Damian Sendler: There is a great deal of concern about adolescent suicidal behavior. The alarming rise in the number of young people presenting to emergency rooms as a result of self-injurious behavior is a direct result of this rise. Interpersonal psychotherapy (IPT) for adolescents was adapted for use with suicidal adults in the development of the intervention described here. It is short and to the point. An immediate response, an understanding of the emotional distress and interpersonal aspects that underlie suicidal behavior, and the generation of hope among adolescents and their parents are the four main objectives of this intervention. Three months of email follow-up follows each of the five weekly intensive sessions.
Damian Jacob Sendler: In the treatment of depression in adults and adolescents (IPT-A)[8,14], as well as other psychiatric disorders (such as anxiety disorders), IPT is a commonly used, evidence-based, time limited treatment. Depressive symptoms can be reduced and overall performance and social functioning can be improved with IPT[16]. Adolescents with depression can benefit from an adaptation of IPT called IPT-A[8]. IPT-A is time-limited and evidence-based, just like the original adult version.[8] IPT-A aims to address the link between depression and current interpersonal difficulties. By focusing on one specific area of interpersonal dysfunction and honing communication/interpersonal, emotional, and problem-solving skills, the IPT-A aims to lessen depressive symptoms while simultaneously enhancing interpersonal functioning[8].
Dr. Sendler: Recent studies have shown that IPT has the potential to help suicidal patients. Preliminary results from a small sample of suicidal adolescents treated with IPT-A by Mufson et al[17] were presented (IPT-A-Suicide Prevention). For adolescents at risk for suicidal behavior, Tang et al[18] studied the effects of intensive interpersonal psychotherapy and compared these adolescents to those who received treatment as usual at schools. Results showed that those who received intensive IPT-A had less depression, anxiety, suicidal ideation, and hopelessness after treatment than those who received standard care.
As far as we know, there is no crisis intervention protocol for children and adolescents at risk of suicide that is very brief, practical, and feasible. An adaptation of IPT-A was used to develop the following brief and focused intervention for suicidal adults, which was found to be effective.
Several studies have demonstrated the effectiveness of IPT in the treatment of suicidal youth[4]. An in-depth description of the intervention follows. An immediate response is needed to deliver the intervention within one month of referral; a short and immediate response to understand emotional distress and interpersonal aspects underlying suicidal behavior and associated, distinct difficulties of the patient (such as interpersonal skills deficits or emotional dysregulation); and a treatment plan built on understanding the patient’s specific difficulties (like interpersonal skills deficits or emotional dysregulation). That’s what we believe will help the patient and their families feel better, which in turn will reduce the patient’s risk of suicide.
In order to build trust and commitment from the start, the first session should include both the patient and the patient’s parents. It should also cover topics such as depression and suicidal risk. An active therapeutic approach is required for this meeting, which includes:
In addition to the initial risk assessment that is generally performed at intake, a brief risk assessment is performed. The Mood and Feelings Questionnaire[21] and the Columbia Suicide Rating Scale[22] and/or the Suicide Ideation Questionnaire[23] are used to assess depressive symptoms in this first session.
Suicidal risk calls for the development of an interpersonal safety plan in collaboration with the patient and their parents. When a suicidal crisis arises, the patient’s safety plan provides the patient with a prioritized list of coping strategies. Having a predetermined plan of action and a list of specific and relevant support resources is the primary goal of the plan. In addition to a list of contacts for people in the patient’s life who can be contacted in real time to help reduce the risk of suicidal behavior, the plan includes internal strategies that a patient uses on his own (e.g., self-talk). The therapist, patient, and parents should work together in a cooperative manner. In order to determine whether or not any adjustments or additions should be made, the patient and therapist will meet on a regular basis to review the plan.
To better understand the events leading up to the attempted assassination, a chain analysis is carried out. The chain analysis sheds light on the events leading up to the suicide attempt and the emotional and interpersonal/social factors that influenced the decision to take one’s own life.
Damian Sendler
Adolescents and their guardians are shown the intervention: The adolescent and his or her parents are given a thorough explanation of the intervention’s nature, structure, and goals. The importance of parental cooperation and the issue of confidentiality are addressed directly. In addition, the need to inform the school of a patient’s risks and needs is discussed. The collaboration with the school is aimed at increasing the school’s support for the patient in the areas where he is most vulnerable (e.g., academic, social or emotional realms). It’s not uncommon for therapists to contact a patient’s elementary and secondary schools after their second session, after they have gotten to know them better and identified the main problem area that drives their suicidal tendencies. Finally, the limitations of the intervention and the need for long-term psychological treatment and/or consultation about psychotropic medication are addressed… Following the acute IPT-A for suicidal children and adolescents intervention, the family is supported in their efforts to find appropriate follow-up care.
Damian Jacob Markiewicz Sendler: Psychoeducation about depression, suicidality, adolescent development and other patient-specific topics is provided. Patients are taught that suicidal thoughts come in waves, and that the goal of treatment is to get them ready for the next one. Even if the patient is currently feeling better, the underlying assumption is that there will be more crises in the future. “Limited Sick Role” is another IPT-A medical model concept that we employ. In this role, it is necessary to match functional requirements with the mood of the patient in order to meet expectations. Patient’s mental state is taken into consideration when setting the pace and progress of treatment. The patient’s parents and teachers are also educated on the concept of a limited sick role.
Each session begins with an evaluation of the patient’s mood and suicidal risk on a scale of 0-10 and a discussion of the changes needed in the patient’s safety plan. After discussing depression and suicidal risk in the first session, the second session focuses solely on interpersonal functioning. The goal of the second session is to identify the main issue that will be addressed in the intervention. The Closeness Circle and the Interpersonal Inventory[25] are two tools the therapist uses to help you get there.
By explaining that the circles around his or her name represent different degrees of closeness, the therapist aims to create a visual representation of the patient’s important relationships by placing them in appropriate circles according to the relevant degree of intimacy. As part of this discussion, the therapist and client use an Interpersonal Inventory to examine the patient’s most important interpersonal relationships. Questions about facts, opinions, specific events and feelings about the patient’s circle of friends are included in the Interpersonal Inventory. We want to get to know the patient’s emotional and interpersonal world as well as we can in order to identify the most important emotional and interpersonal struggles that could be contributing to the patient’s suicidal risk.
Damian Jacob Sendler
The main issue that the patient is currently dealing with was identified in the first two sessions[25]. Patients and therapists work together in the middle phase of the intervention in order to learn and practice new skills. If the therapist wants to get to the bottom of multiple potential issues (such as grief, conflicts, transitions in roles, and interpersonal deficiencies), he or she should ask probing questions to glean the most relevant data. There are four major issues to contend with: I Grief: refers to situations where depression has resulted from difficult grieving after the death of a significant other; (ii) Interpersonal disagreements: concerns conflicts or issues with managing expectations in significant relationships. It’s most common among adolescents, but it can also occur with a teacher or a friend; (3) role transitions: significant life events that can be identified as the point at which the patient became depressed such as the beginning of middle or high school, parental divorce, or a diagnosis of an illness; and (4) interpersonal deficits: difficulties with interpersonal skills that can lead to loneliness or social detachment. The issue can arise in either a group or a one-on-one setting. Understanding the specific hardships involved, such as asking for help, learning to forgive and dealing with disagreements in groups, etc., is essential..
Damien Sendler: Interpersonal, emotional, and behavioral skills are emphasized in these sessions. For each session, the patient’s current mood and suicidal risk are evaluated. An update is made to the safety strategy. These two sessions are devoted to honing problem-solving skills and putting them into action.
The therapist should select one or two IPT-A skills that the patient exhibits the greatest deficits in and that are most relevant to his suicidal risk for this brief intervention. In most cases, these abilities have to do with one’s mood or relationships with others. Emotional, behavioral, and interpersonal skills are among the options that can be selected. There is a strong emphasis on emotional regulation techniques in emotional skills. Working with at-risk children and adolescents on their emotional awareness, cultivating their ability to identify and label their emotions, monitoring their intensity, and learning how to control their behavior associated with these feelings are some of the techniques used. Patients are encouraged to accept their feelings of loneliness, sadness, and hopelessness as normal. However, adolescents should take action to maintain self-control when experiencing intense or overwhelming emotions. Every type of interpersonal interaction necessitates the use of decision analysis (interpersonal problem-solving) among other behavioral skills. This is followed by communication analysis, which teaches the patient to identify and replace ineffective communication skills with more effective ones. Role-playing and interpersonal experiments are used to teach all of the skills, which are then practiced outside of the therapy session and discussed with the therapist. Many parents benefit from these skills trainings and are encouraged to attend these sessions as needed.
There will be a review of previous sessions and recommendations for future treatment in the final session of the intensive phase. In this session, we emphasize the fact that suicidal thoughts and behaviors come in waves, and we talk about relapse prevention in case the adolescent returns to feeling suicidal. We revisit the safety plan we created together at the beginning of treatment to ensure its relevance and to ensure that the patient is familiar with it and willing to use it when necessary.
Rona’s depressive symptoms had decreased significantly by the end of the intervention, and she continued to deny any current suicidal thoughts. Treatment was found to be beneficial and resulted in significant therapeutic gains for the family, who stayed in family therapy for an additional eight months. Rona started long-term treatment at our clinic a year later. Rona’s reluctance to engage in suicidal behavior was notable during this period.
