Exploring paths to youth suicide and sudden violent death : a multimethod case-control investigation

Suicide and other forms of sudden violent death are the most common causes of death among young people worldwide. Both suicide and other forms of sudden violent death are more frequent among males than females. Risk factors, suicidal behavior, and help-seeking patterns differ between young women and men. Aims: To explore the hypothesis that there are similar backgrounds to both death by suicide and to other forms of sudden violent death among youths. The aims of the quantitative studies were: (1) to compare risk factors for youth suicide and for other forms of sudden violent death with matched living controls; (2) to examine associations between life events and coping strategies common in these three groups of young people. The aims of the qualitative studies were: (3) to build a generic conceptual model of the processes underlying youth suicide, grounded in the parents’ perspective; (4) to compare boys’ and girls’ suicidal processes. Material/Methods: In the prospective longitudinal case-control design, 63 consecutive cases of youth suicide and 62 cases of other forms of sudden violent death were compared with 104 matched control cases. Data were collected in 196 psychological autopsy interviews with parents and other relatives and 240 equivalent interviews in the control group. The interviews included DSM-IV-R criteria for selected psychiatric diagnoses and measures of adverse childhood experiences, stressful life events, and ways of coping. Statistical analyses were conducted using logistic regression, factor analysis, mediation analysis, and moderator analysis. Grounded theory methodology was applied in the qualitative studies in order to give voice to and make sense of the parent’s experiences. Results: (1) The number of recent stressful life events was the only common risk factor for suicide and other forms of sudden violent death. Specific risk factors for suicide were any form of addiction and being an inpatient in adult psychiatric care, whereas for other forms of sudden violent death, risk factors were poorer elementary school results, lower educational level, and abuse of psychoactive drugs. (2) Distinctive of the suicide and the sudden violent death group was significantly less Planful Problem-Solving, and more Escape-Avoidance and Confrontive Coping than among the controls. Between-group differences were partly mediated by differences in negative life events, early and late in life. (3) Family alliances, coalitions and secrets were intertwined with the young person concealing problems and “hiding behind a mask,” whereas the professionals did not understand the emergency. Several interacting factors formed negative feedback loops. Finding no way out, the young persons looked for an “emergency exit.” Signs and preparations could be observed at different times but were recognized only in retrospect. Typically, the young persons and their parents asked for professional help but did not receive the help they needed. (4) Different forms of shame were hidden behind gender-specific masks. Both the young men and women were struggling with issues of their gender identity. Five interwoven paths to suicide were found: being hunted and haunted, being addicted, being depressed, being psychotic, or—for the girls—having an eating disorder. Conclusions: The suicide group seems to have been more vulnerable and exposed to different kinds of stressors, whereas the sudden violent death group seems to have been more prone to acting out and risk-taking. Improved recognition and understanding of the interplay between life events, both in the far past and present, and coping styles, may facilitate the identification of young people at risk of suicide and other forms of violent death. Both groups must be the subject of prevention and intervention programs. Future preventive programs need to address barriers to communication among all parties involved: the young people, parents, and community support agencies. Understanding and making use of the parents’ tacit knowledge can contribute to better prevention and treatment. Keywords: Suicide, sudden violent death, case-control study, psychological autopsy, multiple logistic regression, grounded theory, risk factors, youth, adverse childhood experiences, stressful life events, coping strategies, barriers to help, prevention

Successful and Less Successful Psychotherapies Compared: Three Therapists and Their Six Contrasting Cases

Despite the general effectiveness of bona fide psychotherapies, the number of patients who deteriorate or fail to improve is still problematic. Furthermore, there is an increased awareness in the field that the therapists’ individual skills make a significant contribution to the variance in outcome. While some therapists are generally more successful than others, most therapists have experienced both therapeutic success and failure in different cases. The aim of this case-series study was to deepen our understanding of what matters for the therapists’ success in some cases, whereas other patients do not improve. How do the patients and their therapists make sense of and reflect on their therapy experiences in most successful and unsuccessful cases? Are there any distinctive features experienced by the participants at the outset of treatment? To explore these issues, we applied a mixed-method design. Trying to keep the therapist factor constant, we selected contrasting cases from the caseloads of three therapists, following the criterion of reliable and clinically significant symptom reduction or non-improvement at termination. Transcripts of 12 patient interviews and 12 therapist interviews (at baseline and at termination) were analyzed, applying inductive thematic analysis and the multiple-case comparison method. The comparisons within the three therapists’ caseloads revealed that in the successful cases the patient and the therapist shared a common understanding of the presenting problems and the goals of therapy and experienced the therapeutic relationship as both supportive and challenging. Furthermore, the therapists adjusted their way of working to their patients’ needs. In non-improved cases, the participants presented diverging views of the therapeutic process and outcome. The therapists described difficulties in the therapeutic collaboration but not how they dealt with obstacles. They tended to disregard their own role in the interactions and to explain difficulties as being caused by the nature of their patients’ problems. This could indicate that the therapists had difficulty in reflecting on their own contributions, accepting feedback from their patients, and adjusting their work accordingly. These within-therapist differences indicate that taking a “third position” is most needed and seems to be most difficult, when early signs of a lack of therapeutic progress appear

Changes in the anaclitic-introjective personality configurations following psychoanalytic psychotherapy with young adults

Treatment goals in psychoanalytic psychotherapy often include changes in underlying psychological structures, rather than only symptom reduction. This study examines changes in the anaclitic-introjective personality configurations following psychoanalytic psychotherapy with young adults in relation to outcomes. Thirty-three patients were interviewed pretreatment and at termination using the Object Relations Inventory (ORI). Prototype Matching of Anaclitic-Introjective Personality Configuration (PMAI) was applied to the ORI material by two independent judges (intraclass correlation coefficient=0.73). The patients were classified pretreatment as predominately anaclitic (n=13) or introjective (n=20). Outcome measures included the Symptom Checklist-90-R (SCL-90) and Differentiation-Relatedness scale (D-R) pretreatment, at termination, at the 1.5-year and three-year follow-up. Both groups improved post-treatment in terms of symptoms and developmental levels of representations of self, mother, and father. No significant differences between the anaclitic and the introjective group were found in this respect, and could not be expected due to the low power (0.27). The anaclitic group showed better balance between relatedness and self-definition post-treatment, while this improvement was not significant in the introjective group. Further and larger studies are needed to draw more farreaching conclusions about the relations between changes in personality configurations over the course of treatment and the treatment efficacy. The clinical implications of this approach to underlying dynamic psychological structures are discussed

Interactions between Obsessional Symptoms and Interpersonal Ambivalences in Psychodynamic Therapy: An Empirical Case Study

The classical symptom specificity hypothesis (Blatt, 1974) particularly associates obsessional symptoms to interpersonal behavior directed at autonomy and separation from others. Cross-sectional group research, however, has yielded inconsistent findings on this predicted association, and a previous empirical case study (Cornelis et al., in press; see Chapter 2) documented obsessional pathology to be rooted in profound ambivalences between autonomous and dependent interpersonal dynamics. Therefore, in the present empirical case study, concrete operationalizations of the classical symptom specificity hypothesis are contrasted to alternative hypotheses based on the observed complexities in Chapter 2. Dynamic associations between obsessional symptoms and interpersonal functioning is further explored, aiming at further contribution to theory building (i.e., through suggestions for potential hypothesis-refinement; Stiles, 2009). Similar to the first empirical case study (Chapter 1), Consensual Qualitative Research for Case studies is used to quantitatively and qualitatively describe the longitudinal, clinical interplay between obsessional symptoms and interpersonal dynamics throughout the process of supportive-expressive psychodynamic therapy. In line with findings from Chapter 1, findings reveal close associations between obsessions and interpersonal dynamics, and therapist interventions focusing on interpersonal conflicts are documented as related to interpersonal and symptomatic alterations. Observations predominantly accord to the ambivalence-hypothesis rather than to the classical symptom specificity hypothesis. Yet, meaningful differences are observed in concrete manifestations of interpersonal ambivalences within significant relationships. Findings are again discussed in light of conceptual and methodological considerations; and limitations and future research indications are addressed

“Did I bring it on myself?” An exploratory study of the beliefs that adolescents referred to mental health services have about the causes of their depression

Background: The causal beliefs which adults have regarding their mental health difficulties have been linked to help-seeking behaviour, treatment preferences and the outcome of therapy; yet the topic remains a relatively unexplored one in the adolescent literature. Aims: This exploratory study aims to explore the causal beliefs regarding depression among a sample of clinically referred adolescents. Design: 77 adolescents, aged between 11 and 17, all diagnosed with moderate to severe depression, were interviewed using a semi-structured interview schedule, at the beginning of their participation in a randomised controlled trial. Data were analysed qualitatively using Framework Analysis. Findings: The study identified three themes related to causal beliefs: 1) Bewilderment about why they were depressed; 2) Depression as a result of rejection, victimisation and stress; and 3) Something inside is to blame. Conclusion: Although some adolescents struggled to identify the causes of their depression, many identified stressful life experiences as the cause of their current depression. They also tended to emphasise their own negative ways of interpreting those events, and some believed that their depression was caused by something inside them. Adolescents’ causal beliefs are likely to have implications for the way they seek help and engage in treatment, making it important to understand how adolescents understand their difficulties

Tavistock Adult Depression Study (TADS): a randomised controlled trial of psychoanalytic psychotherapy for treatment-resistant/treatment-refractory forms of depression

ABSTRACT: BACKGROUND: Long-term forms of depression represent a significant mental health problem for which there is a lack of effective evidence-based treatment. This study aims to produce findings about the effectiveness of psychoanalytic psychotherapy in patients with treatment-resistant/treatment-refractory depression and to deepen the understanding of this complex form of depression. METHODS: INDEX GROUP: Patients with treatment resistant/treatment refractory depression. DEFINITION & INCLUSION CRITERIA: Current major depressive disorder, 2 years history of depression, a minimum of two failed treatment attempts, [greater than or equal to]14 on the HRSD or [greater than or equal to]21 on the BDI, plus complex personality and/or psycho-social difficulties. EXCLUSION CRITERIA: Moderate or severe learning disability, psychotic illness, bipolar disorder, substance dependency or receipt of test intervention in the previous two years. DESIGN: Pragmatic, randomised controlled trial with qualitative and clinical components. TEST INTERVENTION: 18 months of weekly psychoanalytic psychotherapy, manualised and fidelity-assessed using the Psychotherapy Process Q-Sort. CONTROL CONDITION: Treatment as usual, managed by the referring practitioner. RECRUITMENT: GP referrals from primary care. RCT MAIN OUTCOME: HRSD (with [less than or equal to]14 as remission). SECONDARY OUTCOMES: depression severity (BDI-II), degree of co-morbid disorders Axis-I and Axis-II (SCID-I and SCID-II-PQ), quality of life and functioning (GAF, CORE, Q-les-Q), object relations (PROQ2a), Cost-effectiveness analysis (CSRI and GP medical records). FOLLOW-UP: 2 years. Plus: a). Qualitative study of participants' and therapists' problem formulation, experience of treatment and of participation in trial. (b) Narrative data from semi-structured pre/post psychodynamic interviews to produce prototypes of responders and non-responders. (c) Clinical case-studies of sub-types of TRD and of change. DISCUSSION: TRD needs complex, long-term intervention and extended research follow-up for the proper evaluation of treatment outcome. This pushes at the limits of the design of randomised therapeutic trials,. We discuss some of the consequent problems and suggest how they may be mitigated. Trial registration Current Controlled Trials ISRCTN40586372