Mar 23, 2016 | Article, Volume 6 - Issue 1
Kelly Emelianchik-Key, Rebekah J. Byrd, Amanda C. La Guardia
Self-injury is a significant issue with a variety of psychological, social, legal and ethical consequences and implications (Froeschle & Moyer, 2004; McAllister, 2003; Nock & Mendes, 2008; White Kress, Drouhard, & Costin, 2006). Self-injurious behavior is commonly associated with the cutting, bruising or burning of the skin. It also can include trichotillomania, interfering with wound healing and extreme nail biting (Klonsky & Olino, 2008; Zila & Kiselica, 2001). In assessing severity, it is important to note that self-inflicted wounds typically do not require any medical attention, as those who engage in self-injury will usually care for any open wounds in order to prevent infection (Walsh, 2006). The typical duration of a self-injurious act is usually less than 30 minutes, resulting in immediate relief from the emotional turmoil precipitating the behavior (Alderman, 1997; Gratz, 2007). It is difficult to estimate the prevalence of self-injury for many reasons. Nock (2009) noted that reports indicating increased estimates in this behavior derive from “anecdotal reports and estimates from small cross-sectional studies” (p. 81). Given the many ethical and legal ramifications involved in working with clients that self-injure, it is important to understand how self-injury typically manifests itself, how it affects differing populations based on gender and cultural differences, and the level of danger it truly represents to the person choosing to utilize it.
Self-Injury and Suicidal Intent
The current average age of those beginning to engage in self-injury is as early as 12 years old, but onset typically begins in adolescence (Lundh, Karim, & Quilisch, 2007; Trepal & Wester, 2007). Self-injury is found as a frequently occurring issue in the adolescent population (Jacobson, Muehlenkamp, Miller, & Turner, 2008; Nock, Joiner, Gordon, Lloyd-Richardson, & Prinstein, 2006). The majority of reported self-injury and research regarding it has been focused on Caucasian females. Within this particular population, self-injury is typically not associated with increased danger beyond the injury itself unless onset co-occurs with a psychotic episode or is co-morbid with suicidal ideation (Conaghan & Davidson, 2002; Walsh, 2006). Self-injury is the intentional harm to one’s self (usually in the form of cutting, burning, or hitting) to alleviate distress and regulate emotions (Nock & Favazza, 2009) with no intent to die. Usually, reporting of self-injury is necessitated by the concern that the act may possibly result in unintentional death; however, practitioners often simply confuse the behavior with suicidal intention (McAllister, 2003; Trepal & Wester, 2007). Suicide attempts and intention are clearly defined in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; American Psychiatric Association, 2013) as those that have the intent or aim to die. Self-injurious behaviors should be viewed as a form of self-help or coping to assist the person in feeling something different, instead of a suicide attempt (Favazza, 1998; Klonsky, 2007). A lack of consensus among researchers regarding the defining qualities of self-injurious behaviors has led to difficulty in discerning the difference between self-injury and suicide (Gratz, 2004; McAllister, 2003; Simeon, Favazza, & Hollander, 2001). As self-injury and other self-harming behaviors continue to be identified, researched and understood, new methods of evaluating these behaviors are developed. Suicide and self-injury are typically two different behaviors but often are aggregated in reports and evaluations. It was determined that data regarding the evaluation of risky adolescent behaviors might be useful for providing a tentative source for analysis. Given that self-injury, self-harm, and suicide attempts are a growing area of study, reliance on current and previous data sources for analysis of self-injury and self-harm behaviors can be used in order to highlight possible areas for research. Data from the Youth Risk Behavior Survey (YRBS; CDC, 2006), as gathered by the Centers for Disease Control and Prevention (CDC), has been used for the purpose of determining the prevalence of possible self-injurious behaviors among young women and young men from differing ethnic backgrounds.
Studies indicate mixed views on the degree of overlap between self-injury and suicidal ideation; therefore, data pertinent to the YRBS may only encompass youths within this overlap. Pattison and Kahan (1983) found that only 41% of those who self-injure reported suicidal ideation while self-injuring. “Another problem with much of the current literature is that little differentiation is made between self-injury and suicide attempts, which are very distinct behaviors” (Roberts-Dobie & Donatelle, 2007, p. 258). Therefore, it could be argued that if practitioners cannot clearly make a distinction between self-destructive acts, then adolescents reporting their behaviors might not be able to make the distinction between self-injurious intent and other possible intentions, such as suicide and frequent aggressive behaviors resulting in harm. Roberts-Dobie and Donatelle (2007) went on to state: “Self-injury is not a failed suicide attempt but often a coping mechanism for negative emotions” (p. 258). This conclusion also is shared by many researchers evaluating self-injury (Brown, Williams, & Collins, 2007; Gratz & Roemer, 2008; Klonsky, 2007; Marx & Sloan, 2002). The International Society for the Study of Self-Injury (ISSS), established in 2006, sought to clarify and understand self-injury and specifically define non-suicidal self-injury (NSSI). Following is their agreed upon definition:
The deliberate, self-inflicted destruction of body tissue resulting in immediate damage, without suicidal intent and for purposes not socially sanctioned. As such, this behavior is distinguished from: suicidal behaviors involving intent to die, drug overdoses, and other forms of self-injurious behaviors, including culturally-sanctioned behaviors performed for display or aesthetic purposes; repetitive, stereotypical forms found among individuals with developmental disorders and cognitive disabilities, and severe forms (e.g., self-immolation and auto-castration) found among individuals with psychosis. (ISSS, 2007)
It is important to note, however, that while there is a link between suicide and self-injury, it is a complicated relationship. Therefore, clinicians should always assess for suicidality when confronted with client self-injurious behaviors; however, immediately assuming suicide ideation or an active suicide attempt from reported self-injurious behavior can be therapeutically problematic. The essence of this complication presents a limitation in the analysis of the YRBS behavior data (CDC, 2006).
Treatment of Self-Injury
If self-injury is left untreated, increased severity and possible suicidality or suicide attempts may occur; therefore, it is important to recognize self-injury and treat the client appropriately and quickly in order to prevent complications. Knowledge with regard to possible presentation of self-injurious behavior as it pertains to intersections of gender, age and ethnicity also is important. Additionally, clinicians must recognize typical signs of self-injurious behaviors in relationship to diagnostic criteria. The likelihood of self-injurious behavior as a coping mechanism becomes more prevalent within certain psychological issues. The diagnoses most commonly associated with self-injury include major depression, borderline personality disorder, post-traumatic stress disorder and eating disorders (Klonsky & Muehienkamp, 2007; Marx & Sloan, 2002; Nehls, 1998; Sansone & Levitt, 2002; Sargent, 2003). Self-injury has been found to be associated with acute stress related to relational aggression, abuse and dating violence (Hays, Craigen, Knight, Healey, & Sikes, 2009; Turnage, Jacinto, & Kirven, 2003). Since self-injury also can be co-morbid with suicidality, selected psychological and emotional states will be reviewed separately in terms of their individual indicators related to self-injury, and their effects on the severity of possible danger or harm to provide a framework for the importance of data related to populations not typically studied in association with self-injurious behaviors.
Self-injury has commonly been associated with the diagnosis of borderline personality disorder (BPD), although this association may relate more to ongoing trauma issues (Alderman, 1997; Naomi, 2002). Given the continued prevalence of the diagnosis in relation to self-injury, attention to self-injury with BPD is warranted. Those who are diagnosed with BPD, or display borderline features, and are engaging in self-injury typically display other self-destructive behaviors and decision making (Gratz, 2006; Sansone, Wiederman & Sansone, 1998), tend to have unresolved anger that is noticeable in everyday relations, and also may exhibit a need to distract themselves from their emotions (M. Brown, Comtois, & Linehan, 2002). These characteristics will be prominent over other clinical symptoms associated with BPD. BPD also is more commonly diagnosed among females, as is self-injurious behavior (Lundh et al., 2007). If indeed self-injurious behaviors are associated with a history of trauma, perhaps the presentation of self-injurious behaviors are overlooked when working with male clients due to the association of self-injury with BPD.
Gender and Self-Injury
Potential gender differences in the presentation of self-injury may exist for various reasons. Past studies focusing on particular forms of self-injury have focused on potentially unrepresentative female-only samples, thus misrepresenting the existence of a more diverse population of those engaged in self-injurious behaviors (Marchetto, 2006). Some research proposes that males are just as likely as females to self-injure and perhaps go about it differently or are more secretive (Gratz, 2001). Marchetto’s study of 516 individuals engaged in skin-cutting as a form of self-injury found “no evidence for an overrepresentation of women” (p. 453). Other research supports this notion that there may not be a gender difference among certain types of self-injurious behavior (Izutsu et al., 2006; Muehlenkamp & Gutierrez, 2007). In addition, a recent study found no gender differences in prevalence of self-injury among college students, but noted that far fewer men were willing to complete the study (Heath, Toste, Nedecheva, & Charlebois, 2008). Furthermore, these authors warned against inaccurately interpreting the above issues as meaning a lower prevalence of self-injury exists among males. Seemingly, female adolescents are more likely to self-report instances of self-injury than male adolescents (Heath, Schaub, Holly, & Nixon, 2008), and male self-injurers are not diagnosed and conceptualized the same as females that self-injure (Healey, Trepal, & Emelianchik-Key, 2010). With these two compounding factors, males that self-injure are at a disadvantage to receive help with their self-injurious behaviors.
The information presented in this article is posed to present further evidence that suggests male self-injury exists and needs to be addressed in the assessment and treatment of presenting issues related to self-injury. Since depression is sometimes associated with suicidal ideation, self-injury and other harmful behaviors, recognition of the severity of client depressive symptoms through thorough assessment techniques becomes vital to treatment and selection of therapeutic interventions regardless of gender. Suicide is the third leading cause of death in adolescents and young adults, with 15% of those suffering from clinical depression ending their lives (Suicide Awareness Voices of Education, 2008). Symptoms, as outlined by the National Institute of Mental Health (2009), include and compare the early signs of making statements of prolonged despair or expressions of guilt as critical indicative signs of concrete plans for a suicide attempt. Occurrence of these signs becomes a major factor in assisting with assessment of severity. Suicidality has been linked to substance abuse, anxiety, mood disturbance and disruptive behaviors (Linehan, Comtois, Brown, Heard, & Wagner, 2006; Nock & Banaji, 2007; Wade & Pevalin, 2005). Risk factors that have been identified as highly correlated with successful suicide attempts include highly aggressive behaviors with a history of aggression, psychosis, impulsivity and bi-polar disorder (Renaud, Berlim, McGirr, Tousignant & Turecki, 2008). Becker and Grilo (2007) demonstrated that gender differences impacted how each risk factor affected the severity of the depression; however, low self-esteem was correlated with suicidality across both male and female populations. This article will use data from the YRBS and analyze it to provide empirical evidence for why issues of diversity need to be addressed within the self-injury and suicidality literature.
Data Sources
The YRBS is a national school-based survey developed by the CDC in order to monitor issues such as obesity, substance abuse, dietary habits, and unintentionally injurious and violent behaviors. Data files are made available to the public after analysis is completed through the CDC; data from the 2005, 2009, 2011 and 2013 surveys were used in this analysis.
Response Rate
As per the YRBS (CDC, 2005, 2009, 2011, 2013), at the school level, all regular public, Catholic, and other private school students, in grades 9 through 12, in the 50 States and the District of Columbia were included in the sampling frame. Puerto Rico, the trust territories, and the Virgin Islands were excluded. Schools were selected systematically with probability proportional to enrollment in grades 9 through 12 using a random start. All classes in a required subject or all classes meeting during a particular period of the day, depending on the school, were included in the sampling. Systematic equal probability sampling with a random start was used to select classes from each school that participated in the survey. In 2005, the overall response rate was 67% (158 schools participated); in 2009 the school response was 81% (158 participated); in 2011 it was 81% (158 participated); and in 2013 the response rate was 77% (148 participated). In total, 59,335 student responses were included in the datasets evaluated for the database review of behaviors associated with NSSI.
Methods
YRBS (2005, 2009, 2011, 2013) data were retrieved from the CDC in order to analyze the relationship between depression and self-injurious behaviors, including direct bodily self-injury or frequent aggressive behavior that resulted in bodily injury. The YRBS was designed to monitor health risk behaviors for adolescents in high school. For this analysis, comparisons were made with regard to gender and ethnicity to evaluate issues related to possible self-injurious behaviors, since the YRBS does not differentiate between suicidal attempts and self-injurious behaviors. Data screening methods also were used to evaluate the variables used in the study to assure they met the criteria for logistic regression. Cases with missing data for the self-injury and self-injurious aggression items were excluded.
Variables
To assess for possible NSSI, items that pertained to self-injury and self-injurious aggression within the YRBS were pulled and re-coded into dichotomous variables to include the following questions: “During the past 12 months, how many times did you actually attempt suicide?” and “If you attempted suicide during the past 12 months, did any attempt result in an injury, poisoning, or overdose that had to be treated by a doctor or nurse?” If the participant attempted suicide six or more times but the injury did not require medical attention, the behavior was considered to possibly represent NSSI, since self-injury has been shown to have overlapping qualities with suicidal attempts and is not easily recognizable or differentiated among clients and professionals in the field. Additionally, the following questions were assessed due to research indicating that frequent aggressive behaviors resulting in harm could be viewed as a form of self-injury: “During the past 12 months, how many times were you in a physical fight?” and “During the past 12 months, how many times were you in a physical fight in which you were injured and had to be treated by a doctor or nurse?” For these questions, those respondents who got into fights four or more times in a 12-month period and had to be evaluated by a medical professional were thought to be possibly engaging in self-injurious aggressive behaviors. Correlations were completed on these items in order to justify their grouping as a variable.
The self-injurious behavior questions were correlated at r = .72, p < .001 and coded as self-injurious when participants answered that they had attempted suicide more than four times in one year and/or had injured themselves physically, either requiring outside medical treatment or not requiring medical treatment. Questions regarding physical fighting were combined to form the aggression variable and were significantly correlated at r = .42, p < .01.
Self-injurious aggression was coded based on extremity of engagement in fighting and the resulting personal injury of the participant. As self-injury may manifest itself differently depending on gender and cultural expectations and experiences, extreme aggression that resulted in frequent hospitalization or medical care was considered to be a possible indicator of this alternative behavioral expression (Harris, 1995; McMahon & Watts, 2002). Self-injury has been shown to result in acting in or acting out behaviors as a way of engaging in emotional regulation (Bjärehed, Wängby-Lundh, & Lundh, 2012; Mikolajczak, Petrides, & Hurry, 2009). The way in which one chooses to manifest self-injury or the typology of the non-suicidal self-injurious behavior may present differently for males and females (Heath et al., 2008; Muehlenkamp & Gutierrez, 2007). Thus, both traditional and non-traditional methods for harm were evaluated for this study, as NSSI is sometimes thought to be a suicidal attempt or behavior by clinical professionals wanting to err on the side of caution because those who self-injure also may have co-occurring suicidal ideation. In contrast to the pressure for immediate and safe clinical intervention, however, those who choose to self-injure and those who attempt suicide often have differing attitudes toward life (Muehlenkamp & Gutierrez, 2004). For this study, logic seemed to dictate evaluating frequent suicide attempts that did not result in medical attention as a possible self-injurious behavior. To further evaluate the consideration of frequent suicide attempts (more than four in a year) as possible NSSI, correlations were conducted between the NSSI variable and items stating, “During the past 12 months, did you make a plan about how you would attempt suicide?” and “During the past 12 months, did you ever seriously consider suicide?” In the 2013 sample, the NSSI variable was significantly correlated with both items at p < .001, with correlations of r = .241 and .218 respectively. Therefore, in the 2013 data set, there was indication that as the attempts increased the participant was more likely to state that they had seriously considered suicide or made a plan in the past year. However, the correlation was low, accounting for only 24 and 22% of participants who stated they had attempted four or more times in a year, a similarity with all other years included in this analysis. Thus, the fact that the majority of those who indicated they attempted suicide four or more times did not indicate they had made plans to commit suicide or had even thought about it seriously points toward an indication that the item also may be measuring NSSI rather than just suicide attempts.
With regard to the demographic variables, gender, ethnicity and depression were all coded dichotomously. Variables were created as described in order to complete a binary logistic regression. This analysis was chosen in order to evaluate the odds that a certain behavior would yield results with regard to the predictor variables used. Of those demographic variables included in the study and coded dichotomously from 2005, 60% identified as Caucasian and 37% identified as being from a marginalized or underrepresented group (e.g., Black/African American, Hispanic, multiple heritage). The remainder did not identify their ethnicity. With regard to gender or biological sex, 49% of the sample indicated they were female while 50% of the sample indicated they were male. The remainder did not respond to the item for male or female identification. Concerning age, 37% of the sample indicated they were 15 or younger and 63% of the sample was older than 15. All of the participants sampled were in grades 9–12. Demographic statistics were similar across each year of analysis.
Results
Separate analyses were conducted for each year of the YRBS included in this review. Trends were assessed and will be discussed following the presentation of results. Binary logistic regressions were completed to determine predictors for both possible non-suicidal self-injurious behavior and potentially self-injurious aggressive behaviors. Categorical contrast baselines were set for: Caucasian, male, age less than 15, reports of no feelings of hopelessness, and no self-injurious aggression.
YRBS 2005 Analysis
Using self-injurious behavior as an outcome variable and gender, age, ethnicity, extreme aggression and depression as covariates predictor variables, a binary logistic regression was completed on the available data set to analyze the goodness of fit. The result was Nagelkerke R2 = .240 which indicated that the variables included in the model accounted for 24% of the variance. The Hosmer and Lemeshow test used for the logistic regression was not significant (χ2 = 10.16, p = .180), indicating that the predicted probabilities match the observed probabilities. These results show a probability that it is three times more likely that those engaging in extreme self-injurious aggression also will engage in self-injurious behaviors and 11 times more likely for those who are depressed to engage in self-injurious behaviors controlling for all other predictor variables (see Table 1). Age and race did not seem to play a significant role in predicting self-injurious behavior, as both age groups (early adolescents and late adolescents) were just as likely to engage in self-injury. In addition, those from different ethnic backgrounds were just as likely to engage in self-injury when controlling for all other factors. Males were half as likely as females to engage in self-injury. However, males were three times as likely to engage in extreme aggression while those who were reportedly depressed were twice as likely to engage in possible self-injurious aggressive behavior (see Table 2).
YRBS 2009 Analysis
In Table 3, the regression for self-injurious behavior is presented. Given the base rates of the two coded options, 83% of the sample choose not to involve themselves in possible self-injurious aggressive behaviors (intentional fighting resulting in injury); therefore, the best predictive strategy is to assume that, for every case, the subject will choose not to participate in fighting behavior that would likely result in injury requiring medical attention. In essence, the odds of someone engaging in aggressive self-injury are approximately 20% (ExpB = .205). In testing the predictive model of age, gender, race, depression and likelihood to engage in individual self-injury, results indicate that the model was significantly predictive at Χ2 = 984.4, p < .001. The Nagelkerke R2 = .110 is an indication that this model would only account for 11% of the variance in predicting self-injurious aggressive behaviors (intentionally fighting to result in injury). After adding the predictive model, 83% of cases were correctly classified, as opposed to an 80% classification rate prior to the addition of variables to the predictive model. The Hosmer and Lemeshow test was not significant (χ2 = 18.83, p > .001), indicating that the predicted probabilities match the observed probabilities. According to the predictive model, if the participant were female, she would be .326 as likely to engage in aggressive self-injurious behavior as compared to males. A Wald Test was used to examine the true value of the parameter based on the sample and all were found to be significant at < .001.
YRBS 2011 Analysis
For the 2011 sample population, 1,300 participants indicated engaging in physical fights four or more times in a year, resulting in the need for medical attention more than once, which fit the criteria for self-injurious aggression (approximately 8% of those surveyed; self-injurious aggression variable). Of those included in analysis, 201 participants indicated that they had attempted suicide four or more times, attempts that did not require medical attention (NSSI variable). Of those students responding, over 4,000 (approximately 29%) indicated feeling sad or hopeless every day for 2 weeks or more in a row during the past year. Feeling sad or hopeless had a weak negative correlation with the NSSI variable with r = -.146, p < .001. Similarly, feeling sad or hopeless had a weak negative correlation with self-injurious aggressive behaviors with r = -.097, p < .001. NSSI and self-injurious aggression had a significant weak positive correlation with r = .195, p < .001. Of those responding to the 2011 YRBS, 7,574 indicated they were Caucasian and 1,629 indicated they were younger than 15 years old.
The binary regressive model for the 2011 data indicates a resultant X2 (4) = 370.27, p < .001. The Nagelkerke R2 = .241 indicates that this model would only account for approximately 24% of the variance in predicting self-injurious behaviors as defined by items 27 and 28 of the YRBS. Of those surveyed, 69.3% were included in analysis. The Hosmer and Lemeshow test was not significant (χ2 = 2.39, p = .935), indicating that the predicted probabilities match the observed probabilities. Wald statistics are significant at p < .001 for the item indicating possible depression, age and the variable assessing possible aggressive self-injury (engaging in numerous physical fights). Wald statistics for race were approaching significance at p = .089; however, age and gender were not significant. Therefore, these demographic variables were likely not contributing significantly to the prediction of NSSI as defined in this study.
Of those participants who identified as possibly engaging in non-suicidal self-injurious behaviors, 98.5% of cases were correctly classified by the model. The classification of cases was not changed when the variables of non-suicidal aggression, depression, age, gender and race were included. The calculated r statistic for non-suicidal aggression was .30, and .24 for the depression variable, indicating that both likely accounted for 54% of the predictive power of the model. The demographic variables could not be calculated due to their low contribution to the predictive model. While z2 was significant for age, the Wald statistic itself was not large enough to calculate a standard analogue of r.
It is important to note that the lower end of the confidence interval for all variables included in the model was less than one, with the exception of the item variable measuring depressive symptoms. This finding is indicative of the likelihood that as non-suicidal aggressive behaviors increase, so too will the possibility for NSSI; however, this relational direction may not be true for all cases occurring within the 95% confidence interval. Nevertheless, we can be more confident in the relationship between indications of non-suicidal self-injurious behaviors (as defined by this study) and the depressive symptoms measured through item 24 of the YRBS.
The Hosmer and Lemeshow’s measure of R2 is .24, indicating a moderate effect size. With regard to probability analysis of the significant variables, it should be noted that if a participant were feeling sad or hopeless, they would be 9.47 times more likely to engage in non-suicidal self-injurious behaviors as defined by this study. If a subject were engaging in multiple fights that resulted in injury, the participant would be 9.317 times more likely to engage in multiple “suicide” attempts that did not result in the need for medical attention. Finally, if a participant was younger than age 15 at the time of this survey, the subject was almost twice as likely to engage in non-suicidal self-injurious behavior (Table 4). Probabilities for binary regression of self-injurious aggression with regard to sex and depressive symptoms can be found in Table 5.
YRBS 2013 Analysis
For this sample population, 872 participants indicated that they engaged in physical fights four or more times in a year, resulting in the need for medical attention more than once. Of those students responding, over 4,000 indicated feeling sad or hopeless every day for 2 weeks or more in a row during the past year, and 177 participants indicated that they attempted suicide four or more times but did not require medical attention for those attempts (conceptualized as possible non-suicidal self-injurious behavior). Of those indicating their ethnicity, 6,416 participants indicated that they were Caucasian. The binary regressive model for the 2013 data indicates a resultant X2 (5) = 295.731, p < .001. As indicated in table 6, the Nagelkerke R2 = .222, which indicates that this model would only account for approximately 22% of the variance in predicting self-injurious behaviors as defined by items 27 and 28 of the YRBS. The Hosmer and Lemeshow test was not significant (χ2 (7) = 8.281, p = .308+), indicating that the predicted probabilities match the observed probabilities. Wald statistics are significant at p < .001 for the item indicating possible depression and the variable assessing possible aggressive self-injury (engaging in numerous physical fights). Wald statistics for race, age and gender were not significant; therefore, these demographic variables are not making a statistically significant contribution to the prediction of NSSI.
As indicated in tables 6 and 7, of those participants who identified as possibly engaging in non-suicidal self-injurious behaviors, 98.7% of cases were correctly classified by the model. The classification of cases was not changed when the variables of non-suicidal aggression, depression, age, gender and race were included. Calculated r for non-suicidal aggression was .32, and .22 for the depression variable, indicating that both likely accounted for 54% of the predictive power of the model. The demographic variables could not be calculated due to their low contribution to the predictive model. It is important to note that the lower end of the confidence interval for variables not significantly contributing to the model was less than one.
Discussion
In completing this analysis, it is evident that further study is needed in the area of self-injury with regard to outward expression in the form of extremely aggressive behaviors, prevalence among differing ethnic groups and prevalence in the male population. Currently, most research is focused on adolescent Caucasian females, indicating that self-injury may be more prevalent among females and those of Caucasian decent (Whitlock, 2010). Data from the current study indicates that perhaps males and other ethnic groups also are engaging in this destructive coping mechanism, perhaps in differing ways than are being focused on by current conceptual and empirical works. Researchers (Whitlock, Eckenrode, & Silverman, 2006; Matsumoto et al., 2005) indicate that males are more likely to injure areas of the body that are more sensitive when compared to females and to use more severe methods to self-injure. Male self-injurers show injuries to the chest, face, or genitals and the injuries sustained often have more long-term repercussions than those of females who tend to self-injure arms and legs. Males also tend to burn themselves and use hitting and punching type behaviors, whereas females tend to cut (Sornberger, Heath, Toste, & McLouth, 2012). The results of this analysis is consistent with the literature that indicates self-hitting or physically aggressive behaviors resulting in injury is a more typical typology of self-injurious behaviors for adolescent males (Izutsu et al., 2006). By studying a variety of populations, the definition of self-injury can be extended in order to clinically expand other, less damaging ways of coping with extreme emotional discord. Future research is needed concerning self-injury in adolescent males as a singular group as well as studying both males and females with ethnicity and cultural identity as variables.
Expanding the definition of self-injury to include frequent aggressive behaviors that result in harm to the self may be prudent. For instance, Harris (1995) evaluated 363 Hispanic and Caucasian university students with regard to endorsement of aggressive behaviors. He found that males, in general, were more likely to endorse fighting, and Hispanic males were more likely to endorse aggressive behaviors. Harris theorized that this endorsement might translate to emotional regulation factors. Nock (2009) also stated that the majority of current studies on self-injury have not addressed culture and gender issues when discussing self-injury and would, at times, exclusively focus on samples of Caucasian women. He indicated that this approach could conceivably lead to issues in fully evaluating the legal and ethical ramifications of self-injury. Nock’s criticism of not enough research to evaluate the self-injurious prevalence in different settings, age groups, cultures, and with men underlines the need for more investigation. Limited studies have also examined the differences between race, ethnicity and culture among those that engage in self-injurious behavior (Yates, Tracy, & Luthar, 2008). Gratz et al. (2012) found that reporting rates were higher for Caucasian girls as opposed to Caucasian boys, and higher for African American boys as opposed to African American girls. Such findings provide evidence to support the idea that racial and ethnic backgrounds moderate the gender differences in the rates of self-injury. Results from the YRBS provide further evidence that this is indeed an issue that spans culture and gender domains. Research that expands to fully include gender, racial, cultural and age differences is certainly warranted.
If regular harm-to-self aggressive behaviors were included in the definition of self-injury, assessment practices as well as mental health treatment would benefit. Currently, treatments for self-injury include approaches consistent with dialectical behavioral therapy (DBT) and cognitive-behavioral therapy (CBT), as well as interventions associated with each approach including mindfulness, regulating emotions, distress tolerance, and thought stopping (Trepal & Wester, 2007). However, if intersections of gender and culture are to be considered, it is important that a broader holistic approach to the conceptualization and treatment of self-injury be taken. For example, while CBT can serve to address immediate behavioral concerns and provide alternative coping mechanisms for clients as they process the meaning of their behaviors, treatment for the underlying issue is suggested in order to ensure long-term success. Therefore, for any clinical treatment to be optimally helpful and globally applicable, having useful, relevant research data is a must.
Limitations, Implications and Future Research
The limitations of this study are noted throughout, including a lack of clear consensus among practitioners on how to diagnose and treat self-injury. There is a lack of understanding of how self-injurious behaviors are connected to suicidal intent. Clinicians will diagnose suicidal intent out of fear that the injury could result in unintentional death, which ignores the intention of the act (McAllister, 2003; Trepal & Wester, 2007). By further examining self-injury and the measures that exist, the differences can be more clearly defined so practitioners clearly assess for self-injury. The reporting rates on self-injury are difficult to clearly identify and define due to confusions, including little information regarding culture, ethnicity and gender differences. Measures like the YRBS are beneficial, yet lump together the behaviors and are conducted often. This study attempted to further examine the YRBS responses in hopes to show the importance of differentiation between self-injury and suicide intent among various ethnicities, cultures and genders.
Previous research has shown that when underlying issues related to trauma, depression or other related stressors are not addressed, self-injurious behaviors are likely to reoccur later in life even after they have ceased for a number of years (Alderman, 1997; Conaghan & Davidson, 2002; Walsh, 2006). If other presenting behaviors, such as self-injurious aggression, are not recognized as a similar coping mechanism or way of emotionally regulating distressing feelings, appropriate diagnosis and treatment might be elusive, time-consuming and expensive. Therapeutic interventions need to match the client’s presenting concerns and the underlying purpose driving the behavior. The possible cultural and social context involved in the client’s internal perspectives on behavioral choices and subsequent actions might be useful to evaluate. This would allow for space to create a greater sense of self-awareness and thus provide an increased likelihood that the client will be able to regulate or cope with their distressing emotions in a useful and self-empowering way. Feminist, Adlerian, and narrative interventions could be used to help facilitate this process, as they are each grounded in creating awareness of societal influences with regard to one’s personal process, purpose, and self-perceptions (McAllister, 2001; Sweeney, 2009; Worell & Remer, 2003). Mental health counselors may want to evaluate how their current theoretical orientation can help them conceptualize self-injury in productive and useful ways to empower the client toward gaining a greater sense of self-awareness and openness to treatment. Interventions from a variety of counseling perspectives offer clinicians more treatment choices, and more treatment choices translate into greater success in addressing a client’s problem. Research that includes the whole picture of self-injurious behavior provides the most benefit for successful clinical practice.
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.
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Kelly Emelianchik-Key, NCC, is an Assistant Professor at Florida Atlantic University. Rebekah J. Byrd, NCC, is an Assistant Professor at East Tennessee State University. Amanda C. La Guardia, NCC, is an Assistant Professor at Sam Houston State University. Correspondence can be addressed to Kelly Emelianchik-Key, Department of Counselor Education, 777 Glades Road, Building 47, Room 458, Boca Raton, FL 33431, kemelian@fau.edu.
Mar 23, 2016 | Article, Volume 6 - Issue 1
Robert C. Schmidt
Youth suicide is a significant public health concern and efforts to reduce youth suicide remain a national priority (Kung, Hoyert, Xu, & Murphy, 2008; National Action Alliance for Suicide Prevention: Research Prioritization Task Force, 2014). In the United States, there were 40,600 suicides in 2012, averaging 111 suicides per day (Centers for Disease Control and Prevention [CDC], 2014a). Of the total number of suicides, 5,183 were youth suicides, averaging 14 youth suicides daily, or one youth suicide every 1 hour and 42 minutes (Drapeau & McIntosh, 2014). Youth suicide is the third leading cause of death between the ages of 10 and 14 and has become the second leading cause of death between the ages of 15 and 24 (CDC, 2014a). The results from the 2013 Youth Risk Behavior Surveillance (YRBS) reported 29.9% of high school students felt sad or hopeless almost every day for 2 weeks or more; 17% of high school students seriously considered attempting suicide; 13.6% of high school students made a suicide plan about how they would attempt suicide; and 8% of students attempted suicide one or more times (CDC, 2014b).
Efforts to address the increasing rate of youth suicide call for the identification of existing training and preparation gaps currently faced by practitioners (National Action Alliance for Suicide Prevention: Research Prioritization Task Force, 2014). These gaps pose many challenges for practitioners to effectively provide appropriate interventions. Although previous studies have investigated training gaps among specific professional disciplines (Debski, Spadafore, Jacob, Poole, & Hixson, 2007; Dexter-Mazza, & Freeman, 2003; O’Connor, Warby, Raphael, & Vassallo, 2004), the current study investigated a broader representation of disciplines including social workers, school counselors, professional counselors, school psychologists and psychologists. This study examined practitioner self-perceived levels of preparedness, levels of confidence and methods used in the assessment of youth suicide.
Practitioner readiness in suicide assessment. In approximately eight of ten suicides, youth give advance clues or warning signs of their intentions that can be detected by others (McEvoy & McEvoy, 2000; Poland & Lieberman, 2002). In a study spanning four years of youth in a rural school district (N = 5,949) screened for suicidal thoughts, 670 (11%) reported having suicidal thoughts within the past year or past few days (Schmidt, Iachini, George, Koller, & Weist, 2015). Practitioners working within school or community mental health settings have an opportunity to play a critical role in the identification, assessment and prevention of youth suicide (Singer & Slovak, 2011). Within either setting, practitioners will encounter clients having suicidal thoughts or behaviors (Rudd, 2006). The practitioner’s responsibility in the assessment of suicide is to estimate risk based on identifying warning signs and associated behaviors and to respond appropriately (Bryan & Rudd, 2006).
In a national sampling of social workers, 93% of the respondents reported having worked with a suicidal patient (Feldman & Freedenthal, 2006), and 55% of clinical social workers reported having a patient attempt suicide (Sanders, Jacobson, & Ting, 2008). In a study of psychology doctoral interns (N = 238) completed by Dexter-Mazza and Freeman (2003), 99% reported providing services to suicidal patients and 5% reported experiencing a patient death by suicide. Across professional disciplines, 22% to 30% of social workers, counselors and psychologists reported having a patient die by suicide (Jacobson, Ting, Sanders, & Harrington, 2004).
Irrespective of the level of suicide training, comfort level or experience (i.e., even those with limited training and preparedness), the circumstances for which practitioners meet with a suicidal client are not only stressful, but also have legal and ethical ramifications (Cramer, Johnson, McLaughlin, Rausch, & Conroy 2013; Poland & Lieberman, 2002). Research suggests significant gaps exist related to the practitioner’s training and readiness to perform suicide risk assessments, highlighting training deficits in the level of preparedness, level of confidence and methods used to determine suicide risk level (Smith, Silva, Covington, & Joiner, 2014).
Although youth suicide remains a national concern and priority, gaps appear most prominent in translating research into practice in developing and providing appropriate levels of training and supervision for practitioners (Smith et al., 2014). Research to support this concern offers valuable recommendations (Osteen, Frey, & Ko 2014; Schmitz, Allen, Feldman, et al., 2012); however, despite these recommendations, training and preparation continue to lag (Rudd, Cukrowicz, & Bryan, 2008). Practitioner competency skills in suicide assessment continue to be neglected by colleges, universities, licensing bodies, clinical supervisors and training sites that can have the greatest impact in reducing youth and adult suicide (Schmitz et al., 2012).
Practitioner preparedness. In the past several decades, researchers began identifying gaps in suicide risk knowledge, finding that practitioners were inadequately prepared to assess suicide risk. In master’s and doctoral clinical and counseling psychology training programs, 40–50% were found to offer formalized training in suicide assessment and management of suicide risk (Kleespies, Penk, & Forsyth, 1993). Suicide-specific training was only included in 2% of accredited professional counseling programs and 6% of accredited marriage and family therapist training programs (Wozny, 2005).
Training also has been identified as limited among social work graduate programs,
averaging 4 hours or fewer specific to suicide education (Ruth et al., 2009). In a study by Feldman and Freedenthal (2006) randomly surveying social workers through the National Association of Social Workers (N = 598), almost all of the social work participants (92.3%) reported working with a suicidal client; however, only 21.1% received any formal suicide-related training in their master’s program. Of the 21.1% of social workers receiving formal training, 46% specified their suicide-devoted training was less than 2 hours.
This pattern continued as additional studies found psychology doctoral interns did not receive adequate training in suicide assessment and/or managing suicide risk in clients. Neither did they receive the necessary levels of clinical supervision in suicide assessment (Mackelprang, Karle, Reihl, & Cash, 2014). In a study of psychology graduate school programs, 76% of the program directors indicated a need for more suicide-specific training and education within their programs but discovered barriers to implement this training (Jahn et al., 2012). The chief barrier reported by the directors was the absence of guidance and curriculum requirements to provide training and, secondly, the inability of colleges to create space in the existing curriculum schedule for added classes (Jahn et al., 2012).
In a survey that included members of the National Association of School Psychologists (N = 162), less than half (40%) of the respondents reported receiving graduate-level training in suicide risk assessment (Debski et al., 2007). Most school psychologists in this study reported feeling at least somewhat prepared to work with suicidal students while doctoral trained practitioners reported feeling well prepared.
School counselors share similar gaps in their preparation to provide suicide intervention and assessment to youth. Research conducted by Wachter (2006) indicated that 30% of school counselors had no suicide prevention training. In a study conducted by Wozny (2005), findings indicated that just 52.3% of the school counselors, averaging 5.6 years of experience, were able to identify critical suicide risk factors. This study exposed competency gaps in suicide assessment, training and intervention consistent with practitioner disciplines that were identified within this study. This is consistent with previous study findings (National Action Alliance for Suicide Prevention, 2014; Schmitz et al., 2012) that identified insufficient training and preparation of practitioners in the assessment and prevention of youth suicide and suicide in general.
Practitioner confidence. Although most practitioners will encounter youth with suicidal thoughts and behaviors, many lack the self-confidence to effectively work with suicidal youth. The lack of confidence appears related to competency levels and limited training (National Action Alliance for Suicide Prevention, 2014; Oordt, Jobes, Fonseca, & Schmidt, 2009).
In contrast, researchers found that as practitioner risk assessment skills increased through suicide-specific training, noticeable increases were measured in practitioner self-confidence (McNiel et al., 2008). Oordt and colleagues (2009) studied mental health practitioner levels of confidence after receiving empirically-based suicide assessment and treatment training. The results indicated that self-reported levels of practitioner confidence increased by 44% and measured a 54% increase specific to self-confidence levels related to the management of suicidal patients. In addition, studies of school counselors identified correlations between self-efficacy, confidence and the ability to improve clinical judgment in providing suicide interventions and assessment (Al-Damarki, 2004).
Adequate training and experience in suicide prevention and assessment has been found to increase practitioner levels of confidence in conducting risk assessments and management planning (Singer & Slovak, 2011). Research suggests that confidence increases the practitioner’s ability to estimate suicide risk level, make effective treatment decisions and base recommendations when conducting a quality assessment. However, when the assessor is not confident, the assessment is more prone to errors or missed information, decreasing the accuracy of their assessment (Douglas & Ogloff, 2003). Paradoxically, overconfidence produces similar results as practitioners lacking confidence. Tetlock (2005) reported that overconfident practitioners are more prone to making errors during a suicide risk assessment unless their clinical judgment is further supported by objective evidence such as using a formal, validated and reliable method of assessment.
Methods Used in Suicide Assessment
There are several categories of suicide assessment instruments developed for youth (Goldston, 2003; National Action Alliance for Suicide Prevention, 2014). These include detection instruments like structured and semi-structured interviews; survey screenings that include self-report inventories and behavior checklists; and risk assessment instruments that include screenings, self-report questionnaires and multi-tier screening assessments.
Across settings including schools, emergency departments, primary care offices and community mental health offices, studies indicate that inconsistent methods are used to assess suicide risk (Horowitz, Ballard, & Paoa, 2009). In most instances, the use of published and validated suicide screening tools are not being properly used as intended or designed, which impacts their reliability and validity (Boudreaux & Horowitz, 2014). This may represent and reflect the practitioner’s limited training, confidence and experience in these areas.
In addition, the documentation of the suicide assessment also can reflect the level of the practitioner’s training and knowledge of suicide assessment. O’Connor and colleagues (2004) noted that practitioner skill deficiencies in youth suicide assessment are likely to appear in clinic notes as a brief statement, “patient currently denies suicidal thoughts,” based on the practitioner’s impressionistic and subjective perception after completing a brief unstructured interview. This is commonly the only form of documentation obtained by the practitioner (O’Connor et al., 2004). Research consistently provides evidence across disciplines that some practitioners are not prepared to make clinical judgments (Debski et al., 2007; Jahn et al., 2012; Mackelprang, et al., 2014; Ruth et al., 2009; Smith et al., 2014). This study offered an opportunity to contribute to the understanding of practitioners’ self-perceived competencies in the assessment of youth suicide while identifying existing gaps in training.
The Current Study
In previous studies, research has focused on confidence and preparedness levels only in specific disciplines related to the identification and assessment of suicidal youth (Al-Damarki, 2004; Debski et al., 2007; Wozny, 2005). This study encompassed a much broader representative sample of practitioner disciplines including psychologists, social workers, school counselors, professional counselors and school psychologists.
The purpose of this study was to determine relationships among practitioners’ self-perceived levels of preparedness, levels of confidence and methods used to perform suicide risk assessments in youth. These efforts were guided by the following research question: What are the relationships among the self-perceived levels of preparedness, levels of confidence, and methods used in the assessment of suicide risk for practitioners whose responsibilities require suicide risk assessment and management? In order to address this, survey questions were designed to obtain participant responses related to skill development, preparation, confidence and methods used in the process of conducting suicide risk assessments.
Method
Procedures and Instrumentation
Since this study sought to collect data using human subjects, the proposal was reviewed and approved by the Wilmington University Human Subjects Review Committee prior to beginning this study. An exploratory descriptive survey design examined practitioner self-perceived levels of preparedness, levels of confidence and methods used to assess suicide risk in youth. Using a quantitative method to guide this study, the researcher attempted to recruit practitioners positioned and responsible for suicide risk assessment. This included working in cooperation with and posting the survey on the Maryland School Psychologists’ Association Web site and the University of Maryland Center for School Mental Health Web site. The survey was forwarded to school districts in Maryland and Virginia and directed to school counselors, school psychologists, and school-based mental health professionals, including social workers and professional counselors. In addition, the survey was forwarded to multiple outpatient mental health clinics in the mid-Atlantic region of the United States. Practitioners were provided with information about the survey, study purposes and ethical standards, and it was noted that participation was voluntary and confidential. Practitioners submitted their responses online, allowing the researcher to evaluate self-reported levels related to suicide assessment. Participants were provided with an access link to anonymously complete the survey using SurveyGizmo. The completed data were then entered into an Excel spreadsheet database.
The Child and Adolescent Suicide Intervention Preparedness Survey was the instrument developed for this study. This researcher received prior approval from the authors of two previously published surveys (Debski, et al., 2007; Stein-Erichsen, 2010) while adding specific queries for the purposes of this study. The survey by Debski and colleagues (2007) included a 42-item questionnaire with vignettes that measured the training, roles and knowledge of school psychologists. These questions targeted participant confidence and perceived levels of preparedness that also were sought in this current study, but from a broader discipline base.
The survey by Stein-Erichsen (2010) included a 55-item measure designed to identify confidence levels of school psychologists providing suicide intervention and prevention within schools. The survey questionnaires designed by Stein-Erichsen (2010) and Debski and colleagues (2007) offered questions adapted for this study specifically focusing on preparedness levels, confidence, roles, methods used to assess suicide levels, and omitted survey questions not relevant to this study. This resulted in a 23-item survey targeting practitioner levels of training, preparedness, confidence and the identification of additional training needs.
Participants
The study had 339 participants representing school counselors (N = 107/32%); social workers (N = 90/27%); school psychologists (N = 37/11%); professional counselors (N = 35/11%); psychologists (N = 5/1%); other (N = 62/18%); and three participants with unknown professional identification.
The final sampling of participants included 43 males, 292 females and four participants with unknown gender identification. Participants averaged in age ranges 22–29 (N = 33/10%), 30–39 (N = 105/31%), 40–49 (N = 94/28%), 50–59 (N = 61/18%) and ages 60 and above (N = 45/13%). The participants responded to the item querying level of education as having a bachelor’s degree (N = 18/6%), doctoral degree (N = 14/4%), master’s degree (N = 275/81%), and other (N = 28/8%) including associate levels of education, as well as four (1%) participants with unknown educational levels.
The participants represented a broad but targeted sampling from a variety of employers, including school settings (N = 166/49%); outpatient mental health settings (N = 108/32%); mental health agencies (N = 31/9%); and other settings (N = 33/10%); as well as one participant with an unknown employment setting. The participants also identified their employment environment as urban (N = 56/60%), rural (N = 174/52%), and suburban (N = 105/31%).
Participants identified the practitioner responsible to assess suicide risk within their work setting having multiple response options (see Table 1). These included a psychiatrist (N = 85/25%), nurse (N = 57/17%), school counselor (N = 179/53%), social worker (N = 168/50%), teacher (N = 7/2%), school psychologist (N = 154/46%), school mental health professional (N = 125/37%), psychologist (N = 64/19%), professional counselor (N = 101/30%), and other (N = 29/9%) including paraprofessionals, while 19 participants (6%) reported they do not complete suicide risk assessments.
Prior exposure with suicidal students/clients. In the survey, 288 (86%) of the participants reported having a student or client referred to them for being potentially suicidal; 45 (14%) did not receive a similar referral; and six participants did not respond. A majority of participants (N = 287/86%) reported having worked with a student or client initially found to be presenting with active suicidal thoughts and 48 (14%) reported not yet having worked with a suicidal student or client.
Analysis
Using descriptive data, participant responses were further examined to determine frequency and percentages of the total responses. In addition, inferential statistics were used to compute possible relationships among variables using SPSS. Data from the primary survey questions provided guidance toward establishing possible relationships between practitioner preparedness, confidence and the methods used in determining suicide risk level.
Results
Self-perceived preparedness in suicide assessment. The majority of the respondents reported some type of exposure or training in suicide intervention and assessment. The participants had an opportunity to select multiple answers: graduate course work (N = 174/52%), attending professional development workshops (N = 233/69%), in-service trainings at work (N = 213/63%), and having not received any training (N = 21/6%). In addition, participants had multiple answer options that represented self-perceived preparedness levels: not feeling at all prepared (N = 15/4%), feeling somewhat prepared (N = 120/36%), feeling well prepared (N = 202/60%), and requesting that someone more prepared meet or assess a suicidal student/client (N = 32/9%).
Self-reported confidence in suicide assessment. The confidence levels reported by the participants reflect professional skill development to conduct suicide risk assessments. The responses included feeling very confident (N = 49/15%), confident (N = 212/63%), and not very confident (N = 63/19%). A similar survey item asked about confidence levels working with a suicidal student or client. The responses included feeling very confident (N = 42/12%), confident (N = 231/69%), and not very confident (N = 63/19%). An additional survey item sought information regarding participant feelings when assessing for suicidal thoughts. Results indicated feeling not prepared (N = 39/12%), anxious (N = 116/34%), calm (N = 145/43%), and confident (N = 185/55%).
Methods Used to Determine Suicide Risk Level During Assessment. Several survey items queried participant levels of training and methods used to assess a suicidal student or client. A survey item asked participants if they had received formal training to conduct suicide risk assessments. The respondents indicated Yes (N = 201/60%) or No (N = 133/40%). In addition, a survey question asked participants if they felt qualified to complete a suicide risk assessment: Yes (N = 241/73%) or No (N = 91/27%). A follow-up survey item asked participants how they determined if the student or client was at imminent risk, high to moderate risk or low risk. The participant responses indicated they would conduct an informal, non-structured interview (N = 213/64%) or use a formal, valid suicide assessment instrument (N = 90/27%); the remaining respondents indicated other (N = 31/9%).
Participants were asked what would limit their ability to provide a suicide intervention. Using a “check all that apply” format, responses included practitioners not receiving formal training to work with suicidal students or clients (N = 55/17%), the role of suicide interventions and response is the job of others (N = 19/6%), not feeling adequately prepared to provide a suicide intervention or assessment (N = 65/20%), workplace policy does not allow formal suicide assessments (N = 12/4%), and feeling prepared (N = 225/68%). The discipline most frequently reported to encounter and assess a youth presenting with suicidal thoughts or behaviors in this study was the school counselor (53%). This supported previous research by Poland (1989) who identified that “the task of suicide assessment was likely to fall on the school counselor” (p. 74).
To determine whether relationships existed among self-perceived levels of preparedness, levels of confidence, and methods used in youth suicide assessment, the researcher completed a chi-square statistical analysis to measure numerical and categorical differences. In order to compare differences among several groups, variables were collapsed to include confident/not confident and prepared/not prepared. The first group compared practitioners’ responses of reporting confident/not confident to prepared/not prepared in the process of providing an informal versus formal suicide risk assessment in youth. The analysis indicated that there were significant differences in preparedness levels according to the method used. Seventy-three percent of those reporting use of formal assessments versus approximately 50% of those using informal assessments indicated confidence in their preparedness abilities (X2 = 12.79; df = 1. Cramer’s V = .206, p = .000). A further analysis indicated there were similar significant differences in practitioner confidence levels conducting informal, non-structured suicide risk assessments and formal assessments (X2 = 23.54, DF = 1. Cramer’s V=.280, p = .000). The results showed that 95.6% of the practitioners using formal suicide risk assessments reported higher levels of confidence versus 70.1% of the practitioners using informal, non-structured suicide risk assessments.
To identify existing gaps, participants were asked to rank by priority the trainings they needed to increase competency levels. The highest priority was (1) to receive a comprehensive training on warning signs, symptoms and suicidal behaviors, and (2) to attend several suicide assessment workshops.
Discussion
The purpose of this study was to determine if relationships existed among practitioners’ self-perceived levels of preparedness, levels of confidence and methods used when assessing for suicide risk in youth. A survey was designed to query participants representing a broad sampling of disciplines related to their perceptions, experience and involvement in youth suicide risk assessment. The results of the survey were analyzed using chi-square to determine if relationships existed among variables, including participant perceptions of feeling prepared and confident, and if this contributed to the methods used to determine suicide risk in youth.
Results of the survey indicated that a majority of the participants (86%) reported having worked with suicidal youth; however, inconsistencies in participant responses emerged related to the constructs of feeling prepared and confident in the assessment of suicide. The results suggested preparedness and training in suicide assessment is linked to practitioner confidence levels when assessing for suicide risk among youth. This finding is supported by earlier research by Oordt and colleagues (2009), who reported that practitioner confidence in suicide assessment is primarily related to competency and training levels. The interrelationship between preparedness and confidence is often reflected in the practitioner’s ability to accurately estimate risk level. This may potentially increase the likelihood of omitting critical information, which may affect the estimate of suicide risk (Douglas & Ogloff, 2003; Singer & Slovak, 2011). The results represent an important finding and highlight existing gaps in practitioner preparation. These gaps may reflect a struggle for most university and college graduate school degree programs to offer a more diversified curriculum (Allen, Burt, Bryan, Carter, Orsi, & Durkan, 2002) that includes courses specific to identifying, intervening in and assessing for suicide risk in youth (Schmitz et al., 2012).
The inconsistencies in participant responses related to feeling prepared and confident became apparent when participants rated themselves in working with a suicidal youth. Although over half of the respondents reported feeling well prepared and qualified in their ability, a much smaller percentage reported feeling confident in themselves (12%) and their skill preparation (15%) to assess for suicide. This finding may reflect a self-evaluation dilemma in wanting to self-report feeling prepared to work with a suicidal youth, but in actuality not feeling prepared or confident to provide a suicide intervention or complete an assessment.
As this study broadened its review of practitioner responses related to preparedness and confidence, findings indicated additional inconsistencies in participant responses related to self-reported feelings of preparedness and confidence when conducting a suicide intervention or suicide assessment. Despite predominantly higher levels of reported confidence, skill development and preparedness to determine if a student or client was at imminent risk, high to moderate risk, or low risk, few participants (27%/N = 90) reported using a formal suicide assessment instrument. Most respondents (64%/N = 213) reported basing their clinical judgment solely on using an informal, non-structured interview. Although practitioners reported feeling prepared and having a sense of confidence assessing for suicide risk, basing clinical judgment on this method alone raises concerns. O’Connor and colleagues (2004) described that practitioner skill deficiencies in suicide assessment are commonly reflected in clinic notes such as “patient currently denies suicidal thoughts,” based on the practitioner’s impressionistic and subjective perceptions. Consistent with identifying training deficiencies in preparation, 52% (N = 174) of the participants reported receiving limited suicide intervention or assessment training in graduate coursework.
The participants in this study who reported using a formal suicide assessment, however, indicated feeling better prepared to conduct a suicide assessment versus practitioners using an informal, non-structured interview. In addition, practitioners using a formal assessment also had greater confidence levels versus practitioners using an informal, non-structured interview. When participants were asked to rank their own levels of needed training to provide a more thorough suicide intervention, participants identified skill deficiencies and training gaps in identifying warning signs and behaviors and assessing for suicide using a suicide risk assessment. These deficiencies pose great concern and competency challenges for practitioners charged with assessing for suicide risk. The combination of skill attributes, guided interview and diagnostic assessment synthesizes the information and allows practitioners to determine risk level and base clinical judgment on a variety of sources (Rudd, 2006; Sullivan & Bongar, 2009). The skill deficiencies reflected across all disciplines represented significant training gaps. This study suggests the need for increased commitment by colleges and universities to prepare future practitioners to more effectively address the growing national youth suicide crisis.
Implications
Despite suicide being identified as a national public health priority, no significant reduction in suicide has been recorded in the past 50 years (Kung et al., 2008; National Action Alliance for Suicide Prevention, 2014). “With the majority of youth suicide deaths being preventable,” (O’Connor, Platt, & Gordon, 2011, p. 581), continued and more urgent calls for increasing practitioner preparedness, confidence and competency skills continue to be neglected.
Each of the disciplines represented in this study is faced with the challenge to address and estimate suicide risk. This study highlighted the critical role of school counselors as being identified by participants (53%) to be the most likely practitioner to respond and provide a suicide assessment. Representing a variety of disciplines and settings, participant responses suggest training deficiencies in the levels of preparedness, confidence and exposure to formal assessment measures. Previous research has made strong recommendations to increase the provisions and training in suicide assessment. Despite heeding previous calls and recommendations to prepare practitioners, more attention is needed to address previous and current identified training deficiencies among practitioners.
Transitioning research into practice includes revisiting several identified recommendations by Schmitz et al. (2012). This includes providing consistent core standards and competencies across disciplines by educational accrediting institutions. This may call for increased suicide-specific educational and training requirements beyond the baccalaureate degree level and include dissecting vignettes, role-playing, exposing practitioners to several suicide assessment instruments and interpreting the results (Fenwick, Vassilas, Carter, & Haque, 2004). This would include increased emphasis on recognizing the signs and symptoms of depression, suicidal thoughts and behaviors and increasing an understanding of potential next steps once a suicide risk level has been determined. In addition, to sustain these skills, state licensing boards can require continuing education specific to suicide identification, assessment and management. Rudd and colleagues (2008) placed emphasis on practitioners receiving increased suicide assessment strategies through supervision. The prevailing need practitioners identified as a chief priority in this study was to become more familiar with the warning signs, symptoms and behaviors associated with suicide and suicide assessment. The findings included within this study offer future research opportunities to monitor suicide training, preparation and continuing educational requirements of colleges, universities and licensing boards that govern and are responsible for the production of competent practitioners.
Although attention has focused on practitioner training deficits in the identification and assessment of youth suicide, future studies also are warranted in the measurement and impact of existing suicide prevention training programs that may provide opportunities for practitioners to increase skill sets in these areas. Another area meriting future study might include a national sampling of school counselor preparation in the identification, assessment and exposure to assessment tools. In this study, school counselors were identified to be the most likely practitioner called upon to provide an initial suicide intervention or assessment given their access to a large number of youth. This serves as a valuable finding, highlighting the call for increased and expanded counselor education, training and preparation in suicide risk identification and assessment in graduate school.
Limitations
Providing a suicide intervention or assessment involves many complex issues, and addressing the many variables paralleling these efforts could not be entirely assessed in this study. This study was intended to explore current levels of practitioner preparedness, confidence and the methods used to assess youth suicide. There are some notable limitations regarding the current study; therefore, caution is warranted regarding the generalizability of the findings.
Although the Internet provided a greater opportunity for the researcher to create survey access to targeted participants and disciplines, this method did not provide a sample size completion rate. In addition, previous Internet survey research (W. Schmidt, 1997) reported that participants have access to multiple submissions, although ethical practice instructions and consent to complete this survey was provided. In order to access participants from multiple disciplines, the survey used in this study was available online as a self-report method of completion. In this process, self-report instruments, including surveys, inherently contain participant response bias. This may be reflected in responding to questions in a socially desirable or expected manner (Heppner, Wampold, & Kivlighan 2007). In addition, online surveys can be submitted containing omitted and blank responses (Sue & Ritter, 2012).
As previously noted, The Child and Adolescent Suicide Intervention Preparedness Survey used in this study was adapted from two previous research surveys (Debski et al., 2007; Stein-Erichsen, 2010). In this study design, survey questions were created and adapted to measure participant constructs in the assessment of youth suicide. The use of a psychometrically sound survey instrument would be an ideal application to implement and duplicate for future research.
Conclusion
The findings from this study identify significant interrelationships between the practitioner’s self-perceived feelings of preparedness, confidence levels and methods used to assess for suicide risk among youth. The self-reported feelings of being prepared and confident seem to contradict the method used to obtain a suicide risk level. This finding suggests many practitioners are well intended, but lack the necessary skills to conduct a thorough suicide risk assessment. The majority of practitioners participating in this study reported conducting a suicide risk intervention using an informal, non-structured interview to formulate a suicide risk level versus using a formalized suicide risk assessment instrument. Prior experience and exposure to suicide risk assessment instruments and increased emphasis in suicide-specific training curriculum in graduate school can offer the opportunity for a practitioner to feel better prepared, feel more confident and utilize a more effective method to determine a youth’s suicide risk level. Practitioner gaps in training are typically augmented by the practitioner seeking personal training and workshops to fill these gaps. Efforts must be made by colleges and universities to increase the competency skills in this area if we are to ever reduce the growing number of youth suicides. The findings from this study supported limited previous research sounding urgent calls to better prepare practitioners, especially school counselors, in the identification of youth presenting with suicidal thoughts or behaviors.
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.
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Mar 23, 2016 | Article, Volume 6 - Issue 1
Jeffrey M. Warren, Robyn W. Hale
Non-cognitive factors (NCFs) include strategies, skills, attitudes and behaviors upon which individual success is often dependent (Farrington et al., 2012). While knowledge and ability are important, NCFs are mediating factors that can either assist or hinder individual achievement in educational and career settings. These factors often determine college and career readiness as well as lifelong success. For example, positive self-concept (Brown & Marenco, 1980), grit (Duckworth, Peterson, Matthews, & Kelly, 2007), growth mindset (Dweck, 2006) and social belonging (Walton & Cohen, 2011) are linked to positive outcomes for students and employees and typically lead to a better quality of life.
Sedlacek (2004) noted that NCFs are predictive of the success of students with non-traditional experiences. These students generally include students of historically underrepresented populations such as African Americans, American Indians, and Hispanic and Latino Americans. Students from these groups face higher rates of suspension (Losen, Hodson, Keith, Morrison, & Belway, 2015) and are more likely to have lower GPAs and poorer attendance (Burke, 2015) as compared to their Caucasian counterparts. In the United States, 7% of African American students and 12% of Hispanic students fail to complete high school (Kena et al., 2015). American Indian students are three times more likely to drop out of school than Caucasian students (Burke, 2015). These disparities widen the achievement gap and serve as barriers to postsecondary credentials for students from these groups.
In an effort to close the achievement gap, increase college and career readiness, and promote postsecondary success, many educational organizations and institutions have invested in initiatives that promote NCFs. The American School Counselor Association (ASCA; 2014) endorsed the value of non-cognitive development in a set of standards titled “Mindsets and Behaviors for Student Success.” Professional school counselors use these standards as guides to develop competencies that promote NCFs among students across academic, career and social-emotional domains. Squier, Nailor, and Carey (2015) recently developed a construct-based approach to developing, implementing and assessing school counseling programs based on several NCFs. Initiatives to develop non-cognitive skills continue to emerge in higher education as well (Sedlacek & Sheu, 2013). Through a series of conference calls, the College Access Affinity Group organized by the United States Department of Education (2015) also acknowledged the impact of NCFs on career and college readiness.
An assortment of interventions demonstrates the potential impact of NCFs on academic and career outcomes. Mentoring programs, service learning and social-emotional learning programs show positive effects, although the magnitude of these effects is relatively small (Gutman & Schoon, 2013). Gaps exist in the research when considering long-term outcomes and the transferability of NCFs across contexts (Farrington et al., 2012). Additionally, researchers often identify, describe and measure NCFs in different ways (Duckworth & Quinn, 2009; Dweck, 2006; Farrington et al., 2012; Goldberg, 2001; Tracey & Sedlacek, 1984; Walton & Cohen, 2011). Many of these factors are interrelated; some appear fixed, yet others are malleable (Gutman & Schoon, 2013). Concepts and terms that describe NCFs continue to emerge; however, those identified by Brown and Marenco (1980) and promoted by Sedlacek (2004) are of the most widely researched and linked to college and career success.
Ellis and Bernard (1986) outlined several core values of rational emotive behavior therapy (REBT), a cognitive behavioral framework developed by Ellis (1962). When practicing the principles of REBT, individuals subscribe to a philosophy of life and an accompanying set of sub-goals. This set of sub-goals, based on a philosophy of life rooted in responsible hedonism and preferential, logical thinking, serves as a guide for individuals striving to maintain happiness and life success (Ellis, 1962). These sub-goals parallel the NCFs endorsed by Brown and Marenco (1980), Sedlacek (2004), Duckworth and Quinn (2009), and Dweck (2006). Dryden (2011) described how the REBT philosophy is broadly applied to increase motivation, tolerance and self-control, as well as other NCFs.
This paper highlights the core values of REBT and explains how they align with the NCFs endorsed by Sedlacek (2004). An overview of the philosophical tenets and the theory of REBT is provided. Theoretical and empirical evidence is explored which suggests that REBT can directly and indirectly promote non-cognitive development. Recommendations for school counselors supporting underrepresented students are presented and directions for future research are discussed.
Rational Emotive Behavior Therapy
Developed by Albert Ellis in the mid-1950s, REBT encourages self-actualization and seeks to minimize distress, lengthen life and maximize happiness during all aspects of human development (Ellis, 1962). These core values are woven throughout the philosophical tenets of REBT and serve as guides for rational thought, healthy emotions and functional behavioral outcomes. Several sub-goals, as described by Ellis and Bernard (1986), help facilitate these values: (a) self-interest, (b) social interest, (c) self-direction, (d) tolerance, (e) flexibility, (f) acceptance of uncertainty, (g) commitment, (h) self-acceptance, (i) risk-taking, (j) realistic expectations, (k) high frustration tolerance, and (l) self-responsibility.
Ellis (1962) proposed that humans are genetically predisposed to think in a rigid, irrational manner. Irrational beliefs (IBs) are the root of emotional disturbances according to REBT. While demanding is the core or primary IB, three secondary IBs exist: awfulizing, low frustration tolerance (LFT), and global evaluation (David, 2014; David, Lynn, & Ellis, 2010; Dryden, 2011).
REBT hypothesizes that extreme emotions such as anxiety, anger and depression stem from primary and secondary IBs. These unhealthy negative emotions (UNEs) lead to dysfunctional behaviors (Dryden, 2014). In turn, individuals often behave in ways that prohibit the achievement of desired goals and success.
In accordance with its values and goals, REBT promotes rational beliefs (RBs), or preferential thoughts, which are logical and realistic in nature (David, 2014). RBs are non-awfulizing, demonstrate a tolerance for frustration, and do not indicate global evaluations of self, others or life. Healthy negative emotions such as bother, concern or annoyance stem from these RBs. These emotions lead to functional behaviors and outcomes related to success.
The philosophy and values of REBT encourage lifelong happiness and responsible hedonism. It is at this place where the sub-goals of REBT and the NCFs promoted by Sedlacek (2004) appear to converge. Table 1 provides an overview of the conceptual relationships between these NCFs, the sub-goals of REBT and the IBs (evaluative schema) that impede success. Below, theoretical nuances and empirical evidence supporting the utility of REBT in promoting non-cognitive development are presented. It is important that school counselors are aware of the impact of REBT on NCFs as they strive to ensure that all students, especially those from underrepresented groups, are college and career ready.
REBT and Non-Cognitive Factors
Many factors are critical to K–12 student achievement and postsecondary success. This section presents the NCFs Sedlacek (2004) identified as most valuable in predicting educational outcomes, especially for underrepresented students. These factors include: (a) positive self-concept, (b) realistic self-appraisal, (c) leadership experience, (d) preference for long-term goals, (e) successfully handling the system, (f) availability of strong support person, (g) community involvement, and (h) knowledge in an acquired field. Theoretical and empirical evidence demonstrates how REBT directly and indirectly promotes these factors (see Table 2). Given the role school counselors play in fostering college and career readiness for all students, this evidence may serve as a catalyst for delivering services rooted in REBT.
Positive Self-Concept
Self-concept includes self-confidence and self-esteem (Sedlacek, 2004). Independence and determination also are aspects of self-concept. Positive self-concept is a determinant of success, especially among students with non-traditional experiences (Sedlacek & Sheu, 2013).
REBT promotes positive self-concept through unconditional self-acceptance (USA). Ellis (1962) emphasized self-worth and the importance of accepting the self regardless of faults or flaws. Self-worth is not contingent upon success or failure, as is often the case with self-esteem. London (1997) suggested self-esteem is problematic since the self is conditionally defined by attributes or behaviors. Attempting to constantly hold one’s self in high esteem leads to perpetual damnation and anxiety. However, Kim and Sedlacek (1996) asserted that a relationship exists between the self-concept of students of color and their level of adjustment. This presents a conundrum for students experiencing difficulty adjusting. By practicing USA, students can develop an understanding that they have worth independent of external stimuli or variables. This shift in personal philosophy leads to a stable self-concept and likelihood for greater success (Dryden, 2014).
Studies exploring the direct impact of REBT are vast and stretch over the life span. For example, Donegan and Rust (1998) noted that self-concept among second graders improved as a result of an intervention based on REBT. Additionally, Sapp (1996) and Sapp, Farrell, and Durhand (1995) found that self-concept was a mediating factor between REBT and the success of African American students. Findings from other studies also have suggested that self-concept and self-esteem are associated with IBs (Burnett, 1994; Heppner, Reeder, & Larson, 1983). Sava, Maricutoiu, Rusu, Macsinga, and Virga (2011) described a negative relationship between explicit self-esteem and self-downing IBs of undergraduate students. REBT promotes self-worth and thwarts IBs associated with low self-esteem.
Sedlacek (2004) suggested a strong sense of self is a prerequisite for student success. REBT emphasizes a healthy sense of self by disputing self-downing IBs and promoting preferential, rational thinking. By addressing IBs that impact self-concept, REBT can promote student success.
Realistic Self-Appraisal
Students who accurately evaluate personal weaknesses and strengths demonstrate realistic self-appraisal (Sedlacek, 2004). Self-appraisal is often based on one’s perceived ability to complete tasks, also known as self-efficacy beliefs (Bandura, 1986). Sedlacek and Sheu (2008) suggested that accurate assessment of strengths lead students, especially those from underrepresented groups, toward academic success.
REBT endorses the appraisal of strengths and weaknesses, but it discourages evaluating the self as a whole based on these attributes. As such, realistic expectations serve to ground individuals and promote happiness and success. When realistic expectations are maintained, IBs about the self are minimized.
Warren and Dowden (2012) explored the relationships between IBs, efficacy beliefs and UNEs. IBs were negatively related to efficacy beliefs as well as depression, stress and anxiety (Warren, 2010; Warren & Dowden, 2012). More recently, Warren and Hale (in press) elaborated on the implications that efficacy beliefs and the sources from which they are conceived (e.g., past performance, verbal encouragement) have on performance. Efficacy beliefs, whether accurate or not, can lead to IBs when expected outcomes fail to materialize (Warren & Hale, in press). These cognitive processes produce a host of emotional and behavioral consequences.
Several studies demonstrated how REBT directly promoted a realistic, functional philosophy of self and life. For example, Chamberlain and Haaga (2001) found that non-clinical university students who scored high on a measure of USA could more objectively evaluate their performance on tasks. Alternatively, McCown, Blake, & Keiser (2012) indicated that college students who procrastinated engaged more readily in global evaluations of self, others and life. Negative mood, stemming from irrational thought processes, was associated with procrastination. Similarly, a study conducted by Davies (2006) of a non-clinical sample of adults yielded findings that suggested IBs and USA are negatively related. Davies (2008) later found a causal link between these concepts. Participants exposed to IBs scored lower on a measure of USA, yet scored higher when exposed to RBs. These studies support the premise that promoting a preferential philosophy of life can enhance realistic self-appraisal. Through realistic self-appraisal, students are positioned for success and equipped to respond effectively to adversity and failure.
Leadership Experience
Students can develop abilities to lead through traditional and non-traditional experiences (Sedlacek, 2004). These experiences are often directly related to cultural and community affiliation.
A degree of assertiveness is required to accept leadership roles and achieve related tasks. Assertiveness is a predictor of success (Sedlacek, 2003), while passivity and aggressiveness often hinder success.
REBT encourages self-direction by promoting rational thoughts and minimizing the need for support or approval from others. As such, the importance of assertiveness in leadership endeavors is emphasized in REBT. Rational thoughts lead to assertiveness; IBs tend to result in either passivity or aggression. When assertive, individuals are poised to promote self-interests and social interests in a functional and effective manner. Additionally, individuals often are happier when committed to a cause or invested in a social interest. By responding to challenges or adversity in rational ways, individuals will position themselves as leaders while developing cumulative skill sets adaptable to a variety of settings.
REBT is employed in a variety of settings to directly and indirectly promote leadership skills including assertiveness. In a model of leadership presented by Grieger and Fralick (2007), REBT principles were embedded to enhance training procedures. Murthy (2014) and Nottingham (2013) also described how REBT is used to develop effective leadership practices. Coaches and consultants frequently employ concepts rooted in REBT to establish effective leadership attributes among clients. For example, Woods (1987) found that basic REBT strategies and techniques taught during a series of workshops led to reductions in discomfort and increased assertiveness among participants. REBT also can address perfectionist tendencies, which are often seen as barriers to effective leadership (Ellam-Dyson & Palmer, 2010).
When effective leaders are emotional, they often garner the support of others through the development of interpersonal relationships (George, 2000). However, Filippello, Harrington, Buzzai, Sorrenti, and Costa (2014) found that emotionally intolerant individuals often become distressed when practicing assertiveness. When the principles of REBT are practiced, leaders are viewed as flexible, realistic and authentic in their aim and scope (Fusco, Palmer, & O’Riordan, 2011). Students, especially those from underrepresented groups, can benefit from learning strategies that enhance their ability to serve effectively in leadership roles.
Preference for Long-Term Goals
The establishment of long-range goals often precedes achievement and attainment of those goals. A preference for long-term goals requires that students have the ability to plan and delay gratification. Sedlacek (2003) and Duckworth et al. (2007) suggested that perseverance and determination when striving toward long-range goals are prerequisites of academic achievement.
REBT encourages responsible hedonism, or enjoyment of life. This concept implies a delay of gratification while individuals behave in ways that lead to the attainment of goals. Self-responsibility and high frustration tolerance (HFT) are required to overcome obstacles that impede progress toward goals. Rather than giving up or blaming the self, others or life for these challenges, REBT recommends individuals take responsibility for their thoughts, feelings and behaviors (Dryden, 2014). HFT is promoted by REBT and lies in opposition to LFT, or the inability to persevere during difficult or challenging situations. Preferential thoughts related to challenges or discomforts are realistic and lead toward healthy emotions and functional behaviors. When ownership of thoughts and feelings are accepted and frustrations are tolerated, individuals are better positioned to work toward distal goals that lead to success.
Rodman, Daughters, and Lejuez (2009) described the positive relationships between HFT and distress tolerance (i.e., persistence) and the pursuit of goals despite potential discomfort. HFT is associated with optimism, preferences, non-awfulizing and acceptance—factors that support goal attainment and enhance the quality of life (Morley, 2014). Alternatively, Harrington (2005a, 2005b) found that frustration intolerance was a predictor of procrastination behaviors, including issues of self-control, among students. When working toward goals, especially ones that create discomfort, self-responsibility and HFT help move individuals forward and toward success. Responsible hedonism, a core value of REBT, appears to directly promote a preference for long-term goals rather than simple, rudimentary accomplishments. School counselors can assist students in developing and working toward distal goals such as completion of postsecondary credentials.
Successfully Handling the System
Students from underrepresented groups are not afforded the same benefits as those from privileged backgrounds. The educational system maintains barriers (e.g., racism) that impede the efforts of students from underrepresented groups. The manner in which individuals handle challenging circumstances within the system offers insight into their ability and potential for success (Sedlacek, 2004). Persistence and perseverance are crucial qualities for students who attempt to navigate or handle the system.
REBT can provide direct support to students navigating the educational system. Rather than placing demands on the system, which can lead to UNEs and unproductive responses, REBT encourages acceptance of system inequities through ULA. Additionally, HFT is fundamental to ULA when attempting to navigate the system. REBT promotes tolerance and an understanding that individuals experience difficult situations as a function of life. Tolerance is a key to self-advocacy efforts and helps students move forward productively without condemning others or life.
Responding to or interacting with the system can leave students, especially those from underrepresented groups, emotionally charged or drained and prone to respond in irrational ways. Harrington (2013) described how IBs play a central role for individuals who believe in a just or utopian world. When beliefs are rigid, individuals have difficulty adapting to adverse situations and may retaliate, thus prohibiting success (Veale, 2002). Dryden and Hurton (2013), however, acknowledged that individuals may not always act on their beliefs. When navigating the system, individuals who maintain rigid beliefs tend to be aware of their action tendencies yet refrain from responding in detrimental ways.
The tenets and practices of REBT provide a platform for restructuring students’ cognitions related to systemic prejudice, racism and stereotyping. Gregas (2006) suggested that REBT-based skills are useful for students who face discrimination. Earlier, Sapp (1996) found that African American males who learned the principles of REBT were more successful in school. REBT guided students from beliefs associated with chance or luck (i.e., external locus of control; Rotter, 1966) toward beliefs of personal control over outcomes, which promotes empowerment (i.e., internal locus of control). Regardless of where an individual places responsibility (i.e., locus of responsibility; Jones, 1997), USA, UOA and ULA offer guidance when attempting to hold the self, others, or society accountable. REBT provides psychological resources for handling the system and demonstrating personal influence over outcomes. Students from underrepresented groups who acquire these tools and strategies will respond more effectively when faced with systemic barriers. Evidence also suggested that REBT can propel individuals to reap the benefits of other NCFs such as the availability of a strong support person.
Availability of Strong Support Person
Success is often contingent upon a support network and the use of personal resources. Underrepresented students with a history of supportive relationships perform better in college (Sedlacek, 2004). Individuals should engage with support persons in emotionally healthy ways and ensure that the relationship is mutually understood.
USA and UOA are critical for students seeking support or mentorship in achieving their goals. USA allows individuals to confidently seek support without feeling worthless. With UOA, individuals are accepting of others regardless of faults or failings. Acceptance of uncertainty propels students to take the necessary steps to reach out to others and attempt to form support networks.
Individuals who are self-directed readily seek healthy relationships and support networks. They engage in these relationships to complement their efforts rather than developing a dependency for the support. Reducing anxiety and achieving goals through the incorporation of REBT can lead individuals toward independence rather than maintaining unhealthy, dependent relationships (Wood, 2004). Chamberlain and Haaga (2001) found that USA is negatively related to anxiety, which can stifle autonomy and the confidence to reach out to others for support. Similarly, a study conducted by Davies (2006) revealed that IBs were negatively related to openness, a Big 5 personality dimension promoted by McCrae and Costa (1987). Students considered to possess openness typically have a wide range of interests, creativity and insight, which have implications for establishing a diverse system of support. As such, their relationships are likely to extend well beyond and across cultural boundaries and communities.
Maintaining a strong support system can benefit students navigating difficult tasks or tackling daily life obligations. REBT appears to directly provide the tools and resources necessary for establishing, maintaining and appropriately utilizing support persons. By fostering self-direction and unconditional acceptance, REBT promotes the development of strong systems of support as described by Sedlacek (2004). The availability of a strong support person is critical for students from underrepresented groups; community involvement also plays a key role in the educational success of these students.
Community Involvement
Community involvement encompasses a student’s level of activity or interaction in groups within the larger society (Sedlacek, 2004). Students engaged in their community, or a subset of their community, are more successful than those who are disconnected or isolated. Through involvement in the community, students from underrepresented groups can hone their self-concept, leadership skills and ability to navigate the system.
Ellis and Bernard (1986) suggested that individuals who are actively engaged in something other than themselves are happier. REBT directly promotes community involvement through UOA and ULA. When students are accepting of others and life and remain assertive, they become self-directed and often take interests in the welfare of others and their community. As noted by Sedlacek (2004), a commitment to community initiatives invokes the development and attainment of other goals and skills, which all foster happiness and success.
Warren and Dowden (2012) noted the negative relationships between IBs and depression, anxiety and stress. These psychological disturbances can often impede or debilitate individuals and prevent meaningful interactions within the community. For example, university students were found to moderate their anxiety levels by removing themselves from an activity common in communities of learning (Nicastro, Luskin, Raps, & Benisovich, 1999). Imperative or irrational thinking was related to the speed of the departure, thus demonstrating the influence of thought processes on community engagement.
REBT is effective in promoting social skills, which leads students to engage with society and build a sense of community. For example, Safdari and Hadadi (2013) utilized REBT-based group counseling to reduce symptoms among individuals with mild to moderate depression. The group experience led to a reduction in ruminations about consequences, which often paralyze and prevent a satisfying life. In a study of students enrolled in secondary schools in Nigeria, Ayodele (2011) found that two interventions based on REBT were effective in promoting interpersonal behavior. Students can develop social-emotional competence, a commitment to the community, and other interpersonal skills as a result of participating in REBT interventions. REBT also can position students to more readily acquire knowledge in a field.
Knowledge Acquired in a Field
Knowledge obtained from traditional and non-traditional experiences affords students the opportunity to gain valuable insights into their “place” or “degree of fit” within a particular industry or field (Sedlacek, 2004). While operating in a field, individuals should take full advantage of the opportunities to absorb knowledge and obtain as many skills as possible. These experiences are invaluable for underrepresented students attempting to navigate their chosen field of study or work.
REBT indirectly supports the acquisition of knowledge in a field or career path. For example, individuals must maintain self-direction in order to have varied experiences in a desired field. Drive and determination are required as well as self-interest. REBT suggests that happiness stems from one’s willingness to place personal interests before others (Ellis & Bernard, 1986). Although any experience may lead to benefits, knowledge obtained from a field of interest is gratifying and rewarding. Individuals also must take risks when seeking knowledge. Students who maintain positive emotional health will take appropriate risks when attempting to acquire field experience.
Using the REBT framework, Dryden (2000) described the manner in which procrastination related to work experience, interests, opportunities and advancement hinders self-development and knowledge acquired in a field. Procrastination is related to factors that impact the acquisition of knowledge, such as motivation (Klassen & Kuzucu, 2009) and stress (Stead, Shanahan, & Neufeld, 2010). Harrington (2005b) found that discomfort intolerance, a variation of LFT, was a predictor of procrastination. Students who experience discomfort intolerance will delay experiences that would otherwise lead to knowledge acquisition.
Researchers have established that REBT can help individuals overcome barriers to taking risks and obtaining knowledge in a field. For example, during a demonstration session, Dryden (2012) explained how REBT can assist individuals in overcoming procrastination. More recently, Balkis (2013) found that RBs about studying were a mediating factor in the degree of academic procrastination and level of achievement among college students. It is important that school counselors consider the vast ways in which REBT promotes NCFs and prepares students for college and the world of work.
Recommendations for Developing NCFs Through School Counseling
The values of REBT align with many NCFs, including those endorsed by Sedlacek (2004). A variety of research studies demonstrate the impact REBT can have on NCFs. Through cognitive, emotional and behavioral support, REBT promotes NCFs in direct and indirect ways. When these factors or skills are developed and strengthened, students in elementary, secondary and postsecondary settings are more likely to experience positive educational outcomes.
Students from underrepresented groups are especially susceptible to barriers that impede their educational efforts and goal attainment. As such, disparities in graduation rates, disciplinary referrals and teacher expectations remain prevalent (Holcomb-McCoy, 2007). In order to close the achievement gap, it is imperative for school leaders, specifically school counselors, to establish evidence-based strategies that support non-cognitive development and college and career readiness.
Through comprehensive programs, school counselors can deliver a variety of direct and indirect student services that enhance educational experiences and prepare students for postsecondary success. School counselors can use REBT-based student support services to help students, parents and teachers develop strategies that foster NCFs and lead to college and career readiness. It is important that these services are innovative, extend beyond modifications to the classroom and school environments, and offer all students, especially those from underrepresented groups, skills for lifelong empowerment.
Direct Student Services
School counselors deliver direct student services through the core curriculum, student planning and responsive services (ASCA, 2012). Direct interactions that target academic achievement, personal/social growth and career development occur between school counselors and students during the delivery of these services. Professional school counselors can promote non-cognitive development by incorporating the tenets of REBT into many aspects of direct student services.
Core curriculum. The core curriculum is delivered through instruction and group activities that advance the mission and goals of the school counseling program. School counselors advance knowledge, attitudes and skills that align with standards and competencies based on Mindsets and Behaviors for Student Success (ASCA, 2014). Because these standards are based on non-cognitive research (Farrington et al., 2012), REBT appears to be a viable framework for delivering the core curriculum.
Rational Emotive Education (REE; Knaus, 1974) can promote NCFs while serving as a central component of the school counseling core curriculum. This social-emotional curriculum is based on the philosophy of REBT and aims to foster rational thought, emotional awareness and functional behaviors among children and adolescents. REE lessons can empower students from underrepresented groups who are often subjected to beliefs and emotions related to their perceived inability to succeed (Holcomb-McCoy, 2007).
More recently, Vernon (2006a, 2006b) developed an REBT-based curriculum geared to promote emotional education across K–12 settings. This curriculum fosters non-cognitive development by helping students establish a positive self-concept, engage in realistic self-evaluation, and navigate difficult and challenging situations. REBT has failed to take root in educational settings and is often overlooked when considering evidence-based social-emotional curriculums. However, schools in Australia are beginning to demonstrate the effects of rational emotive behavior education (REBE) on the social-emotional development of children and adolescents (personal communication, G. Bortolozzo, April 15, 2015).
School counselors who utilize these or similar REBT-based curriculums have the opportunity to foster the non-cognitive development of all students. Opportunities for students to apply, practice and test the strategies they learn must accompany these curriculums. For example, school counselors can coordinate and encourage experiences that allow students to become involved in the community (e.g., food drive), acquire knowledge in a field (e.g., job shadowing), and gain leadership experience (e.g., class representative). These experiences, coupled with REBT-based instruction, are especially beneficial for students from underrepresented groups. Students in K–12 settings who develop knowledge, attitudes and skills based on the REBT framework and have guided opportunities for practice will position themselves for postsecondary success.
Individual student planning and advisement. This direct service affords school counselors the opportunity to help students develop, monitor and manage long-range goals and plans (ASCA, 2012). Student advisement is especially important for students from underrepresented groups who may require additional guidance and support (Holcomb-McCoy, 2007). Through planning and advising, school counselors assess and evaluate students’ attitudes, knowledge and skills related to academic, personal and social, and career development.
Using an REBT framework, school counselors can assist students in uncovering IBs that may impede their goals of attaining a postsecondary credential (e.g., certification, degree). In some cases, students may not aspire to pursue postsecondary education due to IBs associated with unrealistic self-appraisal. School counselors can teach students REBT-based strategies that help establish healthy beliefs and emotions related to academic, personal and career planning. In turn, students are more likely to seek and acquire knowledge in a field or strengthen their support network, both keys to postsecondary success. By realizing the influence of thought, students from underrepresented groups become empowered as active participants of their educational pursuits and are positioned to “reach higher.”
Responsive services. School counselors can promote non-cognitive development through counseling and crisis response. Individual and small group counseling are often short-term and designed to address concerns that impact student success (ASCA, 2012). School counselors also assist students in overcoming crisis situations. It is important that interventions utilized during responsive services are evidence-based and promote academic achievement, personal and social growth, and career development.
REBT offers school counselors a framework for providing responsive services that are evidence-based, targeted, brief and solution-focused. School counselors can utilize cognitive, emotional and behavioral strategies to help students overcome irrational thoughts and extreme emotions that are often detrimental to student success. Non-cognitive development is promoted as students learn strategies to effectively navigate classroom, school and community experiences.
Most school counselors lack training in REBT and therefore do not fully understand its theoretical principles. However, resources are available that school counselors can use to promote the principles and philosophy of REBT during the delivery of responsive services. For example, Vernon (2002) developed a resource that offers a variety of individual activities based on the principles of REBT. This set of activities includes strategies and techniques that address issues related to self-acceptance, problem-solving, underachievement, relationships and transitions. More recently, Warren (2011) provided a variety of rational rhymes school counselors can use to promote the tenets of REBT. School counselors can help students memorize and rehearse these short songs in an effort to develop more preferential philosophies of life. These resources help school counselors equip students with tools and strategies that promote rational thought, foster NCFs and lead to empowerment. In addition to direct student services, school counselors also can provide a variety of REBT-based indirect student services. These services are complementary and aim to support non-cognitive growth in all aspects of student life.
Indirect Student Services
Indirect student services include referrals, consultation and collaboration. While often viewed as ancillary in nature, these services are an integral component of school counseling programs. School counselors should consider integrating the philosophy and principles of REBT throughout the delivery of these services. For systemic change to occur, school counselors must remain vigilant and not waiver in their efforts to close the achievement gap and promote student success. Indirect student services can advance this mission by promoting the development of NCFs.
Referrals. School counselors refer students and families to a variety of community based services. Prior to making a referral, it is important that school counselors have a clear understanding of the concerns and presenting issues. As such, school counselors who operate from an REBT perspective assess students for non-cognitive strengths and deficiencies that impact academic, personal and social, and career development. Using this framework, school counselors can more readily identify the root or underlying issues of concern and make appropriate referrals.
School counselors should consider making referrals to community agencies and organizations that understand the framework and philosophical principles used to determine the need for referral. For example, school counselors can refer students and families to mental health agencies that specialize in cognitive behavioral therapies since these frameworks promote NCFs. Local organizations that foster community involvement and establish supportive relationships with their clients also can serve as referral options. Community agencies and organizations that understand the mission of the school counseling program and the benefits of non-cognitive development are key partners in promoting the success of students from underrepresented groups.
Consultation. Consultation is a triadic interaction in which school counselors support teachers’ efforts to promote student success (Warren & Baker, 2013). School counselors also provide consultation to parents, administrators and other educational stakeholders. Consultation is a highly effective means of evoking systemic change and positively impacting the educational experiences of students. Rather than relying on eclectic approaches, school counselors are strongly encouraged to invest in the delivery of evidence-based consultation that promotes NCFs.
Rational Emotive-Social Behavioral (RE-SB) consultation, developed for K–12 teachers, fosters student-teacher relationships and quality instruction by promoting flexibility, acceptance and realistic expectations (Warren, 2013; Warren & Gerler, 2013). School counselors use this model of consultation to address IBs and UNEs commonly associated with teaching. RE-SB consultation also can address the biases and stereotypes that lead teachers to hold low expectations of students from underrepresented groups (Holcomb-McCoy, 2007).
Through RE-SB consultation, school counselors can promote the NCFs of teachers that directly impact the non-cognitive development of students. For example, students vicariously learn strategies that promote non-cognitive development from teachers who have positive self-concepts, demonstrate preferences for long-term goals and maintain strong support systems. Additionally, students are positioned to engage in realistic self-appraisal when teachers maintain high expectations.
School counselors also can utilize this model of consultation when working with parents. RE-SB consultation can promote NCFs that enhance the ways caregivers interact with and support their children. RE-SB consultation can assist parents in overcoming psychosocial barriers that hinder their child’s growth and development. For example, consultation can target a parent’s thoughts, emotions and behaviors that influence their child’s decision regarding postsecondary education.
School counselors can deliver RE-SB consultation in large group, small group and individual sessions. Ideally, school counselors utilize large group consultation in an effort to advance the principles of REBT throughout the systems of the school. For example, school counselors can encourage teachers and parents to develop a common language that promotes rational thoughts and promotes NCFs. Establishing a common set of REBT-based classroom rules and parental guidelines can ensure that students are immersed in environments conducive to promoting NCFs. Small group and individual RE-SB consultation is typically implemented to address specific concerns expressed by individual teachers or parents. Students from underrepresented groups can benefit greatly from interacting with parents and teachers who model NCFs.
Collaboration. School counselors can collaborate with parents, as well as educators and community members, in many ways. These collaborative efforts are aimed at establishing equity and access for all students (ASCA, 2012). As a result of the relationships established through collaboration, members of the school community (e.g., parents) may reach out to the school counselor for consultation and other services more readily.
Through collaborative efforts such as parent trainings, school counselors can inform parents about the value of non-cognitive development and its role in determining postsecondary success. Efforts to engage the school community in initiatives that directly support student success can strengthen the relationships between the school counselor and parents. Collaboration establishes the school counselor as a leader, student advocate and partner in advancing NCFs and college and career readiness.
School counselors also can partner with local universities to promote a college-going culture and set high expectations for postsecondary success for all students. For example, university and school partnerships can establish mentoring programs that couple K–12 students with local college students from similar underrepresented groups. These relationships would reciprocate non-cognitive development for both the mentor and mentee. This experience can empower and create opportunities for K–12 students from underrepresented groups.
It is equally important that university and college initiatives, with involvement from offices such as those responsible for enrollment, retention and diversity, engage school counselors in conversations that explore opportunities to streamline students’ experiences from high school to postsecondary education. These partnerships can lead to collaborative efforts to develop and provide REBT-based transition programs that promote non-cognitive development. These programs can offer students, especially those from underrepresented groups, additional support as they navigate the nuances of postsecondary education. Universities are advised to build on the efforts of professional school counselors and promote non-cognitive development through evidence-based practices rooted in REBT.
Conclusion
The principles and tenets of REBT align and overlap with many NCFs, especially those promoted by Sedlacek (2004). The proposed recommendations for school counselor practice appear to support the aims of ASCA (2012) and the ASCA (2014) Mindsets and Behaviors for Student Success standards and competencies. It is critical that researchers and educational leaders continue to explore ways to embed the principles of REBT throughout the educational experiences of all students in an effort to close the achievement gap, foster college and career readiness, and promote postsecondary success.
School counselors must evaluate the direct and indirect student services they provide. A variety of methods are available to help determine the outcomes of REBT-based services. Both formal and informal methods of data collection are useful in determining the impact of services such as core curriculum, small group counseling, consultation and collaboration. School counselors can attempt to directly measure non-cognitive development, including changes in students’ patterns of thoughts, emotions and behaviors. However, it is critical for school counselors to track changes in achievement-related data including attendance, discipline referrals and homework completion. From a distal perspective, understanding the influence these services have on high school graduation rates and persistence in postsecondary education, especially for students from underrepresented groups, is imperative.
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.
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Jeffrey M. Warren, NCC, is an Assistant Professor at the University of North Carolina at Pembroke. Robyn W. Hale is a School Counselor at Scurlock Elementary School, Hoke County Schools, NC. Correspondence can be addressed to Jeffrey Warren, 1 University Drive, Pembroke, NC 28372, jeffrey.warren@uncp.edu.
Mar 11, 2016 | Book Reviews
Depression 101 by Emily Durbin is a thorough resource for counselors of all skill levels interested in learning or refreshing themselves on the diagnostic and syntonic features of depression. This text covers Major Depressive Disorder (MDD), Dysthymic Disorder (DD), and Bipolar Disorder (BD) in such depth that it could be utilized as a reference text. The author indicates that the aim of the book is to emphasize and bring clarity to the different ways scientific disciplines have approached depression. Dr. Durbin explores how this has affected our understanding of depression spectrum disorders and in turn has resulted in how the field of counseling identifies individuals with depressive mood and structures treatment models.
The text begins by operationalizing and describing the characteristics used to diagnose MDD, DD and BD. Dr. Durbin then explains how these symptoms manifest, who is likely to be diagnosed, and how mood disturbance effects functioning. She concludes with treatment models and recommendations on how to integrate the presented information into practice. The text presents information about depression in a concise manner and consistently includes a variety of references for the topics discussed. It is evident that Dr. Durbin synthesized information from an assortment of sources to give the reader a comprehensive view of the described disorders.
The most applicable section of the text for counselors is the section on integrating the information into practice. Academic books often present a plethora of new information, but it is difficult to figure out how to incorporate it into already established therapeutic practice. This text not only presents an extensive amount of information and research, but summarizes a plan for integration at the end of the book. My only suggestion would be to lengthen this section to further examine the practical implications for the research presented in the subsequent chapters.
Overall, this text is a phenomenal resource for counselors, counselor educators and graduate students alike. I would not consider Dr. Durbin’s book a light read, but she does an excellent job of presenting a vast amount of information in a relatively short text. I have no doubt that I will be referencing this book in the future and utilizing its wide-ranging reference list. After all, depression is considered the “common cold” of psychological disorders. It would be a great disservice to many of our clients to not have a thorough understanding of the disorder that is most frequently reported. Dr. Durbin’s text is an excellent desk reference to serve that purpose.
Durbin, C. E. (2015). Depression 101. New York, NY: Springer.
Reviewed by: Charmayne R. Adams, Wake Forest University
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Mar 11, 2016 | Book Reviews
Psychological Testing That Matters: Creating a Road Map for Effective Treatment is grounded in the Menninger-Topeka psychodynamic approach to testing. It fills a space between diagnostic work and clinical intervention and advances a philosophy of close alliance between those who provide test results and those who use them.
Psychological Testing That Matters lays a foundation for looking at four (and in a few cases, more than four) commonly used diagnostic tests that generate different kinds of data useful for counseling. These tests are discussed in detail, with examples of ways in which the standard administration of these tests can be augmented to discover additional information that deepens one’s ability to interpret client responses. These examples are particularly helpful to the practitioner who is reasonably new to clinical work or who may not have a deep understanding of the various tests.
Technical and specific information on the appropriate applications of the tests is especially interesting and useful. The treatment implications that are explained are good examples of the way in which the authors bring a multitude of testing data together to inform the therapeutic approach. The convergence of data is an important concept that runs through this text and illustrates for the counselor the importance of not relying on a single tool from which to draw conclusions. With precision and nuance, the authors discuss the untangling of story lines and how reserving conclusions is a way of ensuring an accurate depiction of what the data mean: “We are not rushing to conclusions,” but rather “letting connections arrange and rearrange . . . using repetition and convergence to steer the stream of ideas as they flow toward conclusions.”
Especially interesting are the ways in which the authors describe the diagnostic benefits of the test, not only for understanding the client’s ability to function in daily life, but perhaps just as importantly for understanding how the information revealed by the test administration is used to guide therapeutic strategies for engaging with the client in the therapeutic relationship by focusing on identifying circumstances that could interfere and cause a client to shut down. This is where the test results create the road map for treatment.
The organization of the material is one of the strengths of this book. It allows the reader to settle into the material comfortably and deeply, knowing the architecture of the narrative road. It also challenges the reader who may find the level of technicality, particularly in test scoring explanations, repetitive and uninspiring.
The technical diagnostic expertise and clinical prowess of the authors is remarkable and make this book a resource that many clinicians could use. However, as they insightfully acknowledge, the tools available today to simplify diagnosing and reporting also give rise to the concern that the “synthesis from a large quantity of highly complex data[,] . . . wide array of theoretically and empirically based interpretive sources[, and] . . . emotional experiences of the patient’s interior world” make this approach unmanageable in environments where counselors practice now. However, the authors do build a compelling case for the efficacy of their approach, which speaks to the art of their diagnostic and clinical work. It is clear that we may be losing an important piece of clinical competence if we lose appreciation for the knowledge the authors have mastered and share in this book.
Psychological Testing That Matters presents a multi-layered approach to effective treatment with rich case examples of many test applications. This book is important because it reinforces the appropriate uses of certain tests as one element of solid clinical diagnosis and treatment. Further, the book is accessible to a graduate-level practitioner audience in counseling and, with the elegant use of metaphors, is an engaging read.
Bram, A. D., & Peebles, M. J. (2014). Psychological testing that matters: Creating a road map for effective treatment. Washington, DC: American Psychological Association.
Reviewed by: Christine Z. Somervill, University of Phoenix, Tempe, AZ.
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