through an eight-session program delivered via the internet and facilitated by a therapist. The psychoeducational therapy will be provided over 4-8 weeks to help participants internalize the content and benefit from the group experience. The program aims to empower suicidal adolescents to recognize suicide risks and seek professional help.
The goal of the current group is to educate members about suicide, suicide-related behavior, and suicidal thinking to enhance self-awareness. The rationale is to strengthen personal control and coping skills to address maladaptive cognitions and distress that increase the suicide risk. A secondary goal is to empower group members to identify and avoid negative thinking patterns. The group will also create a stable support network for the participants.
The review of the literature found unique aspects of an effective psychoeducational group. It is usually founded on CBT principles and can be universal or selective to modify specific suicide-related behavior. Including an MI component can help screen risk factors and refer high-risk adolescents to psychoeducational therapy. In its design, specified inclusion criteria that reflect group homogeneity and web-based delivery can ensure success. This chapter will describe the procedures for the current group based on the literature review. The primary focus will be on the logistics and structure of the group and participant screening and selection.
The group will be composed of 18 high school students aged 14 to 19 years screened as a high suicide risk cohort. The choice of a small, homogeneous group will enhance its relational dynamics and reduce the iatrogenic effects of therapy, such as psychological stress (Bailey et al., 2017). It will be a finite-open group to provide a safe, youth-friendly psychoeducational experience through eight participatory, web-based sessions. Members will meet twice weekly for one hour over four weeks to complete the program after parental consent, consistent with Thorn et al.’s (2020) design. The psychoeducational group will be held in a high school setting. It will involve a workshop conducted in eight sessions, one hour each, over four weeks between 9th and 27th November 2020.
The group leader will be a registered therapist and will serve as a facilitator during the sessions. A graduate student advisor will also participate in the workshop in a peer capacity and as a co-facilitator. The two leaders will be individuals with current training in suicide risk identification. Applied suicide intervention skills are another qualification that the facilitators will need to have. According to Robinson et al. (2016), suicide education is critical for identifying risk, preventing it, and intervening to ensure positive outcomes. Therefore, the two leaders’ competency in these three areas will be an important prerequisite. They will also be required to follow up with teachers and parents concerning the adolescents’ behavior after every session.
The members appropriate for this group include adolescents not considered high-risk individuals but reporting episodes of suicidal ideation or intent. Following Hill and Pettit’s (2016) inclusion criteria for eligible participants, the current group’s preventive nature may not be suitable for youth with a serious suicide risk during screening. Such adolescents would require more intensive interventions or emergency mental healthcare referrals. Suicidal ideation may manifest as feelings of being a burden to others, depression, or suicide attempt (Hetrick et al., 2017). However, the current group will focus on less severe symptomatology, which is modifiable through preventive psychoeducation.
Subjects will be eligible for group membership if they meet the following inclusion criteria: high school students aged 14-19, English speakers, and experience of recent non-severe suicidal ideation (within the past month). These standards have been adopted in earlier studies (King et al., 2019). The exclusion criteria are adolescents with acute suicidal ideation or those reporting self-harm or suicide attempt. Additionally, candidates exhibiting intellectual incapacity, psychosis symptoms, or under psychiatric treatment will be excluded from the group. These inclusion criteria will ensure only individuals likely to benefit from preventive psychoeducation are included.
Since the intervention will be delivered in school settings, referral to the group will come from teachers. Students often seek help for psychological distress and psychiatric problems from their instructors (Bailey et al., 2017). Therefore, teachers are better placed to identify candidates for referral to the group. Additionally, motivational interviewing can help screen for non-severe suicidal ideation that requires preventive psychoeducation (Grupp-Phelan et al., 2019). The strategies will yield a homogeneous group and ensure optimal outcomes after the intervention.
The preparation of members for the group will occur in a pre-group session and involve an in-person meeting with the facilitators. It will entail welcoming adolescents to the group, followed by brief introductions. They will then fill out informed consent or have their parents complete the forms. Ground rules for the psychoeducational intervention will also be communicated. The preparatory session’s objective is to establish a safe, non-stigmatizing environment where group members and leaders can socialize, directly reducing stigma and loneliness feelings when the intervention starts (Grupp-Phelan et al., 2019). It will also foster the verbalization of information and concerns freely and safely.
The screening procedures will entail an assessment of depressive symptoms and suicide-related behavior, specifically suicidal ideation. Validated scales will be used to ensure only individuals meeting the cutoff scores are included in the intervention. High school students with moderate pre-test suicidal ideation, elevated perceptions of being a burden to others, and low-level self-harm upon screening will be selected for group psychoeducation. They will participate in the eight sessions of the online workshop.
Group confidentiality will be emphasized during the pre-group session to alleviate potential harm to adolescents. Informed consent will allow the facilitators to express their obligation to protect confidential information throughout the intervention (Bailey et al., 2017). Another consideration pertinent to the current group is parental involvement. Follow-ups with parents or guardians via the internet or phone calls will reduce attrition. They will also sign a consent form to enable the group leaders to share the format and objectives of the group.
The procedures described above for psychoeducation highlight the target population’s inclusion criteria, group composition, dynamics, and candidate screening methods. These components comprise the design of the intervention and the outcomes depend on them. Evidence-based procedures for participant inclusion, referral, pre-group preparation, screening, and confidentiality are described. This chapter focuses on group evaluation to measure intervention outcomes and follow-up plans to avoid relapse.
Two validated assessment instruments will be used to measure the effectiveness of the group. The first one is the perceived burdensomeness subscale, a specific tool for evaluating maladaptive perceptions of being a burden to others (Schilling et al., 2016). Pre-test and post-test scores will indicate the efficacy of psychoeducation in preventing adolescent suicide. The second instrument is the suicide ideation scale (SIDAS) will be used to measure the severity of suicide-related symptoms. SIDAS helps estimate the severity of suicidal thoughts (Schilling et al., 2016). It will be used to measure suicidal ideation at baseline, after the intervention, and at a 12-week follow-up. Web-based exit interviews after four weeks will indicate participant satisfaction levels with the group.
To measure the long-term effect of the group on adolescent suicide outcomes, a follow-up will be necessary. It will be conducted 12 weeks after the completion of the workshop. Group members will be contacted, and their level of suicidal ideation measured using the SIDAS scale. Those with higher SIDAS scores will be considered to experience severe suicidal ideation or self-harm and referred to intensive psychiatric care. Perceived burdensomeness, hopelessness, and other depressive symptoms will also be measured at the follow-up to determine the group’s long-term effectiveness. Parents will also be requested to monitor their children when at home and report any suicide-related symptoms. Further, utilization rates of psychiatric care or depression treatment after the intervention will help determine the benefit of group psychoeducation for adolescents.
Bailey, E., Spittal, M. J., Pirkis, J., Gould, M., & Robinson, J. (2017). Universal suicide prevention in young people: An evaluation of the safeTALK program in Australian high schools. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 38(5), 300–308. Web.
Ghoncheh, R., Gould, M. S., Twisk, J. W. R., Kerkhof, A. J. F. M., & Koot, H. M. (2016). Efficacy of adolescent suicide prevention e-learning modules for gatekeepers: A randomized controlled trial. JMIR Mental Health, 3(1), e8. Web.
Grupp-Phelan, J., Stevens, J., Boyd, S., Cohen, D. M., Ammerman, R. T., Liddy-Hicks, S., Heck, K., Marcus, S. C., Stone, L., Campo, J. V., & Bridge, J. A. (2019). Effect of a motivational interviewing-based intervention on initiation of mental health treatment and mental health after an emergency department visit among suicidal adolescents: A randomized clinical trial. JAMA Network Open, 2(12), e1917941. Web.
Hetrick, S. E., Yuen, H. P., Bailey, E., Cox, G. R., Templer, K., Rice, S. M., Bendall, S., & Robinson, J. (2017). Internet-based cognitive behavioural therapy for young people with suicide-related behaviour (Reframe-IT): A randomised controlled trial. Evidence-Based Mental Health, 20(3), 76−82. Web.
Hill, R. M., & Pettit, J. W. (2019). Pilot randomized controlled trial of LEAP: A selective prevention intervention to reduce adolescents’ perceived burdensomeness. Journal of Clinical Child & Adolescent Psychology, 48(1), 45–56. Web.
King, C. A., Arango, A., Kramer, A., Busby, D., Czyz, E., Foster, C. E., & Gillespie, B. W. (2019). Association of the youth-nominated support team intervention for suicidal adolescents with 11- to 14-year mortality outcomes. JAMA Psychiatry, 76(5), 492−498. Web.
McCauley, E., Berk, M. S., Asarnow, J. R., Adrian, M., Cohen, J., Korslund, K., Avina, C., Hughes, J., Harned, M., Gallop, R., & Linehan, M. M. (2018). Efficacy of dialectical behavior therapy for adolescents at high risk for suicide: A randomized clinical trial. JAMA Psychiatry, 75(8), 777−785. Web.
Robinson, J., Hetrick, S., Cox, G., Bendall, S., Yuen, H. P., Yung, A., & Pirkis, J. (2016). Can an internet‐based intervention reduce suicidal ideation, depression and hopelessness among secondary school students: Results from a pilot study. Early Intervention in Psychiatry, 10(1), 28–35. Web.
Schilling, E. A., Aseltine, R. H., Jr., & James, A. (2016). The SOS suicide prevention program: Further evidence of efficacy and effectiveness. Prevention Science, 17(2), 157–166. Web.
Thorn, P., Hill, N. T. M., Lamblin, M., Teh, Z., Battersby-Coulter, R., Rice, S., Bendall, S., Gibson, K. L., Finlay, S. M., Blandon, R., de Souza, L., West, A., Cooksey, A., Sciglitano, J., Goodrich, S., & Robinson, J. (2020). Developing a suicide prevention social media campaign with young people (the #chatsafe project): Co-design approach. JMIR Mental Health, 7(5), e17520. Web.
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