Family Therapy as Hospital Aftercare for Adolescent Suicide Attempters

Annually, more adolescents and young adults in the United States die from suicide than from
cancer, heart disease, AIDS, birth defects, stroke, pneumonia, influenza and chronic lung
disease combined (U.S. Public Health Service, 1999). Each year approximately 1 in 5
teenagers seriously consider killing themselves, over one million teenagers attempt suicide,
and between 1,600 and 2,000 die by suicide (U.S. Public Health Service, 1999). Clearly, the
need for more empirically based treatment models is urgently needed.

Typically, after a suicide attempt or reporting of suicidal ideation with an intent or plan
to kill themselves, adolescents are treated in a psychiatric hospital. In the past, an
inpatient stay could provide intensive individual, group, family, and or medication therapy.
However, managed care has shifted the goal of hospitalizations from treatment to
stabilization. Adolescents are discharged when they are deemed to be no longer a threat to
themselves, leaving the treatment of precipitating factors to outpatient aftercare. In a
recent review of 21 studies on compliance with aftercare, Daniel and colleagues (2004) found
that a majority of youth do received aftercare, but that noncompliance is very high. Very
little evidence was found to support the effectiveness of aftercare. Surprisingly there are
no studies on preventing adolescent reattempts of suicide after hospitalization. Important
studies by Harrington et al. (1998) and King et al. (2007) have shown some promising results
for aftercare reducing suicidal ideation, but no published studies have looked at preventing
reattempts. Given the dearth of treatment studies for youth attempting suicide in general,
it is not surprising that there are even fewer studies of aftercare for this population.
Yet, given the high cost of even a short inpatient treatment, developing and testing
effective aftercare programs that build on the gains made in inpatient treatment for youth
who attempt suicide seems warranted.

One promising outpatient treatment approach for this population is Attachment-Based Family
Therapy (ABFT; Diamond et al., 2002). ABFT is a manualized, brief (i.e., 12 to 16 week)
family-based model designed specifically for treating depressed and suicidal adolescents.
The model aims to reduce adolescent depression, suicidal ideation, family conflict, parental
criticism, and adolescent isolation and hopelessness; all factors associated with adolescent
suicide attempts (e.g., Brent et al., 1988). To accomplish these goals with the parent,
ABFT aims to increase parental warmth, communication skills, and appropriate monitoring. For
the adolescent, treatment aims to improve interpersonal problem solving, emotional
regulation, and reengagement with positive prosocial activities (e.g., school, job, peers).
As communication improves and trust is rebuilt, the parents reclaim their position as a
secure base for adolescent development. The family becomes a context where adolescents learn
to express their emotions and thoughts (including their suicidal ideation) in a
differentiated and regulated manner, problem solve, and control their impulses. In many
families, repairing the attachment rupture requires a "working through" of prior traumatic
events (e.g., loss, divorce, abuse) often associated with the suicidal behavior. As
adolescents become less preoccupied with suicide ideation and family conflict, treatment
focuses on parents helping their adolescent navigate the challenges of school, peer
relations and other life domains.

ABFT has recently proven effective in reducing suicidal ideation and depressive symptoms in
a non-hospitalized population identified in primary care (Diamond et al., 2007). This grant
will set the foundation for a programmatic look at treating adolescents who have been
psychiatrically hospitalized for attempting suicide. This study will have two improvements
over current aftercare services. First, it will improve the quality of aftercare by using an
empirically based, family-based, manualized treatment. Second, it will rely on a continuity
of care model where aftercare treatment begins while families are still in the hospital,
potentially enhancing treatment compliance once the adolescent leaves the hospital.

- Objective 1: Develop a collaborative relationship with Belmont Psychiatric hospital
and their Therapeutic Bridge Program to foster a research infrastructure that can
support future adolescent suicide clinical trials research. This will include
integrating standardized assessment tools into the inpatient procedures and
establishing procedures for making referrals to the research program.

- Objective 2: Evaluate the feasibility and acceptability of ABFT outpatient aftercare
for youth with a suicide attempt, after discharge from inpatient care. This will be
evaluated by our ability to make contact with at least 80% of eligible patients,
collect weekly follow up data, obtain at least 90% post treatment data, meet our
recruitment goals, retain patients in treatment for at least 10 sessions, and be rated
high on patient report of treatment acceptability and satisfaction.

- Objective 3: In an exploratory fashion, examine the differential effect sizes between
EUC and ABFT at 14 weeks post hospital discharge for a) preventing future suicide
attempts, b) reducing associated risk factors (suicide ideation, depression, and family
conflict) and c) increasing treatment compliance (e.g., time to first session, number
of sessions attended).