On the edge

Christina Anderson is a freelance consultant in social
care (children and adults). She has worked as a social
worker/therapist, manager and trainer.

Although the government has an agenda for promoting
psychological well-being and reducing suicide we still do not like
to contemplate the possibility of adolescent suicide.(1),(2) But as
a result of the short-term counselling of a young woman that raised
professional concerns I wanted to consider the risks.

There are issues for adolescents (puberty to mid-twenties), who
might see suicide as an option because of depressed mood or
“identity crisis”. In these cases, it can be difficult to evaluate
potential risk and understand it. Recognition of the extent and
nature of developmental upheaval may be possible at a first meeting
but it can take longer.

Amanda* was 19 when I saw her. She had dropped out of higher
education and had been prescribed medication for depression. With
her “grunge” appearance Amanda could have been any teenager you
passed in the street. She was bored because nothing was changing in
her life and she described being on her own all day with the cat.
Amanda was living with her father who worked long hours.

She had tried to tell her father that she was depressed, but he
didn’t think she looked it. Her mother was volatile, so Amanda
couldn’t share her feelings and her one good friend lived more than
300 miles away.

My assessment was that Amanda displayed some high-risk features
including social isolation; a family history of suicide; apparent
lack of secure attachments and close personal relationships; and
recurrent depressed mood.

Among the skills in discerning whether or not a young person is at
risk of suicide, the process of working with them is important.
Young people experience pervasive change as they make a transition
into adulthood and people can read their “moodiness” as “normal”
teenage behaviour. But adolescents may not want to share personal
information with older people and it is important to be receptive
to a young person’s stance and to be aware of what constitutes
risk.

Formulating a specific plan for suicide is a particularly high risk
factor. Amanda showed anger with her father in one session, because
he had made a fuss of his girlfriend when she had a cold. Amanda
communicated this with an underlying intensity that conveyed a
sense of desperation. When asked about any thoughts of suicide she
replied without hesitation that, if it came to this, she would
throw herself under a train. It would be quick and not give her
time to reconsider.

How do trained workers respond to young people we have concerns
about? In clarifying what is going on with a young person who might
take his or her life, it is important to be aware of known risk
factors. Workers should explore the adolescent’s state of mind and
not just focus on their behaviour. They should take a careful
history, including the nature of early attachments and treat the
young person as someone worth listening to.

We should also:

• Move away from sloppy and dangerous labelling such as
  “attention-seeking”.
• Check out thoughts and intentions about suicide while remaining
  matter-of-fact.
• Obtain agreement about contact with medical and psychiatric
  services.
• Look at sources of support in crises.
• Reflect through supervision how to manage the feelings aroused
  in oneself as the worker.

The boredom Amanda expressed on the surface hid a multitude of
turbulent feelings. We did some task-oriented work and examined her
negative emotions. She looked for confirmation that she was
unimportant. She could appear to have an identity and some control
if she decided whether to live or not. It seemed risky when she was
resentful of the attention her father gave his partner. Her
feelings then were that she was “disappearing” into being “not me”.
There is a danger of suicide as a sudden defining act of
confirmation and defiance.

Thought has been given to whether traditional counselling is
amenable to adolescents. Recent small-scale research suggests that
confidentiality and a non-directive approach can be fruitful as
this phase of life is characterised by issues around power and
authority.3
Counselling and other interventions with young people are aimed at
getting them to accept responsibility and acting for themselves.
How far do we take this? Depression is a numbing condition.
Adolescents regard “doing” by adults as caring sometimes. Amanda
accepted that she would work on her tasks while I searched for
resources and spoke to her GP, which proved to be productive.
Helplines and related services are not always user-friendly. I rang
some of the resources, both for information and to gauge the
initial response. I also talked through with Amanda what it would
be like to contact an organisation for longer term counselling,
which she followed through.

Working with Amanda was naturally an experience filled with mixed
emotions and anxieties for me as the counsellor. Some practitioners
might not have contacted the GP. They would see it as
counter-productive to being a “container”. I was conscious of not
simply reacting to the complex feelings within Amanda and myself
and between us. Seeing her evoked painful memories of the suicide
of a younger person in the adolescent unit where I worked years
ago. She threw herself beneath an underground train.

I knew how essential it was to keep faith with Amanda, stay calm
and be open to her dark feelings. In these respects I was
influenced by writing about internal (self) supervision. Although
this process is important, it is still necessary to have an
external supervisor.

There is even more complexity when thinking about the
organisational context. Adolescent suicide, although rare, can
feature when there is bullying at school, and in situations where
child protection procedures are activated or young people are set
up in accommodation or both. The seeds of self-harm may get rooted
and escalate in adulthood. Signs of deeper, internal upheaval can
be missed, particularly when the attitudes of professionals and
convoluted dynamics can get in the way.

Amanda’s case underlines the importance of a readily available
service. Systems are developing but my emphasis has been on the
initial identification of risk. Working with someone who is “on the
threshold” can present us with life or death challenges.

* Not her real name

Abstract
The article explores how to work with young people at
risk of suicide. Changes in adolescent emotions and their views
about adults present challenges for professionals. There have to be
careful evaluations of risk. Some dilemmas are highlighted,
including the issues of liaison and responsibility, and the
importance of managing the feelings aroused in young people..

References
(1) Department for Education and Skills, Department of
Health, National Service Framework for Children, Young People and
Maternity Services, 2004
(2) Department of Health, A National Suicide Prevention Strategy
for England, 2002
(3) “Young people and counselling – new research”, Counselling and
Psychotherapy Journal, Vol 15 no.1, February 2004

Further Information

• C Fox, K Hawton, Deliberate Self-Harm in Adolescence, Jessica
  Kingsley Publishers, 2004
•  Samaritans, Youth and Self-harm: Perspectives – a Report,
  Samaritans Research Summary, 2000-1
• Royal College of Psychiatrists, Factsheet Nine on Mental Health
  and Growing Up, Suicide and Attempted Suicide, Third Edition, RCP,
  2004
• M Smith, “Half in love with easeful death? Social work with
  adolescents who harm themselves”, The Journal of Social Work
  Practice, 16, 1, pp 55-65, 2002
• A Reeves, P Seber, “Working with the Suicidal Client”, BACP
  Information Sheet, 2004
•  Young Minds: www.youngminds.org.uk

Contact the author
E-mail: cca@thebur.co.uk