|Year : 2021 | Volume
| Issue : 2 | Page : 266-270
Suicide in the Context of Adolescent Development: What Humanitarian Actors Can Do
Seconded by Save the Children to the UNICEF-led Global Child Protection Area of Responsibility, Spain
|Date of Submission||08-Feb-2021|
|Date of Decision||08-Apr-2021|
|Date of Web Publication||09-Sep-2021|
PhD Koen Sevenants
Seconded by Save the Children to the UNICEF-led Global Child Protection Area of Responsibility, Koen Sevenants, Calle Blanquerna 50, 3-1, Palma de Mallorca, CP: 07003
Source of Support: None, Conflict of Interest: None
The author reflects from his own personal experience as a survivor, child psychologist and humanitarian on causes of suicidality among adolescents and prevention strategies. Suicide ideation or attempted suicide is a symptom of underlying issues that complicates developmental tasks. This personal reflection summarises the developmental tasks facing adolescents, carrying out a mental review and the search for self and separation from parents. The author describes major factors that complicate the completion of these developmental tasks in humanitarian contexts. He then discusses action for prevention on two levels: (1) Prevention through the creation of a social ecology that provides the basis for children’s healthy mental and psychosocial development and in which they have the highest chance of succeeding at resolving complicated development tasks. (2) Prevention of further harm when an adolescent has reached the level of ideation, has planned suicide or has already made a suicide attempt. For the first level, he uses Winnicott’s concept of “the holding environment” to guide various humanitarian aid sectors on suicide prevention. For the second level, he stresses the importance of overcoming a sense of isolation and the need for a long-term engagement in which verbal and nonverbal approaches are combined.
Keywords: adolescent development, humanitarian, MHPSS, prevention, suicide
|How to cite this article:|
Sevenants K. Suicide in the Context of Adolescent Development: What Humanitarian Actors Can Do. Intervention 2021;19:266-70
| Background|| |
I was 15 years old. Just like many other adolescents, I could not work things out. I had had another fight with some family members. I tried to suffocate myself. My method was amateurish; hence I am still here today. It was a start of healing, reconnecting with relevant others and addressing underlying issues linked with different critical incidents during childhood. In the process of healing, I got motivated and learned sufficiently to start helping others. In this study, I share some reflections that stem from own experience, from being a child and adolescent psychologist and from observations in humanitarian emergency settings. A suicide attempt is life-threatening and is, for some, traumatic. I believe in my case, it was. It led to posttraumatic growth with its usual features: changing of priorities, warmer, more intimate relationships and a greater sense of personal strength. As a professional, this equips me with compassion, passion and the energy to go the extra mile. We mental health professionals talk with each other. Therefore, I know de facto that in my sector I am not the only one who has walked this path. The views that are expressed are my own and do not reflect formally the views of the agencies that host me (Safe the Children and the UNICEF led Child Protection Area of Responsibility).
| Suicide in the Context of Adolescent Development|| |
Suicide ideation or attempted suicide is a symptom of underlying issues. It is an opportunity to work on what − if not addressed − could develop into a personality disorder in adolescents. The fact that the symptom often surfaces in adolescents is directly related to their developmental stage. The three main interrelated development task or development “jobs” of the adolescent provide us with an explanatory framework that allows us to locate the underlying issues that may result in suicide ideation or attempts. I discuss these developmental tasks below. Accompanying each developmental task is a description of major factors that can complicate the execution of this task.
1. Mental review: At the onset of puberty, it will be the first time the adolescent has the cognitive capacity to do a mental review of his/her life. During childhood, parents are for most children, their absolute heroes, e.g. father is strong and handsome, whereas mother is the best in the world. Upon entering adolescence, views change. Adolescents realise that these views do not quite match reality, e.g. their father is not that handsome, does not have friends and drinks a lot of alcohol. There is disappointment and as a consequence, also anger towards parents. This is a normal phase in adolescents’ development.
However, a number of different factors may significantly complicate this developmental task. Here, I share three frequently observed complicating factors. First, most perpetrators of sexual abuse come from the child’s local community: family members, friends of parents, etc. Children often do not realise that the abuse has taken place until they enter adolescence. When they come to understand what has really happened, their world implodes. People whom the child assumed had a loving and protecting function turn out to be people who are willing to damage the child in their search for sexual gratification. This realisation is similar to grief. Often the adolescent is − explicitly or implicitly − not allowed to talk openly about the issue. This leads to confusion, anger and possibly to psychosomatic symptoms, rage and depressive episodes with suicide ideation.
Another complicating factor associated with the mental review is the loss of a parent during puberty. A parent who passes away is, in most cases, glorified, which is the opposite of the natural dynamic of being disappointed in that parent. Here again, the growing adolescent has a great challenge to give contradictory feelings a place. It is always hard to lose a parent, but particularly during adolescence.
Third, there are increased stress levels among populations in humanitarian settings, which contributes to a higher incidence of gender-based violence and interpartner violence. Recalling images of violence between parents during the phase of mental review are bound to disrupt any attempts to give all that happened in life an orderly place.
2. The search for self: This development task consists of finding answers to the questions, “Who am I?” and “What do I like?” Most aspects of defining one’s identity are not problematic, e.g. “What type of shoes I like?” Yet, a set of complicating factors can also arise in relation to this developmental task. Part of identity formation is coming to terms with one’s sexual orientation and the formation of gender identity. Not having a mainstream sexual orientation is often a vast complicating factor, especially in certain cultures. Another factor that I frequently observe in humanitarian contexts is the fact of belonging, covertly or openly, to an unwanted group or minority. The search for self is for a large part carried out by comparing oneself to others, and likewise, belonging to an aid-dependent population, e.g. refugees. People are at-risk of regarding themselves as inferior compared to “superior” aid providers (Harrell-Bond, 2002).
3. Separation from parents: It is part of a normal life trajectory to distance oneself from parents during adolescence (Levine et al., 1986). However, at least three factors are linked with emergencies that can complicate the completion of this development task. Firstly, ambiguous loss − not knowing the whereabouts of a loved one − makes normal grief very complicated (Brown & Coker, 2019). There is always hope. The missing person is heroised, which does not accommodate the need for separation. Secondly, having a parent who recently passed away can complicate the separation (Canetti et al., 2000). The love for and the glorification of the person who passed away contradicts the desire for separation. A third, frequently observed factor that hinders this development task is overprotecting adolescents (Kapetanovic et al., 2019). I see this mostly with regard to girls. Well-intentioned parents or other family members overprotect the adolescent in the midst of adversity, perceived danger or recent loss. An unintended consequence is that the adolescent is not given the physical and emotional space to reach an acceptable level of independence. This provokes both internal and psychosocial turmoil (Sharma, 2016).
Complicating factors therefore may result in adolescents being unable to reasonably complete age-related developmental tasks. These “incompletions” are the underlying factors of depressive and confused states of mind. However, the symptom of suicide ideation or attempt at suicide tends to appear mostly when this depressive episode is combined with a triggering event (Stewart et al., 2019): a fight with family members, break up or rejection of a boy/girlfriend, fights in schools or with peers and being bullied in “real life” or on social media (Van Geel et al., 2014). By nature, adolescents are already impulsive. In humanitarian settings, several aspects increase this level of impulsivity. Toxic stress can cause the brain to not use the prefrontal cortex for problem-solving (Folha et al., 2017). The prefrontal cortex moderates social behaviour (Harrigan et al., 2017). Instead, older brain parts are activated which are linked to more instinct-like and thus more impulsive reactions. Secondly, alcohol or other mind-altering substances − often used as a coping strategy − also significantly increase impulsivity (Dawe & Loxton, 2004).
| What Can Humanitarian Actors Do?|| |
I distinguish two levels of preventions: The first is prevention through the creation of a social ecology that contributes to a healthy mental and psychosocial development of the child and in which complicated development tasks have the highest possible chance of success. I use psychoanalyst Donald Winnicott’s (Slochower, 1991) conceptual framework about the holding environment to discuss this social ecology. The second is prevention of further harm when an adolescent has reached the level of ideation and has made a plan or if he/she already attempted suicide. The proposed actions are additions to existing suicide protocols that humanitarians currently use. They are in no way intended to be replacements.
| The Holding Environment|| |
Creating a holding environment is creating an optimal psychosocial context for healthy child development. Thus, we reduce both the chance that complicating factors in adolescence occur and increase the likelihood that adolescents fulfil their age-related developmental tasks, even if these are troubled by complicating factors. In other words, we reduce the possibility that underlying issues − from which suicide ideation and suicide attempts are outward symptoms − occur. At the same time, we reduce the impact of underlying problems.
The creation and maintenance of a holding environment is in its nature an intersectoral undertaking. It can − among other applications − possibly be used as a framework for integrating mental health and psychosocial supposrt (MHPSS) in camp management, integration of MHPSS in education and nutrition sectors and as a vision for protection actors and humanitarian actors involved in community-based approaches. I believe it should serve as an anchor for humanitarian actors engaged in community-based work. Concretely, this would mean that the terms of reference for deployment, e.g. a water, sanitation and hygiene (WASH) specialist to an emergency would be to contribute to the creation of a holding environment. The construction of a physical camp constitutes a part of this. Within this camp, water distribution is to be ensured. As the WASH specialist adheres to all five dimensions of the holding environment, his/her focus is the structure dimension of the holding environment through water services delivery.
A holding environment has five dimensions which equally need to be set in place (Stamm, 1985) . Implementing these dimensions should be embedded in local culture and build on existing resources in the communities.
- Structure: Structure is about providing safety, routine and predictability. The latter refers not only to establishing routines but also to keeping promises and “walking what has been talked”. Suppose it has been communicated that support providers will be present daily in the afternoon from 2 pm to 4 pm. In that case, they should be present without that unplanned internal staff meeting being prioritised instead. Structure provides a sense of routine and predictability of what is next, and as such a sense of safety. Structure and safety have proven to be very beneficial in all phases of child development, for enhancing resilience and healing from emotional wounds.
- Support: Support is providing space and encouragement for solving problems him/her/themselves. Often, the aforementioned structural issues are beyond an individual’s reach, which suggests that promoting group-based problem-solving around these issues might be the most effective way to build a holding environment. The challenge that adolescents face to comply with their development tasks is massive, and even more for those with complicating factors. Having learned to solve problems in a supportive environment is a powerful asset in the process.
- Containment: The concept of containment as developed by Wilfred Bion (Szykierski, 2010) is in a sense misleading, as the term may suggest constraining. It actually refers to the impact of uncontained anxiety on thinking. Containment refers to helping somebody who is “falling apart” to “get it together”. It refers to the capacity of assisting people to think clearly throughout their lifespan. The ability to think clearly is a fundamental element to make sense of individuals’ behaviour or as groups. Concretely this implies that all humanitarian actors should be able to engage in psychological first aid (PFA). PFA is not an intervention; it is a skill that can be learned. At the core of PFA is restoring human dignity. The ability to contain should be prioritised in both the selection and training of humanitarians. They should be able and be willing − without fear or hesitation − to engage in containment. The impulsivity embedded in the perception of tragedy is often a driver of a suicide attempt. Not “getting it together” is the opposite of completing the developmental tasks of the adolescent. We cannot leave children alone and isolated in a state of inner chaos and confusion.
- Involvement: In a holding environment, there needs to be an authentic engagement of aid workers to work together with young people. Genuine child and adolescent participation is to become a key element in all aspects of programming (Dickson & Bangpan, 2018). Involvement increases the locus of control. Suicide is often a consequence of having no meaningful control over central parts of life. A lack of control is often observed in children who lost loved ones in conflicts (Ehntholt & Yule, 20066) or natural disasters (Tang et al., 2014). Suicide is a way of taking back control. Having humanitarian actors use more participative methods will enhance the locus of control.
- Validation: Validation in this context is about recognition of the individuality of people. It is about the acceptance and appreciation of the uniqueness of every individual. It is also about respect for the privacy of people. The critical development task of the adolescent regarding the search for self is an introspective process that leads to better results in an accepting nonjudgemental environment. As all aspects of personal preferences are relevant, this is particularly so for issues regarding sexual orientation. In cultures where nonacceptance or taboo is the norm, humanitarian workers can play a very meaningful mitigating role.
Within the dimension of support, schools or alternative learning spaces can play a significant role towards creating a holding environment (Jones & Bouffard, 2012). Schools can integrate psychosocial support (PSS). A good number of initiatives that explore the integration of social and emotional learning (SEL) and PSS exist at the time of writing this study. However, the integration of PSS still depends significantly on the willingness and readiness of individual teachers who have to add this to an already large number of competing priorities. A way forward can be that educational actors create a subject “emotional education (EE)” that is taught weekly just like physical education (PE) or mathematics. If learning objectives exist for EE as well as packages with lesson plans and guidance materials for teachers, then educational authorities and school managers can likely be convinced of upgrading PSS/SEL to a compulsory subject. Aspects such as understanding the five basic emotions and emotional regulation strategies (Gross, Sheppes & Urry, 2011) would then systematically find their way into the basic education of the young populations we are catering for. This will be very helpful in dealing with adversity and complying with development tasks. It will increase their coping skills in dealing with complicating factors and reduce the power of underlying symptoms from which suicide is a symptom.Equally, there is an essential task for nutrition actors in the creation of a holding environment. Humanitarian actors such as Action Against Hunger (Charle-Cuellar et al., 2019) do great work in linking nutrition and breastfeeding activities to working with mothers and engaging them in early stimulation of infants, working with postnatal depression and enhancing the mother–child bond. The creation of secure attachments is an essential developmental task for infants (Stern & Cassidy, 2018), laying the base for positive relations with others in adolescence and adulthood. In psychoeducation programmes, parents are informed about the importance of being emotional available for children. These projects should be an integral part of “suicide prevention campaigns”, even if the results can only be observed 12 years later. Note that emotional availability is the opposite of emotional neglect. Yet it should also not be confused with emotional overprotection in childhood. Children should be given a meaningful space to solve their problems. This will allow them to increase their tolerance for fear and frustration, which will strengthen their resilience. Suicide is an escape route from an unbearable reality, just like dissociation or some forms of substance abuse. Increasing tolerance of frustration and fear will decrease the need to escape.
| Preventing Suicidal Adolescents from Further Harm|| |
In this section, I lay out what can be carried out in humanitarian settings to prevent further harm when an adolescent has reached the level of suicide ideation, has made suicidal plans or he/she already made an attempt at suicide. Crisis interventions are only a small part of the solution. More is needed. Providing mental or psychosocial assistance to a suicidal adolescent is a long-term engagement. Several of the adolescents I have worked with state in retrospect that the following actions should be prioritised:
- Re-establish communication between the adolescent and the outside world. Make the topic of suicide explicit and discussable. This can be carried out by using the Columbia-Suicide Severity Rating Scale (Posner et al., 2008). Involve relevant others such as family in intake conversations. The adolescent must get out of isolation.
- Start working with underlying issues in which ideally nonverbal approaches are combined with verbal approaches. Nonverbal methods include art-based therapies and music-based therapies. There is a strong evidence base that shows these therapies relieve stress and improve symptoms of anxiety and depression (Pifalo, 2006). Underlying issues can gradually surface and become workable when words and language can be assigned to these, e.g. childhood sexual abuse might be too difficult to mention. At the same time, feelings associated with it can be made explicit in the artwork. It is also advised to include psychomotricity in one of its variations. Psychomotricity is based on the interrelationship between motor functions and the psychic life of the individual (Termini & Sciurca, 2017). The positive effects of physical movement on depression and anxiety have been widely documented (Ströhle, 2009). Moreover, psychomotricity fosters cooperation with others and adds to the efforts to break the emotional isolation of the suicidal adolescent.
- Organise positive support groups in which adolescents can engage in peer learning to name and recognise their feelings, learn to talk about critical issues that caused underlying problems and bring order into the chaos of emotions and thoughts. There is a gross shortage of suitable MHPSS level 4 services for children and adolescents in most humanitarian settings (Jordans et al., 2018). However, the establishment of positive support groups does not have to be an MHPSS level 4 intervention. Instead, it can be an MHPSS level-3 intervention, i.e. focused nonspecialised support. Guidance for lay counsellors to become facilitators of positive support groups at the time of writing this study is being developed by UNICEF and the Child Protection Area of Responsibility.
A warning needs to be in place regarding the use of psychotropic medication for suicidal adolescents. In general, there are a multitude of side effects of these medications. I would advise using these types of medications very cautiously, possibly as a last resort, with suicidal adolescents. (1) Antidepressants have a reactivating effect. Energy comes back. However, being without energy and washed-out is a de facto protective factor when someone is planning on suicide. (2) Antidepressants suppress symptoms, whereas it also necessary to disclose and elaborate these symptoms to work through underlying issues. If no sufficient attention is given to these symptoms, it is possible that opportunities for preventing the development of personality disorders in at-risk adolescents are missed. Signs and symptoms that surfaced during the intake of the adolescent client remain relevant throughout the treatment regardless of whether these are still present while medication is being taken. (3) Administering medicine can be part of a holistic approach using several interventions in helping someone. However, as a stand-alone treatment, it is part of a medical view on suicide, in which suicidal behaviour is observed as a disease that can be cured by doctors who prescribe medication. This creates the illusion that neither the adolescents nor his or her parents have a real responsibility to solve what went wrong. For all these reasons, prescribing psychotropic medication should be as much as possible limited to situations in which there is acute danger or severe psychosis. It should merely one of the strategies in a plan to assist the adolescent in his/her healing process.
I still remember my own emotional state at age 15. There was confusion, anger, disappointment, disillusionment, lack of words, impulsivity and incapacity to see elements of hope. I have recognised this state in many other young people. We humanitarians are in the right position to create a holding environment for very vulnerable groups. To make this happen is probably the most important aspect of our job.
The author acknowledges Keven E. Bermudez (PhD), Roei Shaul Hillel and Luc Moyson for their comments and critical reflections.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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