Confound Conflation!


In dipping into the literature on suicide and suicidality, two conflations appear over and over again.

  1. Assessment equals treatment
  2. Distress equals depression (alternatively that the treatment for symptoms of depression will alleviate suicidality)

As far as I can ascertain through my jaunts through the journals, there is no standard of care and treatment for suicidality.  The treatment as usual for imminent suicide is to remove the stated means from the person, to keep them in visual contact until they are deemed not at risk to take suicidal action, and to incarcerate them – in a hospital room, jail cell or home until an external authority figure decides to release them from confinement, voluntary or otherwise.

Today’s latest suicide research press release contains the same errors of conflation:

“We know that asking teens about suicidal ideation does not worsen their problems,” said Dr. McCarty. “It’s absolutely crucial for a teen who is having thoughts of self-harm or significant depression to be able to tell a helpful, trustworthy adult.”

 

“These findings underscore the need for clinicians to be aware of the potential for suicide in adolescence,” added Dr. McCarty. “Primary care physicians and healthcare providers should be specifically assessing suicidal ideation in the context of depression screening for teenagers. Effective screening tools are available, as are effective treatments for depression.”

 

It seems to me that this will result in not much.  Instead, why not invite adolescents to share their thoughts and concerns about belongingness, self worth, and their views of their developing futures?  Joiner’s work – the interpersonal theory of suicide – is largely based on work done with adolescents and young adults.  The two greatest risk factors expressed by people who attempted suicide are the percpetions of thwarted belongingness and perceived burdensomness.

If distress is assessed in those domains, it can lead directly to interventions that can help alleviate acute short term distress and to build social skills for navigating the complicated and complex path to successful adulthood.  Instead of simply affixing a stigmatizing and problematic label of self harm, suicidal, clinical depression, etc. to a troubled youth, why not instead, guide, counsel and eventually partner with that person-in-progress to explore, discover and build character strengths, behavior strategies and social skills development?

Who should be assessing and intervening?  Parents, teachers, coaches, counselors, spiritual leaders/advisors, physicians, nurses – all of the usual cast of adult characters in adolescents’ lives.  Just because teens are trying on independence for size and fit and so most likely won’t initiate these discussions doesn’t mean that they should be held.  And it certainly doesn’t mean that they aren’t important.

I suspect that it would uncover a lot of perceptions of social exclusion, of externally imposed loneliness (cliques and bullies, exclusive teams, clubs and competitive organizations’ closed memberships) and of feeling of failure, inadequacy and uncertainty.  The adults can help youth to identify where actual and potential social connections lie and coach strategies to achieve them. They can monitor and intervene in the situations where youth are at risk (bullying, discrimination, sexual/gender identity, learning problems, disabilities, violence), and they can be stable and predictable lifelines in a world that is neither.

A long time ago a very wise animal trainer explained to me that if “you want the puppy to come to you, quit hitting it on the nose when it does.”  We need to find ways which encourage, entice and reward people for sharing distressors and for engaging in the very hard work it takes – often a lifetime’s worth – to alleviate distress to tolerable levels and find at least minimal satisfaction in belonging and contributing.  The last thing that adolescents need is to have their distress offloaded onto mental health providers who will only intrusively assess and confine them (talk about ostracism!) while not addressing the underlying distress and distressors and who really aren’t the right folks to treat problems of living.

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